[A Case Report of Postoperative Chylous Ascites after Laparoscopic Sigmoidectomy].

A female in her 70s was diagnosed as sigmoid colon cancer. Laparoscopic sigmoidectomy was performed. Chylous ascites was observed after starting oral intake. As we changed the patient's diet to a low fat diet, the chylous ascites disappeared. There are certain numbers of reports of the cases improved by fasting or only fat decreased meal. It is important to prevent this complications using appropriate surgical devices.

[A Case of Ipsilateral Breast Cancer with Contralateral Axillary Node Recurrence after Right Breast Partial Mastectomy].

A female patient who was in her 50s visited our hospital complaining right breast tumor, 18 years after her right breast- conserving partial mastectomy with right axillary lymph nodes dissection. Ultrasonography revealed a right breast tumor and an enlarged lymph node at left axilla. Core needle biopsy(CNB)from the right breast tumor showed the recurrence of her breast cancer and fine-needle aspiration(FNA)from her left axillary lymph node showed Class Ⅴ. We concluded the recurrence of right breast cancer with left axillary metastasis. After neoadjuvant chemotherapy, she underwent right mastectomy and left axillary lymph node dissection. When the recurrence of residual breast is seen, the contralateral axillary lymph node might become a new sentinel lymph node.

[Assessment for Local Treatment for Elderly Breast Cancer Cases].

The number of elderly breast cancer patients has been increasing recently nevertheless the optimal treatment for the elderly breast cancer patients still remains controversial. In this study, 21 primary breast cancer cases who were equal or older than 85 years old at our hospital were examined their clinical and pathological features. These 21 cases were divided into 2 group; Group A; ten cases who received operations, Group B; eleven cases who did not receive operations. T categories, M categories and clinical stages in Group B were significantly higher than those of Group A. The main causing reason why Group B cases had not received operations was that their primary breast cancer were too advanced to perform operation. Instead of operation, most Group B cases received endocrine therapy or radiotherapy. Group A cases received standard operative procedures including partial or total mastectomy and biopsies or dissection of axillary lymph nodes. Besides, their post- operative courses were good and safe. These results suggest that even for elderly patients, early diagnosis and treatment could improve their prognosis and quality of life. In addition, careful surveillances for elderly breast cancer patients, those who tend to stop attending regular check up to their hospital, should be considered for further assessment for characteristics of elderly breast cancer patients.

[A Case of Synchronous Double Lung Cancer Including Intestinal Adenocarcinoma Complicated with Colonic Adenoma].

The patient was a 73-year-old man who was referred to our hospital for increasing bilateral lung nodules. Video-assisted left S9-10 segmentectomy and right S1, S3 partial resection were performed separately for suspect of synchronous double lung cancer. Colonoscopy was performed because left lung tumor was difficult to distinguish between primary lung cancer and metastatic lung cancer. Colonoscopy did not find advanced cancer lesion. We diagnosed the left lung tumor as pT1b, cN0, cM0, Stage ⅠA2 intestinal adenocarcinoma. The right lung tumor was diagnosed as pT1c, cN0, cM0, Stage ⅠA3 papillary adenocarcinoma. Intestinal adenocarcinoma is a rare tissue subtype of lung adenocarcinoma and colonoscopy is useful modality for ruling out metastatic colorectal cancer.

Rupture of perivascular epithelioid cell neoplasm at 34 weeks' gestation: A nonendometriosis case of spontaneous hemoperitoneum in pregnancy.

Spontaneous hemoperitoneum in pregnancy (SHiP) has mainly been discussed in the context of endometriosis. With hormonal changes and enlargement of the uterus during pregnancy, tumors can also increase the chance of rupture and consequent SHiP. We report a case of a 30-year-old primiparous woman presented with sudden-onset intraabdominal hemorrhage at 34 weeks' gestation. The source of bleeding was rupture of a perivascular epithelioid cell neoplasm on the left round ligament of the uterus. The pregnancy ended with an uncomplicated, full-term, vaginal delivery. We performed an additional post-partum surgery to resect the left round ligament and transposition of the right ovary. In cases of SHiP, the possibility of a nonendometriosis origin should be considered. Preoperative imaging and histologic examinations of bleeding lesions are crucial for managing SHiP.

