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BACKGROUND The predictive value of the cardio-ankle vascular index (CAVI) for estimating the efficacy outcome of catheter ablation (CA) in atrial fibrillation (AF) patients is unclear. We aimed to examine the predictive performance of the CAVI for recurrences of atrial arrhythmias after CA. METHODS We enrolled a total of 193 patients with AF (paroxysmal 126 and non-paroxysmal 67) who underwent initial CA procedures at our institute, and CAVI measurements were conducted between January 2016 and March 2017. We evaluated recurrences of atrial arrhythmias after the first CA procedure as a clinical outcome. The CAVI value was assessed and the enrolled patients were divided according to the optimal CAVI value cut-off point (9.5) in the atrial arrhythmia recurrence group. RESULTS During a mean follow-up of 31.3 (17.5-43.0) months, 74 (32.5%; PaAF 41 and 49.3%; non-PaAF 33) patients had recurrences of atrial arrhythmias. The recurrence ratio of atrial arrhythmias was significantly higher in patients with a high CAVI (≥9.5) than those with a low CAVI (

A 70-year-old woman underwent a renal biopsy due to nephrotic syndrome. She had suffered from nontuberculous mycobacterial infection (NTM) for 14 years. The patient was diagnosed as having membranoproliferative glomerulonephritis (MPGN) type 3 and immunoglobulin (Ig)-associated MPGN based upon LM/erythromycin and IF findings, respectively. In high-magnification imaging, electron-dense deposits showed immunotactoid glomerulopathy (ITG). There was no evidence of hematological cancer, and the patient improved after receiving treatments for NTM. To the best of our knowledge, this patient is the first to show an association between ITG and NTM. Although ITG is generally considered as related to lymphoproliferative disease, it is suggested that ITG is driven by bacterial infection and is a potential outcome of Ig-associated MPGN.

Background Dealing with chemotherapy-related cardiac dysfunction (CTRCD) remains a significant problem complicated by the difficulty in early detection of cardiotoxicity. Electrocardiogram (ECG) is expected to be the most realistic methodology due to lower cost-performance and non-invasiveness. We investigated the long-term visual fluctuations in the ECG waveforms in patients with chronic doxorubicin (DOX)-induced cardiotoxicity to identify ECG indices for the early detection of cardiotoxicity. Methods We conducted a retrospective case series study by reviewing the medical records of 470 consecutive patients with malignant lymphoma who were treated with DOX at our institute between January 2010 and December 2017. Of them, 23 (4.9%) patients developed left ventricular dysfunction and were diagnosed with CTRCD using echocardiography. We assessed the ECG indices on 12-lead ECG recordings before and after treatment in 15 patients; eight patients were excluded due to conduction disturbances or atrial fibrillation. Results CTRCD was detected at a median of 475 (interquartile range, IQR: 341–1333) days after initiating chemotherapy. The evaluation of ECG indices preceding CTRCD development was performed 93 (IQR: 52–232) days before the detection of CTRCD. In the stage of CTRCD, the most significant ECG change was T-wave flattening in leads V3–V6 (12 patients, 80%). Additionally, QTa prolongation was observed in leads I and aVL (n = 10, 66%), leads II, III, and aVF (n = 9, 60%), and leads V3–V6 (n = 10, 73%). These ECG changes were not observed before the treatment but were detected mildly in the pre-CTRCD stage, which subsequently worsened in the CTRCD stage. Conclusions This study indicated that T-wave changes and QTa prolongation may be useful as an early indicator before the onset of CTRCD in patients with DOX-induced cardiotoxicity.

Background The clinical evaluation of a direct oral anticoagulant (DOAC) treatment for atrial fibrillation (AF) patients with renal dysfunction has not been sufficiently studied. This study aimed to evaluate the safety and efficacy of DOACs for patients with a severely impaired renal function. Methods This was a retrospective and observational study in a single center. We enrolled 894 consecutive AF patients who were prescribed DOACs, and divided them into three groups based on their creatinine clearance (CrCl) value: CrCl ≥ 50 mL/min group (n = 634), CrCl 30‐49 mL/min group (n = 207), and CrCl 15‐29 mL/min group (n = 53). We evaluated the occurrence of major bleeding (MB) as the safety outcome and thromboembolic events (TEs) as the efficacy outcome during the follow‐up. Results The incidence of MB in the CrCl 15‐29 mL/min group was significantly higher than in the other groups (CrCl ≥ 50 mL/min group, 0.8/100 person‐years; CrCl 30‐49 mL/min group, 1.2/100 person‐years; CrCl 15‐29 mL/min group, 9.0/100 person‐years, log rank test, P, We evaluated the outcomes of AF patients with renal dysfunction receiving DOACs. A severely impaired renal function was associated with increased risk in MB. Apixaban might be safe in AF patients with a severely impaired renal function.

