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This study investigated the morphology of shoulder rotator cuff muscles and shoulder function in tennis players. Ten collegiate male tennis players (tennis group: TG) and 10 adult males (control group: CG) participated in this study. The muscle length, maximal anatomical cross-sectional area, and volume of shoulder rotator cuff muscles (supraspinatus, external muscle: infraspinatus and teres minor, and subscapularis) were mainly measured in their dominant shoulders using magnetic resonance imaging. In addition, isokinetic shoulder internal/ external strength (180 and 300deg/sec) was measured with the shoulder abducted to 90° and the elbow flexed to 90° in both groups. The external/internal strength ratio was also calculated. The unpaired t-test was used to analyze the difference between both groups. The TG showed a significantly larger value than the CG in the maximal anatomical cross-sectional area of the subscapularis (p<0.01). The TG also showed significantly larger values than the CG in the muscle volumes of the subscapularis, the shoulder external muscle, and total shoulder rotator cuff muscles (p<0.01). In addition, the isokinetic shoulder strength (180 and 300deg/sec) of the TG was significantly larger than that of the CG in internal and external rotations (p<0.01). It is possible that the repetitive racket motions resulted in muscle hypertrophy of shoulder rotator cuff muscles and elevated shoulder rotational strength in tennis players. [ABSTRACT FROM AUTHOR]

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

The patient was a 79-year-old man with ureteroileal anastomotic stricture after a Bricker ileal conduit. Endourological treatment of stenosis was performed via percutaneous nephrostomy and ileal conduit. The patient experienced lower abdominal pain on the following day, and computed tomographic (CT) scan showed hematoma retention around the kidney and active bleeding from the renal artery branches. Transarterial embolisation (TAE) was performed and the bleeding was controlled. Two days later, there was a sudden progression of anemia and CT showed an increase in hematoma around the kidney. We subsequently performed nephrectomy for hemostasis. Five days later, the anemia progressed further. There was hematoma retention in the retroperitoneal cavity, and emergency laparotomy hemostasis was performed. Routine coagulation test results were normal. Heavy bleeding was observed several days after TAE and the possibility of coagulation factor XIII deficiency was considered. Factor XIII deficiency was confirmed by a low factor XIII activity level. The patient was given plasma-derived factor XIII. After receiving factor XIII replacement, factor XIII activity remained unchanged and the patient continued to bleed. Thereafter, a cross-mixing test was performed and the patient was diagnosed with autoimmune acquired factor XIII deficiency. Cortical steroids were administered to remove the factor XIII inhibitor. Steroid administration showed a rapid increase in factor XIII activity, and bleeding symptoms were no longer observed. In cases of serious bleeding of unknown cause with a normal coagulation profile, acquired factor XIII deficiency should be suspected and factor XIII activity measured.

Antiresorptive agent-related osteonecrosis of the jaw (ARONJ) is a serious adverse event of bone resorption inhibitors (BRIs), such as zoledronic acid and denosumab. Based on the results of phase 3 clinical trials for BRIs, the frequency of ARONJ is 1 to 2%, but the actual frequency is presumed to be higher. We studied 143 patients with urologic cancers with bone metastases who were treated with zoledronic acid or denosumab at our hospital between April 2007 and March 2020. ARONJ occurred in 24 patients (16.8%) ; that is, 14 of the 113 patients (12.4%) who received zoledronic acid alone, 8 of the 24 patients (33.3%) who received denosumab alone, and 2 of the 6 patients (33.3%) who sequentially switched from zoledronic acid to denosumab. ARONJ was cured in 8 patients (33.3%), improved in 3 patients (12.5%), unchanged in 4 patients (16.7%), and worsened in 9 patients (37.5%). The frequency of ARONJ increased as the duration of BRI administration prolonged. Time-to-ARONJ was shorter in patients treated with denosumab than in patients treated with zoledronic acid. The occurrence of ARONJ may be underestimated; therefore, further studies are needed to investigate the actual frequency of ARONJ in Japan.

75 year-old man followed up regularly for the treatment of lung cancer came to our hospital with a chief complaint of general malaise. Blood test results showed deterioration in the renal function, and computed tomography (CT) confirmed left hydronephrosis. He was admitted to the hospital with the diagnosis of obstructive pyelonephritis. Despite antibiotic therapy after the left ureteral stent placement, CT on day 19 of hospitalization showed an enlarged soft tissue shadow along the renal pelvis and ureter, which was suspected to be peripelvic urinary extravasation caused by stent occlusion. We decided that conservative treatment would not improve his condition and conducted surgical therapy considering the possibility of malignancy. Intraoperatively, viscous and fragile tumor affected the renal pelvis and ureter. The operation resulted in left nephrectomy because radical resection was impossible. The pathological diagnosis was sarcomatoid urothelial carcinoma of the renal pelvis with ureter origin. He died due to multipleorgan failureon day 20 after theope ration. Were port a caseof sarcomatoid urothelial carcinoma in the upper urinary tract that was difficult to diagnose preoperatively based on imaging studies.