[A Case of Locally Advanced Breast Cancer Successfully Treated with Epirubicin/Cyclophosphamide].

A 66-year-old woman was referred to our hospital with the chief complaint of a huge exposed left breast mass with bleeding. Triple-negative invasive ductal carcinoma of the breast was diagnosed by core needle biopsy. Computed tomogra- phy showed axillary and infraclavicular lymph node metastases. Epirubicin/cyclophosphamide(EC)therapy was started. We reduced the dose to 80%during courses 2-4. After 4 courses of treatment, CT showed a complete response. We reduced the dose to 50% during courses 5-12 and stopped chemotherapy. Five years have passed without recurrence since the first treatment.

[A Case of Pancreatic Neuroendocrine Carcinoma Presenting Multiple Liver Metastasis as an Initial Manifestation for Which Diagnosis Confirmation Was Difficult].

A 67-year-old woman with a history of esophageal cancer(poorly-differentiated squamous cell carcinoma, pStageⅡ) was diagnosed with 2 liver tumors by regular checkup CT 10 years after her operation. We also observed elevated levels of tumor marker CEA. The tumors were suspected to be metastatic although no primary lesion was identified. We performed partial hepatectomy for diagnostic therapy. The pathological diagnosis was adenocarcinoma suggestive of metastatic tumors but the primary lesion remained unknown. Tumor marker levels were elevated 2 months after the operation and we detected a pancreatic tumor, multiple liver tumors, peritoneal dissemination, and para-aortic lymph node metastasis. Therefore, our clinical diagnosis was multiple metastases with primary pancreatic cancer and chemotherapy was performed. We conducted a thorough review of the diagnostic images and repeated the pathological analysis. Immunobiological staining showed that the tumor cells were positive for neuroendocrine markers such as chromogranin A, CD56, and Ki-67. We eventually diagnosed the liver tumors as metastasis from the pancreatic neuroendocrine carcinoma(Grade 3).

[Assessment of Prognosis after Surgical Treatment for Colorectal Liver Metastasis Using a Nomogram].

A nomogram is a statistical tool that can provide the specific outcomes of individual patients. In this study, we used a nomogram developed by Beppu et al to evaluate the prognoses of 38 patients who underwent hepaticresec tion at our hospital. This nomogram predicts disease-free survival(DFS)after hepatic resection for colorectal liver metastasis based on 6 clinical and oncological factors. Using this nomogram, we divided the 38 patients into 3 groups: Group N, actual DFS was almost similar to the estimated median DFS(EMDFS)provided by the nomogram; Group A, DFS was longer than EMDFS; and Group B, DFS was shorter than EMDFS. Then, we compared and analyzed clinical and oncological factors between Groups A and B. Group B patients tended to have single metastasis and non-normal levels of CA19-9. Besides, Group B patients had DFS shorter than approximately 2 years. These results suggest that if CA19-9 levels are not normalized after hepaticresec tion for single metastasis, we should consider careful observation and adjuvant chemotherapy for potential micrometastasis.

[A Case of Appendiceal Neuroendocrine Tumor Diagnosed after Appendectomy].

A 25-year-old woman visited our hospital with a complaint of right lower abdominal pain. As a result of the examination, she was diagnosed as having acute appendicitis. After conservative treatment, we planned an elective surgery. At 3 months after discharge, laparoscopic appendectomy was performed. We found a mass of 10mm in diameter at the body of the appendix. Histopathological examination revealed the proliferation of heteromorphic cells with small round nuclei. It was positive for chromogranin A and synaptophysin in immunostaining, so we made a diagnosis of NET G1. Tumor cells infiltrated beyond the intrinsic muscle layer, but no vascular invasion was observed, and the margin was negative. In accordance with the guidelines, we followed up the patient with imaging examination and did not find any signs of recurrence.

