Leptomeningeal carcinomatosis from breast cancer initially mimicking cerebral infarction on MRI.

A female patient in her early 50s with breast cancer underwent breast-conserving surgery, followed by radiation therapy. She developed multiple lung and bone metastases and was started on chemotherapy with bevacizumab and paclitaxel 3 years later. After 6 months of chemotherapy, she developed a decline in conversation and memory. Magnetic resonance imaging (MRI) was conducted and showed multiple cortical and subcortical lesions and nodules with restricted diffusion but with no contrast enhancement on gadolinium (Gd) enhanced T1-weighted image, raising a suspicion of Trousseau's syndrome. A follow-up MRI revealed unchanged signal intensity of the lesions but with minimal enlargement. The cerebrospinal fluid cytology was negative for malignancy. Consequently, an open biopsy of the cortical lesion was conducted. Histopathology showed that the tumor cells were morphologically similar to the primary breast cancer extending from the brain surface along the Virchow-Robin spaces, which yielded a diagnosis of leptomeningeal carcinomatosis from breast cancer. Contrast enhancement on Gd-MRI may be impaired in case of tumor spread along the perivascular space or in patients treated with bevacizumab.

Relief Effect of Carbon Dioxide Insufflation in Transnasal Endoscopy for Health Checks-A Prospective, Double-Blind, Case-Control Trial.

CO2 insufflation has proven effective in reducing patients' pain after colonoscopies but has not been examined in esophagogastroduodenoscopies. Therefore, we examined the effect of CO2 insufflation in examinees who underwent transnasal endoscopies without sedation. This study is a single-center, prospective, double-blind, case-control trial conducted between March 2017 and August 2018. Subjects were assigned weekly to receive insufflation with either CO2 or air. The primary outcome was improvement of abdominal pain and distension at 2 h and 1-day postprocedure. In total, 336 and 338 examinees were assigned to the CO2 and air groups, respectively. Visual analog scale (VAS) scores for abdominal distension (15.4 vs. 25.5; p < 0.001) and distress from flatus (16.0 vs. 28.8; p < 0.001) at 2 h postprocedure were significantly reduced in the CO2 group. VAS scores for pain during the procedure (33.5 vs. 37.1; p = 0.059) and abdominal pain after the procedure (3.9 vs. 5.7; p = 0.052) also tended to be lower at 2 h postprocedure, but all parameters showed no significant difference at 1-day postprocedure. All procedures were safely completed through the planned program, and no apparent adverse events requiring treatment or follow-up occurred. In conclusion, CO2 insufflation may reduce postprocedural abdominal discomfort from transnasal esophagogastroduodenoscopies. (UMIN000028543).

Boron Neutron Capture Therapy (BNCT) for Cutaneous Malignant Melanoma Using 10B-p-Boronophenylalanine (BPA) with Special Reference to the Radiobiological Basis and Clinical Results.

BNCT is a radiotherapeutic method for cancer treatment that uses tumor-targeting 10B-compounds. BNCT for cutaneous melanoma using BPA, a phenylalanine derivative, was first initiated by Mishima et al. in 1987. This article reviews the radiobiological basis of melanoma control and damage to normal tissues as well as the results of clinical studies. Experimental studies showed that the compound biological effectiveness (CBE) values of the 10B (n, α)7Li reaction for melanoma control ranged from 2.5 to 3.3. The CBE values of the 10B (n, α)7Li reaction for skin damage ranged from 2.4 to 3.7 with moist desquamation as the endpoint. The required single radiation dose for controlling human melanoma was estimated to be 25 Gy-Eq or more by analyzing the 50% tumor control dose data of conventional fractionated radiotherapy. From the literature, the maximum permissible dose to human skin by single irradiation was estimated to be 18 Gy-Eq. With respect to the pharmacokinetics of BPA in patients with melanoma treated with 85-350 mg/kg BPA, the melanoma-to-blood ratio ranged from 2.1-3.8 and the skin-to-blood ratio was 1.31 ± 0.22. Good local tumor control and long-term survival of the patients were achieved in two clinical trials of BNCT conducted in Japan.

