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Background Non-occlusive mesenteric ischaemia (NOMI) is a condition in which intestinal ischaemia arises due to spasms of peripheral blood vessels; however, there is no obstruction of the main arteries. Risk factors include hypertension, diabetes, and increasing age, but the traumatic injury triggering NOMI onset is rarely reported. We report a case of NOMI caused by a pelvic fracture due to a fall injury. Case presentation A 77-year-old man was transported to the hospital due to a fall injury. CT revealed a pelvic fracture and a haematoma in the pelvic extraperitoneal space. The next day, the patient developed shock, and CT revealed an increase in haematoma size. Both internal iliac arteries were embolized by transcatheter arterial embolization (TAE). The next day’s CT revealed intestinal necrosis of the ascending colon, and emergency surgery was planned. During surgery, necrosis was identified in the serosa of the ascending, transverse, and sigmoid colon. We performed subtotal excision from the ascending colon to the sigmoid colon. On postoperative day 10, melena was observed, and CT revealed partial thickening of the small intestine and a decrease in the contrast effect. Considering the post-total colectomy and general condition, we proceeded with conservative treatment. Over time, the patient developed liver and renal dysfunction and died 16 days after surgery. Conclusions We experienced a case of NOMI caused by bleeding from a pelvic fracture. It is important to keep in mind the risk of developing NOMI in traumatic bleeding to avoid missing this diagnosis.

We report a patient with liver metastasis from rectal cancer who developed interstitial pneumonia during regorafenib administration. The patient described herein was a 69-year-old female. In January 2011, she underwent low-position anterior resection of rectal cancer at another hospital. In May 2013, right iliac metastasis was detected and she was referred to our hospital. Radiotherapy (30 Gy) was performed to treat bone metastasis and pain was relieved. Ursodeoxycholic acid (300 mg/day) and a glycyrrhizic acid/glycine/l-cysteine injection (20 mL/day) were subsequently administered. In July 2013, the administration of regorafenib (160 mg/day) was initiated and computed tomography (CT) was performed every week. CT revealed the appearance of diffuse ground-glass opacities in the bilateral lungs 13 days after starting the administration of regorafenib. Steroid pulse therapy was started following a tentative diagnosis of regorafenib-related interstitial pneumonia, which resulted in the amelioration of the ground-glass opacities. Although there has been no case report on interstitial pneumonia in a clinical study prior to approval, interstitial pneumonia developed during the administration of regorafenib in the present case. As steroid therapy improved the patient’s condition and CT findings, the patient was diagnosed with regorafenib-related interstitial pneumonia. Prompt management, such as steroid therapy, may be important when interstitial pulmonary disorders are detected during the administration of regorafenib.

With a rapidly growing aging society, many elderly people in Japan have been facing difficulties of shopping in their daily life. Recently, this phenomenon has been found in urban areas, especially local cities. This growth of the aging society, combined with alterations to the food supply system, has caused food insecurity over a large area.The food insecurity may induce poor nutrition and disease in elderly people. The Ministries and local governments have taken measures for improving food access. Although NGOs, social organizations and the private sector manage social-related businesses in many areas, they also rely on government funding. This paper proposes solutions for stakeholders to alleviate this considerable issue: (i) share research outcome, (ii) organize platforms for discussion, and (iii) strengthen community empowerment.

Aim: To examine the feasibility and usefulness of a novel region-based pathway: the Regional Referral Clinical Pathway for Home-Based Palliative Care. Method: This was a feasibility study to evaluate the frequency of variances and the perceived usefulness of pathway using in-depth interviews. All patients with cancer referred to the palliative care team between 2011 and 2013 and received home care services were enrolled. Result: A total of 44 patients were analyzed, and pathway was completed in all the patients. The target outcome was achieved in 61.4% while some variances occurred in 54.5%. Nine categories were identified as the usefulness of the pathway, such as reviewing and sharing information and promoting communication, education, motivation, and relationships. Conclusion: This novel pathway is feasible and seems to be useful.