[Two Cases of Rectal Cancer with Pelvic Local Recurrence Complicated with Sepsis after Rectal Cancer Surgery Successfully Treated with Radiation Therapy].

Treatment of rectal cancer with postoperative pelvic recurrence may complicate infection and may be difficult to treat. We experienced 2 cases complicated with sepsis due to infection in the pelvic local recurrence in which radiation therapy was performed and they were shifted to outpatient molecular-targeted drug therapy. Case 1 involved a 58-year-old woman. In December 2011, colostomy and chemotherapy were performed for locally advanced rectal cancer. In June 2012, we performed low anterior resection. In January 2014, chemotherapy was started for pelvic recurrence. She discontinued treatment for 4 months due to personal circumstances. Recurrence was worsened, and infection caused sepsis and she was admitted to the hospital in February 2017. Infection was not improved with antibiotic drugs, and radiation therapy(60 Gy/30 times)was performed. Infection was improved, and panitumumab monotherapy was started and she was discharged. Case 2 involved a 61-year-old man. In February 2014, a lower anterior resection for rectal cancer was performed. In September 2015, chemotherapy was started for pelvic recurrence. In November 2016, chemotherapy was discontinued due to esophageal variceal rupture. Recurrence was worsened, and infection caused sepsis and he was admitted to the hospital in May 2017. Radiation therapy(50 Gy/20 times)was performed after colostomy. Infection was improved, and cetuximab monotherapy was started and he was discharged.

[Long-Term Survival of a Case with Brain and Lung Metastases from Resected Rectal Cancer by Gamma Knife Radiosurgery].

A 69-year-oldfemale hadund ergone low anterior resection for rectal cancer(Rb). Histological examination showedwell differentiated adenocarcinoma with lymph node metastasis. Adjuvant chemotherapy with UFT was performed postoperatively. Nineteen months later, abdominoperineal resection was performedfor anastomotic recurrence andS -1 chemotherapy was made. As 2 left lung metastases appearedat the 44 months after first surgery, capecitabine was performedfor 4 years. At the 101 months after first surgery, sensory difficulty of right lower limb appearedandMRI revealedbrain tumor(single, 18mm) in the left parietal lobe. We performedgamma knife radiosurgery for the brain metastasis andmultiagent chemotherapy for lung metastases. Although the brain metastases have relapsedtwice, gamma knife providedgoodlocal control. She is surviving without symptom of brain metastases 37 months after the detection.

[Two Cases of Colon Cancer with Severe Liver Dysfunction Due to Multiple Liver Metastases Effectively Treated with Hepatic Arterial Infusion Chemotherapy plus CetuximabFollowed by Systemic Chemotherapy].

Case 1: An 80-year-old man was diagnosed with cecal cancer plus multiple liver metastases and peritoneal disseminations. He underwent surgical resection of the primary tumor to prevent bowel obstruction. Initially, hepatic arterial infusion(HAI) plus cetuximab(Cmab)was administered to reduce the size of the metastatic tumors and prevent liver failure. A partial response(PR)was observed in the liver metastases after 12 courses of treatment and S-1 plus oxaliplatin(SOX)plus bevacizumab was started. Case 2: A 44-year-old man was diagnosed with sigmoid colon cancer with multiple liver, lung and bone metastases, and with obstructive jaundice and cholangitis due to severe liver hilum lymph node metastases. His performance status(PS)score was 3 because of severe liver damage. Initially, he underwent endoscopic nasobiliary drainage for obstructive jaundice, and HAI plus Cmab was started to prevent liver dysfunction and to control all metastases. A PR in the metastatic liver tumors was observed after 18 courses. His PS increased to 1 and he was treated with mFOLFOX6 plus Cmab. HAI plus Cmab might be a treatment option for patients who have RAS-wild type tumors with severe liver dysfunction due to multiple liver metastases; HAI is intended to have few side effects and has a high local control rate.