Response of Normal Tissues to Boron Neutron Capture Therapy (BNCT) with 10B-Borocaptate Sodium (BSH) and 10B-Paraboronophenylalanine (BPA).

Boron neutron capture therapy (BNCT) is a cancer-selective radiotherapy that utilizes the cancer targeting 10B-compound. Cancer cells that take up the compound are substantially damaged by the high liner energy transfer (LET) particles emitted mainly from the 10B(n, α7Li reaction. BNCT can minimize the dose to normal tissues, but it must be performed within the tolerable range of normal tissues. Therefore, it is important to evaluate the response of normal tissues to BNCT. Since BNCT yields a mixture of high and low LET radiations that make it difficult to understand the radiobiological basis of BNCT, it is important to evaluate the relative biological effectiveness (RBE) and compound biological effectiveness (CBE) factors for assessing the responses of normal tissues to BNCT. BSH and BPA are the only 10B-compounds that can be used for clinical BNCT. Their biological behavior and cancer targeting mechanisms are different; therefore, they affect the CBE values differently. In this review, we present the RBE and CBE values of BPA or BSH for normal tissue damage by BNCT irradiation. The skin, brain (spinal cord), mucosa, lung, and liver are included as normal tissues. The CBE values of BPA and BSH for tumor control are also discussed.

Pharmacokinetics of 10B-p-boronophenylalanine (BPA) in the blood and tumors in human patients: A critical review with special reference to tumor-to-blood (T/B) ratios using resected tumor samples.

We reviewed 10B concentration kinetics in the blood and tumors in human patients administered with BPA. The 10B concentration in the blood peaked at the end of intravenous infusion of BPA, followed by a biphasic-decreasing curve with half-lives for the first and second components of the curve being 0.7-3.7 and 7.2-12.0 h, respectively. The mean tumor-to-blood (T/B) ratio obtained from resected tumor samples was 3.40 ± 0.83 for melanoma and the ratio ranged from 1.4 to 4.7 for glioblastoma.

Trajectories of kidney function and associated factors among community-dwelling older Japanese: a 16-year longitudinal study.

BACKGROUND: No study has reported trajectories of kidney function in later life. This long-term prospective study attempted to classify trajectories of estimated glomerular filtration rate (eGFR) and identify factors associated with these trajectories. METHODS: We collected data from annual geriatric health checkups conducted during 2002-2017 in Kusatsu Town, Gunma Prefecture, Japan. The participants were 1990 adults aged 65-90 years (mean [SD] age, 71.0 [5.7] years; 57.0% women), and the total number of observations was 9291. Data were analyzed with a group-based semiparametric mixture model and age-adjusted univariable cumulative logit models. RESULTS: Trajectory of kidney function, as determined by eGFR, was classified as low, middle, and high (4.8%, 38.9%, and 56.3% of men, respectively, and 5.2%, 31.5%, and 63.3% of women). Among men and women in the low trajectory group, chronic kidney disease (CKD) stage worsened from stage G3a (51.8 ml/min/1.73 m2 in men and 53.6 in women) at age 65 years to stage G4 (28.0 ml/min/1.73 m2 in men and 28.5 in women) by age 85 years. A history of hypertension (men and women) and heart disease (men) were more likely in the low trajectory group than in the middle and high trajectory groups. CONCLUSIONS: About 5% of community-dwelling older adults had an eGFR < 30 later in life. Our findings suggest that those with stage G3a CKD at age 65 years should be managed intensively, to control risk factors for CKD progression.

A novel automated image analysis system using deep convolutional neural networks can assist to differentiate MDS and AA.