Purpose: For whole-breast irradiation after breast-conserving surgery, computed tomography simulation (CTS) and irradiation are generally performed during free breathing. In treatment planning, there are three techniques: field-in-field (FIF), physical wedge (PW), and enhanced dynamic wedge (EDW). The aim of this study was to investigate the impact of respiratory motion on doses for these three irradiation techniques., Methods: All doses were measured using an ionization chamber in a cylindrical phantom on a respiratory motion platform. Doses for each technique were measured with and without phantom motion. The dose without phantom motion was defined as the reference. The reference was compared to the dose with the phantom motion. The positions of the isocenter with respect to the ranges of phantom motion were set as exhale and intermediate. The phantom motion amplitude was set to 5 mm or 10 mm. The respiratory phase to initiate irradiation was varied as inhale, intermediate-inhale, exhale and intermediate-exhale., Results: When the motion amplitude was 10 mm, the dose differences for the FIF, PW, and EDW techniques were 4.2%, 0.5%, and 0.8%, respectively, at the maximum. However, the dose difference for the FIF technique was -0.5% when the isocenter position was set to the intermediate phase of phantom motion., Conclusion: We found that the dose difference per fraction was reduced when the respiratory phase during CTS image acquisition was set to the intermediate phase. Meanwhile, the dose differences per fraction for the PW and EDW techniques were less affected by the respiratory motion.

Purpose: In 2011, the International Commissionon Radiological Protection (ICRP) recommended reducing the threshold dose for the lens. Therefore, it is important to reduce the lens exposure dose in medical exposures. In a cranio-caudal (CC) view of mammography, the patient' s lens receives scattered radiation. In this study, we investigated scatter dose around the lens during mammography and reviewed the simple and easy protection methods of the lens., Methods: Optically stimulated luminescence (OSL) dosimeters were placed in front of the device to obtain scattered radiation intensity distribution. The human phantom was placed in the same way as the CC positioning, and BR-12 phantoms with a thickness of 40 mm was placed on the FPD. Then, the scatter dose around the lens was measured using an OSL dosimeter. In order to confirm the change in the scatter radiation dose by the face guard (FG) and eyelid, we measured and compared under the same conditions the presence of FG and adipose tissue about 1 mm thick assuming the eyelid., Results: Scatter radiation intensity decreased around the FG. When the FG was installed, the scatter dose was reduced about 33%, and when the adipose tissue was pasted on the OSL dosimeter, the scatter dose was reduced about 29%., Conclusion: This study suggested that eye closure during mammography was effective in reducing lens exposure. In the future, we would like to expect further protective effects by increasing the thickness of FG and reviewing the materials.

A 37-year-old man with no symptoms or family history of tuberous sclerosis complex presented to our hospital with abdominal pain in 2013. Abdominal computed tomography (CT) revealed a rupture in the right renal angiomyolipoma (AML) having a maximum diameter of 7 cm. He had undergone a transarterial embolization. Follow-up CT showed an increase in the size of the right tumor to 11 cm, and therefore, right nephrectomy was performed in 2016. The diagnosis of epithelioid AML (EAML) was confirmed. In 2019, he was diagnosed with a solitary tumor near right-sided transverse colon, which was resected and showed recurrence of EAML. He was disease-free 6 months after surgery. EAML has malignant potential, with 30-50% of reported EAML cases resulting in local recurrence or distant metastasis. Previous recurrence or metastasis may occur 0.25-12 years postoperatively. Furthermore, multiple and unresectable recurrences or metastases, arising early in the postoperative period may lead to a poor outcome. Therefore, close and long-term follow-up is required.

In June 2015, Japanese diagnostic reference levels (Japan DRLs 2015) was released by Japan Network for Research and Information on Medical Exposures (J-RIME). After six months the release of Japan DRLs 2015, we have conducted a questionnaire and received 222 responses from hospital staff regarding their perception level, and implementation on Japan DRLs 2015 at their facilities. 131 people (59.0%) were familiar with Japan DRLs 2015, of which 56 people (29.2%) were not currently implementation of them. A total of 66 people (30.1%) understood how to implement Japan DRLs 2015. There were 35 people (18.2%) who heard of diagnostic reference levels (DRLs) for the first time through this survey. Those are the levels of perception and implementation on Japan DRLs 2015 became clear. It is necessary to compare the dose levels used at each facility with Japan DRLs 2015 to optimize patient protection during medical exposure. It is essential to continue to grow the medical community's understanding of DRLs with the expanded perception and implementation of this survey as an opinion poll across Japan.

