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A 64-year-old man was diagnosed with KRAS-mutant type sigmoid colon cancer with metastasis in the lung, liver, left adrenal gland, and para-aortic lymph node(T3N1M1b, Stage ⅣB[Union for International Cancer Control 8th edition]). Laparoscopic transverse colostomy was performed to treat colonic obstruction. Subsequently, a combination regimen of capecitabine plus oxaliplatin plus bevacizumab was administered. After 5 courses of chemotherapy, the S8 liver tumor disappeared completely. Sigmoidectomy, para-aortic lymph node dissection, and left adrenal gland resection were performed. After 3 months, right S3 segmental pneumonectomy and right S8 and S10 partial pneumonectomy were performed. R0 resection for the primary lesion and metastatic lesions of the chest and abdomen was achieved. Following the conversion surgery, he was administered the adjuvant chemotherapy regimen of uracil-tegafur plus Leucovorin. After 2 courses of chemotherapy, he presented to our hospital complaining of vomiting and dizziness. Contrast-enhanced magnetic resonance imaging revealed multiple brain metastases. Thus, we should be mindful of the possibility of brain metastasis in cases of unresectable colon cancer showing satisfactory response to chemotherapy with an indication of conversion surgery.

A 75-year-old man who had lymphadenopathy was admitted to our hospital. Histopathological examination of cervical lymph node biopsy specimens showed diffuse proliferation of lymphoma cells with large nuclei. In immunohistochemistry, the lymphoma cells were positive for CD5, CD10, CD20, BCL2, BCL6, and MYC. The patient was diagnosed with CD5- and CD10-positive diffuse large B-cell lymphoma (DLBCL). MYD88 L265P mutations have been detected in DLBCL. Partial response was achieved after six courses of R-THP-COP therapy. However, the patient died because of disease progression 18 months after the diagnosis. On autopsy, lymphoma cells were found in the lymph nodes throughout the body, central nervous system, adrenals, and skin. CD5- and CD10-positive DLBCL account for 0.5-1% of DLBCL cases and have a very poor disease prognosis. This is a rare case of CD5- and CD10-positive DLBCL with MYC and BCL2 expressions harboring MYD88 L265P mutation.

A 40-year-old man visited our hospital with rectal submucosal tumors measuring 5 mm and the 7 mm as detected by colonoscopy, following which an endoscopic submucosal resection was performed. Pathological examination revealed that the tumors was neuroendocrine tumor(NET); the tumor measuring 5 mm was NET G1 without lymphatic and venous invasion, while the 7 mm size was NET G2 with venous invasion but without lymphatic invasion. Lymph node and distant metastasis were not observed by computed tomography. Informed consent was obtained and he agreed to undergo additional rectal resection. Laparoscopic low anterior resection was performed and pathological examination enabled a diagnosis of rectal neuroendocrine tumor with regional lymph node metastases(T1a, N1, M0, Stage ⅢB[Union for International Cancer Control 8th edition]). Post-surgery, he was followed up for 3 years, without recurrence. This report suggests that the determination of treatment plan for rectal neuroendocrine tumor measuring less than 1 cm in diameter should be done carefully.

A 78-year-old man was diagnosed with sigmoid colon cancer, and laparoscopic sigmoidectomy was performed. On pathological examination, he was diagnosed with RAS-wild type sigmoid colon cancer with regional lymph node metastasis (T3, N1, M0, Stage ⅢB[Union for International Cancer Control 8th edition]). Computed tomography revealed S8 and S7 liver metastasis, 3 months after the initial surgery. The location of the S8 tumor was close to the inferior vena cava(IVC), right hepatic vein(RHV)and segment Ⅷ hepatic vein(V8). He was administered cetuximab plus modified FOLFOX6. After 6 courses of chemotherapy, the S8 and S7 liver tumor shrank. S8 plus 4 plus 1 and S7 partial hepatectomy was performed and R0 resection was achieved. The RHV and V8 were resected, while right superficial and middle hepatic veins were preserved. An IVC invasion was not observed. He was administered 12 courses of adjuvant modified FOLFOX6. After the partial hepatectomy, he has been followed up for 1.5 years with no recurrence.

The patient was a 37-year-old man who visited a neighborhood clinic complaining of nausea and upper abdominal pain. Since examination revealed abdominal distention, he was referred to our hospital. Abdominal computed tomography at our hospital revealed retention of gastric contents and contrast-enhancing wall thickening localized to the pyloric region. Upper gastrointestinal endoscopy showed stenosis involving the entire circumference of the pylorus. However, multiple biopsies failed to reveal any evidence of malignancy. Four dilatations were performed, with no improvement. Therefore, the patient was referred to the Department of Surgery. Since malignant disease could not be ruled out, laparoscopic distal gastrectomy with D2 lymph node dissection was performed. Histopathological examination of the resected specimen revealed the presence of ectopic pancreatic tissue in the proper muscle layer of the pylorus. Adenocarcinoma invading and proliferating into the surrounding ectopic mucosal lesion was observed. Therefore, the patient was diagnosed with adenocarcinoma arising from ectopic pancreas. The possibility of ectopic pancreatic cancer may need to be considered in patients with pyloric stenosis caused by a submucosal tumor-like lesion.

An 83-year-old man visited our hospital with liver tumors detected by abdominal ultrasonography. On investigation, he was diagnosed with sigmoid colon cancer with metastasis in the supraclavicular lymph node, liver, and para-aortic lymph node(T3N1M1b, Stage ⅣB[Union for International Cancer Control 8th edition]). He was administered combination therapy with capecitabine and bevacizumab owing to the increased age and Eastern Cooperative Oncology Group performance status score of 1. After 8 courses of chemotherapy, the primary tumor and liver metastases shrank. As he developed Grade 2 hand-foot syndrome, the dose of capecitabine was decreased to 75%(1,500 mg/m2)from the 11th course and to 50% (1,000 mg/m2)from the 31st course. Until 2 years after initiation of the chemotherapy, the patient showed progression-free survival. Heparinoid-containing moisturizer and steroid ointment were administered for treatment of hand-foot syndrome. This report suggests that capecitabine plus bevacizumab therapy can maintain the quality of life and is safe with dose reduction and treatment of adverse reactions for elderly patients with colon cancer.