Detection of dysmorphic cells in peripheral blood (PB) smears is essential in diagnostic screening of hematological diseases. Myelodysplastic syndromes (MDS) are hematopoietic neoplasms characterized by dysplastic and ineffective hematopoiesis, which diagnosis is mainly based on morphological findings of PB and bone marrow. We developed an automated diagnostic support system of MDS by combining an automated blood cell image-recognition system using a deep learning system (DLS) powered by convolutional neural networks (CNNs) with a decision-making system using extreme gradient boosting (XGBoost). The DLS of blood cell image-recognition has been trained using datasets consisting of 695,030 blood cell images taken from 3,261 PB smears including hematopoietic malignancies. The DLS simultaneously classified 17 blood cell types and 97 morphological features of such cells with >93.5% sensitivity and >96.0% specificity. The automated MDS diagnostic system successfully differentiated MDS from aplastic anemia (AA) with high accuracy; 96.2% of sensitivity and 100% of specificity (AUC 0.990). This is the first CNN-based automated initial diagnostic system for MDS using PB smears, which is applicable to develop new automated diagnostic systems for various hematological disorders.

Effectiveness of a new multi-component smoking cessation service package for patients with hypertension and diabetes in northern Thailand: a randomized controlled trial (ESCAPE study).

BACKGROUND: Smoking cessation is an achievable behavioral change, which reduces the risks of cardiovascular diseases, cancers and tobacco-related diseases. There is a need for an effective smoking cessation service for low and middle income country settings where the smoking rate is generally very high whilst a cessation service is not usually accessible. This study devised a new smoking cessation service package and assessed its effectiveness in the primary health care setting of northern Thailand. METHODS: This randomized controlled trial was centered at Maetha district hospital, Lampang province, Thailand, and its network of mobile non-communicable disease clinics at seven primary care units. A total of 319 eligible patients who consented to participate in the study, were randomly allocated to an intervention arm (160) and a control arm (159), applying block randomization. The multi-component intervention service consisted of: (1) regular patient motivation by the same nurse over a 3-month period; (2) a monthly piCO+ Smokerlyzer test for 3 months; (3) continual assistance from a trained family member, using a smoking-cessation- diary; and (4) optional nicotine replacement chewing gum therapy. The control group received the routine service comprising of brief counseling and casual follow-up. Smoking cessation, confirmed by six months of abstinence and the piCo+ Smokerlyzer breath test, was compared between the two services after a year follow-up. The trial is registered as an international current control trial at the ISRCTN registry. ISRCTN89315117. RESULTS: The median age of the participants was 64 years, with females constituting 28.84%. Most of the participants smoke hand-rolled cigarettes (85%). The intervention arm participants achieved a significantly higher smoking cessation rate than the control arm 25.62% vs 11.32%, with an adjusted odd ratio of 2.95 and 95% confidence interval 1.55-5.61. CONCLUSION: In relation to accessing smoking cessation services within the primary health care setting, participants who received the evidence-based intervention package were about three times more likely to succeed in giving up smoking than those who received the routine service. Utilizing community resources as major intervention components, the evidence from this trial may provide a useful and scalable smoking cessation intervention for low and middle income countries. TRIAL REGISTRATION: Current controlled trials ISRCTN89315117 . WHO international clinical trial identifier number: U1111-1145-6916; 3/2013.

Association between high cystatin C levels and carotid atherosclerosis.

AIM: To investigate the association between carotid atherosclerosis and cystatin C (CysC) and to determine the optimal CysC cut-off value. METHODS: One hundred twenty-eight subjects were included in this study. Atherosclerosis was defined as a maximum carotid plaque thickness (MCPT) of greater than 2 mm. A receiver operating characteristic curve analysis was used to determine the diagnostic value of serum CysC for atherosclerosis. The subjects were divided into two groups according to the CysC cut-off value. We screened for diabetes, hypertension, dyslipidemia, smoking status, alcohol consumption, and exercise behavior. The association between atherosclerosis and CysC levels was assessed using multivariate analysis. RESULTS: The subjects were then divided into two groups according to the CysC cut-off value (0.73 mg/L). The median age of the high CysC group was 72 years (85% males), whereas that of the low CysC group was 61 years (63% males). The CysC levels were significantly correlated with Cr and estimated glomerular filtration rate (eGFR) values. Body-mass index, visceral fat area, hypertension, diabetes mellitus, and MCPT were significantly higher in the high CysC group than in the low CysC group. Furthermore, the eGFR was significantly lower in the high CysC group. Regarding lifestyle habits, only the exercise level was lower in the high CysC group than in the low CysC group. Multivariate analysis, adjusted for age and sex, revealed that high CysC levels were significantly associated with an MCPT of ≥ 2 mm (odds ratio: 2.92; 95%CI: 1.13-7.99). CONCLUSION: Higher CysC levels were associated with an MCPT of ≥ 2 mm. The CysC cut-off value of 0.73 mg/L appears to aid in the diagnosis of atherosclerosis.

