[Rupture of Left Ventricular Pseudo-false Aneurysm after Myocardial Infarction].

We herein present a case of ruptured left ventriclular pseudo-false aneurysm. A 73-year-old female had acute myocardial infarction due to occlusion of the left circumflex artery, and subsequently underwent percutaneous coronary intervention. Three weeks later, however, the patient suddenly fell into a state of shock. Contrast-enhanced computed tomography (CT) revealed rupture of left ventricular aneurysm, and emergency surgery was performed. A ruptured aneurysm was observed in the posterior wall, and as the wall of the aneurysm was fragile, it was repaired using double-patch technique. Histopathological examination revealed myocardial cells in the aneurysm wall, confirming diagnosis of pseudo-false aneurysm. Pseudo-false aneurysm is a rare type of left ventricular aneurysm. In cases of rupture in acute or subacute phase of myocardial infarction, when the aneurysm wall is fragile, double-patch repair technique effectively ensures hemostasis and prevents future aneurysm formation.

[Anastomotic Pseudoaneurysms after Graft Replacement for IgG4-related Thoracic Aortic Aneurysm].

We report a case of pseudoaneurysms at the anastomotic sites after prosthetic graft replacement for Immunogloblin G4 (IgG4)-related thoracic aortic aneurysm. A 69-year-old male patient underwent ascending and aortic arch replacement and open stent graft insertion. Five months after the surgery, pseudoaneurysms at the anastomosis to the brachiocephalic artery and to the left common carotid artery developed, and urgency surgery was performed. The right common carotid artery, the right subclavian artery, and the left common carotid artery were individually reconstructed with grafts, and the anastomoses were wrapped with grafts. In IgG4-related aneurysms, complete resection of the diseased tissue and reinforcement of the anastomosis, such as anastomotic wrapping, are important to prevent anastomotic site failure. While serum IgG4 had normalized after the first surgery, C-reactive protein (CRP) remained elevated until the reoperation. Thus, CRP is considered one of the biomarkers for disease activity in IgG4-related vascular disease.

Neoadjuvant Superselective Intra-Arterial Cisplatin Chemoradiotherapy Combined With Surgery in Patients With T4 Squamous Cell Carcinoma of the Maxillary Sinus.

PURPOSE: Squamous cell carcinoma of the maxillary sinus (SCC-MS) is often diagnosed at a locally advanced stage, which is associated with poor prognosis. The purpose of the present study was to investigate clinical outcomes in patients with locally advanced T4 SCC-MS including originally inoperable T4b disease treated with neoadjuvant superselective intra-arterial chemoradiotherapy combined with surgery. METHODS: This study is a retrospective case series. We examined clinical outcomes in the patients with T4 SCC-MS between 2005 and 2017. The outcome variables were 5-year overall survival rate, 5-year disease-free survival rate, and 5-year local control rate. Covariates included age, sex, T classification, N classification, stage classification, type of surgery, number of administrations and total dose of cisplatin, and radiation dose. Descriptive statistics were computed for each study variable. RESULTS: Ten patients with T4 SCC-MS (6 T4a and 4 T4b) were treated. All patients were men, and the median age was 60.5 years (range, 45 to 77). Total maxillectomy was performed in 4 patients, and extended total maxillectomy in 6. The total number of intra-arterial chemotherapy administrations ranged between 2 and 4 for patients with T4a disease and between 3 and 4 for those with T4b disease. The median intra-arterial cisplatin dose was 360 mg (range, 250 to 400) for patients with T4a disease and 360 mg (range, 320 to 480) for those with T4b disease. The 5-year overall survival, 5-year disease-free survival, and 5-year local control rates of all patients were 100%, 70%, and 80%, respectively. The 5-year disease-free survival rate and 5-year local control rate were 83% and 83%, respectively, in the 6 T4a patients and 50% and 75%, respectively, in the 4 T4b patients. CONCLUSION: Neoadjuvant intra-arterial chemoradiotherapy in patients with T4 SCC-MS can achieve good clinical outcomes, and it may enable surgical resection of T4b lesions.

[Total Arch Replacement due to Tracheal Compression by Brachiocephalic Artery with Bovine Aortic Arch:Report of a Case].

A 78-year-old female presented to our institution with a dry cough and dyspnea. Chest computed tomography( CT) revealed tracheal stenosis caused by compression from a brachiocephalic artery with a bovine aortic arch. Subsequently, surgery was performed in which the brachiocephalic artery was resected, and a total arch replacement using a four-branched graft was completed. We paid particular attention to the graft branches, making sure to avoid contact with the trachea. Both the patient's cough and dyspnea dissipated after the surgery, and a CT revealed the tracheal stenosis had been completely relieved. The patient has remained in good condition for the past three years since the surgery showing no respiratory symptoms or thoracic aortic disease. Because the bovine aortic arch is a known risk factor for thoracic aortic disease, rather than simply reconstructing the brachiocephalic artery, we chose a more aggressive surgical treatment to prevent any possible future thoracic aortic disease.