[A Case of Metastasis to the Base of the Skull after Rectal Cancer Operation with Symptom Management via Radiotherapy].

In 2009, A 67-year-old woman underwent high anterior resection for rectal cancer(RS, type 2, pT3, pN1, cM0, pStage III a). U FT/LV was administered for 6 months as adjuvant chemotherapy after the operation. Because peritoneum dissemination and pelvic lymph node metastasis developed 9 months after the operation, CapeOX plus Bmab therapy was started, and we monitored the cancer partial response for the next 6 years. Six years and 9 months after the operation, we detected metastasis to the sacrum; thus, radiotherapy was started. Seven years after the first operation, we detected pulmonary, liver, distant lymph node, and subcutaneous metastasis. Additionally, in the next month, she complained of double vision and dysarthria, and metastasis to the base of the skull was diagnosed via head MRI scanning. We started radiotherapy, and the symptoms gradually improved. Although we started IRIS plus Bmab therapy for pulmonary, liver, distant lymph node, and subcutaneous metastasis, it became a progressive disease(PD). She passed away 7 years and 6 months after the first operation. In this case, radiotherapy was useful for symptom management of metastasis to the base of the skull after surgery for rectal cancer, which is an extremely rare occurrence.

[Relationships between ignoring instructions and response bias when completing questionnaires].

Certain participants are insincere, or careless when they respond to questionnaires. To identify such participants, we included three items in a questionnaire that instructed participants to choose a particular response category. Nurses (N = 1,000) responded to this questionnaire in a Web survey. One-hundred-twenty participants failed to follow the instructions for at least one item (non-followers). Analyzing their responses indicated the following: (a) non-followers were more likely to give identical, or midpoint responses; (b) the correlations between their responses to regular and reversed items were low or positive, and their responses to scales containing reversed items tended to show lower internal consistency; and finally, (c) the mean scores of non-followers were closer to the midpoint of the scale, regardless of whether the scale included reversed items. One reason that including reversed items lead to lower internal consistency could be because participants occasionally missed responding to these items. However, the results suggested that non-followers were not diligent in responding to regular items, and merely deleting reversed items from scales will be insufficient to ensure accurate results.

Cost-effectiveness of cognitive behavioral therapy for insomnia comorbid with depression: Analysis of a randomized controlled trial.

AIM: Although the efficacy of cognitive behavioral therapy for insomnia has been confirmed, dissemination depends on the balance of benefits and costs. This study aimed to examine the cost-effectiveness of cognitive behavioral therapy for insomnia consisting of four weekly individual sessions. METHODS: We conducted a 4-week randomized controlled trial with a 4-week follow up in outpatient clinics in Japan. Thirty-seven patients diagnosed as having major depressive disorder according to DSM-IV and suffering from chronic insomnia were randomized to receive either treatment as usual (TAU) alone or TAU plus cognitive behavioral therapy for insomnia. Effectiveness was evaluated as quality-adjusted life years (QALY) over 8 weeks' time, estimated by bootstrapping of the observed total scores of the Hamilton Depression Rating Scale. Direct medical costs for cognitive behavioral therapy for insomnia and TAU were also evaluated. We calculated the incremental cost-effectiveness ratio. RESULTS: Over the 8 weeks of the study, the group receiving cognitive behavioral therapy for insomnia plus TAU had significantly higher QALY (P = 0.002) than the TAU-alone group with an incremental value of 0.019 (SD 0.006), and had non-significantly higher costs with an incremental value of 254 (SD 203) USD in direct costs. The incremental cost-effectiveness ratio was 13 678 USD (95% confidence interval: -5691 to 71 316). Adding cognitive behavioral therapy for insomnia demonstrated an approximately 95% chance of gaining one more QALY if a decision-maker was willing to pay 60 000 USD, and approximately 90% for 40 000 USD. CONCLUSION: Adding cognitive behavioral therapy for insomnia is highly likely to be cost-effective for patients with residual insomnia and concomitant depression.