Usefulness of stress myocardial perfusion imaging and baseline clinical factors for predicting cardiovascular events in patients with prior coronary artery disease.

BACKGROUND: Stress myocardial perfusion imaging (MPI) is a well-established diagnostic and prognostic tool for coronary artery disease (CAD). However, fixed and/or reversible stress MPI defects vary considerably among patients with CAD. The usefulness of stress MPI and baseline clinical factors as independent predictors of cardiovascular events in patients with prior CAD were assessed. METHODS AND RESULTS: Stress MPI was performed in 354 patients with prior CAD. Their mean age was 71 years; the mean duration from first revascularization and/or myocardial infarction (MI) onset until stress MPI was 7.1 years; and the mean follow-up period was 34 months. Cardiovascular events were observed in 100 patients (28%), and were categorized as cardiac-related death, non-fatal MI, unstable angina, heart failure and late (>2 months from stress MPI) coronary revascularization. Multivariate Cox regression analysis revealed that peripheral arterial disease (hazard ratio [HR]=2.95; P<0.001), current smoking (HR=2.36; P=0.006), chronic kidney disease (HR=2.15; P<0.001), left ventricular ejection fraction (HR=0.98; P=0.017), and grade of myocardial ischemia assessed by stress MPI (HR=1.14; P=0.007) were independent and significant predictors of cardiovascular events. CONCLUSIONS: In patients with prior CAD, baseline clinical factors and grade of myocardial ischemia assessed by stress MPI results are significant predictors of cardiovascular events.

Evidence-based new service package vs. routine service package for smoking cessation to prevent high risk patients from cardiovascular diseases (CVD): study protocol for randomized controlled trial.

BACKGROUND: Smoking cessation is a high-priority intervention to prevent CVD events and deaths in developing countries. While several interventions to stop smoking have been proved successful, the question of how to increase their effectiveness and practicality in developing countries remains. In this study, a newly devised evidence-based smoking cessation service package will be compared with the existing service in a randomized controlled trial within the community setting of Thailand. METHOD/DESIGN: This randomized control trial will recruit 440 current smokers at CVD risk because of being diabetic and/or hypertensive. Informed, consented participants will be randomly allocated into the new service-package arm and the routine service arm. The study will take place in the non-communicable disease clinics of the Maetha District Hospital, Lampang, northern Thailand. The new smoking-cessation service-package comprises (1) regular patient motivation and coaching from the same primary care nurse over a 3-month period; (2) monthly application of piCO + smokerlyzer to sustain motivation of smoker's quitting attempt and provide positive feedback over a 3-month period; (3) assistance by an assigned family member; (4) nicotine replacement chewing gum to relieve withdrawal symptoms. This new service will be compared with the traditional routine service comprising the 5A approach in a 1-year follow-up. Participants who consent to participate in the study but refuse to attempt quitting smoking will be allocated to the non-randomized arm, where they will be just followed up and monitored. Primary outcome of the study is smoking cessation rate at 1-year follow-up proven by breath analysis measuring carbomonoxide in parts per million in expired air. Secondary outcomes are smoking cessation rate at the 6-month follow-up, blood pressure and heart rate, CVD risk according to the Framingham general cardiovascular risk score, CVD events and deaths at the 12-month follow-up, and the cost-effectiveness of the health service packages. Intention-to-treat analysis will be followed. Factors influencing smoking cessation will be analyzed by the structure equation model. DISCUSSION: This multicomponent intervention, accessible at primary healthcare clinics, and focusing on the individual as well as the family and social environment, is unique and expected to work effectively. TRIAL REGISTRATION: Current Controlled Trials ISRCTN89315117.