In this study, we examined 239 outpatients receiving chemotherapy for breast cancer for a period of 6 months from July 2016 to December 2016. Using a questionnaire, we investigated the patients' symptom score and uneasiness. A symptom score of 2 and over was found in 24.7%(59)of the cases. Twenty-seven of the 59 cases experienced adverse effects of chemotherapy. Peripheral neuropathy was observed in 20 cases, of which only 2 cases improved after providing palliative care. Palliative care was effective against nausea, constipation, malaise, and sleeping disorders. Thirty-two cases(13.4%)had 5 or more painful feeling score. Among these, 10 cases resulted from the adverse effects of treatment, 10 cases from the aggravation of existing cancer, and 6 cases showed anxiety for the illness, family, and future. In 15 of the 32 cases, the pain score improved by providing palliative care, conversation with the nursing staff, reduction in the quantity of drug intake, etc.

We evaluated the safety of laparoscopic radical cystectomy (LRC) during initial phases and its learning curve in a Japanese multicenter cohort by studying 436 patients who underwent LRC with no robot assistance at 10 institutions in Japan. We divided the patients into three groups according to cumulative surgical volume at each institution (first 10 cases, 11-30 cases, after 31 cases in each institution), and compared perioperative and pathologic variables among the three groups. The first, second, and third groups included 100, 166, 170 patients, respectively. The preoperative variables were similar in the three groups except for the rate of neoadjuvant chemotherapy. The methods of LRC procedure, such as urinary diversion, the extent of lymph node dissection, and concomitant urethrectomy or nephroureterectomy, were similar in the three groups. Mean operative time was 629, 562 and 531 minutes, respectively, and mean blood loss was 755, 650 and 435 ml, respectively. Both values decreased over time with the institution's experience. There was no significant difference among the three groups in the rate of positive surgical margin, the number of retrieved lymph nodes, and the rate of intra- and postoperative complications. LRC was safely performed during initial phases with an acceptable complication rate and without compromising oncological results, although operative time was longer and blood loss increased.

We report a case of advanced left breast cancer with continuous bleeding from the primary tumor surface in an 81-year-old woman. Pathological findings showed invasive carcinoma with positive expression of hormone receptors. CT and bone scintigraphy showed primary tumor invasion of the greater pectoral muscle and multiple bone metastases. She received Mohs' chemosurgery, endocrine therapy, and denosumab. The bleeding was maintained by weekly treatment. Most of the bulging surface of the tumor decreased and dried up 2 months later. The tumor disappeared almost completely, and the bone metastases achieved stable status 3 months later. Until currently, the primary tumor and metastasis have been controlled for 1.5 years. Mohs' paste was effective for controlling bleeding and exudates of unresectable cancer bulging from the skin surface and played an important role in cancer treatment with systemic therapy.

Background: As the aging of the Japanese population progresses, the administration of postoperative adjuvant chemotherapy( AC)to the elderly is also expected to increase., Objective: To examine the characteristics of AC in cases of colorectal cancer among elderly people aged over 75 years., Patients: Forty-eight cases of colorectal cancer patients who received AC., Methods: The clinicopathological factors, including 14 patient-related factors, 6 operation-related factors, and 2 AC-related factors, as well as the long-term outcomes, were compared between the elderly group of patients aged over 75 years(group O, 12 cases)and the non-elderly group(group Y, 36 cases)., Results: Significant differences were observed between groups in neutrophil count(p=0.044), operation time(p=0.044), AC regimen(p=0.006), and administration completion status (p=0.046). Compared to group Y, a higher proportion of oral drug alone(92% vs 39%)and completion rate of the initial setting dose(75% vs 39%)were observed in group O. There was no significant difference in the 2-year disease-free survival rate., Conclusion: Oral preparations of AC may be useful from the viewpoint of tolerability in the elderly.

A 55-year-old woman was referred to our hospital with dysuria. We were unable to catheterize her using a nelaton catheter because of a urethral stricture, resulting in a large residual urine volume on ultrasonography. The circumference of the periurethral tissue was also thickened and the entire length of the urethra was stenotic, without apparent cause, on magnetic resonance imaging. Biopsy did not reveal malignancy. The pathological diagnosis of the periurethral tissue was simply fibrosis, and there was no definitive diagnosis. We decided to place a guidewire to attempt transurethral dilation, but it was unsuccessful because of the urethral stricture. The patient then underwent Mitrofanoff appendicovesicostomy. Three years later, there was no difficulty with catheterization through the appendix, despite her suffering from a bladder stone during the interim. We consider the Mitrofanoff appendicovesicostomy a good substitute technique for catheterization in patients with very severe urethral stricture.

