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A modified Fong clinical score (m-Fong CS) that includes the RAS mutation status has recently been proposed and offered an improved survival stratification of patients who undergo surgery and systemic chemotherapy for colorectal liver metastases (CLM). The aim of this study is to assess whether a CS that includes RAS status is influenced by whether patients receive perioperative chemotherapy.We created a new CS using multivariate analysis of data of patients who underwent hepatectomy for CLM for the first time between 2010 and 2016 at a single hospital (n = 341, 79% received perioperative chemotherapy). The resulting CS and m-Fong CS were then validated in the patient cohort at three other hospitals (n = 309). Furthermore, the applicability of the two CS in the total cohort (n = 650) was tested according to whether the patients received perioperative chemotherapy.The new CS comprised mutant RAS status, ≥4 CLMs, and a CA19-9 level ≥100 U/mL (1 point per factor). Both the new CS and m-Fong CS failed to stratify the survival of the 309 patients in the validation cohort, including those who did not receive perioperative chemotherapy (29%). Both of the CS accurately stratified the survival of patients who underwent perioperative chemotherapy but not of those who underwent surgery alone.A CS that includes the RAS mutation status can stratify the survival of patients who undergo hepatectomy combined with perioperative chemotherapy, but it has limited value for patients who undergo surgery alone.

Aggregation of protein therapeutics can lead to immunogenicity and loss of function in vivo. Its effective prevention requires an understanding of the conformational and colloidal stability of protein and the improvement of both. Granulocyte colony-stimulating factor (G-CSF), which is one of the most widely used protein therapeutics, was previously shown to be conformationally stabilized by connecting its N- and C-termini with amide bonds (backbone circularization). In this study, we investigated whether circularization affects the colloidal stability of proteins. Colloidal stability was indirectly assessed by analyzing the aggregation behavior of G-CSF variants using analytical ultracentrifugation (AUC) and small-angle X-ray scattering (SAXS). Consequently, we found that the unfolded structure of circularized G-CSF was more compact than non-circularized G-CSF, and that backbone circularization improved its aggregation resistance against chemical denaturation by guanidine hydrochloride (GdnHCl). The improved aggregation resistance suggests that the expansion tolerance of circularized G-CSF in the unfolded state increased its colloidal stability. Thus, backbone circularization is an excellent method for enhancing the colloidal and the conformational stability of protein with minimal sequence changes. It is therefore expected to be effective in extending the storage stability of protein therapeutics, enhancing their biological stability.

A 90-year-old woman presented with a 1-month history of progressive abdominal fullness. Contrast computed tomography (CT) showed a large 17-cm mass located adjacent to the antrum of the stomach without metastatic lesions. She underwent endoscopic ultrasound-guided fine-needle aspiration for diagnosis. Aspiration specimens revealed spindle-shaped cells positive for KIT by immunohistochemistry, with exon 11 mutations of the c-kit gene according to a genetic test. We ultimately diagnosed her with gastrointestinal stromal tumor (GIST). We judged the feasibility of imatinib treatment based on physiological and comprehensive geriatric assessments. We administered imatinib to reduce the tumor size and expected an excellent response based on genetic testing. After 5 months of imatinib administration with therapeutic drug monitoring (TDM), the tumor shrank by 42%. Six months later, there was no significant uptake of 18F-fluorodeoxyglucose on positron emission tomography. We successfully performed partial gastrectomy as conversion surgery, and she was carefully observed without any medication for 10 months after surgery. Here, we report a super elderly patient aged 90 years with a large GIST harboring an exon 11 mutation who underwent surgery after imatinib treatment with appropriate dose reduction during TDM after comprehensive geriatric assessment.

Effects of a microwave voltage on magnetization precession are analyzed based on a macrospin model. The microwave voltage induces the oscillating anisotropy field through the voltage controlled magnetic anisotropy (VCMA) effect, and then stimulates the magnetization. The large angle precession is maintained if the magnetization synchronizes with the microwave voltage. The effective equations of motion of the magnetization with an oscillating anisotropy field are derived, and the mechanism of the synchronization is clarified by analyzing the derived equations of motion. The conditions of the angular frequency detuning and the amplitude of the oscillating anisotropy field for synchronization are obtained. The results are useful for development of the VCMA-based energy-efficient spintronics devices using magnetization precession such as a VCMA-based magnetoresistive random access memory and a nano-scale microwave magnetic field generator., 7 pages, 5 figures

Body weight loss (BWL) after gastrectomy is associated with not only a deteriorated quality of life but also a poor prognosis. Oral nutritional supplements (ONS) may be used to minimize BWL, which is observed in the first 3 months after gastrectomy and becomes stable thereafter, although the results of several randomized trials remain controversial. We performed a multicenter, open-label randomized controlled trial including 1003 gastric cancer patients undergoing curative gastrectomy. Patients were assigned to the ONS group or the control group. In the former, 400 ml (400 kcal) per day for 12 weeks as enteral nutrition was planned, and the actual intake amount was recorded daily by patients themselves. The primary endpoint was BWL 1 year after gastrectomy. BWL data were available in 880 patients (ONS 437, control 443). BWL at 3 months was significantly lower in the ONS group than in the control group (7.1 ± 5.6% and 8.5 ± 5.8%, p = 0.0011). However, the difference gradually declined after 6 months and was not significant 1 year after surgery (9.3 ± 8.2% and 9.8 ± 8.7%, p = 0.37). In the ONS group, 50.4% of patients took more than 200 ml/day of ONS (average 301 ml) and showed significantly less BWL (8.2 ± 7.2%) at 1 year than the control (p = 0.0204). The administration of ONS for 12 weeks after gastrectomy did not improve BWL at 1 year. However, the improvement in BWL remained until 1 year after surgery in patients who took more than 200 kcal/day of ONS.