Pioneering and fundamental achievements on the development of positron emission tomography (PET) in oncology.

Positron emission tomography (PET) with (18)F-fluorodeoxyglucose ((18)F-FDG), a glucose analog, is widely used throughout the world as an indispensable imaging modality for the management of cancer treatment. This article reviews the pioneering achievements of PET in oncology with a focus on the development of PET that occurred from 1980 through the early-1990s. (18)F-FDG was first applied for imaging of animal tumors in 1980 and for brain tumor imaging clinically in 1982. (18)F-FDG enabled to visualize liver metastasis as clear positive image that could not be obtained by conventional nuclear imaging. Subsequently, (18)F-FDG was used for imaging various cancers, such as lung, pancreas, colorectal and hepatoma. (11)C-L-methionine ((11)C-MET) that reflects amino acid transport of cancers has an advantage that its uptake is lower in the brain and inflammatory tissue compared to (18)F-FDG, and was first applied for imaging lung cancer and brain tumor. (18)F-FDG and (11)C-MET were proved to be sensitive tracers that can be used to objectively evaluate the effectiveness of cancer treatment. The diagnostic accuracy of PET, which is critical in clinical practice, was evaluated for the differential diagnosis of malignant and benign lung nodules using (18)F-FDG or (11)C-MET. In addition to (18)F-FDG and (11)C-MET, many radiopharmaceuticals were developed, such as (18)F-labled thymidine analogs for evaluating proliferative activity, (18)F-fluoromisonidazole for imaging of hypoxia, and (18)F-fluorodeoxygalactose for evaluating liver-specific galactose metabolism and for imaging of hepatoma that retains galactose metabolic activity. These early efforts and achievements have greatly contributed to the development and clinical application of (18)F-FDG PET in oncology.

In vitro and in vivo characterization of 2-deoxy-2-18F-fluoro-D-mannose as a tumor-imaging agent for PET.

UNLABELLED: 2-Deoxy-2-(18)F-fluoro-d-mannose ((18)F-FDM) is an (18)F-labeled mannose derivative and a stereoisomer of (18)F-FDG. Our preliminary study demonstrated that (18)F-FDM accumulated in tumors to the same extent as (18)F-FDG, with less uptake in the brain and faster clearance from the blood. However, detailed studies on the uptake of (18)F-FDM in tumors have not been conducted. We undertook this study to establish a practical method of (18)F-FDM synthesis based on an (18)F-nucleophilic substitution (SN2) reaction and to advance the biologic characterization of (18)F-FDM for potential application as a tumor-imaging agent. METHODS: We synthesized 4,6-O-benzylidene-3-O-ethoxymethyl-1-O-methyl-2-O-trifluoromethanesulfonyl-ß-D-glucopyranoside as a precursor for the nucleophilic synthesis of (18)F-FDM. The precursor was radiofluorinated with (18)F-KF/Kryptofix222, followed by removal of the protecting groups with an acid. (18)F-FDM was purified by preparative high-performance liquid chromatography and then subjected to in vitro evaluation regarding phosphorylation by hexokinase as well as uptake and metabolism in AH109A tumor cells. The in vivo properties of (18)F-FDM were examined in Donryu rats bearing AH109A tumor cells by biodistribution studies and imaging with a small-animal PET system. RESULTS: We radiosynthesized (18)F-FDM in sufficient radiochemical yields (50%-68%) with excellent purities (97.6%-98.7%). (18)F-FDM was phosphorylated rapidly by hexokinase, resulting in 98% conversion into (18)F-FDG-6-phosphate within 30 min. Tumor cells showed significant uptake of (18)F-FDM with time in vitro, and uptake was dose-dependently inhibited by D-glucose. (18)F-FDM injected into tumor-bearing rats showed greater uptake in tumors (2.17 ± 0.32 percentage injected dose per gram [%ID/g]) than in the brain (1.42 ± 0.10 %ID/g) at 60 min after injection. PET studies also revealed the tumor uptake of (18)F-FDM (quasi-standardized uptake value, 2.83 ± 0.22) to be the same as that of (18)F-FDG (2.40 ± 0.30), but the brain uptake of (18)F-FDM (1.89 ± 0.13) was ≈ 30% lower than that of (18)F-FDG (2.63 ± 0.26). CONCLUSION: We prepared (18)F-FDM with good radiochemical yield and purity by an SN2 reaction. We demonstrated that (18)F-FDM had adequate tumor cell uptake by a metabolic trapping mechanism and can afford high-contrast tumor images with less uptake in the brain, indicating that (18)F-FDM has almost the same potential as (18)F-FDG for PET tumor imaging, with better advantages with regard to the imaging of brain tumors.