The purpose of our study was to retrospectively evaluate the clinical efficacy and safety of laparoscopy assisted distal gastrectomy (LADG) performed by one operating and advising surgeon in patients with gastric cancer over a period of 10 years. We examined the choice of anastomosis techniques, and compared the duration of surgery, blood loss, number of dissected lymph nodes and intraoperative complications for LADG and open distal gastrectomy (ODG). We studied 254 patients who underwent laparoscopic gastrectomy and 36 patients who underwent ODG. 169 of 254 patients received LADG. Duration of surgery was significantly longer for LADG than that for ODG, blood loss was significantly smaller, and numbers of dissected lymph nodes were similar. With LADG, there was anastomotic leakage in 2 patients and postoperative obstruction in 2 patients. No recurrence of disease and no deaths have been reported to date. Though previous clinical trials have shown that LADG is less invasive, our study of LADG in the real world did not show superiority, but rather equivalence to ODG in terms of other outcomes. This study could be advantageous to evaluate the clinical efficacy and safety of LADG without having to take into account multiple surgeons’ technical levels and the background differences between the facilities.

消化管はアミロイドの沈着好発部位の1つであるが，穿孔をきたすことは稀である．今回透析アミロイドーシスによる小腸穿孔の1例を経験した．患者は68歳の女性で，30年前より血液透析を受けていた．発熱を主訴に当院を受診した．精査の結果，消化管穿孔，汎発性腹膜炎と診断され，手術を行った．回盲部から20cm口側の回腸が壊死しており，回腸瘻造設術を施行した．病理組織学的検査にて透析アミロイドーシスによる回腸壊死と診断された．術後，集中的な治療により救命しえた．10年を経過した血液透析患者は，透析アミロイドーシスによる消化管穿孔のリスクファクターであることを再認識する必要があると考えられた．

症例は68歳,女性.慢性関節リウマチのため10年以上プレドニゾロン10mg/日を服用していた. 2003年9月18日,腹痛を認め救急車にて搬送された.腹部CT検査にて小腸穿孔・汎発性腹膜炎と診断,手術を施行した.回盲部より30cm口側の回腸に穿孔を認め,小腸切除術を施行した.病理組織学的検査では,潰瘍底にカンジダの増殖を伴う潰瘍を2カ所に認め,うち一方が穿孔していた.医学中央雑誌で過去10年間を検索したが,カンジダによる成人の小腸穿孔の報告はなかった.カンジダは易感染性の患者に日和見感染症を起こし重篤になる場合がある.小腸カンジダ症は稀ではあるが,潰瘍や穿孔の一因になりうるということを,再度認識する必要があると思われた.

症例は39歳,女性.腹痛と嘔吐を主訴に当院を受診した.腹部CT検査上回腸閉塞の所見を呈し,また拡張腸管の近傍に不整形高吸収域が認められた.イレウス管を挿入したが症状改善はなく,またCRP値の急激な上昇が認められた.絞扼性イレウスが疑われ,緊急開腹手術を施行した.小腸間膜上に径8 mm大の石灰化腫瘤を認め,そこを発端にした炎症性索状物によって小腸が絞扼され壊死となっていた.病理組織学的にこの腫瘤は多核白血球浸潤を伴う肉芽腫で,内部に壊死に陥った寄生虫が認められた.形態学的にこの虫体はアニサキスIV期幼虫と同定され,陳旧性の消化管外アニサキス症が原因で絞扼性イレウスを発症したものと結論した.自験例のような絞扼性イレウスの発症機転は稀であるが,開腹手術歴がなく絞扼の発生原因として有力な根拠に欠ける場合には,消化管外アニサキス症の関与も念頭に置く必要があると思われる.

症例は67歳,男性.平成7年10月,心窩部不快感・黒色便にて来院.上部消化管内視鏡検査で胃前庭部に3'型腫瘍を認めた.胃癌の診断にて,幽門側胃切除+胆嚢摘出術施行.中分化型腺癌, T3N1M0, Stage IIIA,根治度Aであった.平成11年1月,腹部CTで膵尾部に直径30mmの腫瘍を認めた.膵体尾部切除+脾臓摘出術施行.膵癌(腺扁平上皮癌), T2N0M0, Stage II,根治度Aであった.平成11年6月,嗄声にて来院,両声帯に腫瘍を認め,喉頭癌(角化扁平上皮癌, T3N0M0, Stage III)と診断.放射線照射+化学療法+レーザー焼灼術施行.平成14年3月,腹部CTで左腎に直径27mmの腫瘍を認めた.左腎摘出術施行.腎癌(明細胞癌), TlaN0M0, stage Iであった.無再発にて経過観察中である.重複癌では診断・治療に苦慮することが多いが,外科的切除を含む積極的な治療を行うべきと考えた.