Background: Percutaneous transhepatic gallbladder drainage (PTGBD) is indicated for patients with acute cholecystitis (AC) who are not indicated for urgent surgery, but external tubes reduce quality of life (QOL) while waiting for elective surgery. The objective of the present study was to investigate the feasibility of laparoscopic cholecystectomy after endoscopic trans-papillary gallbladder stenting (ETGBS) comparing with after PTGBD.Methods: Intraoperative and postoperative outcomes of patients with ETGBS and PTGBD were retrospectively compared.Results: Eighteen ETGBS and ten PTGBD patients were compared. Differences in the duration of ETGBS and PTGBD [median 209 minutes (range, 107–357) and median 161 minutes (range, 130–273), respectively, P = 0.10], median blood loss [ETGBS 2 (range, 2–180 ml) and PTGBD 24 (range, 2–100 ml), P = 0.89], switch to laparotomy (ETGBS 11% and PTGBD 20%, P = 0.52), and median postoperative hospital stay [ETGBS 8 (range, 4–24 days) and ETGBS 8 (range 4–16 days), P = 0.99]. Thickening of the cystic duct that occurred in 60% of the ETGBS patients and none of the PTGBD patients (P = 0.005) interfered with closure of the duct by clipping. No obstruction occurred in ETGBS patients.Conclusion: ETGBS did not make laparoscopic cholecystectomy less feasible than after PTGBD.

285 Background: The efficacy of trastuzumab has been established for HER2-positive advanced gastric cancer patients with metastatic disease. However, it remains unclear if the addition of trastuzumab to preoperative chemotherapy is effective for treatment of HER2-positive locally advanced gastric cancer. Methods: Eligible patients with HER2-positive gastric cancer with extensive lymph node metastasis were randomized to preoperative S-1/cisplatin (SP) (group A) or SP plus trastuzumab (group B). In both groups, patients received S-1, 80–120 mg/body, on days 1–14 and cisplatin, 60 mg/m2, on day 1, q21, 3-4 courses. Additionally, in group B, patients received infusions of trastuzumab (first course 8 mg/kg followed by 6 mg/kg, day 1). After gastrectomy, adjuvant chemotherapy with S-1 was performed for 1 year in both groups. The primary endpoint was overall survival, and the sample size was planned to be 130 patients in total, expecting a 10% increase in the 3-year overall survival (70% vs 80%) with a 1-sided alpha of 0.2, a power of 0.75. Results: The study was terminated in March 2021 due to slow patient accrual. In total, 46 patients were randomized to either group A (22 patients) or group B (24 patients). Patient characteristics were well balanced between the groups. Planned preoperative chemotherapy was completed in 20 patients (90.9%) in group A and in 23 patients (95.8%) in group B, and R0 resection was achieved in 20 patients (90.9%) in group A and 22 patients (91.7%) in group B. The incidences of grade 3 or 4 hematological/non-hematological adverse events during preoperative chemotherapy were 27.3/18.2% in group A and 4.2/8.3% in group B. Objective response rate (CR/PR) tended to be higher in group B (66.7% [16/24]) than in group A (36.4% [8/22], p = 0.08). Pathological response rate (> grade 1b in Japanese classification, 22.7% [5/22] vs. 50.0% [12/24], p = 0.07) and the proportion of patients achieving downstage to ypStage 0/I/II (22.7% [5/22] vs. 50.0% [12/24], p = 0.07) were also higher in group B than in group A. Conclusions: Preoperative chemotherapy with SP plus trastuzumab was feasible, and tended to show better radiological and pathological response rates. Better survival outcomes are expected by adding trastuzumab to preoperative chemotherapy with SP for locally advanced gastric cancer with extensive nodal metastasis. Clinical trial information: UMIN000016920.

In spintronics, magnetization switching based on voltage control of magnetic anisotropy (VCMA) continues to attract attention, because it reduces the write power in magnetoresistive random-access memory (MRAM). Further reduction of the write power is required for next-generation MRAM. Conventionally the magnetic anisotropy (MA) is $e\phantom{\rule{0}{0ex}}l\phantom{\rule{0}{0ex}}i\phantom{\rule{0}{0ex}}m\phantom{\rule{0}{0ex}}i\phantom{\rule{0}{0ex}}n\phantom{\rule{0}{0ex}}a\phantom{\rule{0}{0ex}}t\phantom{\rule{0}{0ex}}e\phantom{\rule{0}{0ex}}d$ during the voltage pulse, but here the authors propose a scheme in which the MA is $e\phantom{\rule{0}{0ex}}n\phantom{\rule{0}{0ex}}h\phantom{\rule{0}{0ex}}a\phantom{\rule{0}{0ex}}n\phantom{\rule{0}{0ex}}c\phantom{\rule{0}{0ex}}e\phantom{\rule{0}{0ex}}d$, to induce precession around an almost perpendicular axis. They show that pulse duration can be reduced to a few tens of picoseconds, without deteriorating thermal stability. Such a short pulse helps to reduce energy loss by Joule heating.

Nafamostat mesylate (NM) is a synthetic serine protease inhibitor that can be used as an anticoagulant during blood purification in critically ill patients, as well as a treatment for disseminated intravascular coagulation. Although NM has been reported to reduce the risk of bleeding during blood purification, its effect on survival outcomes of patients who received blood purification treatments is unclear. We hypothesized that administration of NM during blood purification can reduce mortality in patients with sepsis. A post hoc analysis was conducted on a nationwide retrospective registry that included data from 3195 sepsis patients registered at 42 intensive care units throughout Japan. We evaluated the effect of NM on hospital mortality and bleeding complications using propensity score matching in 1216 sepsis patients who underwent blood purification in the intensive care unit (ICU). Two-hundred-and-sixty-eight pairs of propensity score-matched patients who received NM and conventional therapy were compared. Hospital and ICU mortality rates in the NM group were significantly lower than those in the conventional therapy group. However, rates of bleeding complications did not differ significantly between the two groups. These data suggest that administration of NM improved the survival outcomes of sepsis patients who underwent blood purification in the ICU.