Malnutrition has been reported to be associated with worse clinical outcomes in various cardiovascular diseases. We aimed to investigate the clinical significance of the nutritional status in atrial fibrillation (AF) patients aged 80 years and over receiving oral anticoagulants (OACs), focusing on the difference between direct OACs (DOACs) and warfarin treatment.This was a retrospective and observational study. We enrolled 332 consecutive AF patients aged 80 years and over who were treated with OACs: DOACs (n = 256) and warfarin (n = 76). A controlling nutritional status (CONUT) score was used to evaluate the nutritional status. The enrolled patients were divided into two groups based on the CONUT score: CONUT score5 (n = 239) and CONUT score ≥5 (n = 93) groups. We investigated the relationship between the nutritional status and clinical outcomes.The CONUT score ≥5 group had significantly higher incidence of major bleeding (MB) compared to the CONUT score5 group (4.6/100 person-years vs. 0.7/100 person-years, p 0.01). On Cox hazard analysis, CONUT score ≥5 group was significantly associated with increased MB compared with the CONUT score5 group (hazard ratio: 5.80, 95% confidence interval: 1.44-23.33, p = 0.013). In the DOAC group, the incidence of MB did not differ between the CONUT score ≥5 and CONUT score5 groups (p = 0.54). In the warfarin group, MB occurred more frequently in the CONUT score ≥5 group than CONUT score5 group (p 0.01). There was no significant difference in the incidence of thromboembolic events between the CONUT score ≥5 and CONUT score5 groups in both the DOAC and warfarin groups.The prognostic values of the nutritional status based on the CONUT score for MB differed between AF patients aged 80 years and over receiving DOACs and those receiving warfarin. It may be favorable to use DOACs to avoid bleeding events in those with malnutrition.

A case of nasopharyngeal tuberculosis with cervical lymph node tuberculosis is reported. The patient was a 20-year-old female immigrant from Vietnam and cook apprentice. Her chief complaint was left neck swelling with pain for three months. She was diagnosed with left neck lymphadenitis at a previous hospital, which suspected malignant lymphoma and referred her to our hospital. At the time of the first visit, she had left lymph swelling with tenderness and granuloma-like masses in the nasopharynx. PET-CT showed accumulations in both the swollen left neck lymph and nasopharynx. The diagnosis of this case would appear to be nasopharyngeal cancer with left and neck lymph node metastasis or nasopharyngeal tuberculosis with cervical lymph node tuberculosis in addition to malignant lymphoma. Based on some examinations (biopsy, bacteria culture, and imaging), it was diagnosed as nasopharyngeal tuberculosis with cervical lymph node tuberculosis. Therefore, she was treated with anti-tuberculosis agent in respiratory medicine.

Introduction. The canal of Nuck is an embryological remnant of the peritoneal pouch that extends into the labium majus of women. Hydrocele is the most common presentation, but only a small number of cases are reported in association with endometriosis.Case Presentation. The patient is a 45-year-old woman who presented with left inguinal mass with persistent pain. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a 30 mm cystic mass, and a hydrocele of the canal of Nuck (HCN) was suspected. The excised mass was a cyst containing yellow-tan serous fluid, and the cyst wall was lined by mesothelium. The morphology was consistent with conventional HCN. However, since several foci of endometrial-like epithelium and stroma were identified beneath the mesothelium, the mass was diagnosed with HCN with endometriosis (EM-HCN).Discussion. Right-side dominance of EM-HCN is suggested by several authors, but a thorough review has never been performed. For the first time, we reviewed the literature and statistically confirmed that EM-HCNs dominantly occur on the right side compared to those without endometriosis. We consider that this supports the theory that endometriosis derives from retrograde menstruation of endometrial tissue through fallopian tubes. When endometriosis is discovered in HCN, the clinician should be aware of the possibility of pelvic endometriosis.

COVID-19 vaccine-related myocarditis has been reported worldwide. We herein report two Japanese cases with suspected vaccine-related myocarditis. A 27-year-old man was admitted with chest pain 4 days after the second vaccination. An electrocardiogram (ECG) did not reveal any significant abnormalities. The second patient, a 37-year-old man, was admitted with chest pain 9 days after the first vaccination. His ECG exhibited ST-elevation in multiple leads. In both cases, cardiac magnetic resonance imaging findings were consistent with myocarditis. They recovered with symptomatic relief within a few days. These cases suggest that the benefit of COVID-19 vaccination exceeds the risk of vaccine-related myocarditis.

A 45-year-old man suffering from dermal blistering disease with proteinuria and hematuria underwent renal biopsy. The renal biopsy specimen suggested proliferative glomerulonephritis with monoclonal IgG deposits under routine light, immunofluorescence and electron microscopy. The staining for IgG subclasses (IgG1 and IgG2) and κ/λ light chain indicated secondary immune complex type MPGN type 3. The patient had been diagnosed as having dermatitis herpetiformis (DH), a phenotype of gluten hypersensitivity prior to the appearance of the renal abnormality. Although common autoantibodies might be related to the pathogenesis of disorders in the skin and kidney, DH is mainly driven by IgA autoantibody, while MPGN is induced by IgG immune complexes. IgA was not observed in the glomeruli by immunofluorescence. Neither the examination for DH specific autoantibodies nor HLA-DQB1 genotype supported the diagnosis of DH. Reassessment of the skin biopsy record revealed that the blister was localized in the epidermis, suggesting pemphigus herpetiformis by IgG class anti-epidermal autoantibody, which also affected the renal disorder.