[Fatal Cerebral Hemorrhage after Mitral Valve Repair for Active Infective Endocarditis:Report of a Case].

Cerebral hemorrhage is a known complication of infective endocarditis (IE) and is associated with a high mortality rate. We herein present a case of fatal cerebral hemorrhage occurring after successful mitral valve repair in a patient in active phase of IE. A 58-year-old male with active IE underwent an urgent mitral valve repair due to systemic embolisms and a massive mobile vegetation on the mitral valve. During the surgery, a rolled autologous pericardium was fixed onto the annulus, therefore we initiated anticoagulation therapy with warfarin. A follow-up brain MRI on the 18th postoperative day showed several cerebral micro bleedings, and on the next day, the patient suffered massive and fatal cerebral hemorrhage. As cerebral hemorrhage can be fatal especially in patients taking anticoagulants, we believe that anticoagulation therapy should be avoided after mitral valve repair in patients who have cerebral micro bleeding in active phase of IE.

[Primary Pericardial Dedifferentiated Liposarcoma Detected by Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography;Report of a Case].

We herein present a rare case of dedifferentiated liposarcoma originating from the pericardium. A 79-year-old female was referred to our hospital with a pericardial tumor detected by fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). The tumor, 80×48 mm in size, showed increased uptake of fluorodeoxyglucose on the FDG-PET/CT without any evidence of metastasis. The tumor was resected with the pericardium, and a histopathological examination confirmed the diagnosis of dedifferentiated liposarcoma. Additional chemotherapy, radiation therapy, or a combination of both were offered but refused by the patient. Although the patient was discharged without any complications, the tumor recurred locally 2 months after the surgery, and the patient succumbed 15 months later. The FDG-PET/CT was useful not only in detecting this malignant tumor but also in diagnosing its malignant nature.

[Endovascular Treatment Using the Fenestrated Stent Graft for Distal Aortic Arch Aneurysm with Aortic Arch Vessel Anomalies;Report of a Case].

We herein present a case of distal aortic arch aneurysm associated with the bovine arch and the isolated left vertebral artery (ILVA). Incorporating 2 fenestrations, we successfully performed an endovascular repair using the commercially available Najuta fenestrated stent graft system. During surgery, the Najuta was deployed in the aorta so as to allow for the proximal fenestration to be aligned with the orifice of the 1 branch of the aortic arch, and the distal fenestration with the orifice of the ILVA and that of left subclavian artery. Postoperatively, the patient's recovery went well without any cerebral complications, and in a subsequent computed tomography (CT), the patency of all aortic arch vessels and absence of endoleaks was confirmed. For cases of distal aortic arch aneurysm associated with arch anomalies, the endovascular treatment using the Najuta system is not only simple but also reliable in preserving blood flow to the brain and upper extremities.

[Bronchial Occlusion with Endobronchial Watanabe Spigot for Massive Pulmonary Hemorrhage during Heart Surgery;Report of a Case].

Massive pulmonary hemorrhage, although rare, is a potentially life-threatening complications during heart surgery. We herein present 1 such case successfully treated by selective bronchial occlusion using an Endobronchial Watanabe Spigot (EWS). The 82-year-old female underwent mitral valve replacement, tricuspid annuloplasty, and maze procedure. An hour and a half after cessation of cardiopulmonary bypass, the patient suffered a massive pulmonary hemorrhage. A subsequent bronchoscopy identified the hemorrhage site at the right middle lobe bronchus (B5b), and an EWS was then selectively deployed into this bronchus to block the hemorrhage. The following day, bronchial arterial embolization was performed, enabling the removal of the spigot on the next day. The patient's respiratory condition gradually improved, allowing for extubation on the 21st postoperative day. By preventing bleeding into neighboring bronchi, which, in turn, avoids the risk of exacerbating hypoxia, bronchial occlusion with EWSs is highly effective in managing massive pulmonary hemorrhage during heart surgery.

Secondary brain tumors after cranial radiation therapy: A single-institution study.