Splenic tumors irrespective of primary or metastatic lesion, are relatively rare. Thirteen patients with splenic tumor who were treated at the hospital were subjected to a clinical study. Eleven patients had primary splenic tumor. There were four cases of lymphangioma, one case of hemangioma, one case of hamartoma, three cases of malignant lymphoma and two cases of angiosarcomas. The remaining two patients had metastatic splenic tumor, and their primary lesions were ovarian cancer and gastric cascer respectively. Of six patients with benign primary splenic tumor, four patients were asymptomatic and the remaining two patients who had a huge lymphangioma complained of upper abdominal discomfort because of splenomegaly and a rupture of a hemangioma. Subjective symptoms were noted on all five patients with malignant primary splenic tumor. Two patients with metastatic splenic tumor were found due to elevated levels in serum tumor markers. We could not rule out probable malignant tumor on four out of six patients with benign primary splenic tumor. Actual preoperative diagnosis was made on four out of five cases of malignant primary splenic tumor and all two case of metastatic splenic tumor. Splenic tumors prenent difficulty in preoperative diagnosis, and there are some cases showing shock resulting from spontaneous rupture of the tumor. So we consider that all patients with splenic tumor are possible candidates for opreation.

Pregnancy-associated breast carcinoma is generally defined as cancer that occurs during pregnancy or within 1 year of delivery, although treatment options are the most complicated when the disease is diagnosed during pregnancy. We report the case of a 30-year-old woman who was diagnosed with breast cancer at her 9th week of pregnancy. The patient initially had mastectomy with axillary lymph node dissection. She began adjuvant therapy with 3 courses of epirubicin/cyclophosphamide at 19 weeks of gestation. After delivery of a healthy child, she received one course of epirubicin/cyclophosphamide and 4 courses of docetaxel. Although the data are limited, pregnant patients with cancer can be treated with systemic chemotherapy with minimal risks to the fetus during the second or third trimester. Management of breast cancer during pregnancy requires an interdisciplinary care team and careful consideration of the patient's stage of disease, the gestational age of the fetus, and the preferences of the patient and her family.

A 35-year-old woman with taxane and anthracycline-resistant recurrent breast cancer with multiple lung metastasis and carcinomatous lymphangitis was treated with CMF as third-line chemotherapy. A complete response was achieved,and the toxicities were tolerable. We thought that CMF could be a useful regimen as third-line chemotherapy for metastatic breast cancer.

A 72-year-old female was admitted to our hospital with the complaint of left neck lymph node swelling. Abdominal computed tomography (CT) revealed wall thickening of the small intestine and multiple lymph node metastases. Barium meal study of the small intestine showed circular stenosis. The patient was operated on under a diagnosis of tumor of the small intestine and left neck lymph node swelling. Needle biopsy of the left neck lymph node and partial resection of the small intestine was done without regional lymph node dissection because of Virchow lymph node metastasis. On the resected material a 5 x 4 cm type 2 tumor was identified. Pathological findings included poorly-differentiated adenocarcinoma, si (bladder), n 4, P 0, ly 3, v 3, H 0, M(-), Stage IV. The patient received the chemotherapy with TS-1. TS-1(80 mg/body/day) orally administered for 4 weeks followed by a drug-free 2-week period as one course. CT revealed that the metastatic lesion had shrunk markedly after the second course. A complete response (CR) was observed after one year. There were no drug side effects. At present, 3 years and 9 months after the operation, cervical and abdominal CT reveals no evidence of enlargement of the cervical and intraperitoneal lymph nodes.