Background For unresectable or recurrent advanced gastric adenocarcinoma (AGC), tri-weekly administration of nanoparticle albumin-bound paclitaxel (nab-PTX) at 260 mg/m2 achieved a response rate of 27.8% in a phase II trial in Japan. However, frequent neutropenia and peripheral neuropathy limit its use in clinical settings. We, thus, conducted a single-arm phase II trial to investigate the efficacy and safety of a reduced dose (220 mg/m2) of tri-weekly nab-PTX. Methods Eligible patients included those with AGC and ECOG performance status of 0–2 who had received one or more prior chemotherapy containing fluoropyrimidine regimens. A reduced dose of nab-PTX (220 mg/m2) was administered tri-weekly. The primary endpoint was response rate (RR). Secondary endpoints were overall survival (OS), progression-free survival (PFS), disease-control rate (DCR), incidence of adverse events, relative dose intensity (RDI) and proportion of patients receiving subsequent chemotherapy. Results Among 33 patients enrolled, 32 were treated with protocol therapy. RR was 3.1% [95% confidence interval (CI), 0–16.2%], which did not reach the protocol-specified threshold (p = 0.966). DCR was 37.5% (95% CI, 21.1–56.3%). Median OS and PFS were 6.3 (95% CI, 4.4–14.2) and 2.2 (95% CI, 1.8–3.1) months, respectively. RDI was 97.8%. Twenty (62.5%) patients received subsequent chemotherapy. Toxicity was relatively mild with the most common grade ≥ 3 adverse events being neutropenia (38%), anemia (13%), fatigue (19%), anorexia (16%), and peripheral neuropathy (13%). Conclusion Tri-weekly nab-PTX with a reduced dose (220 mg/m2) is not recommended for AGC in a second-line or later setting, despite demonstrating less toxicity than at 260 mg/m2. Clinical trial registration The OGSG1302 trial was registered with UMIN-CTR as UMIN000000714.

We had previously reported that surgical palliation could maintain quality of life (QOL) while improving solid food intake among patients with malignant gastric outlet obstruction (GOO) caused by advanced gastric cancer. The present study aimed to perform a survival analysis according to the patients’ QOL to elucidate its impact on survival. Patients with GOO who underwent either palliative gastrectomy or gastrojejunostomy were included in this study. A validated QOL instrument (EQ-5D) was used to assess QOL at baseline and 2 weeks, 1 month, and 3 months following surgical palliation. Postoperative improvement in oral intake was also evaluated using the GOO scoring system (GOOSS). Thereafter, univariate and multivariate survival analyses were performed to determine independent prognostic factors. The median survival time of the 104 patients included herein was 11.30 months. Patients who received postoperative chemotherapy, PS 0/1, baseline EQ-5D ≥ 0.75, improved or stable EQ-5D, and improved oral intake expressed as GOOSS = 3 had significantly better survival. Multivariate analysis identified postoperative chemotherapy, a better baseline PS, a better baseline EQ5D, improved or stable EQ5D scores, and improved oral intake 3 months after surgical palliation as independent prognostic factors. Apart from preoperative PS and postoperative chemotherapy, the present study identified better baseline QOL, improvement in postoperative QOL, and improvement in oral intake as prognostic factors among patients who underwent palliative surgery for advanced gastric cancer with GOO.

A 70-year-old woman underwent treatment for cecal cancer(pT4bN1M0, Stage Ⅲb)in 2010. Four years and 2 months after the first surgery, she underwent ileum resection for stenosis due to perineal dissemination(P3). Two years after this recurrence, during which time she had completed 26 courses of FOLFIRI plus bevacizumab(Bmab), 9 courses of capecitabine plus oxaliplatin(CapeOX)plus Bmab, and 3 courses of Cape, no peritoneal dissemination was detected by computed tomography( CT). Thereafter, an additional 19 courses of Cape plus Bmab were introduced, but CEA continued to increase. Right ovarian metastasis was suspected based on CT and FDG-PET/CT examination. Four years and 1 month after the initial recurrence of perineal dissemination, the patient underwent bilateral ovarian resection, during which the lack of peritoneal dissemination was confirmed. Pathologically, right ovarian metastasis was diagnosed. The patient is still alive 4 years and 6 months after the first operation.

A 77-year-old woman was referred to our hospital for detailed examination of a cystic liver tumor. Contrast-enhanced CT and MRIshowed a cystic liver tumor with an enhanced mural nodule in S6 of the liver. Under a preoperative diagnosis of hemorrhagic hepatic cyst and mucinous cystic neoplasm(MCN)of the liver, extended posterior segmentectomy was performed. Histological examination of the tumor revealed no neoplastic cells, and the tumor was finally diagnosed as a hemorrhagic hepatic cyst of the liver.Similar to previous reports of hemorrhagic hepatic cysts, preoperative differential diagnosis from MCN of the liver was difficult in this case. Hemorrhagic hepatic cysts are rare and are sometimes confused with MCN of the liver, especially when an enhanced mural nodule is found in the cyst. The possibility of hemorrhagic hepatic cysts should be considered during diagnosis of liver cystic tumors.

Multiple sporadic gastrointestinal stromal tumor(GIST)are rare, except for those restricted to von Recklinghausen disease or hereditary conditions.We reported a case of a gastric GIST resected 9 years after the resection of a duodenal GIST.The patient was a 58-year-old male who had been followed-up with computed tomography scans after pancreatoduodenectomy for a duodenal GIST when he was 49-years-old.The patient was admitted to our hospital for anemia examination.A CT scan detected a tumor in the stomach, with a diameter of over 10 cm, and necrosis.Esophagogastroduodenoscopy revealed the presence of a delle on the gastric SMT.Due to suspected invasion of the spleen and left diaphragm by the tumor, we performed subtotal gastrectomy with splenectomy and left diaphragm segmental resection.In the pathological diagnosis, the tumor was diagnosed as a gastric GIST, because the cell type of the tumor was spindle and tested positive for c-kit.Based on the tumor size and mitotic count, the patient was diagnosed with high-risk GIST by the modified-Fletcher classification, and imatinib 400mg/day was administered.There have been no signs of recurrence for 2 years since the operation.

We describe a case of residual stomach preserving surgery performed under evaluation of residual gastric blood flow with indocyanine green(ICG)fluorography, for gastric cancer with recurrence of splenic lymph node metastasis after distal gastrectomy( DG)in a 65-year-old man. After 4 courses of S-1 plus CDDP(SP)therapy for advanced gastric cancer with ascites, DG, D2 dissection, and Billroth Ⅰ reconstruction were performed and radical resection was obtained(L, Type 3, pap/tub, ypT3N1H0P0CY0M0, ypStage ⅡB). Three years and 6 months after the surgery, a mass 4 cm in diameter was found in the splenic hilum, and a pancreatosplenial resection was performed to remove the tumor for diagnosis and treatment purposes. We confirmed that there was no problem with blood flow, and we were able to preserve the stomach. Intraoperative ICG fluorescence imaging was considered a promising method for evaluating residual gastric blood flow.