AIM: To study the probability of developing secondary brain tumors after cranial radiotherapy.Background Patients treated with cranial radiotherapy are at risk for developing secondary brain tumors. PATIENTS AND METHODS: We planned an institutional survey for secondary brain tumors in survivors after cranial irradiation and reviewed the 30-year duration data. Event analysis and cumulative proportion curves were performed to generally estimate the cumulative proportion of developing secondary brain tumors, cavernoma and meningioma at different periods of time. RESULTS: Secondary brain tumors occurred in 21% of cases: 10% were cavernomas, 6% were meningiomas, 3% were skull osteomas, and 1% were anaplastic astrocytoma. The cumulative proportion of developing secondary brain tumor was 6% at 10 years and 20% at 20 years, while the cumulative proportion for developing cavernomas and meningiomas was 16% and 7% at 20 years, respectively. CONCLUSION: Our study shows that patients who received cranial irradiation were at risk of secondary brain tumors such as cavernomas and meningiomas. Thus, a meticulous follow-up of cancer survivors with history of cranial irradiation by an annual MRI scan is justifiable. This will help clinicians to detect secondary brain tumors early and make its management much easier.

Vegetation demographics in Earth System Models: A review of progress and priorities.

Numerous current efforts seek to improve the representation of ecosystem ecology and vegetation demographic processes within Earth System Models (ESMs). These developments are widely viewed as an important step in developing greater realism in predictions of future ecosystem states and fluxes. Increased realism, however, leads to increased model complexity, with new features raising a suite of ecological questions that require empirical constraints. Here, we review the developments that permit the representation of plant demographics in ESMs, and identify issues raised by these developments that highlight important gaps in ecological understanding. These issues inevitably translate into uncertainty in model projections but also allow models to be applied to new processes and questions concerning the dynamics of real-world ecosystems. We argue that stronger and more innovative connections to data, across the range of scales considered, are required to address these gaps in understanding. The development of first-generation land surface models as a unifying framework for ecophysiological understanding stimulated much research into plant physiological traits and gas exchange. Constraining predictions at ecologically relevant spatial and temporal scales will require a similar investment of effort and intensified inter-disciplinary communication.

[Surgical Repair of Kommerell's Diverticulum with Right Sided Aortic Arch;Report of a Case].

A 54-year-old woman was referred for assessment of dysphagia and extrinsic compression of the esophagus detected by upper gastrointestinal endoscopy. Computed tomography revealed the rightsided aortic arch with mirror image branching and Kommerell's diverticulum. To relieve the esophageal compression, surgical intervention was indicated. Descending aortic replacement with a Dacron graft was performed through right thoracotomy under partial cardiopulmonary bypass. The patient was discharged without any complication, and her dysphagia disappeared.

Tree-ring analysis and modeling approaches yield contrary response of circumboreal forest productivity to climate change.

Circumboreal forest ecosystems are exposed to a larger magnitude of warming in comparison with the global average, as a result of warming-induced environmental changes. However, it is not clear how tree growth in these ecosystems responds to these changes. In this study, we investigated the sensitivity of forest productivity to climate change using ring width indices (RWI) from a tree-ring width dataset accessed from the International Tree-Ring Data Bank and gridded climate datasets from the Climate Research Unit. A negative relationship of RWI with summer temperature and recent reductions in RWI were typically observed in continental dry regions, such as inner Alaska and Canada, southern Europe, and the southern part of eastern Siberia. We then developed a multiple regression model with regional meteorological parameters to predict RWI, and then applied to these models to predict how tree growth will respond to twenty-first-century climate change (RCP8.5 scenario). The projections showed a spatial variation and future continuous reduction in tree growth in those continental dry regions. The spatial variation, however, could not be reproduced by a dynamic global vegetation model (DGVM). The DGVM projected a generally positive trend in future tree growth all over the circumboreal region. These results indicate that DGVMs may overestimate future wood net primary productivity (NPP) in continental dry regions such as these; this seems to be common feature of current DGVMs. DGVMs should be able to express the negative effect of warming on tree growth, so that they simulate the observed recent reduction in tree growth in continental dry regions.

[Total Arch Replacement for Distal Arch Aneurysm with Isolated Left Vertebral Artery;Report of a Case].

We herein present a case of distal aortic arch aneurysm with an isolated left vertebral artery(LVA). In surgery, after establishing cardiopulmonary bypass, the LVA was anastomosed to the left common carotid artery (LCCA) while under moderate hypothermia. Selective cerebral perfusion (SCP) was then initiated by inserting catheters into the brachiocephalic artery( BCA), the LCCA and the left subclavian artery (LSA). The aorta was transected between the BCA and the LCCA, and an open stent graft was deployed into the descending aorta during circulatory arrest. After reconstructing the LSA, LCCA and BCA, the ascending aorta was replaced with a graft. The patient recovered well without any cerebral complications, and computed tomography confirmed the patency of the reconstructed LVA. Regarding the surgical treatment of an aortic arch aneurysm with an isolated LVA, reconstructing the isolated LVA before SCP makes the establishment of SCP straightforward, thereby helping protect the brain from ischemia.