Warfarin is used worldwide to prevent cardioembolic stroke (CES) in patients with atrial fibrillation even in the era of direct oral anticoagulant (DOAC). We evaluated clinical characteristics of the patients with CES and intracerebral hemorrhage (ICH) occurring during warfarin treatment, focusing on prothrombin time-international normalized ratio (PT-INR) at the occurrence. The consecutive 846 CES patients (78 ± 9 years) and 870 ICH patients (68 ± 13 years) admitted to the Hirosaki Stroke and Rehabilitation Center from April 2011 through March 2015 were studied. The antithrombotic agents administered in CES patients before the onset included antiplatelets in 146 patients (17%), warfarin in 205 (24%), DOAC in 37 (5%), and none in the other 458 (54%). Mean PT-INR within 24 hours after the onset in nonvalvular atrial fibrillation patients with warfarin was 1.34 ± 0.33 (n = 129), and 111 of them (86%) showed PT-INR value below the recommended therapeutic range in Japan. The antithrombotic agents administered in ICH patient included antiplatelets in 87 patients (10%), warfarin in 86 (10%), DOAC in 8 (1%), and none in the other 689 (79%). Mean PT-INR within 24 hours after the onset in patients with warfarin was 2.27 ± 0.62 (n = 65), and 56 of them (86%) showed PT-INR < 2.8. Thus, there is a large population with poor warfarin control complicating CES and that with good warfarin control complicating ICH, indicating limitation of warfarin treatment in the DOAC era.

We compared the perioperative and oncological outcomes of laparoscopic radical cystectomy (LRC) between elderly patients over 75 years old and younger patients. Fifty-three patients underwent LRC between 2003 and 2014 at Tenriyorozu Hospital. Eighteen patients were classified as elderly (over 75) and the other 35 patients were considered young. The median operating time (434 vs 465 min, p＝0.35), estimated bloodloss (534 vs 525 g, p＝0.74), time to recommencing foodintake (7 vs 6 days, p＝1.00), and hospital stay (35 vs 32 days, p＝0.81) were not significantly different between the groups. Perioperative pyelonephritis was significantly more frequent in the elderly group (50% vs 20%, p＝0.02), while other complications were not significantly different between the two groups. The perioperative mortality rate was 0% in both groups. There were no significant differences between the elderly and young groups with respect to 2-year overall survival (74. 4% vs 91. 6%), cancer-specific survival (74. 4% vs 91. 6%), and recurrence-free survival (70.2% vs 81. 8%). LRC is a safe andefficient procedure for selected elderly patients.

We report a case of a 22-year-old male with juxtaglomerular cell tumor treated with laparoscopic partial nephrectomy. He was referred to our hospital with hypertension, high concentration of plasma renin activity (PRA) and renal mass. Dynamic enhanced computed tomography showed 17-mm weak contrast-enhancing tumor at the upper pole of the left kidney. Renin suppression and stimulation test revealed autonomous renin secretion although renal venous sampling failed to show significant difference in the PRA between the right and left renal vein. We performed laparoscopic left partial nephrectomy. The histological diagnosis was juxtaglomerular cell tumor. After the operation, his blood pressure and PRA were immediately normalized. Juxtaglomerular cell tumor is an important renal tumor as a curable cause of secondary hypertension.

A 58-year-old man had undergone laparoscopic radical nephrectomy for right renal cell carcinoma. The histopathological diagnosis was clear cell carcinoma, grade 2＞3, pT1b. Two years and 10 months postoperatively, computed tomography scans demonstrated an enhanced mass on the right adrenal gland. As we could not detect other metastatic lesions, it was diagnosed as solitary adrenal metastasis of renal cell carcinoma. Albeit metastasectomy was planned with curative intent, right hemihepatectomy was also required for surgical removal because the tumor was adherent to the right lobe of the liver broadly and had indistinct margins. So we started neoadjuvant therapy with sunitinib. Eight courses of treatment shrunk the metastatic tumor enough to allow it to be removed completely without partial hepatectomy. Neoadjuvant therapy with the molecular targeted drugs may provide an effective option for metastasectomy in renal cell carcinoma regarding increased curability and decreased the risk of an operation.