Intracardiac defibrillation (IDF) is performed to restore sinus rhythm (SR) during radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). This study aimed to investigate the change in the IDF threshold before and after RFCA during the ablation procedure and determine whether the IDF threshold after RFCA was associated with the AF substrate and AF recurrence. A total of 141 consecutive patients with drug-refractory persistent AF (age 62.5 ± 10.3 years, 84.4% male) were enrolled in this study. Before RFCA, we initially performed IDF with an output of 1 J. When IDF failed to restore SR, the output was gradually increased to 30 J. After RFCA, we attempted pacing-induced AF to provoke other focuses of AF. When AF was induced, we performed IDF again to terminate AF with outputs of 1 to 30 J. The change in the IDF threshold to restore SR before and after RFCA was evaluated. After RFCA, the IDF threshold for restoring SR significantly decreased (from 11.5 ± 8.6 J to 4.0 ± 3.8 J, P0.001). During the follow-up (24.3 ± 12.2 months), SR was maintained in 107 patients (75.9%). The multivariate analysis using a Cox proportional-hazards model revealed that an IDF threshold of5 J after RFCA was significantly associated with the AF recurrence (HR, 3.99; 95% confidence interval 1.93-8.22; P = 0.0001). RFCA decreased the IDF threshold for restoring SR in patients with persistent AF. The IDF output of5 J after RFCA could be a predictor of AF recurrence independent of the AF substrate.

Background: Dealing with chemotherapy-related cardiac dysfunction (CTRCD) remains a significant problem complicated by the difficulty in early detection of cardiotoxicity. Electrocardiogram (ECG) is expected to be the most realistic methodology due to lower cost-performance and non-invasiveness. We investigated the long-term visual fluctuations in the ECG waveforms in patients with chronic doxorubicin (DOX)-induced cardiotoxicity to identify ECG indices for the early detection of cardiotoxicity. Methods: We conducted a retrospective case series study by reviewing the medical records of 470 consecutive patients with malignant lymphoma who were treated with DOX at our institute between January 2010 and December 2017. Of them, 23 (4.9%) patients developed left ventricular dysfunction and were diagnosed with CTRCD using echocardiography. We assessed the ECG indices on 12-lead ECG recordings before and after treatment in 15 patients; eight patients were excluded due to conduction disturbances or atrial fibrillation. Results: CTRCD was detected at a median of 475 (interquartile range, IQR: 341–1333) days after initiating chemotherapy. The evaluation of ECG indices preceding CTRCD development was performed 93 (IQR: 52–232) days before the detection of CTRCD. In the stage of CTRCD, the most significant ECG change was T-wave flattening in leads V3–V6 (12 patients, 80%). Additionally, QTa prolongation was observed in leads I and aVL (n=10, 66%), leads II, III, and aVF (n=9, 60%), and leads V3–V6 (n=10, 73%). These ECG changes were not observed before the treatment but were detected mildly in the pre-CTRCD stage, which subsequently worsened in the CTRCD stage.Conclusions: This study indicated that T-wave changes and QTa prolongation may be useful as an early indicator before the onset of CTRCD in patients with DOX-induced cardiotoxicity.

Management of hemosuccus pancreaticus (HP) due to pancreatic adenocarcinoma is problematic. This is the first report of the successful management of HP caused by pancreatic adenocarcinoma by chemoradiotherapy, which is a treatment option for cases with a high surgical risk that are not suitable for interventional radiology. In the present case, bloody pancreatic juice was detected in the main pancreatic duct, and anemia worsened without repeated blood transfusions. The patient ultimately underwent chemoradiotherapy comprising radiation of 3 Gy in 15 fractions concomitant with systemic chemotherapy of S-1. After the treatments, the anemia improved, and the patient was discharged on day 45.

In recent years, embedded real-time systems have grown in complexity and are required to be able to handle both periodic and aperiodic tasks. When an external interrupt occurs via an I/O peripheral, the program counter jumps to the corresponding exception vector. This results in large overhead due to context switching. However, embedded real-time systems are required to execute tasks in real-time with high precision. The Responsive Multithreaded Processor (RMTP), a prioritized SMT CPU, consists of eight hardware contexts treated as eight logical processing cores and has various hardware mechanisms for fine-grained real-time processing on the order of 10 µs. One hardware mechanism implemented in RMTP is an interrupt wake-up mechanism that enables interrupt-triggered thread wake ups. When a thread is designated to be an interrupt handling thread, it starts execution one clock cycle after an interrupt occurs. In this paper, we design and implement a software mechanism which reduces the interrupt response time by using this mechanism and demonstrate the effectiveness of our proposed method by RTL simulations. Evaluation results show that our proposed method achieves high real-time performance by reducing the interrupt response time by up to 82% compared to the baseline.

Introduction: In rectal cancer, distal intramural spread may sometimes occur, but a maximum extent of distal spread of > 6 cm is very rare. Case Presentation: A 65-year-old Japanese male with an advanced rectal cancer tumor with para-aortic lymph node metastasis was admitted. We performed a low anterior resection with lymphadenectomy, but the intraoperative frozen-section analysis of margins revealed malignant cell positivity; we, therefore, performed an abdominoperineal resection. Pathological findings showed that the maximum extent of distal spread was 6 cm. After 12 courses of FOLFOX4 as adjuvant chemotherapy, abdominal computed tomography revealed whole lymph node metastases, including Virchow’s node. Though FOLFIRI + panitumumab was started, he was not eligible for additional chemotherapy after 10 cycles. Conclusion: An intraoperative frozen pathology examination was helpful for the additional resection, when unexpected distal spreading had occurred in rectal cancer. The evidence of a distal negative margin should not be underestimated.