We herein report a case of ruptured arterio-venous malformation(AVM)detected using three-dimensional digital subtraction angiography(3DDSA)fusion images and successfully treated with target embolization for pseudoaneurysm. A 50-year-old man with a history of AVM was admitted to our department for the treatment of ruptured high-grade AVM in the right parietal lobe. Although a bleeding point was not evident on DSA, the patient had re-rupture in the right ventricle, one month after admission. Chronological 3DDSA fusion images generated from 3DDSA images taken on admission and after re-rupture revealed a newly visualized intranidal pseudoaneurysm near a hematoma. Contrast-enhanced magnetic resonance imaging showed vessel wall enhancement along the posterior horn of the right ventricle;this enhancement corresponded to the location of the pseudoaneurysm. We planned target embolization for the intranidal pseudoaneurysm to prevent re-bleeding. The origin of the feeder was so steep that a microcatheter could not be advanced deeply, and embolization with 20% n-butyl-2-cyanoacrylate resulted in proximal occlusion. Follow-up angiography 1 week after embolization showed complete disappearance of the pseudoaneurysm, and the patient had no recurrence of aneurysm until one year.

He was a 92-year-old male patient with mild cognitive impairment while preserved activity of daily life. His renal dysfunction gradually increased due to the nephrosclerosis accompanied by systemic edema and water retention. We eventually decided to initiate peritoneal dialysis instead of standard hemodialysis for his end-stage renal dysfunction refractory to optimal medical therapy, given his preserved cognitive function and family support. He underwent an established therapeutic program for the peritoneal dialysis at home with an Information and Communication Technology (ICT).Given the increase in age of the patients with renal dysfunction, peritoneal dialysis has been receiving great attention as a home care strategy. The recent improvement in the device technology and ICT that enables us remote monitoring would reduce patients' effort in the management of peritoneal dialysis. Collaboration with home nursing and care workers would also be warranted for successful home care.

Radical cystectomy (RC) is the gold standard for managing muscle-invasive and high-risknon-muscleinvasive bladder cancer, but is accompanied by non-negligible operative risk. The aim of this study is to identify preoperative variables to predict major perioperative complications after RC and to develop a nomogram using the cohort from multiple institutions in Japan. We retrospectively reviewed 668 patients who underwent open RC with ileal conduit or neobladder at Hokkaido University hospital and 20 affiliated institutions between 1997 and 2010. Complications occurring within 90 days of surgery were graded using modified Clavien classification system. We defined modified Clavien grade 3 or more as major complications and performed univariate and multivariate logistic regression analyses. Predictive accuracy of the nomogram was evaluated with the area under the receiver operating characteristics curve (AUC). A total of 528 men and 140 women were included in this study. There were a total of 160/668 patients (24%) with major perioperative complications. A multivariate model identified gender (OR : 1. 63, p=0. 04), cardiovascular comorbidity (OR : 1.48, p=0.03) and simultaneous nephroureterectomy (OR : 2.81, p=0. 01) as independent predictors. Using these 3 variables, a nomogram was developed with the AUC of 0.58. Predictive performance of our nomogram showed only fair performance ; but at least, we identified male, cardiovascular comorbidity and simultaneous nephroureterectomy as independent predictors of perioperative major complications.

A patient in his 60s had undergone laparoscopic anterior resection for the treatment of carcinoma of the rectum in February 2016. Histopathologic examination revealed the lesion as a pT2(MP)n(-)M0, fStage Ⅰrectal cancer. One year post-surgery, contrast-enhanced computed tomography(CT)revealed enhancement of parts of the intrapancreatic distal bile ducts. Magnetic resonance cholangiopancreatography(MRCP)showed filling defects at the same site. Magnetic resonance imaging( MRI)with an endorectal coil(ERC)was then performed to identify reproducible bile duct filling defects. Neither cytology nor biopsy yielded any findings that definitely indicated malignancy. Intraductal ultrasonography(IDUS)led to the suspicion of a nonepithelial tumor or an enlarged lymph node. Repeated biopsies via ERC were performed based on the absence of evidence of malignancy and revealed the presence of some atypical cells within the lesions. Although no definitive diagnosis could be made, the patient was scheduled for surgery in June 2017 after obtaining his consent. Upon taping of the common bile duct during surgery, a tumor was palpable on the dorsal aspect of the pancreas. The bile duct tumor was completely excised and submitted for intraoperative diagnosis; the pancreatic dorsal aspect appeared to be totally split. There was no evidence of atypia in the neoplasm, which was therefore considered to be benign; however, malignancy could not be completely ruled out because the patient had presented with elevated serum levels of carbohydrate antigen(CA)19-9 once before the operation. After intraoperative consultation with the patient's family members, who were reluctant to provide consent for pancreaticoduodenectomy, we completed the operation with resection of the bile duct tumor, followed by choledochojejunostomy. The tumor was found to be chromogranin A(+), cluster of differentiation(CD)56(+/-), CA19-9(+, solely ductal structure), carcinoembryonic antigen(CEA)(+, solely ductal structure), and intranuclear p53(-), with an MIB- 1 index of<2%. With regard to neuroendocrine markers, a region that could potentially have been a carcinoid tumor, based on the findings on hematoxylin and eosin(HE)staining, and a lumenized superficial region showed positivity in toto. Therefore, the lesion as a whole was diagnosed as a G1 carcinoid neuroendocrine tumor(NET). However, the superficial lumenized layer was positive for both CA19-9 and CEA; therefore, the tumor was thought to concurrently have epithelial characteristics. The lateral stumpwas negative, while the status of the ablated region remained unclear. After discussing the histopathologic examination results with the patient and his family members, the patient's follow-upwas decided to consist of periodic checkups without any further surgical intervention. The patient has since remained free of recurrence. Carcinoid tumor of the bile duct is extremely rare but should be considered in cases involving bile duct tumors that show enhancement on imaging prior to surgery and for which no definitive diagnosis can be established despite repeated biopsy explorations.

