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Background: Takotsubo cardiomyopathy (TCM) is a nonischemic cardiomyopathy characterized by chest pain, typically manifesting transient left ventricular (LV) apical akinesis, and ischemic electrocardiographic changes, mimicking acute coronary syndrome (ACS). Although ventricular septal perforation (VSP) is a rare complication of TCM, it is potentially life-threatening if left untreated. Whether the conventional electrocardiographic criteria for TCM are beneficial, even in patients of TCM with VSP, remains unclear., Case Presentation: An 87-year-old woman was admitted for worsening dyspnea. Elevated serum cardiac enzyme levels, LV dysfunction on echocardiography, and ST-segment elevation in leads V1-4 on electrocardiogram were initially suggestive of ACS. An emergency coronary angiography revealed 90 % focal stenosis of the mid-portion of the right coronary artery (RCA) with Thrombolysis in Myocardial Infarction flow grade 2. However, left ventriculography revealed LV apical ballooning with a coexisting left-to-right shunting, which was beyond single RCA distributions, leading to a final diagnosis of TCM with VSP. Repeat echocardiography confirmed VSP and right ventricular involvement with severe pulmonary hypertension. Following successful percutaneous coronary intervention with a drug-eluting stent for RCA stenosis, the patient was managed with medical treatment without surgical intervention. Eventually, VSP and associated pulmonary hypertension markedly improved along with the normalization of the patient's cardiac structure and function. The patient's clinical course was uneventful at the 1-year follow-up., Conclusions: Herein, we describe the case of TCM with VSP that we successfully managed with medical treatments. Our case highlights the significance of elucidating this rare complication of TCM, pitfalls of the conventional electrocardiographic diagnostic criteria for TCM, and potential of this unique electrocardiographic pattern for identifying TCM-associated VSP., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Coronavirus disease (COVID-19)-associated acute pericarditis has recently received much attention owing to its high frequency associated with pericardial tamponade (PT), showing unfavorable prognosis. However, early diagnosis and treatment remain challenging in cases of non-specific signs and symptoms., Case Presentation: A 64-year-old man was admitted to our hospital for acute osteomyelitis of the toes and was properly treated with antimicrobial agents. Three days after admission, the patient developed mild COVID-19 without pneumonia, for which early anti-COVID-19 agents were initiated. Nevertheless, the patient developed hemorrhagic PT due to acute pericarditis 2 weeks later, which was confirmed by cardiac magnetic resonance, requiring an urgent pericardiocentesis. Although cytological analysis of the hemorrhagic pericardial fluid strongly suggested adenocarcinoma, the atypical cells were eventually proven to be mesothelial cells with reactive atypia. Furthermore, lymph nodes swelling with abnormal 2-[18F]-fluoro-2-deoxy-D-glucose accumulation on imaging were suggestive of malignancy. However, biopsy examination revealed multiple non-caseating granulomas in the lymph node, unlikely due to malignancy. Eventually, the temporal association of the preceding COVID-19 with the occurrence of subacute PT without other identifiable cause led to a final diagnosis of COVID-19-associated acute pericarditis. With anti-inflammatory and corticosteroids treatment, the patient's symptoms involving the pericardial structure and function were completely resolved along with improvements in size of the affected lymphadenopathies., Conclusions: We encountered a unique case of COVID-19-associated acute pericarditis exhibiting hemorrhagic PT. This case underscores the residual risk of delayed pericardial involvement even in patients with mild COVID-19 who receive early treatment, and the recognition that COVID-19 may cause various cytomorphological and histological features. Additionally, the importance of considering this rare entity as a cause of hemorrhagic pericardial effusions should be highlighted., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Yamamoto, Kume, Hashimoto, Isogai, Kuwabara, Noguchi, Murayama, Hashimoto and Ogino.)

The patient is a 74-year-old woman. She had breast cancer(invasive ductal carcinoma, ER[+], PgR[+], HER2[-], Ki-67: 30-40%)and primary right lung cancer with lumbar metastasis, which led to the diagnosis synchronous double cancers of the breast and the lung. We decided to precede surgery for lung cancer because breast cancer was indicated hormonal receptor positive. Breast cancer is treated with anastrozole, thoracoscopic right upper lobectomy was performed for the lung cancer. Radiation therapy was performed for metastatic bone tumors. 13 months later, partial mastectomy sentinel lymph node biopsy performed. The histopathological diagnosis of breast cancer was pT2, pN0, cM0, pStage ⅡA, and histological response was Grade 2a. The remaining breast was treated radiation therapy. The breast cancer has not recurred and is doing well 6 months after surgery. As for primary lung cancer, 19 months have passed since surgery, and the patient is in complete remission without recurrence.

An 88-year-old man underwent thoracoscopic lower lobectomy for left lung cancer at the age of 87. Ten months later, he was examined closely for abdominal distention, frequent constipation, and anemia with a decreased Hb of 6.1 g/dL. The CT scan revealed an irregular tumor with contrast effect. The patient was diagnosed with malignant tumor of small intestine. At laparotomy, a tumor of 5 cm in diameter was found in the jejunum, and small bowel resection was done. Pathological examination revealed that the tumor was a metastasis of lung cancer. Seven months later, the patient is currently an outpatient, with no evidence of cancer recurrence.