We organized a home medical care training workshop to offer community pharmacists an opportunity to learn more about home medical care. The workshop consisted of lectures by the doctor, the nurse, and the pharmacist. A questionnaire was handed out to all the participants once the workshop had ended. On an average, the participants rated the overall quality of the workshop as 8.1 out of 10. Our results revealed that 62.7% of the participating pharmacists were experienced in home medical care, with the majority having between 1 and 5 years of experience. Most pharmacists with experience in home care had provided services such as delivering medicines to or instructing patients on the use of medicines at patient homes. Participants suggested that the qualities necessary for providing effective home medical care were knowledge of home-based care and a positive attitude, among others. Participants also made suggestions for lecture contents in future workshops, such as contract procedures or specific cases of home medical care. Furthermore, participants expressed many positive opinions such as the desire to hear the views of other professionals on home medical care. In conclusion, participation in the home medical care training workshop increased the participants' desire to learn and perform home medical care. This indicates that a subsequent workshop with the cooperation of other professionals is indispensable.

A 69-year-old man complaining of left abdominal pain was referred from a private clinic for retroperitoneal masses that were discovered on abdominal ultrasound in November 2010. CT scan showed retroperitoneal masses, located above the left kidney, measuring 10 cm. Para-aortic lymph nodes were swelling. We performed open biopsy to make the diagnosis in December 2010. The diagnosis was primary retroperitoneal GIST (gastrointestinal stromal tumor). We started imatinib 400 mg/day according to the Japan GIST guideline in January 2011. However the tumor pogressed rapidly, after 1 month the patient died.

We report a case of an 8-year-old girl with fulminant myocarditis successfully treated with percutaneous cardiopulmonary support (PCPS). She was first taken to our hospital for treatment of suspected infective enterocolitis since her main symptoms were fever, vomiting and diarrhea. On day 2 after admission, her ECG showed wide QRS and echocardiography demonstrated severe hypokinesis. She was transferred to the ICU with suspected acute myocarditis. On admission to the ICU, circulatory collapse was not detected. ECG showed severe bradycardia and ventricular fibrillation after intubation. Cardiopulmonary resuscitation was performed immediately for 50 minutes prior to initiation of PCPS. She was treated intensively with catecholamines, plasma exchange, continuous hemodiafiltration, high-dose gamma-globulin, and high dose methylprednisolone. Hypothermia therapy was also performed. She was weaned from PCPS on day 6 after initiation of PCPS. The patient was finally discharged from the hospital without any neurological complications on day 68 after weaning from PCPS. The proportion of patients in whom cardiopulmonary resuscitation was performed or having ventricular tachycardia or fibrillation were higher in non-survivors than in survivors.

We report a case of advanced rectal cancer with bladder carcinoma. The patient was a 81-year-old man who complained of abdominal bloating. A colonoscopy showed that he had advanced lower rectal cancer. CT scan revealed many lymph node metastases around the tumor, and also a bladder tumor. He experienced myocardial infarction during the operation but was relieved by PCI. During the operation, sigmoid colostomy was performed. The curative operation was declined and chemotherapy was selected. Capecitabine(2, 000mg/m / 2, biweekly)plus oxaliplatin(130mg/m2, day 1)was selected. At first, he complained of peripheral vein pain. The speed of oxaliplatin infusion was slowed and the pain was relieved. He had Grade 3 platelet decrease, but the number improved after 3 weeks. The tumor marker decreased after 3 courses, 6 courses after CT scan revealed that the tumor and lymph node metastases had evidently decreased. Capecitabine plus oxaliplatin(XELOX)was considered to be a useful chemotherapy against advanced rectal cancer, even for older patients or high risk groups.

We report three pediatric cases of group A coxsackievirus-associated encephalitis/encephalopathy. A 4-year-old girl with coxsackievirus A6 infection presented with an exanthem on her upper body on the fourth day of fever. The following day, she developed an episode of convulsions, and subsequently experienced sudden cardiopulmonary arrest. A head computed tomography scan revealed severe brain edema. Two patients with neurological sequelae had initially presented with status epilepticus that required intravenous barbiturate treatment. Both cases had high-signal-intensity lesions on their diffusion-weighted brain magnetic resonance images. A 5-year-old girl with subcortical white matter lesions was diagnosed with acute encephalopathy with febrile convulsive status epilepticus, and a 2-year-old boy with bilateral hippocampal lesions was diagnosed with parainfectious limbic encephalitis. These findings indicate that group A coxsackievirus is a causative agent of pediatric encephalitis/encephalopathy; moreover, the prognosis may be poor in some cases.

We report a successful arterial switch operation for complete transposition of great arteries with atrial and visceral situs inversus totalis and mirror image dextrocardia in a 12-day-old infant girl. The aorta was located left side-by-side to the pulmonary trunk with a single coronary artery (mirror image of 1RLCx). After French maneuver, the posterior circumference of the neo-aorta was reconstructed. Then the coronary button was transplanted into the neo-aorta with a trap door technique carefully avoiding any twist and over-stretch. The neo-pulmonary trunk was reconstructed with an autologous pericardial patch and sutured to the longitudinal incision made into the left central pulmonary artery. The baby was discharged from hospital and has been doing well without any morbidity relating myocardial ischemia.