A man in his 50s visitedour hospital with complaints of frequent urination, painful micturition, macrohematuria, and weight loss. On examination, he was diagnosed with RAS-wild-type sigmoid colon cancer invading the urinary bladder, ureter, andexternal iliac artery, with para-aortic lymph node metastasis(T4b, NX, M1a, Stage ⅣA according to the Union for International Cancer Control 8th edition guidelines)andsigmoid -vesical fistula. Thus, sigmoidcolostomy was performed. Postoperatively, S-1 plus oxaliplatin was administered. After 3 courses of chemotherapy, the primary tumor and para-aortic lymph node metastases shrunk. Moreover, after 8 courses of chemotherapy, further shrinkage of the primary tumor and paraaortic lymph node metastases was confirmed; however, tumor markers in the blood increased. Therefore, the patient received 3 additional courses of S-1 plus oxaliplatin plus cetuximab, which resultedin complete response. Sigmoidectomy, partial cystectomy, ureterectomy, resection of the external iliac artery, andreconstruction using a prosthetic vascular graft were performed. Subsequent pathological examination revealed no viable cancer cells(pathological response), achieving R0 resection. The patient has been followedup for 2.5 years after the curative resection, with no recurrence.

A 73-year-old woman had a history of medication, including methotrexate for rheumatoid arthritis, for 5 years. She had chronic epigastralgia for 2 weeks and found to have multiple submucosal tumors on upper gastrointestinal endoscopy in another hospital. She had a strong abdominal pain thereafter and diagnosed as having gastrointestinal perforation on the basis of CT scans. Abdominal examination revealed disseminated peritonitis, and emergency laparoscopic surgery was performed on the day of admission. A 1 cm perforation of the ileum was identified, and a 5 cm mass of the mesentery near the perforation was also identified. Small bowel partial resection, including both lesions, was performed. From the intraoperative findings, methotrexate-associated lymphoproliferative disorders(MTX-LPD)was suspected, and methotrexate was discontinued after the surgery. At a later date, the pathological result from both the surgical specimen and upper gastrointestinal endoscopy was diffuse large B cell lymphoma(DLBCL). CT scan, PET-CT scan, and upper gastrointestinal endoscopy were performed 1-2 months after surgery, and no tumor was identified. Currently, 6 months after the surgery, the patient is still alive without any progression of the lymphoma.

Cardiac involvement during lymphoma often causes complications, including arrhythmia. A 68-year-old male with cardiac tamponade was diagnosed with diffuse large B-cell lymphoma with cardiac involvement based on the presence of the tumor mass in the myocardium and lymphoma cells in the pericardial effusion. He developed atrial fibrillation, ventricular tachycardia, and atrial flutter after initiating chemotherapy. Following chemotherapy, sinus rhythm was restored without invasive treatment for arrhythmia, while the cardiac mass disappeared. No recurrent arrhythmias were observed. In lymphoma with cardiac involvement, unexpected arrhythmias can emerge after initiation of chemotherapy, which could potentially be related to accelerated cardiac remodeling owing to the rapid relief of cardiac damage. Follow-up using electrocardiogram is thus necessary during chemotherapy for cardiac lymphoma, despite the absence of arrhythmia at the time of diagnosis.

A man in the 60s visited our hospital with the complaints of epigastralgia and weight loss. Following an investigation, he was diagnosed with human epidermal growth factor receptor 2(HER2)-positive gastric cancer with invasion to the pancreas (T4b[pancreas], N2, M0, Stage ⅣA[Union for International Cancer Control 8th edition]). Preoperatively, he was administered a chemotherapeutic regimen of S-1 and cisplatin plus trastuzumab. After 2 courses of chemotherapy, computed tomography revealed invasion to the abdominal wall and pyloric stenosis; however, invasion to the pancreas was obscured, and the lymph node metastases had shrunk. He underwent laparoscopic gastro-jejunostomy. After 4 courses of chemotherapy, his condition was considered stable. A laparoscopic distal gastrectomy was performed together with resection of the abdominal wall invasion. The pathological stage was pT4b(abdominal wall), pN0, M0, Stage ⅢA, and R0 resection was achieved. The patient was administered 4 courses of adjuvant capecitabine plus oxaliplatin therapy and 4 courses of capecitabine monotherapy. He has been followed-up for 1.5 years since the curative resection and has not developed recurrences. This case suggests the usefulness of multimodal therapy for locally advanced gastric cancer.

The patient was a man in his 40s, who had undergone laparoscopic ileocecal resection with lymph node dissection(D3)for cecal cancer in January 2012. Histopathological examination of the resected specimens had revealed StageⅡ primary tumor with subserosal invasion and positive metastasis in 1-3 regional lymph nodes(pT2[SS]n1[+]). The pathological stage was Ⅲa(fStage Ⅲa), and the tumor showed RAS gene mutation. The patient was administered 5 cycles of postoperative adjuvant chemotherapy with oral tegafur/uracil(UFT)in combination with calcium folinate(UZEL). Abdominal computed tomography( CT)performed 1.5 years postoperatively revealed liver metastasis, and a laparoscopic partial hepatectomy was performed in August 2015. In addition, a node in the greater omentum, located in the inferior surface of the liver, was also resected. Histopathological examination of the resected specimens revealed peritoneal metastasis, based on the identification of the same type of adenocarcinoma as the colon cancer. The patient was given 8 cycles of adjuvant chemotherapy with capecitabine and oxaliplatin(CapeOX). Then, he presented with colonic ileus, caused by recurrent dissemination, and underwent a laparoscopic transverse colectomy in October 2015. Multiple perineal disseminations were found intraoperatively, and chemotherapy was initiated with irinotecan plus tegafur/gimeracil/oteracil(S-1)plus bevacizumab(IRIS/BV)for the recurrent and unresectable disease. After 27 cycles of this regimen, lung metastasis was detected; in addition, progression of the para-aortic node metastasis around the celiac plexus was also observed, and the patient was considered as having pro- gressive disease(PD). Treatment with trifluridine/tipiracil(TAS102)was started in September 2017. Prior to the initiation of this regimen, the dose of opioid rescue medication previously started for back and abdominal pain was rapidly increased. Accordingly, the base dose was increased, but the pain could not be controlled, and the major pain was consistently located along the area of innervation in the celiac plexus. Therefore, celiac plexus neurolysis(CPN)was performed as a local therapy. A CT-guided injection technique was used to administer urografin, bupivacaine, and absolute ethanol to complete the procedure. The patient was discharged without major complications, and the base opioid dose was gradually reduced. Since the patient did not require any rescue medication during daytime on some days, the reduction of the base opioid dose was significantly effective in improving the patient's quality of life(QOL). In patients with pain possibly caused by metastasis to the para-aortic nodes, this local therapy technique may be considered.