Background: We describe a case of segmental arterial mediolysis in which a vessel ruptured on two consecutive days., Case Presentation: A 69-year-old man presented with sudden-onset abdominal pain. Computed tomography showed a hematoma in the gastric wall. The patient was discharged after the pain was relieved but returned 8 h later with abdominal pain and shock. Repeated computed tomography revealed a massive intra-abdominal hemorrhage without previous aneurysm formation. Emergency angiography and coil embolization were successfully carried out. Segmental arterial mediolysis was diagnosed after irregular vasodilated lesions were observed in multiple arteries., Conclusion: This case suggests that accurately predicting the next vessel rupture is difficult. For patients experiencing intra-abdominal bleeding with segmental arterial mediolysis, we suggest treating only ruptured aneurysms and closely following-up unruptured aneurysms., Competing Interests: The authors declare no conflict of interests for this article., (© 2023 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Background: Transient constrictive pericarditis (TCP) is a distinct constrictive pericarditis (CP) subtype characterized by acute pericardial inflammation and transient constrictive physiology. If left untreated, it may progress to irreversible CP requiring pericardiectomy. However, making an early diagnosis of TCP remains difficult., Case Presentation: A 51-year-old man presented with fever, chest pain, and dyspnea following preceding flu symptoms. An initial investigation suggested right-sided heart failure. Laboratory results revealed elevated inflammatory markers and hepatic enzyme levels. Echocardiography revealed pericardial effusion with a normal ejection fraction and diastolic ventricular septal bounce suggestive of pericardial constriction. Computed tomography suggested acute descending mediastinitis with pericarditis and pleuritis; however, detailed examinations ruled out this possibility. The constellation of increased serological inflammation, pericardial thickness/effusion, and constrictive physiology suggested TCP, confirmed by cardiac magnetic resonance (CMR) and hemodynamic studies. CMR also revealed coexistent myocarditis. After a thorough assessment for the cause of TCP, a viral etiology was suspected. Paired serology for virus antibody titers revealed a significant increase only in coxsackievirus A4 (CVA4) titers. With prompt anti-inflammatory treatment, the patient's pericardial structure and function and concomitant inflammation of the surrounding tissues were nearly completely recovered, leading to a final diagnosis of TCP caused by CVA4. The subsequent clinical course was uneventful without recurrence at the 1-year follow-up., Conclusions: Here we described the first case of TCP caused by CVA4 concurrent with mediastinitis, myocarditis, and pleuritis, all of which were successfully resolved with anti-inflammatory treatment. Acute mediastinitis secondary to TCP is rare. This case highlights the clinical importance of assessing pericardial diseases as a source of acute mediastinitis and considering CVA4 as an etiology of TCP. An evaluation including multimodal cardiac imaging and serology for virus antibody titers may be useful for an exploratory diagnosis of TCP in right-sided heart failure patients with pericardial effusion., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: For pharmacists expected to encounter the deaths of many of their patients in the near future, it is important to understand the perception of a "good death" for patients with cancer who are likely to be aware of the circumstances of their poor prognosis. In this study, we clarified pharmacists' perceptions of a "good death" and considered the differences in perception among patients with cancer, oncologists, and oncology nurses., Methods: From April to June 2022, an anonymous questionnaire survey was conducted on pharmacists working in hospitals and pharmacies and on members of the Japanese Society for Pharmaceutical Palliative Care and Sciences. The questionnaire consisted of 57 questions, called attributes, developed by Miyashita et al. to investigate the perception of "good death" in Japanese cancer medicine. The importance of those attributes was investigated using a 7-point Likert scale., Results: Three thousand four hundred thirty-two pharmacists were made aware of this survey, and 207 participated in the survey. The responses of pharmacists to the 57 questions were very similar to those of the oncologists. Among them, "Fighting against disease until one's last moment" and "Not making trouble for others" had very low importance, which was the most significantly different from the responses of patients with cancer. "Fighting against disease until one's last moment" tended to be significantly underestimated by pharmacists engaged in patient guidance and interview compared to that by pharmacists not engaged in the duty (p = 0.02). Also, when we compared pharmacists with or without qualifications related to cancer and palliative care, there was no significant difference in the importance of "Fighting against disease until one's last moment." However, the importance of "Not making trouble for others" for qualified pharmacists was significantly underestimated (p = 0.04)., Conclusion: Since pharmacists understand the limits of chemotherapy, they may want to be close to the patient but may not strongly agree with the "Fighting against cancer" component that patients with cancer prefer. It may be necessary to reconsider better ways of approaching the wishes and satisfaction of patients with cancer under the care of medical professionals in the field of oncology., (© 2023. The Author(s).)

The patient underwent partial sigmoid colon resection for sigmoid colon cancer with hyper CEA blood(1,110.6 ng/mL) and concurrent liver metastases mostly in the right lobe of the liver, followed by systemic chemotherapy(SOX plus BEV). Seven courses of chemotherapy resulted in PR on imaging, and CEA was reduced to 5.0 ng/mL, which was within reference values. As he continued chemotherapy, frequent hematologic toxicities and adverse events forced frequent dose reductions and changes in the chemotherapy schedule. About 2 years after surgery(19 courses of SOX plus BEV), the liver metastases became slightly enlarged on imaging, and the CEA was also increasing. The patient did not wish to undergo systemic chemotherapy and requested hepatic arterial infusion chemotherapy(HAIC), which has relatively few side effects and adverse events. HAIC with pyrimidine fluoride alone is ongoing for 22 courses, and tumor markers have decreased again with PR on imaging. Performance status has been good without hematologic toxicity or adverse events for approximately 1 year during the course of HAIC. HAIC is a weakly recommended therapy in the colorectal cancer treatment guidelines, but it is considered one of the most effective therapies with relatively few side effects.

The patient was a 79-year-old man with complaints of defecation difficulties and constipation. CT scan showed a 7.5 cm diameter mass in the lower rectum, and biopsy revealed GIST. MRI findings suggested prostate invasion, and the patient was started treatment with imatinib. Six months later, the tumor shrank to 4.5 cm in diameter. However, the patient refused surgery and continued taking Imatinib. The tumor continued to shrink gradually. Currently, 7 years later at the age of 86, it is only 2 cm in diameter and its inside has almost completely been replaced with calcifications.

Infectious aortic aneurysm (IAA) can be a rare but potentially fatal sequela of infectious inflammatory disease of the aortic wall with a high incidence of rupture. The definitive diagnosis is based on vascular imaging of the aneurysm using contrast-enhanced computed tomography (CE-CT) and identification of the causative microorganism from positive blood cultures (BCs). However, IAA remains extremely difficult to diagnose and treat in patients with prior antimicrobial treatment or with renal dysfunction. Here we describe a case of an 85-year-old woman with IAA caused by Arthrobacter russicus presenting with abdominal pain and fever that was initially diagnosed as a presumptive urinary tract infection and treated with empiric antimicrobial therapy. However, persistent abdominal pain with increased serological inflammation necessitated further evaluation. Unenhanced multimodality imaging considering the renal dysfunction revealed infectious aortitis of the infrarenal abdominal aorta, together with the initial culture results, leading to the tentative diagnosis of Klebsiella pneumoniae aortitis. Thereafter, serial monitoring with unenhanced magnetic resonance angiography (MRA) using thin-slab maximum intensity projection (TS-MIP) revealed acute aortic expansion strongly suggestive of a pseudoaneurysm that was successfully treated with early surgical repair under adequate infection control. Despite negative Gram staining and tissue culture results for the excised aortic wall, a definitive diagnosis of IAA secondary to A. russicus rather than K. pneumoniae was finally made by confirming the histologic findings consistent with IAA and the identification of A. russicus 16S rRNA on the resected aortic wall. The patient also developed a vascular graft infection during the postoperative course that required long-term systemic antimicrobial therapy. This case highlights the value of unenhanced MRA in the early detection of IAA in patients with renal dysfunction and the importance of a molecular diagnosis for identifying the causative microorganism in cases of culture- or tissue-negative IAA., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Yamamoto, Fukushima, Ikeda, Suda, Goto, Isogai, Hashimoto, Takahashi and Ogino.)