Predicting malignancy is important for adequate adjuvant therapy in patients with cancer. Due to cancer being a genetic disease, the detection of gene mutations could be helpful in predicting the prognosis and efficacy of drugs. Gastric cancer is the fifth most common cancer and is the third leading cause of cancer associated mortality worldwide. Mutations in genes may correlate with clinical information in patients with gastric cancer after surgery and, therefore, may be useful for predicting the prognosis of this disease. In the present study, to assess the usefulness of a commercial sequencing panel, TruSeq® Amplicon-Cancer Panel (Illumina), using a next-generation sequencer (Illumina MiSeq), mutation analysis of fresh as well as formalin-fixed paraffin-embedded (FFPE) gastric cancer tissues was performed retrospectively. The study group comprised of 4 patients who underwent gastrectomy for gastric cancer. Cancer and normal stomach tissues were collected immediately following surgical removal. Thereafter, the specimens were fixed in 10% neutral formalin for 24–72 h. Normal and FFPE cancer tissues were histologically examined and confirmed. A total of 3 mutations were identified in the driver genes (KRAS, TP53 and APC) in cancer tissues from 2 of the 4 patients, using fresh samples. In addition, FFPE samples were analysed for the same tissues and the same results were obtained by setting the threshold for the percentage of the mutation rate to avoid detection of pseudo-positive mutations. In conclusion, the sequencing analysis using FFPE-derived DNA samples was successfully performed.

AIM Chronic liver insufficiency is often associated with alteration in amino acid metabolism. We evaluated the prognostic value of changes in serum amino acid concentrations in patients with primary biliary cholangitis. METHODS A total of 75 primary biliary cholangitis patients who started urusodeoxycholic acid therapy were retrospectively enrolled. Baseline serum concentrations of branched-chain amino acids and tyrosine, and branched-chain amino acid-to-tyrosine ratio were determined. The hazard ratios of factors associated with liver-related events were analyzed by Cox proportional hazard analysis. RESULTS Of the 75 patients enrolled, 12 showed a decrease in serum branched-chain amino acid levels, and 15 showed an increase in serum tyrosine levels. The branched-chain amino acid-to-tyrosine ratio decreased in 16 patients. During a median 5.6-year follow up, liver-related events occurred in 11 patients. Multivariate analysis showed that high serum tyrosine levels at baseline and high alkaline phosphatase levels 48 weeks after starting urusodeoxycholic acid therapy were independent risk factors for event occurrence. From the receiver operator characteristics curve analysis, serum tyrosine concentration >110 μmol/L was identified as a cut-off value with an adjusted hazard ratio of 20.9 (95% confidence interval 4.3-101.5, P

Although primary (PGC) and remnant gastric cancers (RGC) both originate from the same gastrointestinal organ, they have very distinct clinicopathological behaviors. We hypothesized that there would be distinct differences in DNA methylation patterns that would occur during carcinogenesis of RGC and PGC, and that the differences in methylation patterns may help identify the primary factor contributing to chronic inflammation in patients with RGC. We investigated the genome-wide DNA methylation patterns of PGC and RGC tissues from 48 patients using the Infinium HumanMethylation450 Beadchip assay. The results were validated by quantitative methylation-specific PCR (qMSP) in separate, independent cohorts. We found that in our training cohort of 48 patients, the most variable genes from the gastric cancer tissues identified by the Infinium HumanMethylation450 Beadchip clustered the resultant heatmap into high and low methylation groups. On multivariate analysis, PGCs contributed significantly to the high methylation group (p = 0.004, OR 12.33), which suggested that the promoter methylation status in PGC is higher than that in RGC. Supporting this conclusion was the finding that in a separate qMSP analysis in a test cohort, the EPB41L3 gene, chosen because of its high β value on microarray analysis in the gastric cancer tissues, had significantly higher DNA promoter methylation in cancer tissues in the validation PGC tissues than in RGC. This study demonstrated that promoter methylation status in PGC is higher than in RGC. This result may reflect the effects of the absence of Helicobacter pylori on the reduced DNA methylation in the remnant stomach.

Early detection and accurate diagnosis have strong impacts on cancer care; therefore, pathological diagnosis of biopsy specimen is important. It is too late that the lesion is followed up until the carcinoma invades the submucosa or more. For the better quality of life (QOL) of patients, carcinomas should be endoscopically diagnosed and resected before metastasis. To achieve correct histological diagnosis on early-stage gastric carcinomas by biopsy specimen, it is necessary to understand the difference in histological diagnosis between Japanese and Western pathologists and learn the characteristic histological features of noninvasive well-differentiated adenocarcinomas, especially those of low-grade atypia. In addition, for selecting the suitable therapy, it is also necessary to know the clinicopathological features of special types of gastric carcinomas and how to correctly perform a histological evaluation of endoscopically resected specimens.