[Ventricular Septal Perforation after Inferior Myocardial Infarction].

We report a rare case of ventricular septal perforation (VSP) after inferior myocardial infarction. Surgical repair of VSP after inferior infarction is technically difficult because of its anatomical location. An 81-year-old female presented with dyspnea on the 8th day after percutaneous coronary intervention for acute inferior myocardial infarction. Echocardiography revealed a ventricular septal perforation. Urgent operation was performed. There was a VSP around the base of the ventricular septum. The myocardial infarction extended to the adjacent muscle of the mitral valve annulus. Two bovine pericardial patches were used in the left ventricular cavity. The patches were sewn on the mitral valve annulus which was the only normal tissue in the region. The 1st patch was used to close the VSP directly, and the 2nd patch was sutured to the normal myocardium to exclude the infracted area. No residual shunt flow was observed. The postoperative course was uneventful.

Investigation of the clinicopathological features of squamous cell carcinoma of the vulva: a retrospective survey of the Tohoku Gynecologic Cancer Unit.

BACKGROUND: This multi-institutional study was conducted to clarify the clinicopathological features of squamous cell carcinomas of the vulva. METHODS: The medical records of vulvar cancer patients treated between 2002 and 2012 were retrospectively reviewed following approval by the Institutional Review Board of each institution. RESULTS: One hundred and eleven patients with vulvar malignancies were included. Of these, 63 patients had squamous cell carcinoma (57 %). Initial treatment was surgery, radiation therapy (RT), and concurrent chemoradiotherapy (CCRT) in 34 (54 %), 15 (24 %), and 11 (17 %) patients, respectively. Nineteen, 11, 26, and 7 patients had stage I, II, III, and IV disease, respectively. Of the 34 patients who had surgical treatment, 50 % had stage I disease, while 74 % of those who received CCRT had stage III or IV disease. Complete response (CR) rates for the surgery, RT, and CCRT groups were 73, 60, and 64 %, respectively. The 5-year survival rates for stage I/II and III/IV disease were 64 and 39 %, respectively (P = 0.019). The 5-year survival rates for the surgery, RT, and CCRT groups were 53, 38, and 50 %, respectively, and the prognosis of patients treated with surgery or CCRT was significantly better than that of patients who received RT (P < 0.05). In multivariate analysis, clinical response to initial treatment was an independent prognostic factor (P < 0.001). CONCLUSIONS: Although many patients had advanced-stage disease in the CCRT group, the therapeutic outcome for the surgery and CCRT groups was similar. Thus, CCRT may be a promising treatment for squamous cell carcinoma of the vulva.

[Incidentally detected bronchial artery aneurysm with combined operation for mitral regurgitation;report of a case].

A 77-year-old woman was admitted to the hospital for heart failure with orthopnea. Echocardiography revealed massive mitral regurgitation. During preoperative cardiac catheterization, an aneurysm was indentified incidentally just below the tracheal carina. Three dimensional computed tomography showed three bronchial artery aneurysms behind the pulmonary artery and the left atrium. The proximal aneurysm was the largest and was 22 mm in diameter. It was resected by retracting the ascending aorta to the left, the superior vana cava to the right and right pulmonary artery cranially under cardiopulmonary bypass, and mitral valve plasty was performed. We believed that resection of the proximal aneurysm would cause thrombotic occlusion of the other 2 aneurysms. Bronchial artery aneurysm is a rare entity that is observed in fewer than 1% of those who undergo selective bronchial arteriography. In addition, because bronchial artery aneurysm is a potentially life-threatening lesion, it should be treated promptly when diagnosed.

[Surgical Repair of Severely Calcific Constrictive Pericarditis;Report of a Case].

A 74-year-old male presented with exertional dyspnea and leg edema. Chest X-ray and computed tomography demonstrated dense calcification of the pericardium. Based on a diagnosis of constrictive pericarditis, pericardiectomy was performed without the use of extracorporeal circulation. During the operation, we employed a Harmonic Scalpel (Naginata-type) to peel off the calcified pericardium around the right and left ventricles. The calcified pericardium around the right atrium was found to be so firmly adhered to the atrial wall that peeling off the calcified tissue was difficult. Therefore, we used a Cavitron Ultrasonic Surgical Aspirator (CUSA) to break down the calcification. After the surgery, the patient's dyspnea on exertion and leg edema resolved, and he recovered without any complications. Regarding the surgical treatment of severely calcific constrictive pericarditis, Naginata-type Harmonic Scalpel and CUSA are very useful for peeling off the calcified tissue of the pericardium and/or breaking down the calcification.