A92 -year-old man was diagnosed with pancreatic cancer 14 years after undergoing distal gastrectomy for gastric cancer. His remnant stomach was fed by the cardiac branch of the left inferior phrenic artery, short gastric artery, and posterior gastric artery. We planned distal pancreatectomy(DP). Intraoperative indocyanine green(ICG)fluorography showed that the remnant stomach was perfused under the clamp of the splenic artery. We also confirmed that regional oxygen saturation (rSO2)of the remnant stomach was not decreased by the clamp. Based on the findings, we judged that blood flow in the remnant stomach was preserved at the clamp. We then performed DP with preservation of the remnant stomach. Postoperative complications associated with the remnant stomach were not observed. The patient is alive without any postoperative recurrences of pancreatic cancer or trouble associated with the remnant stomach 22 months after the surgery. This case suggested that ICG fluorography and rSO2 monitoring are useful to evaluate blood flow in the remnant stomach.

A 68-year-old man underwent a subtotal stomach-preserving pancreatoduodenectomy(SSPPD)for a distal bile duct carcinoma(BDC)pT3aN1M0, pStage ⅡB and adjuvant chemotherapy with gemcitabine. One year 7 months after the initial surgery, CT revealed a nodule with an increasing tendency in the left lung. As it was difficult to distinguish primary lung cancer from BDC lung metastasis, we performed a thoracoscopic left wedge resection. The histopathology of the resected specimen was BDC lung metastasis. In the follow-up with adjuvant chemotherapy with S-1 for 10 months, 2 nodules were found in the right lung, and we performed thoracoscopic right S6 segmentectomy. Eight months later, another nodule was found in the left lung, and we performed thoracoscopic left wedge resection. The histopathology was BDC lung metastasis for all the resected specimens. The patient is alive with no evidence of recurrence after 9 months of the latest surgery(4 years 11 months after the initial surgery). Although the standard treatment for metastatic recurrence of BDC is systemic chemotherapy, some cases treated with surgical resection had relatively good prognosis, such as the present case. Surgical resection might be feasible as a treatment option for metastatic recurrence of BDC.

A 65-year-old man visited our hospital for hepatocellular carcinoma(HCC)and underwent extended posterior sectionectomy. Eight months after the hepatic resection, follow-up computed tomography(CT)revealed a solitary, recurrent tumor in S4 of the liver, and transcatheter arterial chemoembolization and radiofrequency ablation were performed for the intrahepatic recurrence. After 12 postoperative months, follow-up CT demonstrated pulmonary metastases in S5 of the right lung and S10 of the left lung. Since there were no other metastases, the 2 metastatic lesions were resected using video-assisted thoracoscopic surgery(VATS). The resected tumors were histologically diagnosed as pulmonary metastases of HCC. Three years after the pulmonary resection, 3 additional pulmonary metastases were detected on CT in S3 and S10 of the right lung and S4 of the left lung. No other metastases were found. Bilateral VATSmetastasectomy was performed for the metastases. The tumors were diagnosed as pulmonary metastases of HCC on histological examination. One year and 8 months after the surgery, he was alive in a good condition, with no recurrences. The present case suggested that some patients with pulmonary metastasis of HCC can have long-term survival with surgical resection of the metastasis. Therefore, while systemic chemotherapy is generally considered the standard treatment for extrahepatic metastasis of HCC, surgical resection might be an option.

A 70s man presented with a solitary liver tumor measuring 4.5 cm on CT. On contrast-enhanced CT, the tumor appeared partly well-enhanced in the late phase, and the remaining part was enhanced in the early phase and washed out in the late phase. Contrast-enhanced MRIshowed fused multiple nodules, and the enhancement/washout pattern was clearer than that of the contrast-enhanced CT. The tumor showed a defective image in the hepatobiliary phase and a high signal on diffusionweighted imaging. Then, the tumor was diagnosed as hepatocellular carcinoma, and thus, left liver lobectomy was performed. On histological examination of the resected specimen, the tumor was found to be composed of uniform and small tumor cells with solid or trabecular growth fashion. On immunohistochemical staining, synaptophysin and chromogranin A positivity was noted, and the Ki-67 index was 14%. Finally, the tumor was diagnosed as a NET G2. Postoperatively, somatostatin receptor scintigraphy was performed to identify the primary site; however, no obvious primary site could not be identified, and thus a diagnosis of primary hepatic NET was made. Eighteen months postoperatively, the patient is alive without relapse. Preoperative diagnosis of primary hepatic NETs is difficult because NETs present various imaging findings and are rare. Moreover, no accurate preoperative diagnosis was reached in our case, suggesting the difficulty in the preoperative diagnosis of NETs.

A 60s man underwent upper gastrointestinal endoscopy at a regular medical check-up without symptoms, which showed an ulcerative region in the duodenal ampulla, measuring 3 cm in diameter. He was diagnosed with poorly differentiated adenocarcinoma on biopsy and referred to our hospital. Abdominal contrast-enhanced CT scan revealed an enhanced-ulcerative tumor, measuring 3 cm, at the duodenal ampulla. After the preoperative diagnosis of adenocarcinoma of the duodenal ampulla, subtotal stomach-preserving pancreatoduodenectomy with regional lymph node dissection was performed. The final diagnosis was neuroendocrine carcinoma(NEC)of the duodenal ampulla. He has been alive for 9 years with no recurrences. NEC of the duodenal ampulla is rare, and its prognosis is poor. We report a case of long-term survival after resection of NEC of the duodenal ampulla.

Laparoscopic hepatectomy has gained popularity owing to its merits, such as low invasiveness and reduced bleeding. However, the efficacy of laparoscopic repeat hepatectomy(LRH)has not been confirmed. The aim of this study was to evaluate the feasibility and efficacy of LRH compared to that of open repeat hepatectomy(ORH). We performed 60 repeat hepatectomies from January 2011 to March 2019, of which 19 were LRH(Lap group)and 41 were ORH(Open group). This study retrospectively compared the patient characteristics and short-term outcomes of repeat hepatectomy between the Lap and Open groups. There were no significant differences in patient characteristics, except for the type of approach in the previous hepatectomy(p0.01). The Lap group had lesser blood loss(median: 150 mL vs 355 mL, p0.01)and shorter postoperative hospital stays(median: 8 days vs 11 days, p0.01). There were no differences in operation time or severe postoperative complications. LRH is feasible and useful, providing good short-term outcomes.