AIM To clarify the association between aldo-keto reductase family 1 member B10 (AKR1B10) expression and hepatocarcinogenesis after hepatitis C virus eradication. METHODS In this study, we enrolled 303 chronic hepatitis C patients who had achieved sustained virological response (SVR) through interferon-based antiviral therapy. Pretreatment AKR1B10 expression in the liver was immunohistochemically assessed and quantified as a percentage of positive staining area by using image-analysis software. A multivariate Cox analysis was used to estimate the hazard ratios (HRs) of AKR1B10 expression for hepatocellular carcinoma (HCC) development after achieving SVR. The cumulative incidences of HCC development were evaluated using Kaplan-Meier analysis and the log-rank test. RESULTS Of the 303 chronic hepatitis C patients, 153 (50.5%) showed scarce hepatic AKR1B10 expression, quantified as 0%, which was similar to the expression in control normal liver tissues. However, the remaining 150 patients (49.5%) exhibited various degrees of AKR1B10 expression in the liver, with a maximal AKR1B10 expression of 73%. During the median follow-up time of 3.6 years (range 1.0-10.0 years), 8/303 patients developed HCC. Multivariate analysis revealed that only high AKR1B10 expression (≥ 8%) was an independent risk factor for HCC development (HR = 15.4, 95%CI: 1.8-132.5, P = 0.012). The 5-year cumulative incidences of HCC development were 13.7% and 0.5% in patients with high and low AKR1B10 expression, respectively (P < 0.001). During the follow-up period after viral eradication, patients expressing high levels of AKR1B10 expressed markedly higher levels of alanine aminotransferase and α-fetoprotein than did patients exhibiting low AKR1B10 expression. CONCLUSION Chronic hepatitis C patients expressing high levels of hepatic AKR1B10 had an increased risk of HCC development even after SVR.

BACKGROUND AND AIM Aldo-keto reductase family 1 member B10 (AKR1B10), a cancer-related oxidoreductase, was recently reported to be upregulated in some chronic liver diseases. However, its relevance in hepatocellular carcinoma (HCC) development is not fully assessed, especially in patients with chronic hepatitis C virus (HCV) infection. METHODS Aldo-keto reductase family 1 member B10 expression in the liver of 550 patients with chronic HCV infection was immunohistochemically assessed and quantified. A multivariate Cox model was used to estimate the hazard ratios (HRs) of AKR1B10 expression for HCC development, and the cumulative incidence of HCC was evaluated using the Kaplan-Meier method. RESULTS Aldo-keto reductase family 1 member B10 expression in the patients ranged from 0% to 80%. During the median follow-up of 3.2 years, 43 of 550 patients developed HCC. Multivariate analysis demonstrated that high AKR1B10 expression (≥6%) was an independent risk factor for HCC (HR, 6.43; 95% confidence interval, 2.90-14.25; P

Aim Recent reports have indicated that aldo-keto reductase family 1 member B10 (AKR1B10), a cancer-related oxidoreductase, was upregulated in some chronic liver diseases. However, few studies have reported AKR1B10 expression in chronic hepatitis B virus (HBV)-infected patients. The aim of the present study was to analyze AKR1B10 expression and its relevance on hepatocellular carcinoma (HCC) development in patients with chronic HBV infection. Methods Expression of AKR1B10 in the liver of 119 chronic HBV-infected patients was assessed and quantified immunohistochemically. A multivariate Cox model was used to estimate the hazard ratios of AKR1B10 expression for HCC development. The cumulative incidences of HCC were evaluated using Kaplan–Meier analysis. Results Expression of AKR1B10 in the study cohort ranged from 0% to 84%. During the median follow-up time (6.2 years), 13 patients developed HCC. Multivariate analysis revealed that high AKR1B10 expression (≥15%) was an independent risk factor for HCC (hazard ratio, 10.8; 95% confidence interval, 3.0–38.6; P

We experienced a case of huge chronic thyroiditis with malignant lymphoma that caused dyspnea with tracheal stenosis, dysphagia with esophagus stenosis and recurrent nerve paralysis. In this case, thyroidectomy was performed and, after the surgery, there was no sign of breathing or swallowing difficulties, and it was confirmed by the postoperative computed tomography that the tracheal stenosis had improved. We considered two possible explanations for the preoperative right recurrent nerve paralysis. In the first, the right recurrent nerve could have suffered from mechanical stimulation such as compression and traction to the recurrent nerve due to enlargement of the malignant lymphoma together with chronic thyroiditis. The second possible explanation was that malignant cells had invaded neurons. We could not distinguish between the two possibilities, since this right recurrent nerve was spared and could not be examined histopathologically.

A 69-year-old man was under maintenance dialysis due to diabetic renal failure. He had a drop in blood pressure during dialysis, developed hematemesis, and was transported to our hospital. Emergency upper gastrointestinal endoscopy revealed diffuse erosion, mucosal sloughing, and edematous mucosa in the upper body of the stomach to the posterior wall of the antrum and to the greater curvature, which were considered to be an ischemic change. His underlying diseases included diabetic renal failure, chronic arteriosclerosis obliterans, cerebral infarction, internal carotid artery stenosis, hypertension, and myocardial infarction. Blood evaluation showed only mild inflammation and no fibrinolytic hyperactivity. Contrast-enhanced computed tomography (CECT) showed no occlusion of blood vessels. It was considered that the patient had a transient ischemic change due to blood pressure drop. The patient's condition improved with conservative treatment.

