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The patient was a 81-year-old female with a history of treatment for the right breast cancer 29 years earlier. She presented with a chief complaint of dyspnea. CT showed pleural effusion and a mediastinal tumor. A biopsy was performed on the mediastinal tumor, and not only pathological but also immunohistological examination findings were similar to those of the surgical specimens 29 years ago. In view of the patient's age, we initiated treatment by anastrozole. The treatment was effective, and other forms of endocrine therapy were administered. She continued to be treated with the endocrine therapy over 4.5 years. The late recurrence of breast cancer in the form of carcinomatous pleurisy 29 years postoperatively is rare.

Objective The crural diaphragm is responsible for pulmonary ventilation in the early period after lobectomy. However, the role of its thickness in pulmonary ventilation remains unclear. We investigated the impact of crural diaphragm thickness on pulmonary oxygenation and gas exchange early after lobectomy. Methods We enrolled 32 patients with non-small-cell lung cancer who underwent video-assisted thoracoscopic lobectomy. Crural diaphragm thickness was defined as the average of the maximum thicknesses of the right and left crural diaphragm at the level of the median arcuate ligament on computed tomography. Pulmonary oxygenation and gas exchange were evaluated by the ratio of arterial oxygen tension/fraction of inspiratory oxygen and alveolar-arterial oxygen difference on the second postoperative day. Results Crural diaphragm thickness of 7.0 ± 1.7 mm was associated with vital capacity. After lobectomy, arterial oxygen tension/fraction of inspiratory oxygen decreased significantly and alveolar-arterial oxygen difference increased significantly. Five patients with oxygen saturation via pulse oximetry ≤92% had a lower arterial oxygen tension/fraction of inspiratory oxygen and higher alveolar-arterial oxygen difference than the others. Crural diaphragm thickness in these patients was less than in the others (5.5 ± 1.9 vs. 7.3 ± 1.5 mm, p = 0.033). In multivariate analysis, crural diaphragm thickness remained an independent factor affecting arterial oxygen tension/fraction of inspiratory oxygen and alveolar-arterial oxygen difference ( p = 0.044, p = 0.049). Crural diaphragm thickness was positively associated with arterial oxygen tension/fraction of inspiratory oxygen and negatively associated with alveolar-arterial oxygen difference. Conclusion Crural diaphragm thickness affects pulmonary ventilation early after lobectomy.

BackgroundDesmoplastic fibroblastoma is an uncommon, benign, fibrous tumor exhibiting infiltrative growth. Most of these tumors are small, slow-growing, and develop as subcutaneous lesions in the extremities. Cases of desmoplastic fibroblastoma in the chest wall are quite rare, and the preoperative diagnosis of such cases remains challenging as these tumors can mimic the characteristics of desmoid-type fibromatosis, which often occurs in the chest wall. We aimed to describe a rare case of desmoplastic fibroblastoma exhibiting rapid growth in the chest wall of a patient that was successfully treated with marginal excision only by diagnostic imaging before surgery.Case presentationA 79-year-old man was admitted to our hospital after experiencing right shoulder pain lasting for a few months. A 4 × 4 × 2 cm mass was incidentally detected at the right second rib two years prior. Chest computed tomography revealed a well-defined homogeneous mass with a muscle-like density along the right lateral chest wall, the size of which had increased to 12 × 10 × 4.5 cm in two years. Dynamic contrast-enhanced computed tomography revealed abundant vascularity at the periphery of the tumor. Magnetic resonance imaging revealed iso-intensity to muscle on T1-weighted images, slightly high intensity on T2-weighted images, and rim-like contrast enhancement at the periphery of the tumor, with uniform thickness on gadolinium-enhanced T1-weighted images with fat suppression. Rim-like contrast enhancement is an imaging feature that can distinguish cases of desmoplastic fibroblastoma from desmoid-type fibromatosis. We diagnosed the tumor as desmoplastic fibroblastoma by diagnostic imaging without tissue biopsy. Marginal excision with videoscopic assistance was performed through a small incision. The pathological diagnosis was desmoplastic fibroblastoma. The patient’s postoperative course was uneventful, and his shoulder pain was relieved after the surgery.ConclusionsDesmoplastic fibroblastoma in the chest wall is extremely rare, but should be considered in the differential diagnosis when desmoid-type fibromatosis is clinically suspected. Gadolinium-enhanced magnetic resonance imaging is helpful in confirming the differential diagnosis.