Microsatellite instability (MSI) is caused mainly by dysfunction of hMLH1, where aberrant hypermethylation (HM) of its promoter region is involved. Previously, we suggested that HM in the proximal region of the hMLH1 promoter plays a critical role in progression of gastric cancer with MSI and this specific region should be analyzed for diagnostic use of hMLH1 HM. We expanded the analyses of hMLH1 HM and MSI phenotype to sporadic colorectal cancer (CRC) and non-small cell lung cancer (NSCLC) to further evaluate the diagnostic value of hMLH1 HM. A total of 174 CRC and 94 NSCLC samples were used for hMLH1 methylation analysis by real-time methylation-specific PCR. Methylation levels were measured in three distinct regions of the promoter, designated as hMLH1-A, hMLH1-B, and hMLH1-C from distal to proximal. MSI phenotype was determined using five microsatellite markers, BAT25, BAT26, D2S123, D5S346, and D17S250. Methylation profile of the hMLH1 promoter varies between CRC and NSCLC. High methylation levels were observed in a group of CRC samples. Consequently, three patterns of methylation in the hMLH1 promoter regions were found: 1) low methylation level in all regions, 2) high methylation level in hMLH1-A with low methylation level in hMLH1-C, 3) high methylation level in all regions. In contrast, only one NSCLC showed high methylation level in hMLH1-A. Of the 134 CRCs examined, 14 (10.4%) showed MSI phenotype. No MSI phenotype was found in the initial 80 NSCLCs analyzed. Eight (57.1%) of 14 CRC with MSI showed HM in hMLH1-C, which was linked exclusively with MSI phenotype. However, the HM in hMLH1-A or -B was not sufficient for MSI. CRC with MSI phenotype was significantly more frequent in older patients and in the proximal colon, and was more evident in cases with hMLH1-C HM. The results suggested that hMLH1 HM cannot be used as an alternative diagnostic marker of MSI phenotype in sporadic CRC and NSCLC. CRC with MSI might have clinicopathologically distinct subgroups according to hMLH1-C HM status. The observed profiles of hMLH1 methylation and MSI in gastric cancer, CRC, and NSCLC were quite different from each other, facilitating the better understanding of the pathogenesis of these cancers.

Methylenetetrahydrofolate reductase (MTHFR) plays a critical role in folate metabolism, which is an important pathway of the methyl donor for DNA methylation. The MTHFR gene has genetic variants (C667T and A1298C), which cause reduced enzyme activity. Impaired folate metabolism by these genetic variants of MTHFR could change the methylation pattern of DNA including promoter hypermethylation, which has been frequently observed in cancer. In this study, we compared the MTHFR genotypes and haplotype to the features of colorectal cancer focusing on the promoter methylation of tumor DNA.Genomic DNA was isolated from 194 colorectal cancer tissues and subjected to MTHFR genotyping by PCR-based restriction fragment length polymorphism analysis. The MTHFR haplotype was determined by combination of C667T and A1298C genotype and classified into 2 groups, high (H-haplotype) or low (L-haplotype) enzymatic activity of MTHFR. The methylation level of tumor suppressor genes (CDKN2A, hMLH1, ARF and TIMP3) was measured by a fluorescence-based, real-time methylation specific PCR method.There was no significant association of the clinicopathological features with either C667T genotype, A1298C genotype or haplotype of MTHFR. The methylation level of CDKN2A was higher in cancer with the L-haplotype of MTHFR than in that with the H-haplotype when cancers of proximal origin were considered (p=0.029). hMLH1 methylation also tended to be higher in proximal colon cancers of MTHFR L-haplotype (p=0.059). In addition, the proximal colon cancers showing CpG island methylator phenotype (CIMP) were significantly more frequent in L-haplotype than in H-haplotype.These results suggest that the haplotype with low enzymatic activity of MTHFR is linked with promoter hypermethylation and consequently modifies the risk of CIMP(+) proximal colon cancer development in the Japanese people. The relationship between MTHFR polymorphism and DNA methylation in the Japanese is contrary to the previous results in Caucasians. Further study is needed focusing on ethnic variations in the relationships among MTHFR polymorphism, DNA methylation and the development of CIMP(+) colorectal cancer.

Primary retroperitoneal cystic tumor is extremely rare, and its histogenesis and biological behavior remain speculative. Two surgical cases of retroperitoneal mucinous cystadenoma (Case 1, an 18-year-old woman; and Case 2, an 85-year-old woman) are reported. The cystadenomas in these cases were mainly lined by a monolayer of columnar or thin flat cells. Case 1 was positive for mucin and epithelial membrane antigen, whereas Case 2 was positive for a mesothelial marker (calretinin). Ciliated epithelium was also interspersed in Case 2. Some parts showed papillary projections, resembling well-differentiated papillary mesothelioma. Within the cyst walls of both cases, ovarian-like stroma that was positive for both estrogen and progesterone receptors was found. Interestingly, focal nodular hyperplasia of the liver was also detected in Case 1. We believe the retroperitoneal mucinous cystadenoma might have arisen from the peritoneum via mucinous epithelial metaplasia with a phenotype of extragenital Mullerian system.