Laryngeal polyps are common, but some hospitals have reported that a giant vocal fold polyp could cause dyspnea. We encountered a giant vocal fold polyp with dyspnea. Under general anesthesia, laryngomicrosurgery successfully improved the symptoms of the dyspnea. In this case, stenosis of the posterior glottis (considered to be the respiratory glottis) due to a giant vocal fold polyp was thought to be the cause of the preoperative dyspnea.

Background. Although segmental arterial mediolysis (SAM) has been increasingly recognized as arteriopathy and there are some case reports about SAM, it is still very rare. It is characterized clinically by aneurysm, dissection, stenosis, and occlusion within splanchnic arterial branches, causing intra-abdominal hemorrhage or bowel ischemia. Mortality is as high as 50% in acute events. Case Presentation. A 51-year-old man was referred to our hospital with hematemesis. Gastroscopy revealed a submucosal-like tumor on the posterior wall of gastric angle with ulceration. Computed tomography indicated a tumor measuring 65×50 mm in the stomach, which was suspected to have invaded into the pancreas. Significant hematemesis recurred; the patient developed shock and underwent emergency distal gastrectomy, distal pancreatectomy, and splenectomy. The pathology and the clinical course were compatible with SAM splenic artery rupture causing retroperitoneal hemorrhage that penetrated into the stomach. After that surgery, aneurysm of common hepatic artery ruptured and coil embolization was performed. Conclusion. SAM is an important cause of intra-abdominal or retroperitoneal hemorrhage in patients without underlying disease. SAM typically presents as intra-abdominal hemorrhage, but, in this case, the retroperitoneal hemorrhage penetrated into the stomach and it looked like a submucosal tumor.

Background. Despite complete resection of gastrointestinal stromal tumors (GIST), recurrent and/or metastatic disease occurs, often depending on the grade of malignancy. As such, markers are needed that accurately predict patients at high risk for recurrence. Previously our group reported Pfetin as a prognostic biomarker for GIST. In order to create an approach for predicting risk of recurrence, we incorporated Pfetin expression with clinicopathological data to produce a predictive model.Object. Forty-five patients with localized primary GIST were treated with complete gross surgical resection surgically at our institution between 1995 and 2010 were included. The majority of tumors originated in the stomach (38 cases), as well as small intestine (6 cases) and rectum (1 case).Method. (1) We performed retrospective analysis of the connection between Pfetin expression, clinicopathological data, and incidences of recurrence, using bivariate and multivariate analyses. (2) The reactivity of the monoclonal antibody against Pfetin was examined by immunohistochemistry.Pfetin. We have reported Pfetin, identified microarray technology, and compared between statistically different GISTs for good and poor prognoses and for prognostic marker.Results. There were 7 cases of recurrences. (1) By univariate analysis, tumor size, mitoses, exposure to abdominal cavity, and complete tumor removal predicted risk of recurrence. (2) Pfetin-negative cases were significantly related to recurrence (P= 0.002).Conclusions. This analysis demonstrates that lack of Pfetin expression is an additional predictor of recurrence in resected GIST. Further study may determine the role of this variable added to the current predictive model for selection of adjuvant therapy.

Gastric cancer is the second leading cause of cancer mortality in the world. It is important to develop biomarkers for detecting new cancers at an early stage and for treating them early during recurrence in order to guide optimal treatment. Fatty acid synthase (FAS) is highly expressed in numerous human cancers and thus could potentially serve as such a biomarker, but the potential utility of measuring FAS for detecting gastric cancer has not been previously investigated. The aim of the present study was to provide a preliminary assessment of serum FAS as a marker of gastric carcinoma. The study included 47 patients with gastric cancer and 150 healthy subjects. Blood samples were collected from each cancer patient prior to treatment. Serum FAS levels were measured by ELISA and compared across the two groups of patients. Significantly higher levels of serum FAS were found in the gastric cancer patients [95% confidence interval (CI), 30.37–52.46] compared with the healthy controls (95% CI, 1.331–2.131), with elevated levels even in patients with early-stage tumors. These results indicate that measuring serum FAS levels has strong potential to provide a biomarker for the detection of gastric cancer, with high sensitivity and specificity.

Purpose: Submucosal invasive colorectal carcinoma (SICC) exhibits lymph node metastasis in about 10% of patients. Therefore, endoscopic resection is insufficient for cases of SICC at risk of lymph node metastasis, and surgical resection accompanied with lymph node dissection is necessary. However, because additional intestinal resection is unnecessary for cases without lymph node metastasis, more rigid criteria are required in order to decrease the incidence of unnecessary further intestinal resection. We retrospectively identified predictive factors for lymph node metastasis in submucosal invasive colorectal carcinoma. Methods: One hundred and two patients who underwent intestinal resection as the first treatment or additional intestinal resection after endoscopic resection at our department between 1999 and 2012 were enrolled in the present study. Clinicopathological factors were analyzed to determine predictive factors related to lymph node metastasis. Results: The multivariate analysis revealing only depth of submucosal invasion (≤2700 μm) was found to be a significant, independent predictive factor of lymph node metastasis (P = 0.04, Odds ratio: 4.18, 95% CI: 1.06 - 16.40). Conclusion: It is considered that the refinement of the criteria in the present study will be very useful, especially in the patients for whom careful judgment is required when considering additional intestinal resection.