FDG-PET/CT of sarcoidosis and sarcoid reactions following antineoplastic treatment.

Sarcoidosis or sarcoid reactions, which appear as FDG-avid lesions in oncologic patients, need to be differentiated from disseminated malignancies. We aimed to promote awareness of development of sarcoidosis or sarcoid reactions after antineoplastic therapy to avoid diagnostic errors with FDG-PET/CT findings and assess the utility of FDG-PET/CT for follow-up. We retrospectively reviewed radiological reports of FDG-PET/CT scans performed between January 2009 and December 2011. Among oncologic patients with more than 2 FDG-PET/CT scans, those with nearly symmetrical increases in FDG uptake in the hilar or mediastinal lymph nodes were identified, and those with known sarcoidosis, concurrent diagnoses of sarcoidosis with malignancy, or histopathologically proven malignancies were excluded. Then, only those cases were selected for which sarcoidosis or sarcoid reactions were diagnosed. Four of 376 oncologic cases met the criteria. At 9 months to 6 years after antineoplastic therapy, abnormal FDG uptakes were observed in the hilar, mediastinal, abdominal, pelvic, and inguinal nodes, and/or spleen and lung parenchyma with SUVmax up to 17.7. On the basis of these findings, 1 patient received anticancer chemotherapy because of tumor recurrence suspicion. A gradual decrease in FDG uptake was observed on subsequent PET/CT scans. Sarcoidosis or sarcoid reactions should be considered in differential diagnosis of oncologic patients who have developed FDG-avid lesions any time after antineoplastic therapy. FDG-PET/CT can be used for follow-up in nondiagnostic situations to detect decreases in FDG uptake due to presence of sarcoidal granulomas.

Change in lifestyle through health promotion program without face-to-face intervention in a large-scale Japanese enterprise.

OBJECTIVE: The aim of this study was to assess the effect of a health promotion program with 2-3-month Internet or printed material support without a face-to-face intervention at a large-scale worksite. METHODS: An uncontrolled intervention was conducted. In 2005, 22,429 employees underwent a health check-up and a lifestyle assessment. In 2006, 2,096 employees were recruited to participate in an intervention group (IntG), and the remaining 20,228 employees were allocated to a control group (ConG). After one-year follow-up, 1,888 employees in IntG and 15,474 employees in ConG were analyzed by Breslow's lifestyle index, overall prevalence of cardiovascular risk (OPCR) and 10% 10-year risk based on cardiovascular risk factors in 2007. RESULTS: Breslow's lifestyle index (over 5 points) in IntG showed a higher OR (1.13 with a 95% CI of 1.01-1.26) than that in ConG. Compared with those with a poor lifestyle, the subjects who had maintained or improved their lifestyle showed a lower OPCR (OR 0.88, 95% CI 0.79-0.97; OR 0.84, 95% CI 0.74-0.95 [p for trend=0.003]) and 10% 10-year risk trend (OR 0.38, 95% CI 0.31-0.47; OR: 0.29, 0.22-0.37 [p for trend <0.001]). CONCLUSION: The present study showed that there was a modest lifestyle behavior change using a program without face-to-face contact. The employees who maintained and improved their lifestyle had a lower OPCR and 10% 10-year risk. Future study should increase the number of employees actively attempting to improve their lifestyles at a worksite

Correlation between pulmonary function and brain volume in healthy elderly subjects.