Hyponatremia occurs while receiving bortezomib-containing combination therapy in multiple myeloma (MM) ; however, the mechanism of hyponatremia remains unclear. A 65-year-old female with MM was treated with bortezomib, lenalidomide, and dexamethasone. Fourteen days after chemotherapy initiation, she developed hyponatremia (serum sodium, 127 mEq/l, compared with 136 mEq/l before chemotherapy) with plasma hypo-osmolality and urine hyper-osmolality. She exhibited neither dehydration nor adrenal insufficiency. Her serum arginine vasopressin peptide (AVP) level was 1.5 pg/ml. She was diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH), wherein causative roles of inflammatory cytokines were strongly suggested in the development because (1) SIADH was triggered by the cessation of the dexamethasone treatment and (2) hyponatremia was successfully treated with prednisolone, which was administered for the complication of drug eruption. Perhaps, bortezomib-induced immune reactions could be involved in a subset of hyponatremia during bortezomib-containing antimyeloma chemotherapy.

A man aged 66 years presented with pneumaturia as a major complaint. Cancer of the sigmoid colon with infiltration to the urinary bladder was diagnosed and the patient underwent colectomy of the sigmoid colon and partial cystectomy of the bladder in May 2015. Histopathologic examinations revealed pT4b, Si(bladder), pN(-), cM0, fStage II . Because intestinal sub-obstruction and lymphatic invasion were present, CapeOX was administered as an adjunctive chemotherapy for the high-risk Stage II cancer. Because Grade 2 peripheral neuropathy appeared as a side effect, the dose was decreased to 80% from the 3 cycle. After the 7 cycle, cough and disturbed breathing appeared. The chest CT scans did not reveal drug-induced interstitial pneumonia, but indicated an elevated right diaphragm and zosteroid changes in the medial lobe of the right lung due to discoid atelectatic condition. The Grade 1 respiratory symptoms were mild, and the lung field was considered to exhibit no problems. Thus, the 8 cycle was administered. The symptoms disappeared after about 2 weeks following completion of oral administration of capecitabine. The diaphragm also recovered to its original height. In the attached document, the frequency is unknown and "dyspnea" is written for L-OHP and capecitabine, respectively. It is unknown whether phrenic nerve paralysis occurs. However, because other organic lesions were absent and the symptoms appeared during chemotherapy, the possibility is not deniable. At present, 2 years postoperatively, recurrent lesions in the mediastinum and recurrent respiratory difficulties are absent. Generally, although phrenic nerve paralysis is not considered to be a specific side effect, it was considered that for respiratory difficulties, CT reveals not only the affected condition in the lung fields, but is also useful for detection.

We report a rare case of arteriovenous malformation(AVM)of the parotid gland associated with Cowden disease successfully treated with preoperative embolization followed by surgical removal. A 39-year-old man with a history of Cowden disease presented with a pulsating and growing mass on his left lower jaw. Contrast-enhanced computed tomography(CT)and angiography revealed a high-flow AVM in the deep lobe of the left parotid gland. After intravascular embolization of the feeding arteries, surgery was performed using the NIM-response ® 3.0, facial nerve monitoring system. The AVM was almost completely removed and the facial nerves were morphologically preserved. Interestingly, the intraoperative findings revealed that the enlarged vasa nervorum of the facial nerve also fed the AVM. Although left facial nerve palsy appeared after the surgery, the nerve function gradually improved over one year. No recurrence of the AVM has been observed for one year.

A 72-year-old man was admitted to our hospital department in September 2014 because of a positive fecal occult blood test.Colonoscopy showed a type 2 tumor in half of the AV 15 cm rectosigmoid colon.Histology of the biopsy indicated a moderately differentiated adenocarcinoma, and the RAS gene test found wild type.On CT examination, there were multiple liver lung metastases and a 30mm diameter tumor with pancreatic duct extension to the pancreatic body.A PET-CT examination had a high SUVmax at the same site.Because of the location of the tumor EUS-FNA was not used.However, the possibility of pancreatic body cancer could not be denied after the CT examination.Treatment by radical resection was impossible because of the spread of the cancer so we selected chemotherapy.Undeniable pancreatic metastasis of rectal cancer, pancreatic cancer was used as a prognostic factor as double cancer of rectal cancer and pancreatic cancer, from that UGT1A1 test side effects appearance was a low-risk decision, was selected FOLFIRINOX in the treatment regimen.After 25 cycles, the pancreatic body tumor and liver metastases and also the primary tumor were reduced, the multiple lung metastases disappeared, and disease control was good.Side effects were diarrhea on the day of administration of irinotecan, but this was controllable by administering oral loperamide when starting the infusion.Grade 3 or more peripheral neuropathy has not developed, and this regimen is continuing.Pancreatic cancer is a solid cancer with a poor prognosis; if you do not reach the tissue diagnosis of metastatic pancreatic cancer, was a case in which no choice but to select a regimen to carcinoma of the prognostic.

A 62-year-old woman was admitted with abdominal pain and distention in July 2013. Computed tomography (CT) revealed a small bowel obstruction caused by an ileocecal tumor, and colonoscopy revealed a type 3 cecal tumor. Because an ileus tube was not effective to relieve her symptoms, she was transferred to the Department of Surgery for an emergency operation. Open resection of the ileocecal tumor along with the right ureter and psoas was performed. Histological examination showed that cancer cells were present in the radial margin. The patient was treated with a post-operative course of chemotherapy (capecitabine and oxaliplatin), but the level of carcinoembryonic antigen was increasing; positron emission tomography (PET) revealed a local cancer recurrence. Although the right external iliac artery and reconstructed right ureter were encased by the tumor, there were no signs of lymph node metastasis or distant metastasis. Because the tumor was localized, we decided to perform a re-excision. Intraoperatively, the right external iliac vein was difficult to separate from the tumor. Therefore, we resected the right ureter, kidney, and right external iliac artery and vein en bloc. The right external iliac artery and vein were replaced with grafts. Histopathologically, the reconstructed right ureter was completely invaded by the tumor, and cancer cells had invaded the nearby adventitia of the artery, but the surgical margin was negative. Four months after the second operation, peritoneal dissemination was detected on PET. The patient was followed-up in an outpatient clinic without chemotherapy.