[A Case of Stage â £ Rectal Cancer with No Evidence of Disease after Neoadjuvant Chemotherapy and Surgery].

A 46-year-old man presented with hematochezia in October 2012. A circumferential type 2 rectal cancer was detected with colonoscopy. Contrast-enhanced CT showed multiple liver and lung metastases. Chemotherapy was administered after the diagnosis of cStage Ⅳ rectal cancer. After 1 course of XELOX plus Bmab, the treatment was changed to XELOX plus Cmab for 21 courses. An infusion reaction occurred during the 21st course. Because a complete response of the liver metastases and a reduction in size of the primary tumor had been achieved, we performed a low anterior resection in April 2014. The final pathological diagnosis was type 2, 10×25 mm, tub1, pMP, int, INF b, pN1 (251). There was no evidence of disease (NED) after the surgery. We are closely following up this patient with no postoperative chemotherapy, and as of July 2015, there is no sign of recurrence. We describe a case of a Stage Ⅳ rectal cancer that was resected with radical surgery after neoadjuvant chemotherapy. We also include a brief review of the literature.

Assessment of metabolic status in young Japanese females using postprandial glucose and insulin levels.

Lifestyle-related diseases develop through the accumulation of undesirable lifestyle habits both prior to the onset of disease as well as during normal healthy life. Accordingly, early detection of, and intervention in, metabolic disorders is desirable, but is hampered by the lack of an established evaluation index for young individuals. The purpose of this study was to investigate the utility of a biomarker of health in young female subjects. The subjects were young healthy Japanese females in whom energy expenditure was measured for a period of 210 min after a test meal. In addition, Δplasma glucose and Δserum insulin were calculated from the fasting and 30 min values. ΔPlasma glucose and Δserum insulin levels varied widely compared to fasting levels. Both the area under the curve of carbohydrate oxidation rate and serum free fatty acid levels were higher in individuals in the high Δplasma glucose group. Moreover, Δplasma glucose was higher in individuals in the high Δserum insulin group than in the low Δserum insulin group. We conclude that nutritional balanced liquid loading test using Δplasma glucose and Δserum insulin as the evaluation index is useful for the detection of primary metabolic disorders in young females.

Comparison of short-term outcomes and defecatory function following robotic and conventional laparoscopic surgery for stapled-ileal pouch-anal anastomosis-a retrospective cohort study.

BACKGROUND: This study assessed the potential advantages of robotic-assisted Stapled ileal pouch-anal anastomosis (Ro Stapled-IPAA) in ulcerative colitis (UC) compared to conventional laparoscopic surgery (Lap), with a focus on short-term outcomes and postoperative defecatory function, an aspect not previously explored. MATERIALS AND METHODS: Out of a total of 132 patients who underwent proctocolectomy or residual rectal resection, consecutive patients undergoing minimally invasive Stapled-IPAA for UC at our hospital from May 2014 to May 2024 were included. The Ro approach was chosen for individuals with severe colitis extending into the anal canal, deeper rectal cancers (beyond T1), and cases requiring residual rectal resection, taking advantage of its benefits. Perioperative outcomes, including anastomosis height, operative time, intraoperative blood loss, complication rate, postoperative hospital stay, and defecatory function using Wexner scores and anorectal manometry before proctocolectomy and 6 months after stoma closure, were compared between the Ro and Lap groups. RESULTS: 33 patients (Lap, n=21; Ro, n=12) were included. The Ro group demonstrated a significantly lower anastomosis height (0.5 vs. 3.0 cm, P<0.001), reduced intraoperative blood loss (35 vs. 118 mL, P=0.032), shorter postoperative hospital stay (8 vs. 10.5 d), and no cases of anastomotic leakage (0% vs. 14.3%), as compared to the Lap group. Pouch failure occurred in 14% of Lap group; none were observed in the Ro group. Wexner scores favored the Ro group at 12 months after stoma closure (0 vs. 8 points), and there was better maximum voluntary squeeze pressure (302 mmHg vs. 175 mmHg, P=0.03), indicating preserved contraction of the external sphincter muscle despite the lower anastomosis. CONCLUSION: Ro Stapled-IPAA for patients with UC led to better short-term outcomes and preservation of defecatory function with lower anastomosis than Lap, suggesting the clinical advantages of the robotic approach in this field.