We report two cases of advanced gastric cancer. The first was a 77-year-old man who had experienced distal gastrectomy about 35 years ago. He complained of abdominal bloating, and a gastrointestinal scope showed that he had advanced gastric cancer. CT scan revealed massive ascites. Dissemination of the peritoneum was suspected, and chemotherapy using S-1 (80mg/m², biweekly)plus paclitaxel (50mg/m², on days 1 and 8) was selected, He had no major side effects and the ascites disappeared. He was able to receive 18 courses on an outpatient basis. The second case was a 79-year-old man who had total gastrectomy performed 1 year ago. Invasion to the diaphragm and lymph node metastasis were detected. We selected S-1 (80 mg/m²)as adjuvant chemotherapy but that caused severe fatigue. Eventually he refused the drug. Six month later, he had abdominal bloating and CT scan revealed that he had massive ascites. UFT-E (1. 5 g/body) was administered and paclitaxe (l 50 mg/m²) was added. The ascites disappeared and he has had a stable life. DIF (S-1, UFT) plus paclitaxel is considered to be a useful chemotherapy combination against advanced gastric cancer that has peritoneal dissemination or ascites, even for older patients.

A 54-year-old man presented with pollakiuria and dysuria. Ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) showed a retroperitoneal tumor 10 cm in diameter. Pathological examination of a transrectal biopsy specimen obtained from the patient revealed the presence of an inflammatory myofibroblastic tumor (IMT). The patient underwent surgical resection of the tumor. Histopathologically, the tumor was composed of 3 parts : the largest part was compatible with an inflammatory pseudotumor: the second part, well-differentiated liposarcoma: and the third part, a myxoid liposarcoma. He has been followed up for 14 months ; but there was no evidence of local recurrence of the tumor. We believe that the inflammatory pseudotumor complicated in repairing the inflammation arising from the liposarcoma.

Acute encephalopathy with bilateral striatal necrosis (EBSN) is a rare reversible neurological disease characterized by an abrupt onset following an acute infectious disease and by severe extra-pyramidal signs associated with striatal lesions. Brainstem involvement is rarely observed in this disease. We report a 10-year-old boy who had EBSN associated with Mycoplasma pneumoniae. He became lethargic after acute bronchitis. A few days later, he showed extra-pyramidal signs, pyramidal signs and overactive urinary bladder symptoms. Cranial T2-weighted and diffusion-weighted magnetic resonance imaging (MRI) demonstrated high-signal intensity in the bilateral striatum and substantia nigra. These symptoms improved soon after the administration of L-dopa in the acute phase. The effects of corticosteroids were not apparent in the acute phase. The serum particle agglutination titers against Mycoplasma pneumoniae determined on admission, the 12th hospital day and 2 months later were 1:2,560, 1:2,560 and 1:320, respectively. Two years later, a mild tic was observed. A mild atrophy was noted in the bilateral basal ganglia, but not in the substantia nigra on cranial MRI. This case is the first reported one with EBSN with the presence of an overactive urinary bladder, which could possibly caused by loss of dopaminergic inhibition.

An 83-year-old man visited our department with a slightly enhanced mass of about 2 cm in diameter, detected incidentally in the left kidney on computed tomography (CT) performed for other reasons in a different department. Fluorodeoxyglucose-positron emission tomography was performed under the suspicion of metastatic renal tumor and malignant lymphoma. Accumulation was observed in the mass but not in other regions. The tumor size was about 2 mm on CT 4 months previously, indicating rapid enlargement. Based on these observations, a malignant renal tumor was diagnosed and laparoscopic left nephrectomy was performed. Pathologic examination revealed relatively large cells diffused within a background of many small lymphocytes and histiocytes. The large cells were positive when tested by Epstein-Barr virus (EBV)-encoded RNA in situ hybridization. No clinically apparent immunodeficiency was observed, suggesting age-related EBV-associated lymphoproliferative disorder caused by an underlying age-related reduction in immunocompetence. This is the first report of a kidney-localized case in Japan.

A 50-year-old male had been maintained on hemodialysis for 12 years because of chronic renal failure. The patient experienced sudden left flank pain. Computed tomography (CT) showed a huge left perirenal hematoma, which was diagnosed as a spontaneous rupture of the left kidney. CT also showed multiple cysts in both kidneys and a right renal tumor suspected to be renal cell carcinoma. Although the cause of the rupture was unknown, bilateral nephrectomy was performed. Histological study revealed acquired cystic disease of the kidney (ACDK) with bilateral renal cell carcinoma. Our diagnosis was rupture of the renal cell carcinoma. The patient was free of recurrence at 17 months postoperatively. To our knowledge, this case is the fifth report of renal cell carcinoma in ACDK manifesting as spontaneous rupture in the Japanese literature.