We study the influence of inverse biases applied before and after a write pulse on the write-error rate (WER) of voltage-driven magnetization switching in magnetic tunnel junctions. It is demonstrated that the inverse bias applied after the write pulse is effective not only for improving the minimum value of the WER but also for broadening the operating pulse-width window. In contrast, an inverse bias applied before the write pulse hardly improves the WER or even narrows the operating window. Numerical simulations based on the macrospin approximation reproduce these experimental results well and a detailed analysis of the magnetization trajectory reveals that the observed write-error increase is due to a change in the magnetization angle before writing. These experimental results, as well as the numerical analysis, should facilitate the development of writing schemes in voltage-driven magnetic random-access memories.

Several studies have shown that postoperative complications worsen the prognosis of patients with malignancies. However, our previous study showed that C-reactive protein (CRP) elevation over 12 mg/dL was a more reliable prognostic indicator than complication occurrence. This large-scale, multicenter validation study aimed to confirm the prognostic value of postoperative CRP elevation in resectable gastric cancer. Data of 1456 patients with pT2–T4 gastric cancer who underwent R0 resection were collected from 21 institutions. The prognostic value of the highest postoperative serum level of CRP (CRPmax) during hospitalization was evaluated using the Kaplan–Meier method. The prognostic independence of CRPmax with assessed with a Cox multivariate analysis of recurrence-free survival (RFS). RFS in the high CRPmax (≥ 12 mg/dL) group was significantly worse than that in the low CRPmax (

We fabricated fully epitaxial Fe/ZnO/MgO/Fe magnetic tunnel junctions (MTJs) with low junction resistance-area products (several $\Omega$ $\mu$m$^2$) and conducted a theoretical estimation of square-low rectifying performance for a terahertz electromagnetic wave. Effective current responsivity up to 0.09 A/W at 1 THz was obtained under zero-bias voltage condition at room temperature. The result is approximately half the value of the best result obtained for experiments in semiconductor-based diodes, performed under similar conditions. The study strongly suggests that this MTJ system has a great potential for the rectifying element of the terahertz wave., Comment: 4 pages, 6 figures

A 42-year-old woman presented with fever, dyspnea, lower-leg edema, significant pulmonary congestion, pleural effusion, and severely reduced left ventricular contractions. She was resistant to treatment for heart failure, including catecholamines, furosemide, phosphodiesterase III inhibitors, and human atrial natriuretic peptide, and antibiotics failed to reduce her inflammation. She had renal dysfunction and hypocomplementemia and was positive for anti-nuclear and anti-ds-DNA antibodies. The patient was diagnosed with myocarditis and pleurisy associated with systemic lupus erythematosus (SLE). Prednisolone administration improved her general condition, reducing inflammation and improving left ventricular function. On day 1, an electrocardiography (ECG) revealed a T-wave inversion similar to a T-U complex configuration in leads II, aVF, and V3-6. By day 8, however, ECG showed prolonged corrected QT (QTc) and T-wave alternans (alternating beat-to-beat T-wave patterns) in lead V3-6. Careful ECG monitoring should be used to identify potentially fatal ventricular arrhythmias during the recovery phase of SLE-related myocarditis. .

Gallbladder torsion is one subtype of acute cholecystitis. Because of the very low incidence of the condition, there are few reports analyzing multiple cases of gallbladder torsion. The preoperative diagnosis is difficult and reported to be made in only 26% of patients. Herein, we report 6 consecutive cases of gallbladder torsion in 7 years and highlight the clinical and radiologic findings that facilitate preoperative diagnosis. Between 2005 and 2011, a total of 6 patients received a diagnosis of and were treated for gallbladder torsion in Toyonaka Municipal Hospital. A total of 5 patients received a diagnosis of gallbladder torsion or were suspected of having gallbladder torsion preoperatively, and 1 additional patient was diagnosed intraoperatively. The computed tomography findings of both excessive gallbladder swelling and rotation of the gallbladder fundus were observed in 5 patients, which were indicative findings of gallbladder torsion. The remaining 1 patient received a diagnosis intraoperatively. The twisted cystic duct and artery had been observed as a “whirl sign” preoperatively in 2 patients. Emergency cholecystectomy was performed: laparoscopic cholecystectomy was performed in 4 patients and open cholecystectomy in 2 patients. The patients treated by laparoscopic approach showed more rapid recovery and shorter postoperative hospital stay before discharge. The radiologic findings of both excessive gallbladder swelling and rotation of the gallbladder fundus are indicative of gallbladder torsion. The laparoscopic cholecystectomy approach could be considered the first choice for patients with gallbladder torsion.

Aim The efficacy of non‐invasive positive pressure ventilation (NPPV) in acute respiratory distress syndrome (ARDS) remains unclear. Variation in both the etiology of ARDS and patient factors has resulted in inconsistent application of NPPV. We have developed a protocol‐based NPPV strategy as a first‐line intervention for ARDS. The aim of this observational study was to determine if protocol‐based NPPV improves the outcome in patients with ARDS. Methods We identified patients with ARDS treated by protocol‐based NPPV at our institution between March 2006 and March 2010 and categorized them according to NPPV success or failure. Success was defined as avoidance of intubation and remaining alive during NPPV. Results Eighty‐eight of 169 patients diagnosed with ARDS during the study period were treated using the protocol. Fifty‐two (76%) of 68 patients who were eligible for the study were successfully treated and did not require endotracheal intubation. The overall mortality rate at 28 days after initiation of NPPV was 12%. The mortality rate was significantly lower in the success group than in the failure group (P, The aim of this observational study was to determine whether protocol‐based non‐invasive positive pressure ventilation (NPPV) could be effective for patients with acute respiratory distress syndrome (ARDS). The success rate was higher and the mortality was lower in patients than in historical controls. Protocol‐based NPPV can be effective in patients with ARDS.