The novel coronavirus disease (COVID-19) has resulted in a global pandemic. Recently, COVID-19-related pneumothorax has gained attention because of the associated prolonged hospital stay and high mortality. While most cases of pneumothorax respond well to conservative and supportive care, some cases of refractory pneumothorax with persistent air leaks (PALs) do not respond to conventional therapies. There is a lack of evidence-based management strategies to this regard. We describe the case of a 73-year-old man with COVID-19-related acute respiratory distress syndrome (ARDS) who developed delayed tension pneumothorax with PALs caused by alveolopleural fistulas. Despite chest tube drainage, autologous blood pleurodesis, and endoscopic procedures, the PALs could not be closed, and were complicated by thoracic empyema. Subsequent minimally invasive open-window thoracostomy (OWT) with vacuum-assisted closure (VAC) therapy helped successfully control the refractory PALs. Serial chest computed tomography monitoring was useful for the early detection of the pneumothorax and understanding of its temporal relationship with air-filled lung cysts. Our case provides a new perspective to the underlying cause of refractory pneumothorax with PALs, secondary to COVID-19-related ARDS, and underscores the potential of OWT with VAC therapy as a therapeutic alternative in such cases., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Konagaya, Yamamoto, Nishida, Morita, Suda, Isogai, Murayama and Ogino.)

Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis involving small-to-medium-sized vessels characterized by asthma, vasculitis, and peripheral eosinophilia. EGPA-associated eosinophilic myocarditis (EM) occurs rarely, yet can be fatal if left untreated. Moreover, the accurate diagnosis of EGPA-associated EM without vasculitis is exceptionally difficult because of the overlapping features with EM of other causes. We report a case of probable EGPA with subclinical neurological involvement that presented with acute EM. The constellation of peripheral eosinophilia, left ventricular dysfunction, and normal epicardial coronary arteries raised suspicion of acute EM, which was confirmed by cardiac magnetic resonance (CMR) investigation and endomyocardial biopsy (EMB). Prompt systemic administration of corticosteroids completely restored and normalized myocardial structure and function. Although the patient's history suggested the presumed hypersensitivity myocarditis, EMB revealed EM without vasculitis, not hypersensitivity, leading to a tentative diagnosis of idiopathic hypereosinophilic syndrome. Interestingly, the characteristic findings of vasculitis on CMR imaging strongly suggested EGPA-associated EM. Although the patient had no clinical neurological manifestations, a nerve conduction study confirmed mononeuritis multiplex, leading to the final diagnosis of probable EGPA. Therefore, this case highlights the diagnostic challenge associated with EGPA and the diagnostic synergy of CMR and EMB for an exploratory diagnosis of EGPA-associated EM., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Yamamoto, Hashimoto, Ikeda, Isogai and Hashimoto.)

Vaccine-associated myocarditis (VAM) is a rare entity but can result in potentially serious sequelae if left untreated. However, the mechanisms of the complications of VAM and its treatment remain unclear. Herein, we report the first case of VAM related to pneumococcal immunization, presenting as a local and systemic inflammatory reaction, in which the patient developed significant secondary mitral regurgitation, resulting in acute heart failure. Finally, the patient recovered completely following corticosteroid treatment. This case highlights the value of cardiac magnetic resonance and the pitfall of endomyocardial biopsy in establishing the definitive diagnosis of VAM and emphasizes the importance of optimal management in understanding the mechanism and instituting the treatment for secondary mitral regurgitation caused by VAM., (© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Emphysematous prostatic abscess (EPA) is an extremely rare but potentially fatal urinary tract infection (UTI). Here, we describe a case (a 69-year-old male with prediabetes) of ruptured EPA caused by a hypervirulent Klebsiella pneumoniae (hvKp) K1-ST23 strain, presenting as motor aphasia. Our patient presented with ruptured EPA concurrent with various severe systemic pyogenic complications (e.g., urethro-prostatic fistula, ascending UTIs, epididymal and scrotal abscesses, and liver, lung, and brain abscesses). Whole-body computed tomography (CT) and next-generation sequencing (NGS) were useful for the detection of ruptured EPA and its systemic complications, and for identification of K1-ST23 hvKp strains, respectively. Subsequently, the infections were successfully treated with aggressive antimicrobial therapy and multiple surgical procedures. This case highlights the significance of awareness of this rare entity, the clinical importance of CT for the early diagnosis of EPA and the detection of its systemic complications in view of hvKp being an important causative organism of severe community-acquired UTI, and the usefulness of NGS to identify hvKp strains., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Konagaya, Yamamoto, Suda, Tsuda, Isogai, Murayama, Arakawa and Ogino.)

The patient was a 29-year-old female with a chief complaint of transient right-sided abdominal pain. A CT scan revealed homogenously contrasted tumor of 4 cm in diameter with smooth margins and clear borders in the lower part of the pancreatic head. The tumor was contrast-enhanced on MRI and stained on abdominal angiography using the proximal branch of the right colonic artery as a feeding vessel. PET scan showed moderate accumulation. Malignancy could not be ruled out, and tumor resection including the ascending colon was performed. The pathological diagnosis was hyaline vascular-type Castleman's disease in the mesentery of the colon.

Eosinophilic myocarditis is a rare subtype of myocarditis characterized by myocardial eosinophilic infiltration, and it is potentially fatal if left untreated. Although endomyocardial biopsy (EMB) is a cornerstone for the histological diagnosis of acute eosinophilic myocarditis (AEM), as it is an invasive procedure and has a low diagnostic accuracy, the diagnosis of AEM with hemodynamic instability remains challenging. We describe a case of AEM presenting as low-flow heart failure with preserved ejection fraction (HFpEF), with rapid progression to cardiogenic shock. The constellation of peripheral eosinophilia, increased left ventricular wall thickness, and HFpEF raised the suspicion of AEM. Contrast-enhanced computed tomography (CT) scan revealed heterogeneous hypoenhancement localized in the basal-to-mid septal and mid anterolateral walls of the left ventricle, strongly suggestive of acute inflammation. Based upon these findings, we performed CT-guided EMB, which lead to a definitive diagnosis. Subsequent high-dose corticosteroids allowed a rapid and dramatic recovery and normalization of cardiac structure and function. This case highlights the clinical importance of assessing AEM as a rare cause of HFpEF and the usefulness of CT-guided EMB in patients with hemodynamic instability., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Aota, Yamamoto, Isogai, Imanaka-Yoshida, Hiroe and Tanaka.)