The patient was a 36-year-old male. He visited our department in February 2004 as a prior chest X-ray revealed multiple nodular shadows. After further examinations, he was diagnosed with stage IV adenocarcinoma of the lung. As treatment, 5 courses of carboplatin (CBDCA)+docetaxel (DOC), 3 courses of CBDCA+gemcitabine (GEM), 6 weeks of gefitinib, and 3 courses of GEM were administered. However, the tumor progressed, and S-1 (120 mg/day, 2 weeks on, 1 week off) was administered as the sixth regimen from May 2006. No severe side effects were observed, and an antitumor action was achieved over a relatively long period. Therefore, it was suggested that a single administration of S-1 for non-small cell lung cancer, which had been treated with other multiple regimens, is safe, and long-term control of the disease can be expected.

A 31-year-old female with 2 episodes of right pneumothorax related to onset of menstruation was reported. Thoracoscopy revealed the presence of some cystic lesions in the diaphragm. Partial resection of the diaphragm including the lesions was performed. Histologial findings of the resected diaphragm showed stromal endometriosis. One month after operation, she had a recurrent right pneumothorax related to onset of menstruation. A pinhole perforation of the lower lobe was noted at 2nd surgery. Microscopic examination of the resected lung disclosed endometrial stroma in the macroscopically normal lung tissue. Since air leakage from chest tube continued after surgery, the hormonal therapy with a gonadotropin-releasing hormone analogue was started, and she was discharged from the hospital 3 weeks after hormonal therapy. Report of the demonstration of endmetriosis in the visceral pleura and diaphragm is very rare and the present case is very suggestive is considering the mechanism of the development of this disease.

A 58-year-old man was referred to our hospital for investigation and treatment of a retrovesical cystic tumor that was detected during his annual health check-up. Computed tomography and magnetic resonance imaging (MRI) showed a 5 cm cystic mass including a 1.5 cm solid mass between the bladder and rectum. Transrectal biopsy was performed successfully, and did not show any evidence of malignancy. Six months later, the cystic mass enlarged, and video-assisted laparoscopic excision of the cystic mass was performed. The mass was pathologically diagnosed as a seminal vesicle cyst. Because of the rarity of this lesion, only 11 cases of laparoscopic excision have been reported and, to our knowledge, this is the first case in the Japanese literature. Under the laparoscopic prostatectomy approach, we could safely resect the lesion.

A 17-year-old man with severe cardiac failure due to dilated cardiomyopathy was treated by medication. As he did not improve, he had indication for transplantation of the heart and was put on a ventricular assist system as a bridge until he could be transplanted. He also had severe tricuspid regurgitation and tricuspid annuloplasty was performed. Inhalation of nitric oxide was used to decrease pulmonary vascular resistance. Although cerebral infarction was present postoperatively, he is waiting for transplant without paralysis. The ventricular assist system proved to be useful therapy for serious cardiac failure due to terminal dilated cardiomyopathy.

Purpose: Our previous study indicated that there was a great variety in the perioperative management of radical prostatectomy among hospitals. Therefore we conducted a multiinstitutional study in order to standardize the perioperative management using clinical pathways., Materials and Methods: The perioperative data on radical prostatectomy were collected between January and December 2004 (Period 1) from eight hospitals. These outcomes were discussed by researchers and the clinical pathway used at each hospital was constructed or revised. The outcomes using these pathways in Period 2 (January 2005 to March 2006) were compared with those in Period 1., Results: Three hundred seventy-eight men in Period 1 and 360 in Period 2 were enrolled in this study. The settings of perioperative management using the new pathways were relatively similar among hospitals. A majority of perioperative management procedures in Period 2 were conducted as described in the new clinical pathways, judging from the median days. The day of initiating the resumption of fluid intake, meals and removing the epidural anesthetic catheter and drain changed from 1.2 +/- 0.7 to 1.3 +/- 1.4 postoperative day, 1.9 +/- 1.2 to 1.8 +/- 1.7, 2.4 +/- 0.7 to 2.5 +/- 0.6, 3.8 +/- 2.5 to 3.8 +/- 2.8, respectively, without a significant difference. The postoperative day of initiating the walking and discontinuing continuous drip infusion and intravenous antibiotics were shortened from 1.9 +/- 0.9 to 1.5 +/- 0.6, 3.7 +/- 2.1 to 3.1 +/- 2.2 and 3.6 +/- 2.0 to 2.5 +/- 2.2, respectively, which did show a significant difference. The day of removing the urethral catheter was changed 9.1 +/- 4.9 to 8.6 +/- 5.4 without significant difference. But the durations of preoperative hospitalization, hospitalization after removing the urethral catheter and postoperative hospitalization were significantly shortened from 3.4 +/- 2.1 to 2.5 +/- 1.0 days, 8.9 +/- 10.1 to 5.6 +/- 3.8, and 17.9 +/- 10.9 to 14.4 +/- 9.1, respectively., Conclusions: The clinical pathways established or revised at these hospitals after discussing the perioperative management in multiple hospitals were similar, and using such pathways advanced the standardization of peri-operative management after radical prostatectomy.