Assessment of Mild Cognitive Impairment Using CogEvo: A Computerized Cognitive Function Assessment Tool.

INTRODUCTION/OBJECTIVES: To assess the utility of the computerized cognitive function assessment tool, CogEvo, as a screening tool for mild cognitive impairment in primary care, we explored the relationship between CogEvo performance, age, and the severity of cognitive dysfunction evaluated by the Mini-Mental State Examination (MMSE). METHODS: The observational cross-sectional study included 209 individuals' data (mean age 79.4 ± 8.9 years). We conducted a correlation analysis between CogEvo and MMSE scores, compared the performance among the 3 cognitive function groups (MMSE ≥ 28 group; MMSE24-27 group; MMSE ≤ 23 group) using the MMSE cut-off, and evaluated CogEvo's predictive accuracy for cognitive dysfunction through ROC analysis. RESULTS: Both total CogEvo and MMSE scores significantly decreased with age. A significant positive correlation was observed between total CogEvo and MMSE scores, but a ceiling effect was detected in MMSE performance. Significant differences were observed in the total CogEvo score, including orientation and spatial cognitive function scores, among the 3 groups. CogEvo showed no educational bias. ROC analyses indicated moderate discrimination between the MMSE ≥ 28 group and the MMSE24-27 and MMSE ≤ 23 groups. CONCLUSIONS: The computer-administered CogEvo has the advantage of not exhibiting ceiling effects or educational bias like the MMSE, and was found to be able to detect age-related cognitive decline and impairment.

Does Pathological T-Factor Affect Long-term Prognosis of Locally Advanced Colorectal Cancer Treated With Laparoscopic Multivisceral Resection?

BACKGROUND/AIM: Locally advanced colorectal cancer (LACC) has poor long-term outcomes. Our hypothesis was that the pathological tumor depth would affect postoperative outcomes in patients who underwent multivisceral resection with clear margins (R0). The aim of this study was to analyze short- and long-term outcomes in patients who underwent multivisceral resection for LACC, comparing between T3 and T4 stages. PATIENTS AND METHODS: This was a propensity score-matched, retrospective study. All 8,764 consecutive patients who underwent surgery for colorectal cancer between April 2007 and January 2021 at the Saitama Medical University International Medical Center were screened; 572 underwent multivisceral resection for LACC. We compared the T3 and T4 groups to evaluate outcomes. RESULTS: The 5-year disease-free survival (DFS) rates did not significantly differ between the two groups (hazard ratio=1.344, 95% confidence interval=0.638-2.907, p=0.33). The 5-year overall survival (OS) rates were significantly worse for the T4 group than for the T3 group (hazard ratio=3.162, 95% confidence interval=1.077-11.44), p=0.037). To determine the association between American Society of Anesthesiologists (ASA) score, transfusion, pathological T and OS, we performed univariate and multivariate analyses. ASA, transfusion, and pathological T-stage were associated with worse OS in univariate analysis (T4 vs. T3, respectively). CONCLUSION: Our study showed that postoperative complications and DFS of the T4 group were similar to those of the T3 group of locally advanced colorectal cancer treated with laparoscopic multivisceral resection. However, OS was worse in the T4 group compared with the T3 group. Multivariate risk factors for poor OS were ASA>2, transfusion, and T4 stage.