90 Y-Ibritumomab tiuxetan (IT) therapy is a radioimmunotherapy for indolent B-cell lymphoma. Several predictors of insufficient therapeutic effects have been reported. We performed a retrospective study at a single institute to investigate whether 111 In SPECT/CT can predict the therapeutic effects and grade of cytopenia due to 90 Y-IT therapy. We enrolled 16 consecutive patients who underwent 90 Y-IT therapy, including 15 who underwent 111 In-IT SPECT/CT. After 90 Y-IT therapy, there were 4 patients in complete remission in whom the lesion SUV max on 111 In-IT SPECT/CT and soluble IL-2 receptor were significantly lower than those of the other patients (P<0.05 and P<0.05, respectively). Based on the log-rank test of factors associated with the progression-free survival (PFS), ≥2 previous treatment regimens was significantly associated with a poor prognosis (P<0.05). The SUV on 111 In-IT SPECT/CT may be a good predictor of the clinical response to 90 Y-IT therapy.

A 68-year-old man having a descending colon cancer with multiple metastases of up to 9.5 cm in the right lobe of the liver(T3, N0, M1a)underwent laparoscopic colon resection for anemia control. Chemotherapy with mFOLFOX6 plus Bmab was administered postoperatively. Because this treatment had little effect, FOLFIRI plus Pmab was initiated 3 months later. A significant reduction in the tumor size was observed. Therefore, we performed laparotomy. However, the liver metastasis had invaded the inferior vena cava, which was not resectable. After the second surgery, we introduced the 5-FU hepatic arterial injection port ia plus Pmab iv, which was effective for 8 months. We then restarted chemotherapy with FOLFIRI plus Pmab. However, the tumor became more enlarged; therefore, we changed the chemotherapy regimen to SOX plus Bmab. Partial reduction in the tumor size was observed again, and the effects lasted for a while. The patient continued visiting the outpatient clinic with almost no symptoms for more than 1 year. He died of the primary cancer 3 years and 8 months after the first visit. We report a case of liver metastasis of colon cancer that could have been controlled successfully by repeatedly using the same pharmacotherapy.

Löffler's endocarditis (cardiac involvement in hypereosinophilic syndrome) is rare yet life-threatening if left untreated. We describe a case of hypereosinophilic syndrome presenting as a cardiac mass with an abnormal electrocardiogram. Diagnostic studies of the cardiac mass strongly suggested a malignant cardiac tumor invading the papillary muscle. Thus, excision of the cardiac mass and endomyocardial resection with mitral valve replacement were successfully performed. Pathology revealed various stages of thrombosis and irreversible myocardial damage caused by eosinophilic infiltration with no malignancy, leading to the correct diagnosis of late-stage Löffler's endocarditis. The subsequent combination of anticoagulation and corticosteroids was effective with a favorable outcome. This case highlights pitfalls in multimodality imaging of cardiac thrombus and the clinical significance of considering Löffler's endocarditis in the diagnostic work-up of a cardiac mass., (Copyright © 2020 Koyama, Yamamoto, Matsumoto, Isogai, Isomura and Tanaka.)

Background: Meigs' syndrome is a rare disease characterized by a triad of presentations, including benign ovarian tumor, ascites, and pleural effusion. However, a clinical diagnosis of Meigs' syndrome remains challenging because pleural and ascitic effusions can be common findings in a variety of underlying conditions. Furthermore, these findings can often be misdiagnosed as pleural and peritoneal dissemination caused by potentially malignant tumors, leading to the administration of improper treatment., Case Presentation: We described a case of an 85-year-old postmenopausal female patient with atypical Meigs' syndrome presenting with right-sided pleural effusion, notable leg edema, and trivial ascites, which was initially mistaken as heart failure with preserved ejection fraction. However, pleural effusion was totally ineffective against diuretic therapy. Subsequently, thoracentesis yielded serosanguineous exudative effusion. Moreover, refractory pleural effusions and abdominal/pelvic computed tomography and magnetic resonance imaging findings strongly suggested bilateral malignant ovarian tumors with pleural dissemination. Repetitive negative cytological results allowed the patient to undergo bilateral salpingo-oophorectomy. Finally, a definitive diagnosis of Meigs' syndrome was made by confirming the presence of a benign mitotically active cellular fibroma of the ovary by pathology and that pleural effusion resolved following tumor resection., Conclusions: Our case highlights the clinical importance of assessing Meigs' syndrome in the diagnostic workup of pleural effusion in postmenopausal female patients. Given the favorable prognosis of Meigs' syndrome, clinicians should consider surgical resection, even with potentially malignant ovarian tumors with accompanying pleural effusion, ascites, or both.

Immunoglobulin G4 (IgG4)-related pericarditis, an immune-mediated fibro-inflammatory condition, is a rare yet life-threatening disease presenting with constrictive pericarditis. We describe a case of IgG4-related pericarditis presenting with epicardial nodules successfully treated with corticosteroids. This case highlights the clinical significance of assessing IgG4-related pericarditis in the diagnostic workup of pericardial masses. ( Level of Difficulty: Advanced. )., (© 2020 The Authors.)

Coronary artery aneurysm (CAA) is potentially life-threatening. We describe a case of multiple giant CAAs and a single left gastric artery aneurysm caused by immunoglobulin G4-related disease (IgG4-RD). Our case highlights the significance of assessing IgG4-RD in the diagnosis of CAA and screening for other concurrent cardiovascular involvements. ( Level of Difficulty: Intermediate. )., (© 2020 The Authors.)