In June 2010, a 73-year old man diagnosed with sigmoid colon cancer underwent laparoscopic sigmoidectomy. The histopathological diagnosis was tub2, pSS, n (-), stageⅡ.Vascular invasion was present; however, at the patient's request, no adjuvant chemotherapy was administered.Computed tomography (CT) performed at the outpatient follow-up 4 years and 6 months after the surgery revealed a para-aortic lymph node metastasis in the caudal aspect of the left renal artery branch point. No other definite mass shadows were detected. Positron emission (PET)-CT revealed high tracer accumulation (SUVmax) not only in the CT-identified lymph node, but also near the site of the anastomosis in the bowel. Considering that no tracer accumulation was detected at any other sites and the patient's compliance with medication and scheduled visits was poor, surgical resection rather than chemotherapy was adopted as the treatment strategy. No metastases other than at the sites identified by the diagnostic imaging were found during the surgery. Since the findings on palpation did not rule out the possibility that the nodule near the anastomotic site was present inside the intestinal tract, lymph node dissection, resection of the intestinal tract including the anastomotic site, and re-anastomosis were performed. The most likely diagnosis based on the histopathological findings was dissemination for both the adenocarcinoma and the nodule near the anastomotic site. At present, the patient is being treated with adjuvant chemotherapy. In the Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines for the Treatment of Colorectal Cancer, the recommended therapeutic intervention is surgical resection of hematogenous metastases; however, no treatment is specified for lymph node metastases. In general, chemotherapy is administered for distant metastases. However, we have found no reports of cases in which a complete remission has been achieved. There are reports of improvement of survival by surgical resection in cases with solitary lymph node metastasis or isolated dissemination of colorectal cancer. These observations suggest that surgical therapy may have contributed to the improved prognosis in the present case.

A 51-year-old woman had previously received treatment for breast cancer at another hospital but had refused early and aggressive treatment. Therefore, she was treated with symptomatic therapy. As her disease progressed, the patient wished to receive palliative care, and was transferred to a palliative care hospital. However, based on her general condition, it was determined that aggressive treatment should not be abandoned, and she was referred to our hospital for treatment. During her initial visit, the patient was found to have left breast cancer with chest wall invasion, right breast metastasis, multiple liver and lung metastases, left pleural effusion accompanied by pleural dissemination, and left upper limb edema. There was no evidence of bone metastases. The patient's pain was managed with oral oxycodone sustained-release tablets (320 mg daily), using high-dose (80 mg) oral oxycodone hydrochloride hydrate as rescue medication. The results of immunohistochemical testing, confirmed by her previous hospital, were ER (-), PgR (-) and HER2/neu positive. First-line treatment was initiated with paclitaxel (PTX) plus trastuzumab (Tmab), and the response was rated as stable disease (SD). During the course of treatment, she developed drug-induced interstitial pneumonia, which was probably caused by the taxane. Therefore, the first-line treatment was discontinued and T-DM1 was initiated as second-line treatment. However, beginning with cycle 3 of the T-DM1 treatment, the patient began complaining of joint pain, mainly in the upper limbs. Therefore, the dose of oxycodone sustained-release tablets was increased to 600 mg per day. However, the patient's joint pain showed no improvement and it was considered unlikely that the pain was due to bone metastases. It was suspected that the pain was an adverse reaction to T-DM1, and the dose of T-DM1 was reduced by one step in cycle 7 of treatment. This resulted in a dramatic improvement of the patient's symptoms. Since oxycodone sustained-release tablets was being used at a high dose, sleepiness caused by the drug interfered with her activities of daily living. Consequently, as part of an opioid rotation scheme, topical fentanyl citrate was used concomitantly, and the initial daily oxycodone sustained-release tablets dose of 600 mg was reduced to 40 mg and administered in combination with fentanyl citrate (12mg). These findings suggest that uncontrollable joint pain can occur as an adverse reaction to T-DM1.

A 72-year old woman visited our hospital complaining of an umbilical mass and a foul smell from the umbilical region. During the evaluation, a massive immobile tumor was palpated in the center of the lower abdomen in addition to an umbilical mass with necrosis. Computed tomography (CT) revealed a massive ovarian tumor accompanied by an umbilical tumor and cyst with peritoneal dissemination, metastases in the liver and spleen and a urachal tumor. There were no symptoms or imaging findings of gastrointestinal obstruction. While searching for the primary focus, it was determined that the ovarian tumor was not of ovarian origin. Under these circumstances, colonoscopy was the only remaining diagnostic modality. However, evaluation of the large intestine was impossible due to compression by the tumor, and diverticulosis of the sigmoid colon did not allow smooth insertion of the colonoscope. Therefore, an excisional biopsy of the umbilical tumor was performed. The most likely diagnoses based on the histopathological findings were colorectal cancer and urachal cancer. Therefore , mFOLFOX6 was selected for chemotherapy because it has been reported to be effective against both urachal and colorectal cancer. At the time of writing, good tumor control had been achieved in the lesions evaluated. Cases of Sister Mary Joseph's nodule have sporadically been reported. The most common primary foci for peritoneal metastases are the stomach, pancreas and ovary. However, in the present case, these sites were ruled out and the primary focus remained unidentified, making it difficult to select appropriate treatment. We present this case with a discussion of the literature.

The patient was a 79-year-old male complaining of fever, loss of appetite, cough, and a feeling of obstruction when swallowing. He was diagnosed with pneumonia and admitted as an emergency case the same day. Because an esophagus space-occupying lesion was observed on chest computed tomography(CT), in addition to evidence of pneumonia, an upper gastrointestinal endoscopy was performed. A tumor, protruding into the lumen of the esophagus, was seen in the midesophagus, 25-30 cm from the incisors. Because of the narrow lumen, only a fine caliber fiber could be passed. Biopsy results indicated only necrotic tissue, and a repeat biopsy was performed, with similar histological findings. No esophagobronchial fistulas were observed during bronchoscopy. We therefore diagnosed the patient with aspiration pneumonia, secondary to esophageal narrowing by a tumor. A preoperative diagnosis of cancer could not be made, and no distant organ metastasis was detected, but surgery was indicated because of the narrowing of the esophagus, regardless of the possibility of cancer. After the pneumonia improved, total thoracic esophagectomy was performed through a right thoracolaparotomy, plus a 3- region cervico-thoraco-abdominal lymph node dissection. Pathological examination of the surgical specimen revealed autolysis of the superficial layer with progression to necrosis and associated inflammation. The majority of the tumor was composed of spindle-shaped atypical cells, but because a very small transitional area between squamous cell carcinoma and sarcoma was noted, a diagnosis of carcinosarcoma was made. Depth of invasion was sm3, and no regional lymph node metastasis was detected. The patient's disease was classified as pT1b(sm3)N0M0, StageI. No definite diagnosis was made preoperatively. Although carcinosarcoma of the esophagus is rare, the endoscopic findings are characteristic. We report this case with a review of the literature.