Case 1: A 68-year-old woman was diagnosed with advanced HER2-positive breast cancer(T2N2aM0, cStage ⅢA). She was treated with 4 courses of preoperative chemotherapy with pertuzumab, trastuzumab, and docetaxel. She was diagnosed to have achieved partial remission(PR), and subsequently underwent a mastectomy and axillary dissection. Pathological examination revealed smaller than 1 mm(Grade 2b). Case 2: A 59-year-old woman was diagnosed with advanced HER2-positive breast cancer(T4bN1M0, cStage ⅢB). She was treated with 4 courses of preoperative chemotherapy with pertuzumab, trastuzumab, and docetaxel. She was diagnosed to have achieved PR(primary lesion: complete remission), and subsequently underwent a mastectomy and axillary dissection. Pathological examination revealed complete pathological response(Grade 3). Combination therapy with pertuzumab, trastuzumab, and docetaxel appears to be a useful preoperative chemotherapy regimen for locally advanced HER2-positive breast cancer.

Pancreatic cancer in young adults is very rare. We report a case of young-onset poorly differentiated pancreatic ductal adenocarcinoma with rapid progression and poor prognosis in a 31-year-old Japanese man with no obvious family history of malignancy. Preoperative examinations revealed a mass lesion in the body of the pancreas, accompanied by a slightly dilated main pancreatic duct distal to the mass lesion. Pancreatic cancer with acute pancreatitis was suspected because of an elevation of serum pancreatic enzyme and tumor marker, along with imaging findings. Distal pancreatectomy with resection of the common hepatic artery and splenectomy along with lymph node dissection was performed. Microscopically, the tumor was mainly composed of poorly differentiated ductal adenocarcinoma. The postoperative course was uneventful, but the patient had multiple liver metastases 2 months postoperatively, in spite of adjuvant chemotherapy, and died 8 months postoperatively. This case may represent a rare instance of young-onset poorly differentiated ductal adenocarcinoma with rapid progression and may indicate potential risk factors of pancreatic cancer in young adults.

ミトコンドリアの機能異常により発症する神経筋疾患をミトコンドリア脳筋症（MELAS）とよぶが，その機能不全は骨格筋と中枢神経症状だけでなく，内分泌，腎，心，消化器症状などがみられる．われわれはS状結腸粘膜壊死を伴ったミトコンドリア脳筋症を経験したので報告する．症例は以前にMELASと診断されていた53歳の女性．腹痛および吐き気で発症し，大腸ファイバー上，広範なS状結腸粘膜壊死が認められ，左半結腸切除術を施行した．本症例での虚血性変化以外の形態学的異常として，i）固有筋層の外縦層の萎縮，ii）筋層間神経叢におけるガングリオン細胞の変性や脱落・減少，iii）血管壁の厚さに異常が認められた．i）およびii）は，文献的にもMELASによる変化として報告されており，本症例もMELASによって虚血性変化が起こったと考えられる．MELASの治療法がない以上，今後も厳重なfollowが必要と思われた．

A 65-year-old woman with a right breast tumor and right arm pain was seen in our hospital. She was diagnosed with scirrhous carcinoma (Stage IV, hormone receptor-positive, and HER2-negative) with pleural effusion and metastasis to the lung, liver, bone, and multiple lymph nodes. Systemic chemotherapy with biweekly bevacizumab and weekly paclitaxel was administered, and an opioid (oxycodone 40 mg/day) was administered for pain control. At the end of the first course, the patient's pain was improved, and the opioid dose was reduced (oxycodone 20 mg/day). The patient had a partial response (PR) over 24 treatment courses (1 year 10 months), and good pain control was obtained. Bevacizumab and paclitaxel therapy successfully brought about a rapid and good response and improved the patient's quality of life as palliative chemo- therapy.