Combination of oligo-fractionated irradiation with nivolumab can induce immune modulation in gastric cancer.

BACKGROUND: Tumor-associated antigen (TAA)-specific CD8(+) T cells are essential for nivolumab therapy, and irradiation has been reported to have the potential to generate and activate TAA-specific CD8(+) T cells. However, mechanistic insights of T-cell response during combinatorial immunotherapy using radiotherapy and nivolumab are still largely unknown. METHODS: Twenty patients included in this study were registered in the CIRCUIT trial (ClinicalTrials.gov, NCT03453164). All patients had multiple distant metastases and were intolerance or had progressed after primary and secondary chemotherapy without any immune checkpoint inhibitor. In the CIRCUIT trial, eligible patients were treated with a total of 22.5 Gy/5 fractions/5 days of radiotherapy to the largest or symptomatic lesion prior to receiving nivolumab every 2 weeks. In these 20 patients, T-cell responses during the combinatorial immunotherapy were monitored longitudinally by high-dimensional flow cytometry-based, multiplexed major histocompatibility complex multimer analysis using a total of 46 TAAs and 10 virus epitopes, repertoire analysis of T-cell receptor ß-chain (TCRß), together with circulating tumor DNA analysis to evaluate tumor mutational burden (TMB). RESULTS: Although most TAA-specific CD8(+) T cells could be tracked longitudinally, several TAA-specific CD8(+) T cells were detected de novo after irradiation, but viral-specific CD8(+) T cells did not show obvious changes during treatment, indicating potential irradiation-driven antigen spreading. Irradiation was associated with phenotypical changes of TAA-specific CD8(+) T cells towards higher expression of killer cell lectin-like receptor subfamily G, member 1, human leukocyte antigen D-related antigen, T-cell immunoglobulin and immunoreceptor tyrosine-based inhibitory motif domain, CD160, and CD45RO together with lower expression of CD27 and CD127. Of importance, TAA-specific CD8(+) T cells in non-progressors frequently showed a phenotype of CD45RO(+)CD27(+)CD127(+) central memory T cells compared with those in progressors. TCRß clonality (inverted Pielou's evenness) increased and TCRß diversity (Pielou's evenness and Diversity Evenness score) decreased during treatment in progressors (p=0.029, p=0.029, p=0.012, respectively). TMB score was significantly lower in non-progressors after irradiation (p=0.023). CONCLUSION: Oligo-fractionated irradiation induces an immune-modulating effect with potential antigen spreading and the combination of radiotherapy and nivolumab may be effective in a subset of patients with gastric cancer.

[Primary left atrial myxofibrosarcoma; report of a case].

We herein report a very rare case of a primary left atrial myxofibrosarcoma. A 61-year-old female presented with dyspnea and a wet cough. Chest X-ray film showed cardiomegaly and pulmonary congestion. Echocardiography and computed tomography revealed a left atrial tumor obstructing blood flow to the left ventricle. She was diagnosed with acute congestive heart failure due to functional mitralstenosis secondary to a left atrial tumor, and an emergency operation was performed. The tumor, which occupied left atrium, attached to the posterior wall of the left atrium and to the mitral valve, but had not invaded the left atrial wall. The tumor was removed from the left atrial wall, preserving the mitral valve and valve leaflets. The patient's post operative course was uneventful. The pathological diagnosis was myxofibrosarcoma, which rarely develops in the heart.

Structural modification of WC-Co cutting tools by laser doping treatment.

We have previously shown that sharpening the cutting edge of a cemented carbide tool by chemical-mechanical polishing (CMP) improved the cutting speed by approximately 150% and reduced the wear on the flank surface by approximately 50% compared to a commercial tool when cutting a heat-resistant alloy. In addition, the cutting edges of carbide tools treated by laser doping (LD) using boron nitride as doping material achieved approximately 100 times longer cutting distance in glass machining than the edges of carbide tools treated with CMP grinding wheels. In this study, LD was conducted on a tool base material (WC-Co) to investigate and understand the crystal structure changes of the base material upon treatment. Electron backscatter diffraction and X-ray diffraction results show that the effect of LD was observed in the region 50 nm below the surface. LD improved the strength by approximately 11.7% without destroying the surface crystal structure. Thus, doping can be performed on tool tips while maintaining the WC structure to improve the performance of WC-Co cutting tools.