Background and Aim The purpose of this study was to evaluate the usefulness of liver stiffness measurement (LSM) for assessing the risk of hepatocellular carcinoma (HCC) in chronic hepatitis C (CHC) patients receiving interferon (IFN) therapy. Methods One hundred fifty-one CHC patients who underwent LSM and received IFN therapy were included in the estimation cohort, and 56 were included in the validation study. The cumulative HCC incidences were evaluated using Kaplan–Meier plot analysis and the log-rank test. Multivariate Cox proportional hazard analyses were used to estimate the hazard ratios (HRs) of variables for HCC. Results In the estimation cohort, 9 of 151 patients developed HCC during the median follow-up time of 722 days. Multivariate analysis identified three independent risk factors for HCC: LSM (≥ 14.0 kPa, HR 5.58, P = 0.020), platelet count (

We previously reported a relationship between depth of submucosal invasion of early colorectal carcinomas and desmoplastic reaction (DR). However, poor inter-observer agreement on the histopathological diagnosis of DR in biopsy specimens with hematoxylin and eosin (H&E) staining has been the major critique of this tool. In this study, reproducibility of the histopathological diagnosis of DR was evaluated. Furthermore, we investigated the possible improvement of the reproducibility after education about histological characteristics and tried to identify histological characteristics that are most important in the recognition of DR. A total of 34 H&E stained slides were included in this study and analyzed by three pathologists. Slides were reviewed before and after education about histological characteristics of DR. Kappa statistics were used to compare the inter-observer variability. We investigated the relationship between DR and histopathological factor. The inter-observer agreement during the first session varied between 0.30 and 0.63, which improved during the second session toward an agreement between 0.58 and 0.71. Myofibroblast proliferation associated with cancer invasion was found to be the most useful in the diagnosis of DR. In conclusion, the correct detection of myofibroblasts may facilitate the standardization of diagnosis of DR.

Two cases of mucinous cystadenoma of the appendix successfully treated by laparoscopy are reported. An 81-year-old woman with lower right back pain was diagnosed with mucinous cystadenoma of the appendix or appendiceal carcinoma and underwent elective laparoscopic surgery. The other case involved a 70-year-old man with hematochezia who was diagnosed with mucinous cystadenoma. He also underwent elective laparoscopic surgery. In these two cases, gauze was folded around the tumors rather than grasping them directly. The postoperative courses were uneventful, and these patients had no recurrent disease at 2-year follow-up. In such cases, surgical excision of the tumor without rupture is of paramount importance because rupture of the lesion can cause pseudomyxoma peritonei. Though appendiceal mucinous cystadenoma has been considered a contraindication of laparoscopic resection, it was possible to achieve this by using a laparoscopic procedure with a gauze technique.

OBJECTIVE Genotype 1 chronic hepatitis C (G1CHC) is generally accompanied by metabolic disturbances related to visceral obesity, such as insulin resistance, steatosis, or dyslipidemia. Because these abnormalities negatively influence the clinical course of G1CHC, we sought to clarify the effect of visceral obesity on the pathophysiology of G1CHC. METHODS We evaluated 180G1CHC patients for the presence of visceral obesity on the basis of computed tomography findings. Multivariate analysis was performed to estimate the relationship between visceral obesity and demographic, viral, and biochemical characteristics of patients. The associations of visceral obesity with histological findings and serum adipokine levels were also analyzed. RESULTS Multiple logistic regression analysis revealed that visceral obesity was independently associated with metabolic syndrome, platelet count, high-density lipoprotein level, and serum viral load in elderly patients (≥65 years). Multiple linear regression analysis confirmed the association between visceral obesity and high viral load. However, visceral obesity was not correlated with viral load in non-elderly patients (

Although both lung cancer and pulmonary tuberculosis (TB) commonly occur in clinical practice, little attention has been paid to their coexistence. A 62‐year‐old female was admitted with acute dyspnoea secondary to cardiac tamponade. During her admission, a mass lesion harbouring air bronchograms in the right upper lobe rapidly increased in size. Surgical lung, pericardial, and pleural specimens yielded TB from a nodule in the right upper lobe and lung adenocarcinoma from the pericardium and pleura. Anti‐tuberculous therapy was administered and gefitinib was subsequently started after the positive identification of epidermal growth factor receptor (EGFR) mutation (exon 19 deletion). The patient's general condition gradually improved with the anti‐tuberculous and the EGFR‐tyrosine kinase inhibitor (EGFR‐TKI) treatment. Dual pathology is important to consider in patients with atypical radiological appearances. In those with proven EGFR mutation positive for lung cancer and pulmonary TB, sequential anti‐tuberculous medication followed by EGFR‐TKI treatment is advised.