Understanding the anatomy of the inferior pancreaticoduodenal artery (IPDA) is important in patients undergoing pancreaticoduodenectomy, especially in an artery-first approach, resulting in some studies focusing on IPDA anatomy. However, the studies have covered only cases without variation in hepatic arterial anatomy, a common arterial variant, suggesting the necessity of the investigation of IPDA anatomy in cases with the variant. Using images of multidetector row computed tomography, cases with replaced right hepatic artery (rRHA) were picked out among 714 patients undergoing multidetector row computed tomography for determining arteries of the pancreatic head at our institution. IPDA branching pattern was investigated in the rRHA cases. Three-dimensional reconstruction was performed to visually understand the branching pattern in representative cases. rRHA was identified in 139 cases (19.5%); rRHA originating from the superior mesenteric artery (SMA) (type 1; 74.1%), celiac axis (type 2; 18.0%), and others (type 3; 7.9%). IPDA branching pattern was categorized; IPDA originated from SMA (type A), posterior and anterior IPDA originated from rRHA and SMA, respectively (type B), or IPDA originated from rRHA (type C). Of type 1 cases, 69, 23, and 11 cases showed type A, B, and C pattern, respectively. Of type 2 cases, 16 and 9 cases showed type A and B, respectively. All 11 type 3 cases showed type C. IPDA branching pattern was determined in the rRHA cases. This would help identification of rRHA cases where the artery-first approach is technically less feasible at pancreaticoduodenectomy (type 1-B, 1-C, and 2-B).

Less intraoperative blood loss is frequently reported as an advantage of laparoscopic hepatectomy (LH) over open hepatectomy (OH). However, the small work space during laparoscopic surgery could lead to insufficient blood suction from the abdominal cavity, with possible underestimation of intraoperative blood loss. This study compared estimated blood loss (E-BL) with intraoperatively counted blood loss (IC-BL) in patients undergoing LH.This study included 110 consecutive patients undergoing partial hepatectomy for solitary liver tumors (59 had OH and 51 had LH). IC-BL and E-BL were determined, and the difference between them was calculated based on the surgical approach. Factors affecting the difference were investigated. IC-BL was quantified from the suction fluid volume and weight of surgical gauzes used for blood and fluid collection. E-BL was calculated with the total blood volume and change in hematocrit.Although there were no significant differences between IC-BL and E-BL in the OH group (292 ± 198 vs. 259 ± 167 mL, p = 0.1239), E-BL was significantly greater than IC-BL in the LH group (273 ± 166 vs. 128 ± 177 mL, p 0.0001). Percentage of patients with E-BL IC-BL in the LH group was significantly greater than in the OH group (86.3 vs. 42.4%, p 0.0001). The surgical approach (OH/LH) was the only significant independent factor determining E-BL IC-BL status.E-BL was significantly greater than IC-BL only in patients undergoing LH, and the surgical approach (OH/LH) was the only factor affecting E-BL IC-BL status. These results suggest that intraoperative blood loss may be underestimated during LH.

Background D-dimer shows high sensitivity but low specificity for the diagnosis of acute aortic dissection (AAD). Previous reports indicated that negative D-dimer patients have shorter dissection length. However, whether patients with negative D-dimer results have a good prognosis is unknown. This study aimed to elucidate the clinical characteristics and implications of a negative D-dimer result on AAD diagnosis. Methods The study group comprised 126 patients (71 males, 55 females; mean age, 69 ± 11 years) with AAD admitted to our hospital between April 2009 and March 2015. Blood samples on presentation were used for D-dimer measurement. Clinical characteristics and outcomes were assessed. Results Nine (7.1%) and 117 (92.9%) exhibited negative and positive D-dimer results, respectively. The negative group showed a significantly lower extension score and a higher platelet count than the positive group. Multivariate analysis demonstrated that platelet count (odds ratio, 1.31 (1.09–1.58), p = 0.003) and extension score (odds ratio, 0.56 (0.33–0.96), p = 0.03) were significantly related to a negative result. Notably, 44% of patients in the negative group had type A dissection and 33% underwent an emergency operation due to cardiac tamponade. Conclusion We found that high platelet count and low extension score were independent factors related to a negative D-dimer result. Even if the length of the dissection is short, an emergency operation is necessary in some patients with a negative D-dimer result. Physicians should recognize that a negative D-dimer result alone cannot exclude patients with fatal AAD conditions.

The technical difficulty of laparoscopic surgery for transverse colon cancer is partly due to the vascular variability around the middle colic vessels. Although individual variations in the arteries or veins in this area were previously investigated, the vascular interrelationships between these vessels remain unknown. This study was designed to investigate the vascular interrelationships between the arteries and veins around the middle colic vessels and to provide practically useful classifications. This study included 105 consecutive patients who underwent colorectal surgery for colorectal tumors in our institution in 2016. Patients with a history of colectomy were excluded. Vascular anatomical classifications were analyzed by evaluating thin-slice images of preoperative contrast-enhanced computed tomography. Vascular anatomical patterns were classified according to whether the first jejunal vein ran behind (type A) or in front (type B) of the superior mesenteric artery. Type B was subclassified into two subtypes, depending on whether the middle colic artery originated cephalad (type B1) or caudad (type B2) to the first jejunal vein. We identified 83 (79.0%) cases of type A, 11 (10.5%) of type B1, and 11 (10.5%) of type B2. In 17 cases, the middle colic vein drained into the inferior mesenteric vein, and all of these were type A (P = 0.0202). Furthermore, in eight cases, the middle colic vein drained into the first jejunal vein, and all of these were type B (P

Patient: Male, 90 Final Diagnosis: Ruptured cystic artery pseudoaneurysm Symptoms: Epigastric pain • Fever Medication: — Clinical Procedure: Open cholecystectomy Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Cystic artery pseudoaneurysm is rare, and some cases are associated with inflammation of the gallbladder. There is limited information regarding this condition, and the clinical features remain unclear. This report is a case of ruptured cystic artery pseudoaneurysm diagnosed by computed tomography (CT) imaging and treated with urgent cholecystectomy and is supported by a literature review of previous cases. Case Report: A 90-year-old man, who had developed acute cholecystitis due to a gallstone one month previously, was referred to our hospital. He developed fever and epigastric pain while waiting for a scheduled elective cholecystectomy. Laboratory investigations showed elevated markers of inflammation and elevated hepatobiliary enzyme levels. Computed tomography (CT) imaging showed cholecystitis and pseudoaneurysm of the cystic artery. The pseudo-aneurysm had ruptured and was accompanied by the formation of a hematoma within the gallbladder that involved the liver bed. Having made the preoperative diagnosis, an urgent open laparotomy was performed, during which the gallbladder was found to have perforated. The hematoma penetrated into the liver bed. Cholecystectomy was performed, and the pseudoaneurysm of the cystic artery was extirpated. There were no serious postoperative complications. A literature review identified 50 previously reported case of cystic artery pseudoaneurysm. Conclusions: A case of ruptured cystic artery pseudoaneurysm, successfully treated with urgent cholecystectomy is reported, supported by a literature review of previous cases and characterization of the clinical features of this rare condition.