INTRODUCTION: Cigarette smoking decreases brain regional gray matter volume and is related to chronic obstructive lung disease (COPD). COPD leads to decreased pulmonary function, which is represented by forced expiratory volume in one second percentage (FEV1.0 %); however, it is unclear if decreased pulmonary function is directly related to brain gray matter volume decline. Because there is a link between COPD and cognitive decline, revealing a direct relationship between pulmonary function and brain structure is important to better understand how pulmonary function affects brain structure and cognitive function. Therefore, the purpose of this study was to analyze whether there were significant correlations between FEV1.0 % and brain regional gray and white matter volumes using brain magnetic resonance (MR) image data from 109 community-dwelling healthy elderly individuals. METHODS: Brain MR images were processed with voxel-based morphometry using a custom template by applying diffeomorphic anatomical registration using the exponentiated lie algebra procedure. RESULTS: We found a significant positive correlation between the regional white matter volume of the cerebellum and FEV1.0 % after adjusting for age, sex, and intracranial volume. CONCLUSION: Our results suggest that elderly individuals who have a lower FEV1.0 % have decreased regional white matter volume in the cerebellum. Therefore, preventing decreased pulmonary function is important for cerebellar white matter volume in the healthy elderly population.

Utility of thallium-201 scintigraphy in Tolosa-Hunt syndrome.

Tolosa-Hunt syndrome (THS) is a rare disorder, especially in the pediatric population, characterized by unilateral painful ophthalmoplegia with a relapsing-remitting course. Because the diagnosis of THS is based on the exclusion of other causes of painful ophthalmoplegia, attention should be paid to possible alternative diagnoses. Thallium-201 chloride ((201)Tl) scintigraphy has been used to evaluate tissue histology in clinical oncology with a marker, the retention index (RI). A higher value indicates histological malignancy. Although its utility in pediatric THS has not been discussed, we suggest that (201)Tl scintigraphy may be informative as a marker in the diagnosis. We present an 11-year-old boy with THS who was evaluated with (201)Tl scintigraphy before treatment with corticosteroids, when he had headache, photophobia, and diplopia. The RI of (201)Tl indicated that the lesion would be benign. Although his clinical symptoms did not fulfill the THS criteria completely, his eye symptoms disappeared 2 weeks after corticosteroid treatment, which was not within the 72 h as in the diagnostic criteria of THS. He has been symptom-free for more than 2 years with only an initial 4-week corticosteroid therapy. This report not only shows the potential of (201)Tl scintigraphy to contribute to the correct diagnosis of pediatric THS but also suggests the possibility that the diagnosis of THS could be supported uniquely even in a pediatric THS-suspicious patient who did not fulfill the current THS criteria completely. In conclusion, we suggest that (201)Tl scintigraphy may be useful for making the diagnosis of THS, especially in pediatric patients.

The predictive value of chronic kidney disease for assessing cardiovascular events under consideration of pretest probability for coronary artery disease in patients who underwent stress myocardial perfusion imaging.

Pretest probability of coronary artery disease (CAD) facilitates diagnosis and risk stratification of CAD. Stress myocardial perfusion imaging (MPI) and chronic kidney disease (CKD) are established major predictors of cardiovascular events. However, the role of CKD to assess pretest probability of CAD has been unclear. This study evaluates the role of CKD to assess the predictive value of cardiovascular events under consideration of pretest probability in patients who underwent stress MPI. Patients with no history of CAD underwent stress MPI (n = 310; male = 166; age = 70; CKD = 111; low/intermediate/high pretest probability = 17/194/99) and were followed for 24 months. Cardiovascular events included cardiac death and nonfatal acute coronary syndrome. Cardiovascular events occurred in 15 of the 310 patients (4.8 %), but not in those with low pretest probability which included 2 CKD patients. In patients with intermediate to high pretest probability (n = 293), multivariate Cox regression analysis identified only CKD [hazard ratio (HR) = 4.88; P = 0.022) and summed stress score of stress MPI (HR = 1.50; P < 0.001) as independent and significant predictors of cardiovascular events. Cardiovascular events were not observed in patients with low pretest probability. In patients with intermediate to high pretest probability, CKD and stress MPI are independent predictors of cardiovascular events considering the pretest probability of CAD in patients with no history of CAD. In assessing pretest probability of CAD, CKD might be an important factor for assessing future cardiovascular prognosis.