We experienced two rare cases with laryngeal cystic lesions (laryngocele and laryngeal cyst). In the first case, the laryngocele case was removed by laryngomicrosurgery using an oral approach under general anesthesia. In the second case, the magnetic resonance imaging demonstrated a dumbbell-type cyst with mucus widely extending from the laryngeal lumen to the neck through the thyroid cartilage. The patient had undergone chemotherapy for renal carcinoma with multiple lung and bone metastases. Therefore, we performed only fine needle aspiration rather than aggressive surgery for extirpation of the cyst using an external approach. This fine needle aspiration could improve the quality of life by decreasing both the left laryngeal swelling and the resulting pain, which were the chief complaints.

We previously reported that detection of desmoplastic reaction (DR) in pretreatment biopsy specimens was useful for predicting the depth of submucosal invasion (SM depth) in nonpedunculated early colorectal cancers (ECRCs) in a retrospective study. Here, we performed a prospective multicenter study for verification of our previous findings. Subjects were diagnosed with ECRC by endoscopy, and with adenocarcinoma from the biopsy specimens. Eleven institutions affiliated with the Japanese Society for Cancer of the Colon and Rectum participated in this collaborative study. A total of 112 patients with ECRC were enrolled. For nonpedunculated ECRCs, presence of DR was significantly correlated with SM depth. The sensitivity and specificity of detection of DR for prediction of pSM2 (tumor invasion ≥1000 µm) in nonpedunculated ECRCs were 68.6% and 92.0%, respectively. Evaluation of DR in pretreatment biopsy specimens may be useful for the clinicopathological diagnosis of colorectal carcinoma with massive invasion into the submucosal layer.

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third most common cause of cancer-related death worldwide 1. Approximately 70–90% of patients with HCC have an established background of chronic liver disease and cirrhosis 1. Persistent infection with the hepatitis C virus (HCV) is one of the major causes of chronic liver disease leading to the development of HCC. Persistent HCV infection is responsible for 27–75% of the HCC cases in Europe and the United States and >80% of the HCC cases in Japan 2, 3. The annual incidence of HCC development is 2–8% in cirrhotic patients with chronic HCV infection 4, 5. Persons with anti-HCV positivity were shown to have a 20-fold increased risk of developing HCC in comparison with those who were negative for anti-HCV 6. Thus, the carcinogenic role of persistent HCV infection appears to be significant. However, the molecular mechanism of HCV-related hepatocarcinogenesis is not completely understood, particularly in its early stages. Alpha-fetoprotein (AFP) is the most thoroughly characterized carcinofetal gene product and its usefulness in the surveillance and diagnosis of HCC is well established. On the other hand, AFP elevation is recognized not only in patients with HCC but also in patients with chronic viral hepatitis or cirrhosis, who have no evidence of HCC. AFP elevation was observed in over 15% of patients with chronic hepatitis C in the absence of HCC 7. In addition, several studies have indicated that AFP elevation is a significant predictor of HCC development 8–10. Recent reports reveal that the estimated HCC risk in patients with elevated AFP is over three-fold higher than that in patients with normal AFP 11, 12. These observations suggest that the molecular alterations associated with the very early stages of hepatocarcinogenesis have occurred in the livers of patients with chronic hepatitis C with AFP elevation. In this study, we attempted to identify a specific gene expression signature by performing microarray analysis on the livers of patients with chronic hepatitis C and AFP elevation, which is considered high risk for development of HCC.

Perpose: In order to establish the pathophysiological features and strategy for stercoral perforation of the colon, we herein analyze a series of stercoral perforation of the colon. Method: Ten patients were diagnosed with stercoral perforation. Clinical features, primary diseases, triggers, causative bacteria in ascites, postoperative complications, pathological features, severity of the disease, and effect of direct hemoperfusion with polymyxin B immobilized fiber (PMX-DHP) were investigated. Results: Nine patients had a long history of serious and chronic constipation and 7 patients had hypertension. Causative bacteria in ascites during the operation were most commonly Escherichia coli. There were a lot of severe postoperative complications such as sepsis, disseminated intravascular coagulation, and acute lung injury. With regard to the microscopic findings of the perforation site, the intestinal wall showed severe nonspecific inflammatory changes, including an increase of mononuclear cells in the lamina propria. There were 4 hospital deaths, so the mortality rate was 40%. APACHEII and SOFA score were high postoperation and 24 hours after the operation. PMX-DHP was performed in 8 cases of severe conditions of stercoral perforation of the colon. Because the catecholamine index improved within 24 hours, four of 8 cases were rescued. Conclusion: Most of the patients with stercoral perforation of the colon had severe postoperative complications. The severity of the disease was extremely high, therefore, early diagnosis based on pathophysiological features and comprehensive therapies including PMX-DHP were necessary for strategy of treating stercoral perforation of the colon.

We experienced a rare case of laryngeal cancer associated with dermatomyositis. The patient was a 63-year-old male and Japanese. He was admitted to our department of Otorhinolaryngology with dysphagia for a day as a chief complaint. He became aware of hoarseness with bloody sputum and then face edema with redness a half year before. At first physical examination, he had bilateral eyelid edema with erythema, finger edema with keratinizing erythema and limb extensor erythema. Serous creatine phosphokinase was 850 IU/mL (normal range: 40-200 IU/mL). Later, he was referred to the rheumatology department and was diagnosed as having dermatomyositis. Fiberscopic examination revealed laryngeal cancer with left laryngeal palsy. We gave priority to the laryngeal treatment. As a result, the symptoms of dermatomyositis were improved.