Background Surgical Apgar score (SAS) was recently proposed as a simple predictor of postoperative complications. A few studies have shown the utility of the SAS in some kinds of surgeries, but it has not been investigated in patients undergoing hepatectomy for hepatocellular carcinoma (HCC). Methods This study included 158 patients undergoing hepatectomy for HCC. The association between SAS and postoperative complications was examined. The patients had postoperative morbidities classified as Clavien–Dindo grade II or higher. Multivariate regression analysis was performed to identify independent factors that significantly influenced the development of postoperative complications. Results Postoperative complications developed in 28 (17.7%) of the 158 patients. The proportion of cases with complications was significantly inversely correlated with SAS (Spearman rank correlation 0.829). The SAS was significantly lower in cases with complications than those without complications (5.6 ± 1.3 points versus 6.6 ± 1.3 points, P = 0.0004). Comparisons between patients with and without complication showed that preoperative serum albumin level and operation time, as well as SAS, were associated with complications. Multivariate analysis revealed that postoperative complications significantly correlated with the SAS. Conclusions This study demonstrated the clinical utility of SAS in predicting the development of postoperative complications after hepatectomy for HCC.

A mutant of cutinase-like enzyme from Saccharomonospora viridis AHK190, Cut190_S226P/R228S, designated as Cut190*, possesses high-thermal stability and has high polyethylene terephthalate (PET)-degrading activity. The functional characterizations of PET-degrading enzymes are generally conducted using accessible substrates such as poly(butylene succinate-co-adipate) (PBSA) and p-nitrophenyl butyrate (pNPB), even though their structures are different from that of PET. Bis(2-hydroxyethyl) terephthalate (BHET) is a component of PET, and the structure is similar to that of PET compared to PBSA and pNPB. Therefore, the analysis using BHET as the substrate is important to evaluate effective PET degradation. In this study, we analyzed the enzymatic activity of Cut190* using BHET under various conditions including Ca2+ concentration and pressure. Although terephthalate was supposed to be the final product, the intermediate product, mono(2-hydroxyethyl) terephthalate (MHET), was the only product generated, possibly due to the low binding affinity of MHET. The Cut190* activity towards BHET was observed even in the absence of Ca2+ and increased with increasing Ca2+ concentration, which is similar to its activity towards pNPB, but different from its activity towards PBSA. The difference can be attributed to the size of substrates. We also analyzed the activities of Cut190* and another high-activity mutant, Cut190*Q138A/D250C-E296C, under high pressures up to 400 MPa. BHET was non-enzymatically hydrolyzed under high pressure at 37 ℃. Enzyme activities were maintained under high pressures, and degradation of BHET in the presence of enzyme was higher than that in the absence of enzyme. Furthermore, the structural analysis of Cut190* under high pressure using Fourier transform infrared spectroscopy showed that most of the enzyme molecules were populated in the native structure below 400 MPa. These results indicate that BHET can contribute to the effective functional analysis of PET-degrading enzyme, and the combination of enzyme and pressure can lead to eco-friendly PET degradation.

Stochastic phase synchronization is investigated for spin-torque oscillators (STOs) with perpendicularly magnetized free layer with the first- and second-order magnetic anisotropy. We numerically calculated the magnetization dynamics for the pair of STOs receiving a dc current with Gaussian noise through common current source, and found that the STOs with the second-order magnetic anisotropy synchronized more effectively than that without the second-order magnetic anisotropy. We analyzed the response of the oscillation phase to a perturbative current, i.e., phase resetting curve, and also found that the STO with the second-order uniaxial anisotropy performs better with stochastic phase synchronization.

Background: Spontaneous spinal epidural hematoma (SSEH) is a rare disease. Despite numerous case reports, the clinical characteristics and prognosis of patients with SSEH in the contemporary aging population are unknown. The purpose of this study was to clarify the clinical characteristics, prognostic factors, and optimal management of SSEH. Methods: We retrospectively reviewed and analyzed patients with SSEH who were admitted to Shinshu University Hospital between July 2009 and October 2019. The modified Rankin Scale (mRS) was used to measure the degree of disability in patients with SSEH at discharge as a functional outcome and patients were classified accordingly. Clinical variables of patients with good (mRS 0–2) and poor (mRS > 2) outcomes were compared. Results: We identified 30 patients with SSEH (17 men and 13 women) aged 36–89 years (median age, 67 years). Twelve patients had hypertension. Surgical treatment was performed in 11 patients. The number of patients who had taken anticoagulants was higher in the poor outcome group than in the good outcome group (p = 0.01). The poor outcome group were older (p = 0.048), had a higher operation rate (p = 0.04) and longer lengths of hospitalization (p

Therapeutic IgG becomes unstable under various stresses in the manufacturing process. The resulting non-native IgG molecules tend to associate with each other and form aggregates. Because such aggregates not only decrease the pharmacological effect but also become a potential risk factor for immunogenicity, rapid analysis of aggregation is required for quality control of therapeutic IgG. In this study, we developed a homogeneous assay using AlphaScreen and AF.2A1. AF.2A1 is a 25-residue artificial protein that binds specifically to non-native IgG generated under chemical and physical stresses. This assay is performed in a short period of time. Our results show that AF.2A1-AlphaScreen may be used to evaluate the various types of IgG, as AF.2A1 recognizes the non-native structure in the constant region (Fc region) of IgG. The assay was effective for detection of non-native IgG, with particle size up to ca. 500 nm, generated under acid, heat, and stirring conditions. In addition, this technique is suitable for analyzing non-native IgG in CHO cell culture supernatant and mixed with large amounts of native IgG. These results indicate the potential of AF.2A1-AlphaScreen to be used as a high-throughput evaluation method for process monitoring as well as quality testing in the manufacturing of therapeutic IgG.