A 79-year-old woman was admitted with cholangitis caused by a common bile duct stone (CBDS), and the CBDS was removed by endoscopic sphincterotomy (EST). The patient had undergone distal gastrectomy for gastric cancer located in the lower body of the stomach in 2006. A flat, elevated lesion of the cardiac region was noted in the preoperative examination; however, this lesion was not treated because there was no clear evidence of malignancy upon histopathological examination of the biopsy specimen. Following esophagogastroduodenoscopy in 2013, the macroscopic findings had changed to infiltrative cancer. The lesion was considered to be a submucosal(sm)cancer, and the patient underwent simultaneous cholecystectomy and remnant gastrectomy. The histopathological examination of the surgical specimens revealed a well differentiated tubular adenocarcinoma, type 0-IIb+0-IIa, tub1>tub2, pT1b1, ly0, v0, n0.

A 74-year-old man complained of blood in his urine over a 1-week period beginning in early October 2013, and was examined in the urology department of our hospital. A thorough examination revealed bladder cancer, and surgery was planned after two cycles of preoperative gemcitabine plus cisplatin chemotherapy. A chest computed tomography (CT) performed to evaluate the response to chemotherapy revealed a mass in the right breast. The patient had previously complained about the same site, and mammography and ultrasonography had suggested the possibility of a malignant mammary gland tumor. The results of aspiration cytology were Class V, and based on that finding, a diagnosis of cancer of the right breast was made. In February 2014, we performed a mastectomy, while preserving the pectoral muscles, along with sentinel node biopsy, total cystectomy, urethrectomy, pelvic lymph node dissection, and ureteroileal anastomosis. The histopathological diagnosis of the right breast tumor was invasive ductal carcinoma[scirrhous carcinoma, ly (+), v (-), g (+), f (+), s (+), nuclear grade 1=atypia 2+mitosis 1, EIC (-), ICT (-), NCAT (-)]. A micrometastatic tumor measuring approximately 1mm was observed in the sentinel lymph node. The breast disease was classified as pT1N1mi(sn)M0, Stage IIA, and the tumor was ER (+), PgR (+), HER2/neu (2+), and FISH (-). The bladder cancer was diagnosed as urothelial carcinoma, non-papillary, invasive G2>G3, pT2a; no pelvic lymph node metastases were detected, and it was classified as pT2aN0M0, Stage II. Synchronous male breast cancer and bladder cancer is a very rare condition, and we report the case with a review of the literature.

A 71-year-old postmenopausal woman was undergoing treatment for depression. She visited the hospital with a chief complaint of fibrosclerosis of the entire left breast 8 years previously. She was diagnosed as having stage IV( T3N1M1b) left breast cancer (papillotubular>scirrhous carcinoma, g+, f+, estrogen receptor [ER]-negative, progesterone receptor [PgR]-negative, and human epidermal growth factor receptor 2[ HER2/neu]-positive[ 3+]). Synchronous bone metastases were detected in the left tenth rib, the eleventh dorsal vertebra, and in the area spanning the lower lumbar to sacral vertebrae. First-line treatment was systemic therapy with 4 cycles of Adriamycin and cyclophosphamide (AC) followed by 4 cycles of trastuzumab and paclitaxel. The breast mass initially observed on clinical imaging disappeared and only calcifications were observed. Bone metastases were detected only in the left tenth rib. As an additional therapy, 3-dimensional radiotherapy( 50 Gy/25 fractions), which irradiated the left mammary gland, axilla, and supraclavicular fossa, was administered. The tumor was well controlled for approximately 3 years. However, a gradual increase in the level of carcinoembryonic antigen( CEA) was accompanied by an increase in the left breast mass and enlargement of left axillary lymph nodes. Modified radical mastectomy (Bt+Ax [level I]) was performed for this condition 3 years ago. Papillotubular-type invasive ductal carcinoma (INF β, ly3, v0, g+, f+, s+, nuclear grade 3 [atypia 3+mitosis 3]) was diagnosed histopathologically. Lymph node metastases were also detected. As histopathological examination of the bone metastatic lesion showed no progression, administration of lapatinib and capecitabine was initiated. After 15 cycles of treatment, enlarged right axillary lymph nodes were observed and local excision was performed. Histopathological examination revealed recurrence of the breast cancer. The patient was diagnosed as having grade 3( atypia 3, mitosis 2) breast cancer( ER-negative, PgR-negative, HER2/neu positive[ 3+], and MIB-1 index 50%). The response to treatment with lapatinib and capecitabine was progressive disease( PD), and therefore, trastuzumab and gemcitabine therapy was selected. Currently, the patient has undergone 30 cycles of this regimen and the tumor is well controlled. This regimen was considered effective for the treatment of patients with HER2-positive metastatic breast cancer.

A 78-year-old man was admitted to Ogikubo Hospital for pancreatic tumors detected by computed tomography (CT). The patient had undergone right nephrectomy for renal cell carcinoma (RCC) 27 years previously. Dynamic CT revealed a hypervascular mass in the pancreatic head and a cystic mass in the pancreatic body that were approximately 35 mm and 20 mm in size, respectively. Total pancreatectomy and splenectomy were performed. Histological examination of the resected specimens revealed metastatic tumors from RCC and they were diagnosed as clear cell type. Metastatic carcinoma of the pancreas is uncommon. Pancreatic metastasis from RCC is rare; however, it could occur many years after the initial diagnosis and treatment of the primary tumor. A long and careful follow-up that includes examination of the pancreas is mandatory after nephrectomy for RCC. In this paper, we discuss a case of RCC metastasis to the pancreas and report it in the literature.