We report a case of a 61-year-old man with granulomatosis with polyangiitis (GPA) complicated with refractory optic neuritis and maxillary osteomyelitis. He had been treated with prednisolone (PSL) as cryptogenic organizing pneumonia in the respiratory department for 2 years. Afterward, he complained tenderness of paranasal sinuses and rapidly progressive visual loss of the left eye. Although both MPO-ANCA and PR3-ANCA were negative, he was diagnosed as GPA based on the American College of Rheumatology 1990 criteria. Ophthalmologic and oral examination revealed left optic neuritis and destructive maxillary bone. Magnetic resonance imaging (MRI) showed the optic neuritis and inflammation around the optic nerve. This finding suggested that the direct spread of inflammation from paranasal sinuses caused the optic neuritis. In a short time, increasing a dose of PSL and administration of intravenous cyclophosphamide were initiated. Antibiotics were also administered to treat sinusitis. Although his visual acuity of the left eye deteriorated to no light perception temporarily, it finally improved after treatment and findings of MRI were also improved. In contrast, destruction of maxilla bone had been progressing. This is a rare case of GPA complicated with optic neuritis due to sinusitis and maxillary osteomyelitis.

Background: This retrospective study examined the performance of computer-assisted detection in the identification of pulmonary metastases., Methods: Fifty-five patients (41.8% male) who underwent surgery for metastatic lung tumors in our hospital from 2005 to 2012 were included. Computer-assisted detection software configured to display the top five nodule candidates according to likelihood was applied as the first reader for the preoperative computed tomography images. Results from the software were classified as "metastatic nodule", "benign nodule", or "false-positive finding" by two observers., Results: Computer-assisted detection identified 85.3% (64/75) of pulmonary metastases that radiologists had detected, and 3 more (4%, 3/75) that radiologists had overlooked. Nodule candidates identified by computer-assisted detection included 86 benign nodules (median size 3.1 mm, range 1.2-18.7 mm) and 121 false-positive findings., Conclusions: Computer-assisted detection identified pulmonary metastases overlooked by radiologists. However, this was at the cost of identifying a substantial number of benign nodules and false-positive findings.

The is a case involving a 55-year-old man with advanced rectal cancer(type 3). MRI showed urinary tract and regional lymph node metastases without distant metastasis. The tumor was reduced(PR)after neoadjuvant chemotherapy(mFOL FOX6 plus Bmab, 4 courses). The patient underwent an abdominoperineal resection. Because infiltration of the tumor into the lower urinary tract was deep, it was also resected and repaired. The clip was placed to mark the repaired region. Pathological examination revealed that excision stump at the anterior wall of the urethra was cancer positive without lymph node metastasis. He was then administered chemotherapy(mFOLFOX6 4 courses)and irradiated 60 Gy in both sides of the inguinal lymph node to prevent metastasis to the pelvicdomain. One year and 6 months postoperatively, as the left inguinal lymph node swelled at 3.7 cm irregularly, he further received chemotherapy(FOLFIRI 8 courses). The size of the lymph node became normal with a good response to FOLFIRI. Six years postoperatively, he remains alive and well with no evidence of recurrence.

Purpose: To evaluate potential of a semiquantitative method using standardized uptake value (SUV) in 123 I-2β-carbomethoxy-3β-(4-iodophenyl)-N-(3-fluoropropyl) nortropane ( 123 I-FP-CIT) single photon emission computed tomography/computed tomography (SPECT/CT) compared with specific binding ratio (SBR)., Materials and Methods: First, we performed a phantom study to validate the accuracy of measuring SUV. 52 patients (25 male, 27 female; mean age of 75.1-year-old; 40 and 12 patients with neurodegenerative diseases with or without presynaptic dopaminergic deficits, respectively) were enrolled in a retrospective study. We measured SBR, maximum SUV, peak SUV, mean SUV, and striatum-to-background ratio of SUV (SUV ratio ) for striatum with lower 123 I-FP-CIT uptake using commercial software. We calculated Pearson's correlation coefficient between SBR and SUV. We also calculated the sensitivity, specificity, and accuracy of each parameter for differential diagnosis., Results: The phantom study revealed errors of <10% between theoretical and actual SUVs. Although there were significant correlations between SBR and all SUV-based parameters, SUV ratio showed the most strong correlation with SBR (r = 0.877, p < 0.001). However, diagnostic capability of SUV ratio (cutoff = 2.35) yielded to that of SBR (cutoff = 3.90) for diagnosing neurodegenerative diseases with presynaptic dopaminergic deficits (sensitivity of 85.0% vs 92.5%, specificity of 100% vs 91.7%, and accuracy of 88.5% vs 92.3%, respectively)., Conclusion: SBR is a promising parameter to aid differential diagnosis of neurodegenerative diseases with or without presynaptic dopaminergic deficit. Although technically acceptable, SUV may not be superior to SBR when clinically applied in 123 I-FP-CIT SPECT/CT., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Recently, semiquantitative analysis using standardized uptake value (SUV) has been introduced in bone single-photon emission computed tomography/computed tomography (SPECT/CT). Our purposes were to apply SUV-based semiquantitative analytic method for gallium-67 (Ga)-citrate SPECT/CT and to evaluate correlation between SUV of physiological uptake and blood test results in representative organs., Methods: The accuracy of semiquantitative method was validated using an National Electrical Manufacturers Association body phantom study (radioactivity ratio of sphere : background=4 : 1). Thereafter, 59 patients (34 male and 25 female; mean age, 66.9 years) who had undergone Ga-citrate SPECT/CT were retrospectively enrolled in the study. A mean SUV of physiological uptake was calculated for the following organs: the lungs, right atrium, liver, kidneys, spleen, gluteal muscles, and bone marrow. The correlation between physiological uptakes and blood test results was evaluated using Pearson's correlation coefficient., Results: The phantom study revealed only 1% error between theoretical and actual SUVs in the background, suggesting the sufficient accuracy of scatter and attenuation corrections. However, a partial volume effect could not be overlooked, particularly in small spheres with a diameter of less than 28 mm. The highest mean SUV was observed in the liver (range: 0.44-4.64), followed by bone marrow (range: 0.33-3.60), spleen (range: 0.52-2.12), and kidneys (range: 0.42-1.45). There was no significant correlation between hepatic uptake and liver function, renal uptake and renal function, or bone marrow uptake and blood cell count (P>0.05)., Conclusion: The physiological uptake in Ga-citrate SPECT/CT can be represented as SUVs, which are not significantly correlated with corresponding blood test results.