Treatment outcome of patients with extragonadal nonseminomatous germ cell tumors: the Saitama Cancer Center experience.

BACKGROUND: Survival of patients with extragonadal nonseminomatous germ cell tumors remains inferior to that of patients with advanced testicular cancer, although treatment is often the same for both conditions. In addition, the prognosis for nonseminomatous tumors has been shown to be worse than for seminoma. METHODS: Thirteen patients with extragonadal nonseminomatous germ cell tumors were treated between 1998 and 2011; the primary tumors were located in the mediastinum in six and in the retroperitoneum in seven. At initial diagnosis seven patients had distant metastases. According to the IGCCC, eleven patients had poor prognosis and two were intermediate. All 13 patients received cisplatin or carboplatin-based chemotherapy as initial treatment. The patients were further treated by use of a multi-modal strategy which included high-dose chemotherapy, aggressive surgery, and early introduction of salvage regimens. RESULTS: Complete response was obtained for eight patients. Among these complete responders, one patient remained relapse-free after post-chemotherapy surgical excision of viable cancer tissue. In the course of the chemotherapy, four patients died from cancer progression and one patient died as a result of post-chemotherapeutic sepsis. The other eight patients were alive at the end of the observation period. At the last observation all surviving patients were without evidence of disease. Five-year overall survival for all 13 patients was 62 %, and 5-year cancer-specific survival was 68 %. CONCLUSION: Our results indicate that even patients with far-advanced extragonadal nonseminomatous germ cell tumors can be cured by intensive chemotherapy plus surgery.

The current status of an FDG-PET cancer screening program in Japan, based on a 4-year (2006-2009) nationwide survey.

OBJECTIVE: The aim of this study was to survey the 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) cancer screening program conducted in Japan. METHODS: The "FDG-PET cancer screening program" included both FDG-PET and positron emission tomography with computed tomography (PET/CT) with or without other combined screening tests that were performed for cancer screening in asymptomatic subjects. A total of 155,456 subjects who underwent the FDG-PET cancer screening program during 2006-2009 were analyzed. RESULTS: Of the 155,456 subjects, positive findings suggesting possible cancer were noted in 16,955 (10.9 %). The number of cases with detected cancer was 1,912 (1.23 % of the total screened cases, annual range 1.14-1.30 %). Of the 1,912 cases of detected cancer, positive findings on FDG-PET were present in 1,491 cases (0.96 % of the total number of screened cases). According to the results of further examinations, the true positive rate for subjects with suggested possible cancer (positive predictive value) was 32.3 % with FDG-PET. Cancers of the colon/rectum, thyroid, lung, and breast were most frequently found (396, 353, 319, and 163 cases, respectively) with high PET sensitivity (85.9, 90.7, 86.8, 84.0 %, respectively). Prostate cancer and gastric cancer (165 and 124 cases, respectively) had low PET sensitivity (37.0 and 37.9 %, respectively). The Union for International Cancer Control (UICC) clinical stage of cancer found with the FDG-PET cancer screening program was mainly Stage I. CONCLUSIONS: The FDG-PET screening program in Japan has detected a variety of cancers at an early stage. However, several cancers were found in repeated FDG-PET cancer screening program, indicating the limitation of a one-time FDG-PET cancer screening program. The value of the FDG-PET cancer screening program is left to the judgment of individuals with regard to its potentials and limitations.