A 59-year-old woman with an exudative, reddish bilateral breast tumor and dyspnea visited our hospital. She was diagnosed as having scirrhous carcinoma with metastasis to the liver and pleural effusion, designated as Stage IV, hormone receptor positive, and human epidermal growth factor receptor-2 (HER2) negative. Systemic chemotherapy (3 regimens) and endocrine therapy (5 regimens) were administered for a total of 5 years 7 months. Eribulin was administered as fourth line systemic chemotherapy. The pleural effusion reduced and dyspnea improved. Her status was maintained for 1 year 3 months. This case suggests that eribulin may provide long-term survival and maintenance of quality of life (QOL) in metastatic breast cancer patients.

食道平滑筋腫は食道良性腫瘍のうちでは最も頻度の高い疾患であるが,画像診断の発達した今日においても平滑筋肉腫との鑑別は困難であり,粘膜下腫瘍の内視鏡的生検での良悪の診断も困難であると言われている.悪性を示唆する所見としては,潰瘍の形成,腫瘍の増殖速度が速いことなどが挙げられる.今回われわれは,潰瘍形成を伴った稀な食道平滑筋腫を経験した. 本症例は,腫瘍サイズおよび内視鏡的生検からは良性の平滑筋腫と考えられたが,腫瘍頂部に潰瘍を伴っていたため悪性の可能性もあり,手術適応と判断した. 手術は,本症例の場合,腫瘍が粘膜筋板由来であり,頂部に潰瘍形成もあったこともあり,腫瘍を含めた食道壁の模状切除をVATSにて行った.食道粘膜下腫瘍のVATS手術は,内視鏡下にバルーンを用いて腫瘍を突出させることが重要なポイントであるが,本症例のように腫瘍が小さい場合には,特に内視鏡担当医師との密な連係が必要である.

症例は45歳の女性.腹部膨満感を主訴に当院を受診.卵巣癌・腹水貯留の診断にて2000年6月1日に産婦人科で手術を施行し,後腹膜の広範囲な線維化を認めた.右乳腺腫瘍も伴っていたため,外科転科の上で6月14日に右乳房切除術と開腹生検術を施行した.病理組織学的には,乳腺浸潤性小葉癌からの腹膜播種と診断された.術後にCEF療法(CPA, EPI, 5-FU)とMPA投与を行ったところ腹水が消失したため,退院.以後は外来で同療法を継続している.開始後約1年6カ月経過し,再燃は認めていない. 浸潤性小葉癌は,本邦では比較的稀な疾患である.特異的な転移形式として腹膜播種や後腹膜転移,卵巣転移をきたすことがある.本症例のように特異な経過をたどることがあるため,注意を払う必要がある.

Patients who have undergone major surgery such as esophagectomy may develop peripheral edema in the immediate postoperative period, the cause of which is not fully understood. The purpose of this study was therefore to determine the mechanism of this phenomenon. Finger edema was measured as a marker for peripheral edema before and after esophagectomy in eight patients. Plasma interleukin-6 (IL-6) was also measured by an enzyme-linked immunosorbent assay. Finger edema markedly increased in the immediate postoperative period and remained significantly elevated until after postoperative day (POD) 3 compared to the preoperative value (P0.05). Plasma IL-6 also markedly increased in the immediate postoperative period and remained significantly elevated on POD 2 compared to the preoperative value (P0.05). The degree of finger edema highly correlated with the level of plasma IL-6 (r = 0.71, P = 0.0001). These findings indicate that peripheral edema after esophagectomy might be caused by a proinflammatory cytokine response.