Most sporadic gastric cancer with the microsatellite instability (MSI) phenotype is linked with hypermethylation (HM) of hMLH1. However, a part of gastric cancer with hMLH1 HM does not show MSI, suggesting a region-specific effect of hMLH1 promoter methylation on developing MSI. To test this possibility, we measured the methylation level in 3 distinct areas of hMLH1 promoter and compared them with MSI in 129 sporadic gastric cancer patients. Three areas of hMLH1 promoter, from distal toward proximal, were designated as hMLH1-A, hMLH1-B, and hMLH1-C, respectively. The methylation level was measured by fluorescence-based real-time methylation specific PCR. MSI status was tested using a panel of 5 microsatellite markers (BAT25, BAT26, D2S123, D5S346, and D17S250). Gastric cancers with no HM in hMLH1-A (n=105, 81.4%) also showed no HM in 2 other regions of hMLH1 promoter. On the other hand, the cancers with HM in hMLH1-A (n=24, 18.6%) showed various levels of methylation in 2 other regions. In most cases, the methylation value was the highest in hMLH1-A and the lowest in hMLH1-C. We found the MSI phenotype in 12 cancers (13%) of 92 tested cases and these cancers were all associated with HM in the region of hMLH1-C. A third of hypermethylated cancers in the hMLH1-A region did not show the MSI phenotype. The survival of the patients with HM in hMLH1-C was significantly better than that of patients without HM (P

Promoter hypermethylation of the CDKN2A gene has been suspected to be involved in the carcinogenesis of colorectal cancers. However, the relations between CDKN2A hypermethylation and clinicopathological findings, and patient prognosis, remain inconclusive. We analyzed the CDKN2A methylation status in primary colorectal cancers using real-time methylation specific PCR (MethyLight) which enables quantitative measuring of the methylation level. CDKN2A promoter methylation was detectable in 55 (61.1%) of 90 tumor samples and the median level of the methylation was 0.187 (range 0.00-197.9). The methylation value of CDKN2A was correlated with certain clinicopathological findings, including tumor differentiation (p=0.018), and Dukes stage (p=0.016). In survival analysis, the CDKN2A methylation level was correlated with a poor prognosis of the patient with colorectal cancer for either all cases (p=0.014) or Dukes C (p=0.004) cases that were analyzed. These results suggest that CDKN2A methylation status is a prognostic factor in colorectal cancer and may be of use for the patient specific design of therapy.

MA (WDPTC) shows good prognosis even with lymphatic gland involvement. Although invasion of the upper aerodigestive tract by WDPTC is rare, it results in serious morbidity and mortality.1,2 The prognosis of WDPTC invading the upper aerodigestive tract appears to correlate with the site and depth of invasion.3,4 Extensive invasion of these structures produces dyspnea, dysphagia, and hemoptysis. Life-threatening airway hemorrhage and suffocation due to airway invasion by the carcinoma are common direct causes of death from WDPTC,5 and surgery for such patients remains a challenge. Wide resection of the invaded structure sometimes causes the patient significant inconvenience, including loss of voice. However, incomplete resection of the lesion results in early recurrence.6 Adequate local control of invasive WDPTC is therefore an important clinical consideration. Grillo and Zannini7 reported pharyngolaryngoesophagectomy for locally advanced or recurrent papillary thyroid carcinoma, which widely invades both the trachea and esophagus. PATIENTS AND SURGICAL PROCEDURE We performed pharyngolaryngoesophagectomy for WDPTC with laryngotracheo-esophageal or tracheoesophageal invasion (Table). Three patients had primary disease and 2 had recurrent disease after a subtotal or total thyroidectomy. Patient 1 had undergone a total thyroidectomy and shave excision for tracheal invasion of the tumor. Patient 5 had undergone circumferential sleeve resection of the trachea concomitantly to total thyroidectomy. Neither of these 2 patients had been treated with 131I therapy or external-beam radiotherapy. Three patients complained of dyspnea due to stenosis of the trachea derived from invasion of the tumor. Two patients had hemoptysis, which strongly suggested transmural invasion of the tumor. Bronchoscopy, performed on all patients but patient 4, confirmed tracheal invasion. Patient 4 underwent emergency tracheostomy due to suffocation following intratracheal bleeding on the day of admission. Wide and transmural invasion of the larynx and/or trachea had been detected in all patients preoperatively. Two patients, who had previously undergone a thyroidectomy, were diagnosed with WDPTC by histological examination following the first surgery. The other 3 patients were diagnosed with WDPTC after total thyroidectomy with pharyngolaryngoesophagectomy. All 5 patients were therefore diagnosed with WDPTC. Bilateral pulmonary metastases were detected by chest roentgenography before surgery in patients 2 and 3. Pharyngolaryngoesophagectomy was initially intended for 4 of the 5 patients, with patient 4 Brief clinical reports