Purpose: Several technological advances have been made in laparoscopic surgery, and the use of reduced port surgery (RPS)has gradually become widespread. To assess the safety and usefulness of RPS, we compared the short -term outcomes of conventional laparoscopy-assisted total gastrectomy(LATG)and LATG with the RPS approach., Patients and Methods: From April 2009 to February 2012, 16 cases with gastric cancer underwent conventional LATG with 5 ports as well as minilaparotomy for anastomosis(Conventional group). From February 2012 to November 2012, 12 cases underwent RPS LATG(RPS group). In the RPS group, a multi-instrument port at the umbilicus was used during surgery. This port held 3 trocars and 2 5-mm trocars that were inserted under the right lumbocostal arch., Results: The mean operation time was 333 minutes in the Conventional group, and 370 minutes in the RPS group. The mean postoperative hospital stay was 23 days in the Conventional group, and 17 days in the RPS group. Postoperative mortality was 0% in both groups. Anastomotic leakage occurred in 2 cases in the Conventional group, whereas pancreatic fistula occurred in 2 cases in the RPS group. Due to postoperative bleeding, 1 case in the RPS group underwent redo laparoscopic operation. Anastomotic stenosis was noted in 4 cases in each group. The patients with stenosis required endoscopic balloon dilation several times and the symptom eventually resolved in all cases., Conclusion: By comparing the short-term outcomes for conventional LATG and RPS LATG, we noted that reduced port laparoscopy-assisted total gastrectomy is a feasible procedure.

A 60-year-old woman receiving treatment for diabetes underwent laparoscopic-assisted low anterior resection and was diagnosed as having rectosigmoid cancer in January 2010( pSS, n2[ +], sM0 fStage IIIb, mutant-type K-ras). She refused adjuvant chemotherapy. In July, after surgery, chest-abdominal-pelvic computed tomography( CT) scans showed bilateral lobe multiple liver metastases and right lobe lung metastases. We recommended oxaliplatin and capecitabine (CapeOX) plus bevacizumab( BV) chemotherapy or surgery. The CapeOX plus BV regimen was initiated at the patient's request. After 8 cycles of chemotherapy, a partial response was observed in the metastatic liver tumors and stable disease was observed in the lung metastases. As hypertension appeared after 16 cycles of chemotherapy, we switched the treatment to CapeOX. After 10 cycles of CapeOX, the chemotherapy was changed to capecitabine at the patient's request owing to the development of grade 2 chronic peripheral neuropathy. Chest-abdominal-pelvic CT scans after 32 cycles of this regimen revealed shrinkage of the multiple liver metastases. The patient has been receiving treatment as an outpatient. Surgical resection should be considered for patients with initially unresectable colon cancer with liver and/or lung metastases if systemic chemotherapy is effective.

A 55-year-old female was admitted to Ogikubo Hospital for severe anemia and prolapse of a tumor from the anus, which had developed over 2 years. Rectal examination revealed a giant soft tumor. Endoscopic study revealed a lobulated giant tumor with a granular surface. Gastrografin-enema study showed a giant tumor, which was full of the rectum. Pathological examination showed a well differentiated carcinoma. No other prominent metastatic lesions were demonstrated. The transanal diagnostic resection of rectal cancer was performed in October 2010. This correct diagnosis showed both well differentiated adenocarcinoma and intramucosal carcinoma. We therefore recommend that a tumor of the lower rectum should undergo a diagnostic excision by means of either a local excision, ESD or TEM.

A 62-year-old female was diagnosed with type 2 advanced gastric cancer in May 2003. Pathological examination showed a poorly differentiated carcinoma. Computed tomography (CT) revealed paraaortic lymph node metastasis, duodenal metastasis and ascites due to peritoneal dissemination. Chemotherapy with CDDP+S-1 was started and continued. After the chemotherapy, there were progressive diseases. Therefore, paclitaxel (PTX) was administered at a dose of 80 mg/m2/day for 3 weeks followed by a week rest. Clinical symptoms were relieved, and CT scan revealed metastatic lymph nodes were reduced after 4 cycles. After 13 cycles, MRI revealed a solitary brain mass was detected. She was resected for a right temporal-occipital brain metastatic tumor, and local cerebral irradiation was performed. After this operation, she was diagnosed with brain metastasis from advanced gastric cancer. The procedure was interrupted for about 6 months. After rehabilitation, PTX treatment was restarted as 14th cycle. She has survived without recurrence more than 30 cycles after the resection. A weekly administration of PTX may be a promising regimen as second-line chemotherapy for S-1 resistant recurrent gastric cancer.

A 58-year-old female was admitted to Ogikubo Hospital for advanced hepatocellular carcinoma in April 2007. Pathological examination showed moderately differentiated hepatocellular carcinoma. Tumor marker increased the PIVKA-II level became 129 mAU/mL after the operation. FDG-PET was showed a solitary pelvic tumor sized about 2.5 cm in diameter. No other prominent metastatic lesions were demonstrated, so that a resection of intrapelvic tumor was performed in May 2008. The report which exhibited an asynchronism recurrence of peritoneal dissemination after hepatectomy is very rare. She has survived without a recurrence more than 13 months after the resection.

This paper describes an integrated methodology that addresses the operation of 3D imaging and measurement for the diagnosis and surgical operation of breast cancer. The main system for breast CT imaging used a multi-slice CT scanner and 3D-workstation. The clinical sequence was performed in three phases with non-contrast and biphasic contrast-enhanced studies that were performed with multi-slice helical CT scanning. Acquired DICOM images were directly sent to the 3D workstation that implemented our developed functions. Four types of transfer functions (mammary skin, vessel, lymph node, and tumor) were set based on region-of-interest (ROI) measurements. After that, two types of segmentation were prepared with volumetry and measurement of the size of breast cancer. Batch processing for 3D visualization and the measurement of breast tumors was helpful for diagnosis and surgical planning.

Immunocompromised or malnutritional hosts are high risk group of pulmonary tuberculosis. Chronic liver disease especially decompensated cirrhosis of the liver is one of the risk group for this infection. When ascites or pleural effusion developed in patient with hepatic cirrhosis, complication of pulmonary tuberculosis must be considered. In such condition, drug metabolism was impaired so that anti-tuberculous drugs should be used carefully, but in almost cases except decompensated cirrhotic patients are tolerable for standard anti-tuberculous combination therapy and they could be cured. Hepatitis C virus infection is common in patients with old pulmonary tuberculosis because many of them were infected Hepatitis C virus at the time of blood transfusion for pulmonary resection or thoracoplasty. In such condition recurrence of pulmonary tuberculosis is rare but probability of recurrence must be considered when they developed decompensated cirrhosis.