食道癌術後早期には呼吸機能低下を認めるが, その原因については十分検討されていない. 今回, 我々は食道癌術後早期の呼吸機能低下を呼吸筋力の面から検討した. 1995年2月から9月の間に右開胸, 胸腹部食道全摘, 後縦隔経路頸部食道胃管吻合術を施行した食道癌患者13例を対象とした. 呼吸筋力の指標として最大吸気口腔内圧 (MIP) と最大呼気口腔内圧 (MEP), 骨格筋力の指標に握力を, 術前日, 第3, 4, 5, 6, 7, 14, 21病日に測定した. MIP, MEPは, それぞれ第3病日で術前の42-2%, 34.7%と有意な低下を認め, 21病日には87.2%, 86l4%に回復し, FVC, FEV1.0との間にそれぞれ有意な相関を認めた. 一方, 握力はMIP, MEPとの問に強い相関を認めなかった. 以上の結果から術後呼吸機能評価の指標としてMIP, MEPは有用と考えられ, 食道癌術後早期の呼吸機能低下には骨格筋力など全身的因子よりも呼吸筋障害, 肺・胸郭complianceの低下など局所的要因が強く影響していると推測された.

食道癌患者の退院後の栄養状態の改善を目的として1989年より導入した在宅経腸栄養補助 (home enteral nutritional support: HENS) の意義について, 根治術を受けた51例を対象とし検討した. HENSは42例 (82%) に平均486kca1で5.4か月間投与されていた. 結果: 体重は退院時のレベルで推移した. 理想体重比 (%IBW, 入院時90%, 退院時87%), 健常時体重比 (%UBW, 入院時97%, 退院時93%) も退院時のレベルを維持できた. 血清総蛋白 (TP), アルブミン値 (Alb), 総コレステロール値の回復も良好であった. 一方, 上腕三頭筋部皮下脂肪厚 (%TSF) は約70%の例が中-高度の低下を呈した. 上腕筋囲 (%AMC) の低下は軽度であった. 結論: 退院後の体重減少が防止でき, 血液検査成績も良好であったことからHENSは有用であった. TP, Alb, %AMCに比較して%TSFの低下は著しく, 体脂肪を消費し体蛋白や内臓蛋白を維持するのが, 食道癌患者の退院後の栄養状態の本態と考えられる. %TSFの低下を防止すべく, %IBWや%UBWを目安とする入院直後からのより積極的な栄養管理が今後の課題である.

The patient was a 48-year-old male with a right subclavicular tumor. The pathological diagnosis showed primitive neuroectodermal tumor(PNET)because of the rosette formation and the positive neurogenic marker.Radiation was administered at a total dose of 50 Gy, because surgical resection would induce the loss of right arm function. CT examination demonstrated a reduction of the primary tumor and new multiple lung metastases. The patient received intravenous AI regimen(ADM and IFM). After the 7th course, both the primary tumor and multiple lung metastases decreased. AI regimen might be effective for PNET.

This paper considers a high-performance architecture for Variable Length Instructions (VLI) and its evaluation. The VLI studied here are characterized by a multioperand which can treat several independent operands, and orthogonality which can specify the operand address independently of the operation code. This architecture consists of the pipeline processing method suitable for multioperand instruction format, instruction/data separate-type dual cache memory configuration to obtain memory throughput necessary for efficient operation of pipeline, and the operand location-free microprogramming method with virtualized operand interface. The basic ideas of the pipeline processing method are the operand specifier (OSP) based pipeline processing which is realized by Inter-OSP based pipeline processing and two simultaneously processing OSPs. From the mixed value analysis and the simulation result, it is clarified that this architecture makes it possible to improve the performance 1.8 times faster than without it. The additional hardware increase for this architecture is 33%.