The purpose of this study was to investigate the efficacy of F-fluoro-deoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for evaluating the ocular adnexal lymphoma treatment responses.We retrospectively reviewed data for 9 histologically confirmed cases of malignant lymphoma. All patients had at least one ocular adnexal tumor site and underwent FDG PET/CT before and after treatment. Patients' histological disease subtypes included diffuse large B-cell lymphoma (n = 3), mucosa-associated lymphoid tissue lymphoma (n = 2), follicular lymphoma (n = 1), NK/T-cell lymphoma (n = 1), lymphoplasmacytic lymphoma (n = 1), and Hodgkin lymphoma (n = 1). The highest FDG uptake by the ocular adnexal lesions was calculated as the maximum standardized uptake value (SUVmax). FDG uptake at ocular adnexal sites and sites of systemic disease after treatment were also assessed using the 5-point Deauville scale.In 1 of the 9 patients, a conjunctival lesion could not be detected by either pre- or posttreatment PET/CT. For 8 of the 9 patients, the SUVmax value at the ocular adnexal site significantly decreased after treatment (7.1 ± 5.1 vs 1.6 ± 0.58; P = .0196). For 7 of the 9 patients, the first posttreatment FDG uptake at the ocular adnexal site was considered a complete metabolic response, and these patients showed an improved clinical ophthalmic presentation with no relapse at ocular adnexal sites during follow-up.FDG PET/CT is useful for evaluation of the response of ocular adnexal lymphoma to treatment, although its usefulness may depend on the histological subtype and site of the lesion.

A 61-year-old woman was introduced for consultation with a chief complaint of frequent vomiting. CT revealed a pancreatic body cancer approximately 40mm in size; an invading stenosis from the horizontal part of the duodenum to the jejunum, superior mesenteric artery, and portal vein, splenic vein obstruction, lymphadenopathy, and some ascitic fluid. We diagnosed a passage disorder due to the invasive stenosis from the horizontal part of the duodenum of the pancreatic body cancer to the jejunum, and subsequently performed a duodenum and jejunum bypass operation. We controlled cancer pain with opioid analgesia, and S-1 monotherapy was chosen as the primary chemotherapy. A tendency to increase and the cancer pain of the tumor was aggravated when 5 courses took effect, so gemcitabine plus nab-paclitaxel(GEM plus nab-PTX)therapy was chosen as the second-line chemotherapy because of adverse Grade 3 events due to difficulties with S-1 internal use. We tapered off the opioid analgesia dosage because the cancer pain was relieved after 1 course. The imaging top indicated stable disease at the end of 5 courses, but the pain was relieved so opioid pain killers were unnecessary. Foreign continuation is under treatment with 10-course GEM plus nab-PTX therapy after initial diagnosis. Currently, the patient has undergone 5 courses of S-1 for approximately 18 months, and has achieved stable disease. The only adverse events were nausea, fatigue, Grade 1 malaise, and Grade 2 alopecia, as detected with imaging.

Background: In addition to its established role in oncologic imaging, F-fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) is useful for the assessment of inflammatory activity. However, subacute thyroiditis (SAT) in thyrotoxicosis is rarely detected during these scans., Case: A 66-year-old man with SAT in thyrotoxicosis demonstrated symptoms of transient fatigue, headache, and fever, without typical neck pain. Using F-FDG PET/CT, we found increased F-FDG uptake in the thyroid gland, predominantly in the right side due to SAT. We also observed a coexisting decrease in F-FDG uptake in the liver and increased F-FDG uptake in skeletal muscle due to thyrotoxicosis., Conclusion: Using F-FDG PET/CT, the combined observations of increased F-FDG uptake in the thyroid and skeletal muscle, and decreased F-FDG uptake in the liver, even when the typical symptom of neck pain is subtle or absent, may be helpful for the differential diagnosis of SAT in thyrotoxicosis.

Objective: To assess 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) images in primary thyroid lymphoma (PTL) patients before and after treatment., Methods: We conducted a retrospective review of data for ten patients (four men, six women) of mean age 65 (range 48-88) years, with histopathologically confirmed malignant thyroid lymphoma who underwent pre-treatment and post-treatment 18 F-FDG PET between January 2005 and December 2014. Thyroid uptake was assessed by the 5-point scale score based on maximum intensity projection images., Results: Four of the ten patients were judged to have a complete metabolic response (scores 1-3) and four to have a partial metabolic response (PMR; scores 4-5). Three of the four PMR patients had a good outcome with a treatment-free interval and overall survival of at least 53.0 months, although two of these three patients showed residual FDG uptake in the thyroid for more than 2 years after completion of treatment. Two of the ten patients were considered to have progressive metabolic disease., Conclusions: In patients with PTL, residual FDG uptake in the thyroid after treatment that corresponds to a PMR may not always indicate a poor outcome.

Objective: We retrospectively investigated changes of (18)F-fluorodeocyglucose ((18)F-FDG) uptake in the spinal cord, inside and outside the radiation fields, in patients with esophageal cancer before and after conventional dose radiotherapy., Methods: A total of 17 consecutive patients with esophageal cancer (16 males, one female; age 50-83 years, mean 67.0 years), who underwent conventional dose radiotherapy and (18)F-FDG PET/CT before and 5.1 months (range 1.6-8.6 months) after the radiotherapy, were retrospectively evaluated. Sixteen patients had esophageal cancer and one patient had esophageal metastasis from thyroid cancer. Mean standardized uptake values (SUVmean) of the cervical, thoracic (inside and outside the radiation fields) and lumbar spinal cord were measured., Results: SUVmean of the thoracic spinal cord inside the radiation field was decreased significantly after radiotherapy compared to those before radiotherapy (p < 0.001). SUVmean of the cervical spinal cord showed the same trend but it was not statistically significant (p = 0.051). SUVmean of the thoracic spinal cord outside the radiation field and the lumbar spinal cord did not differ significantly before and after the radiotherapy (p = 0.146 and p = 0.701, respectively)., Conclusions: The results suggest that glucose metabolism of the spinal cord is decreased in esophageal cancer patients after conventional dose radiotherapy.

Herein, we report of a long-term survivor who underwent local combined modality therapy for local hepatic recurrences detected 10 years after initial surgery for colorectal cancer and 7 years after metachronous liver metastasis. In the third year after surgery for colorectal cancer, a solitary liver metastasis was detected, and curative surgical resection was performed. However, because local recurrence developed 3 years later, curative resection was repeated. When local recurrence developed again 1.5 years later, the patient declined surgery and systemic chemotherapy, and radiofrequency ablation was performed. However, because of the development of another local recurrence 6 months later, hepatic arterial infusion chemotherapy was initiated. This therapy has been continued for 1.5 years to date, with successful local disease control and no adverse events. Although surgical resection is the first choice for resectable liver metastases of colorectal cancer, thermocoagulation and hepatic arterial infusion chemotherapy can also be valid options for patients who are inoperable or refuse surgery as well as for those who are not suitable for or refuse systemic chemotherapy. Notwithstanding, the guidelines for the treatment of colorectal cancer (2014 edition) now include the following statement: thermocoagulation is not recommended as an alternative to surgical resection. Hepatic arterial infusion chemotherapy appears to be a promising treatment strategy associated with antitumor effects with few adverse events. It is also relatively less expensive than systemic chemotherapy.