A 44-year-old woman was admitted to our hospital because of mediastinal mass. Serum levels of carcinoembryonic antigen (CEA) were found to be elevated. No preoperative examination could detect the primary lesion. The tumor was resected through right thoracotomy. Histological examination revealed poorly differentiated adenocarcinoma. She was diagonosed as metastatic mediastinal lymph node carcinoma of unknown primary site. She received radiotherapy and chemotherapy and is desease free 29 months after operation. Good results may be obtained by multimodality therapies for cancer in mediastinal lymph node of unknown primary site.

A metastatic penile tumor of malignant melanoma is very rare. The patient had priapism caused by metastatic penile tumor and the primary cancer was in the end stage. However, in this case, we could relieve the dysuria and pain by percutaneous cystostomy and partial penectomy. The corpus spongiosumcorpus cavernosum shunt could not relieve the priapism and might have accelerated the metastasis.

Transurethral resection of the prostate was performed on 584 consecutive patients with clinically diagnosed benign prostatic hyperplasia between April 2001 and July 2007. Pathological examinations revealed prostatic cancer in 30 (5.1%) of them. Seventeen patients had stage A1, and 13 stage A2 cancer. Prostatic biopsy was performed on 7 patients. The mean patient age was 69.4 years (range 60-78 years) for stage A1 cancer and 76.6 years (range 62-90 years) for stage A2. The mean serum PSA concentration was 8.9 ng/ml (range 1.18-41.3 ng/ml) for stage A1 cancer and 9.55 ng/ml (range 2.0-23.9 ng/ml) for stage A2. The mean follow-up period was 25.8 months (range 3-82 months) for stage A1 cancer and 27.3 months (range 1-82 months) for stage A2. In stage A1, all patients had a Gleason sum of 6 or less. In stage A2, 11 patients had a Gleason sum of 7 and 2 patients were 8 or more. Total prostatectomy was performed on 2 patients and no therapy on 15 patients with stage A1. Endocrine therapy was given to 1 patient, radiation therapy to 1 patient and no therapy to 11 patients with stage A2. Adjuvant therapy was given to 2 patients with stage A1 and to no one with stage A2. We concluded that PSA monitoring is an option in stage A2 cancer.

A 35-day-old female was referred to our department because of congenital chylothorax. Medical treatment with dietary restriction was undertaken for 5 weeks without resolution of the effusion. A video-assisted thoracic surgery was performed. The mediastinal pleura was covered with fibrin glue. The postoperative course was satisfactory. She was discharged with resolution of the effusion. Video-assisted thoracic surgery offers an effective means of treating chylothorax.

We conducted a multi-institute survey on the conditions related to urologic management of severe voiding dysfunction after hysterectomy for uterine cancer with or without postoperative irradiation. Our first study population was a group of adult female patients currently managed by urologists, using clean intermittent catheterization (CIC). Of the 287 patients in this group, 99 (34%) had suffered from uterine cancer. Of these patients, 94 underwent hysterectomy for this disease; 44 and 30 were treated with or without postoperative radiation, respectively, while postoperative irradiation status was unknown for 20. Median follow-up after surgery was 21 (0.2-52) years and median interval from operation to the introduction of CIC was 4.0 (0-49) years. CIC tended to be introduced later for patients with postoperative radiation than those without it. Seventy-four patients, who required invasive urologic interventions other than CIC for voiding dysfunction after hysterectomy, are the second study population. Most of these (82%) had received postoperative irradiation. Continuous Foley catheter placement was the most frequent procedure. Long-term follow-up and urologic management for voiding dysfunction is required for patients undergoing hysterectomy.

Two episode of junctional ectopic tachycardia (JET) caused hemodynamic deterioration early after tetralogy of Fallot repair in an 8-month-old infant. Sinus rhythm resumed in each of the episodes immediately after intravenous administration of nifekalant hydrochloride (NIF), a newly developed Vaughan-Williams class III antiarrhythmic drug in Japan. Although QT interval was modestly prolonged with NIF, no life-threatening ventricular arrhythmia (i.e., torsades de pointes) occurred. NIF might be an effective alternative in the treatment of postoperative JET in congenital cardiac surgery.