This report deals with three different maze methods using spontaneous learning behavior. Forty-eight mice housed in an apparatus with a multiple maze mastered the maze task on the 5th day after the start of housing. Then they were divided into four groups, and two of the groups were treated with AF64A (3.5 nmol, i.c.v.) or trimethyltin (TMT, 3 mg/kg, p.o.), and the other two groups were treated with the vehicle as the respective control. Seven days after the treatment, their memory retrieval was tested. Subsequently, the same mice were housed in the apparatus with a T-maze. After the finish of the experiment using the T-maze, they were housed in the apparatus with an eight arm radial maze. The control groups mastered the T-maze task with a 3-sec delay on the 4th day after the start of housing and the radial maze task on the 10th day after the start of housing. Both the treatments lowered the performance in all maze tasks. These results show that the mice housed in the apparatus with maze learned to negotiate the maze spontaneously, and the apparatuses are useful for estimating memory in mice with little effort.

Male ddY mice were housed in a 4-, 6-, or 8-arm radial maze apparatus for 6 hr a day and then removed to a normal cage for fasting until the next day's trial. A water bottle was placed at the central platform. The end of each arm ran to the home cage through a guillotine door (G). Food was placed in the home cage. During the housing in the apparatus, one G was opened, and the remaining Gs were shut. The opened G was changed in random order during the housing period of 6 hr. At the beginning of the trial, all Gs were shut. The mouse was placed on the platform and was permitted to choose the arms until it chose all arms. When the mouse chose the last arm, the G was opened to allow stepping into the home cage. The mice housed in these apparatus learned to go to the home cage without entering already chosen arms within 4-6 days. Scopolamine (0.2 and 0.4 mg/kg, i.p.) impaired the maze performance. A 1- to 4-min delay impaired the performance slightly, but did not show any significant effect depending on the delay intervals. These results suggest that the apparatus is a useful and easy method for estimating working memory and the drug effects thereon in mice.

Mice were housed in a cage with a T-maze for 7-9 h a day. A watering place was equipped at one end of the maze. At the other end of the maze, the right and left arms each have two exits, one of which leads to the home cage where food is placed, and the other of which leads to the watering place via a bypass. The exit leading to the home cage in either the right or left was alternately closed every two hours. One-way swinging doors were inserted at the entrance to each arm and between each bypass and the watering place. The mice housed in this apparatus acquired the alternation task at 5 s delay on the 6th day. As the delay became longer (5-150 s), correct response rate showed gradual decrease. Scopolamine (0.1-0.4 mg/kg) did not decrease correct response rate at 5 s delay, but did at longer delay (30 s and 60 s). These results suggest that this method is useful in estimating working memory of mice.

The apparatus consists of a home cage, a maze cage and a starting box. A maze with four right-middle-left decisions was placed in the maze cage. The starting box was attached and a water tap was placed at an area corresponding to the entrance of the maze. The exit of the maze and the home cage are connected with a tunnel. Food was placed in the home cage. 1) Mice were housed for 10 hr a day in the apparatus and then removed to another cage for fasting. One trial a day was carried out after fasting for more than 12 hr. In each trial, a mouse was put at the starting box, and then the number of errors (entering a blind alley) and the time until the mouse reached the home cage were counted. The mouse passed through the maze with a small number of errors and time. 2) Administration of scopolamine (0.125-0.5 mg/kg, i.p.) to a mouse that had mastered the maze transiently disturbed the maze performance dose-dependently. 3) Mice were housed for 4 hr a day. Scopolamine (0.25 mg/kg, i.p.) was administered either before or after the housing. Scopolamine disturbed the maze performance in the case of both procedures. These results suggest that the method is useful for estimating the memory in mice.

Fifty-eight children (from 4 to 19 years of age) with bilateral, symmetrical, sensorineural hearing loss, who had used a hearing aid in only one ear for 1 to 19 years were investigated to study the influence of hearing-aid upon the residual hearing between the used and no used ears. The results were as follows, 1) The average hearing level for the used ear at seven frequencies was 49. 5 dB of pre-hearing-aid usage and was 53. 8 dB of post-hearing-aid usage. The discrepancy of audiograms between the aided and unaided ear was not remarkable. 2) The hearings for both the aided and the unaided ears in Audiograms was progressive for a long time. But no significance relation was observed between changes in used-ear hearing of the aided and unaided ears. 3) When the hearing levels of the children were scrutinised on an individual basis, it was found that 9 cases (15.5%) in both ears, 2 cases (3.4%) in only used ear and 1 case (1.7%) in only no used ear out of 58 cases showed deterioration of hearing. 4) These data did not lead us to the conclusion that hearing-aid usage was detrimental on the residual hearing of children with sensorineural hearing loss.

Although the orthodontist is constantly aware of the developing third molar and its possible effects on the dentition during and after orthodontic treatment, the relationship between the third molar and the development of malocclusion had not been resolved. To attempt to clarify some of the problems associated with the third molar, an analysis of the factor in fluencing on the dentition and denture frame was performed. In this study, twenty-one adult cases which had no prothodontic correction of the tooth shape and orthodontic treatment with at least three wisdom teeth were used for evaluation of the denture frame structure and occlusion. The case which impacted third molar (M3 impacted group) showed less than 25 degree mandibular plane angle (FH-MP) without exception, while the case which the third molar erupted (M3 erupted group) were able to divide into high angle (more than 30 degree of FH-MP) and low angle (less than 29 degree of FH-MP) groups. The M3 impacted with low angle group and M3 erupted with low angle group showed relatively normal occlusion and favorable denture frame structure, but M3 erupted with high angle group indicated that the denture frame composition was affected by posterior discrepancy especially the steepness of occlusal plane which might be the over eruption of posterior teeth. The M3 erupted with high angle group also included two cases of severe anterior open-bite with skeletal deformity. These findings suggest that the posterior discrepancy due to existence of third molars influence on the dento-facial-skeletal structure and development of malocclusions.

The purpose of this study is to assess the dentifrice abrasivity of both commercially available products and test products. The assessment of abrasivity was carried out by the measurement of 32P released from tooth by using radioactive dentifrice abrasion (RDA) method. In dentine, RDA values, which show the polishing ability for dentine, were 65-100 with dentifrices with normal cleaning power and 106-182 with those with high cleaning power, respectively. On the other hand, REA values which show the polishing ability for enamel were 12-405 with both market products and test products. The difference of the REA values according to the dentifrices appears to be largely influenced by the difference of polishing agents of each dentifrice. It is concluded that RDA method is usefull for assessing of dentifrice abrasivity. However, particular attention should be given to the abrasion of dentine.