We report our experience with a case of iatrogenic immunodeficiency-associated lymphoproliferative disease in a patient who had been treated with methotrexate (MTX) for rheumatoid arthritis for 9 consecutive years, which showed natural remission after discontinuation of the MTX therapy. The patient was a 64-year-old woman who was admitted emergently to our hospital with hematemesis and melena. She presented with multiple gastric ulcers and bilateral tonsillitis with a central ulcer. Biopsy of these lesions raised the suspicion of diffuse large B-cell lymphoma. Positron emission tomography (PET)- computed tomography( CT) showed increased fluorodeoxyglucose( FDG) accumulation in the pharynx, cervical lymph nodes, liver, spleen, stomach, distal part of the ileum, and para-aortic lymph nodes, with a maximum standard uptake value of 26.85. Blood test showed elevated lactate dehydrogenase( LDH)( 321 U/L) and interleukin( IL)-2R( 3,531 U/mL) levels. After discontinuation of MTX, the sore throat subsided, and the tonsillitis, lymph node enlargement, and ulcers were resolved. The levels of LDH and IL-2R returned to within the normal range. The patient could be categorized into a regressive disease group with relatively favorable prognosis among patients with MTX-induced lymphoproliferative disease. However, she should continue to be followed up regularly because there remains a possibility that lymphoproliferative disease may relapse after the discontinuation of MTX.

A 75-year-old woman with a chief complain of anal pain visited the emergency department. She was diagnosed as having S-colon cancer perforation accompanied by an intra-abdominal abscess. Computed tomography (CT)-guided drainage was applied to the intra-abdominal abscess. Six days after drainage, the patient's condition progressed to acute respiratory failure due to heart failure, and ventilator support was provided temporarily. The patient's cardiopulmonary function improved with conservative management. S-colon cancer was detected during colonoscopy examination, and biopsy indicated a tub2 tumor. Next, S-colon resection with D3 lymph node dissection was performed. The postoperative course was uncomplicated. Two months after surgery, liver metastases were detected on CT. Since the patient's performance status (PS) was 3, it was impossible for her to undergo chemotherapy. Four months after surgery, her PS was restored to 2 and the liver metastases were exacerbated, as seen on CT. The patient began chemotherapy (XELOX plus bevacizumab, 30% reduced dose). Eight months after the start of chemotherapy, 9 courses had been administered, the carcinoembryonic antigen (CEA)/carbohydrate antigen (CA) 19-9 level had decreased to the reference value, and the decrease in size of the liver metastases indicated a partial response (PR), as assessed by CT.

We report a case of a 64-year-old man with multiple lung metastases after gastric cancer surgery. This patient was initially treated with S-1. However, he experienced adverse effects, and subsequently, he was effectively treated with cisplatin (CDDP) and irinotecan (CPT-11). In July 2010, the patient experienced a decrease in appetite and underwent a detailed examination. He also underwent distal gastrectomy in the same month. The postoperative diagnosis was T4a( SE), N2, M0, Stage IIIB. In November 2010, adjuvant chemotherapy with S-1 was initiated. In February 2011, the patient developed a skin disorder( grade 3) and generalized edema along with walking difficulty, which were identified as adverse effects of S-1. Evidently, S-1 was contraindicated for this patient, and adjuvant therapy was discontinued. In September 2011, contrast -enhanced thoracoabdominal computed tomography( CT) was performed and para-aortic lymph node metastasis and multiple lung metastases were detected. CDDP+CPT-11 therapy was initiated. By June 2012, 8 courses had been administered, and the patient had a good partial response. With regard to chemotherapy for advanced or recurrent gastric cancer, there is no consensus on a treatment policy for cases in which S-1 cannot be used owing to adverse effects. CDDP+CPT-11 therapy is considered a safe and effective choice.

Spontaneous intrahepatic hematoma caused by hepatocellular carcinoma is a rare condition since usually the circumference shows liver cirrhosis. We report a case of hepatocellular carcinoma with an intrahepatic hematoma. A 79-year-old man was admitted to our hospital with sudden onset upper abdominal pain and high fever. Laboratory data showed that the patient had liver dysfunction but was not anemic. Abdominal computed tomography( CT) revealed an intrahepatic tumor with a hematoma measuring 8.5 cm in diameter in the right lobe of the liver. An enhancing lesion and pooling of contrast media inside the tumor was observed. Angiography also revealed a microaneurysm in the tumor. The patient underwent right hepatic lobectomy, and histopathological examination showed hepatocellular carcinoma.

A 68-year-old man underwent total gastrectomy for gastric cancer(Stage II). Adjuvant chemotherapy with S-1 was administered. At 21 months after the operation, he received a nephron catheter because of hydronephrosis caused by para-aortic lymph node metastases. Then, weekly paclitaxel was given as a second-line treatment. However, his tumor marker level increased and he therefore received CPT-11 (160 mg/m2) as a third-line treatment at 28 months after the operation. At 7 days after the first CPT-11 administration, he was hospitalized because of a severe adverse event involving nausea and general fatigue, which caused a continuous fever of 39°C and renal failure at 14 days after administration. However, hydration enabled him to recover several days later. Computed tomography scan revealed the lymph node metastases to be partial remission.