Antibodies are therapeutic proteins that are becoming indispensable for the treatment of serious diseases. Their efficacies depend on their folded structures, the loss of which, through unfolding or aggregation, should be closely monitored during their manufacture, storage, and dosing for safe usage. In downstream processes, exposure of the crude antibody solution to acid, followed by neutralization, is an established standard protocol for antibody purification and inactivation of viruses in antibody preparations. Nevertheless, this treatment also triggers an unwanted side reaction, i.e., antibody aggregation. The aggregates continuously evolve at neutral pH. It remains unclear whether the aggregates progressively incorporate the native, folded, monomers into themselves, enabling aggregate growth as seen in amyloid fibrils. In the present study, the diffusion of fluorescently labeled monoclonal humanized immunoglobulin G1 monomers in aggregates produced by pH-shift stress was tracked by fluorescence correlation spectroscopy. This method was used in addition to monitoring aggregate formation by dynamic light scattering. The diffusing velocities of the monomers indicated that the folded monomers were not involved in aggregate formation, in contrast with unfolded monomers. On the basis of the results, we propose a bifurcated pathway for the refolding and aggregation of antibodies triggered by a pH shift from acidic to neutral. In the scheme, the refolded monomers survive until their unfolding. The insights in this study will contribute to the manufacture of aggregation-resistant therapeutic antibodies.

Aim To study the most effective body position for Heimlich maneuver. Methods A choking simulation manikin was connected to a laryngeal model of a child or an adult, and a differential pressure transducer recorded the airway pressure and waveform during the maneuver. A konjac jelly was placed on the larynx to mimic complete supralaryngeal obstruction. The maneuver (five successive compressions) was carried out six times each in standing, prone, and supine positions. For cases of children, we added a supine position with a pillow under the back. Results In the adult model, airway obstruction was more frequently relieved in the supine and prone positions than in the standing position (P < 0.001). In the child model, airway obstruction was more frequently relieved in the supine position, with a pillow, and in the prone position, than in the standing position (P < 0.001). Without relief, successive Heimlich maneuvers made the airway pressure increasingly negative (adult, from −21.9 ± 6.5 cmH2O to −31.5 ± 9.1 cmH2O in the standing position [P < 0.001]; child, from −15.0 ± 9.5 cmH2O to −30.0 ± 9.2 cmH2O in the standing position [P < 0.001] and from −35.0 ± 17.4 cmH2O to −47.3 ± 25.1 cmH2O in the supine position without a pillow [P = 0.002]). Conclusions The Heimlich maneuver was more effective in the supine and prone positions. In children, the prone position may be most effective. Successive Heimlich maneuvers may be harmful when the airway is not relieved after the first compression.

To study the structural fluctuation of supercritical solutions, we introduced three fluctuational parameters, a scattering factor, a density factor and a volume factor, which were based on the Bhatia–Thornton theory. In the present study, the density dependence of the structural inhomogeneity in a supercritical aqueous solution of n -pentane was discussed using the scattering factor and the density factor obtained from small-angle X-ray scattering and the fluid density measurements, respectively. Although both these factors have their maxima at the same density position in the case of neat supercritical fluids, a significant difference between the two factors is observed in the binary solution. The large difference occurs by the contribution of the concentration fluctuation in the system. Based on the difference between the factors, it is suggested that a phase separation of the system exists in the higher-fluid-density region.

// Masanori Terashima 1,* , Wataru Ichikawa 2,* , Atsushi Ochiai 3 , Koji Kitada 4 , Issei Kurahashi 5 , Shinichi Sakuramoto 6 , Hitoshi Katai 7 , Takeshi Sano 8 , Hiroshi Imamura 9 , and Mitsuru Sasako 10 ; for the ACTS-GC Group 1 Division of Gastric Surgery, Shizuoka Cancer Center, Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, Japan 2 Division of Medical Oncology, Showa University Fujigaoka Hospital, Kanagawa, Japan 3 Division of Pathology, National Cancer Center Hospital East, Kashiwanoha, Kashiwa, Chiba, Japan 4 Department of Surgery, National Hospital Organization Fukuyama Medical Center, Okinogami-cho, Fukuyama, Hiroshima, Japan 5 Data Innovation Center, iAnalysis LLC, Minamiaoyama, Minato-ku, Tokyo, Japan 6 Department of Surgery, Saitama Medical University International Medical Center, Yamane, Hidaka, Saitama, Japan 7 Gastric Surgery Division, National Cancer Center Hospital, Tsukiji, Chuo, Tokyo, Japan 8 Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Koto-Ku, Tokyo, Japan 9 Department of Surgery, Toyonaka Municipal Hospital, Shibahara-cho, Toyonaka, Osaka, Japan 10 Department of Surgery, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan * These authors have contributed equally to this work Correspondence to: Masanori Terashima, email: // Keywords : stomach neoplasm, DNA topoisomerase II alpha, gamma-glutamyl hydrolase, CD31 Received : September 24, 2016 Accepted : February 12, 2017 Published : March 04, 2017 Abstract Background: To identify factors related to relapse sites, we carried out an exploratory biomarker analysis of data from the Adjuvant Chemotherapy Trial of TS-1 for Gastric Cancer study, which is a randomized, controlled trial comparing postoperative adjuvant S-1 therapy with surgery alone in 1,059 patients with stage II/III gastric cancer. Patients and Methods: Surgical specimens from 829 patients were retrospectively examined, and 63 genes involved in a variety of biological processes were analyzed by quantitative real-time PCR. Gene expression normalized to reference genes was categorized as lower or higher than the median, and association with relapse sites was analyzed based on 5-year relapse-free survival. Results: Hematogenous, lymph node, and peritoneal recurrence developed in 72, 105, and 138 of the 829 patients, respectively; hazard ratios were 0.79 (95% confidential interval: 0.54–1.16), 0.51 (0.31–0.82), and 0.60 (0.42–0.84), respectively. Expression of platelet/endothelial cell adhesion molecule 1 (PECAM1) and topoisomerase II alpha ( TOP2A ) was strongly correlated with hematogenous recurrence and peritoneal recurrence, respectively (false discovery rate = 7.7×10 -5 and 0.002, respectively). Gamma-glutamyl hydrolase ( GGH ) expression was moderately correlated with lymph node recurrence (false discovery rate = 0.34). Relapse-free survival was worse in patients expressing high levels of PECAM1 (hazard ratio = 2.37, 1.65–3.41), TOP2A (hazard ratio = 2.35, 1.55–3.57), or GGH (hazard ratio = 1.87, 1.13–3.08), respectively. A multivariate analysis revealed that these were stronger independent risk factors than tumor histological type. Conclusion: In patients with stage II/III gastric cancer, TOP2A , GGH , and PECAM1 levels in primary tumors are linked to high risk of hematogenous, lymph node, and peritoneal recurrence, respectively.