In a patient with multiple liver metastases of colorectal cancer in whom tumor response had been achieved by 5-FU hepatic arterial infusion, the catheter for arterial infusion chemotherapy was occluded resulting in re-elevation of tumor marker levels. Second-line IRIS therapy using S-1 and CPT-11 was started. IRIS therapy reduced tumor marker levels to a degree greater than that previously achieved with 5-FU hepatic arterial infusion, and diagnostic imaging allowed a judgment of partial response. But tumor marker levels increased gradually. After all, diagnostic imaging allowed a judgment of progressive disease and an eminent elevation of tumor marker levels in one year. Third-line panitumumab therapy was started. Panitumumab therapy reduced tumor marker levels to a degree greater than that previously achieved with 5-FU hepatic arterial infusion and IRIS therapy, and diagnostic imaging allowed a judgment of partial response. We report herein a successful case. Hepatic arterial infusion therapy is one of the treatment methods characterized by a lower incidence of adverse reactions, relatively low cost, and expectation of high anti-tumor efficacy as compared to chemotherapy such as FOLFIRI. IRIS therapy does not require a port insertion and pump carrying, and its cost is about half of FOLFIRI therapy. When used as second-line therapy for unresectable colorectal cancer, non-inferiority of IRIS therapy to FOLFIRI therapy has been demonstrated in a phase II/III clinica (l FIRIS) study. We may say that IRIS therapy is promising as an equivalent to hepatic arterial infusion therapy in the treatment of liver metastases of colorectal cancer. In addition, we may say that panitumumab therapy is promising as an equivalent to hepatic arterial infusion therapy and IRIS therapy.

A 55-year-old woman who had a chief complaint of left abdominal and back pain. She was diagnosed with pancreatic cancer associated with splenic metastasis (Stage IVb) by CT and MRI study and was treated with chemotherapy of gemcitabine (GEM). Chemotherapy was discontinued due to adverse event (grade 3). CT study at this point reveals the effectiveness of GEM. The tumor was localized, and an operation was performed. The tumor was diagnosed as primary malignant lymphoma (diffuse large B-cell lymphoma) of the spleen. The splentic tumor is extremely rare, so a surgical treatment was indicated for making a correct diagnosis. This was an interesting case of malignant lymphoma that GEM revealed a cytoreductive result.

In August 2008, a 52-year-old woman presented to our hospital with a complaint of bleeding upon defecation. The patient underwent lower gastrointestinal endoscopy with biopsy. PRb indicated a type 2 lesion in one-third of the circumference. The patient was diagnosed with squamous cell carcinoma by biopsy. Imaging did not reveal any metastasis to other organs. In September, she underwent an abdominoperineal resection of the rectum. Postoperative histopathological findings were PRb, type 2, A, N3, H0, P0, M0, and Stage III b. Adjuvant chemotherapy of oral S-1 was started. In January 2009, contrast-enhanced abdominal CT revealed a pelvic recurrence, and the patient underwent chemoradiotherapy. In October, chest CT showed a 5-mm solitary pulmonary metastasis in the right apex of the lung. In March 2010, chest CT showed a slight enlargement of the tumor in the right apex, but no other metastatic lesion was observed. In April, the patient underwent a thoracoscopic partial pneumonectomy. It has been 16 months postoperatively, and no recurrence has been observed. In the present report, we describe a case of squamous cell carcinoma of the anal canal that underwent multidisciplinary treatment including pneumonectomy. We also include a brief literature review.

The patient was a 59-year-old man who was hospitalized at our department for intestinal obstruction. Contrast enhanced abdominal CT showed a rectosigmoid tumor invading the left pelvic wall and multiple metastatic hepatic tumors. Colonoscopy showed a type-2 cancer in the rectosigmoid region. The patient underwent sigmoid colostomy 3 days after admission. Postoperative upper gastrointestinal endoscopy showed a type 3 cancer in the fornix. From the above findings, the patient was diagnosed with unresectable gastric and rectosigmoid cancers with multiple hepatic metastases, and systemic chemotherapy was initiated. The first line treatment was two courses of S-1, but it was discontinued due to PD. FOLFIRI was begun as the second line treatment. After 5 courses of FOLFIRI, upper gastrointestinal endoscopy showed a marked reduction in tumor size. Twelve courses of FOLFIRI chemotherapy were performed in total. Subsequently, 11 courses of mFOLFOX6 and 1 course of RPMI were performed, but the patient died from carcinomatous peritonitis. However, the gastric lesion had been controlled well after the second line treatment. The findings of the present study suggested that FOLFIRI could be an effective treatment for unresectable multiple advanced cancers of the stomach and colorectal cancer.

In a patient with multiple liver metastases of colorectal cancer whose tumor response had been achieved by 5-FU hepatic arterial infusion, a catheter for arterial infusion chemotherapy was occluded resulting in re-elevation of tumor marker levels. For this reason, a second-line IRIS therapy using S-1 and CPT-11 was started. IRIS therapy reduced tumor marker levels to a degree greater than that of previously achieved with 5-FU hepatic arterial infusion, and a diagnostic imaging allowed a judgment of partial response. Although a ratio of liver tumor volume to liver volume was 57% on admission of this patient, the ratio was reduced to 16% by the 14th course of 5-FU hepatic arterial infusion immediately before the catheter was occluded. The ratio was 18% after the 7th course of IRIS therapy, and the diagnostic imaging showed a partial response. Hepatic arterial infusion therapy is one of the treatment methods characterized by a lower incidence of adverse reactions, relatively low cost, and expectation of high anti-tumor efficacy as compared to chemotherapy such as FOLFIRI. IRIS therapy does not require a port insertion and it costs about a half of FOLFIRI therapy. When used as a second-line therapy for unresectable colorectal cancer, IRIS therapy has demonstrated non-inferiority compared to FOLFIRI in a phase III clinica (l FIRIS) study.

Purpose: Extraperitoneal spaces, such as the mesenteric space and the retroperitoneal space, can serve as areas that enable a reduction in the pressure exerted by extraperitoneal fluid collection and infiltrating diseases. In clinical practice, understanding the existence of these decompression spaces (or pathways) is very important for making accurate diagnoses. Here, we evaluated potential anatomical extraperitoneal spaces based on the extraluminal gas distribution in patients with pneumatosis intestinalis without intestinal ischemia., Methods: The computed tomography scans of ten patients with pneumatosis intestinalis without intestinal ischemia were reviewed, and the anatomic location of the extraluminal gas distribution was investigated., Results: Four patients were diagnosed as having pneumatosis intestinalis of the small intestine and six were diagnosed as having pneumatosis intestinalis of the large intestine. Mesenteric pneumatosis was observed in nine (90%) of the ten patients. The potential anatomical extraperitoneal spaces (or decompression pathways) were classified as follows: mesenteric (n = 3), retroperitoneal (n = 4), and direct (n = 5)., Conclusions: The distributions of the extraluminal gas were classified into three categories, and each location may characterize a different decompression pathway. The existence of a potential extraperitoneal space continuous with the peri-intestinal space was confirmed in living subjects.