Comparison Study of Self-Sampled and Physician-Sampled Specimens for High-Risk Human Papillomavirus Test and Cytology.

OBJECTIVE: The objective of this study was to calculate the positive rate and overall concordance rate of high-risk human papillomavirus (hrHPV) test and cytology using self-sampled and physician-sampled cervicovaginal tests and to compare both specimens. METHODS: In collaboration with 3 private hospitals in Sapporo city, 300 women visiting these organizations were enrolled in the study by previously signing an informed consent. From these women, both types of samples (self-obtained and physician-sampled) were obtained at the same time. HrHPV test and cytology were performed on both specimens, and the positive rate and overall concordance rate were calculated to compare both specimens. RESULTS: HrHPV-positive women were 13.7% in physician-sampled specimens and 14.7% in self-sampled specimens, with an overall concordance rate of 96.3% (95% confidence interval [CI]: 94-98%). On the other hand, the positive rate of the cases higher than or equal to atypical squamous cells of undetermined significance (ASCUS) on cytology was different between both groups, that is, 12.3% in physician-obtained and 5.3% in self-sampled specimens; the overall concordance rate was 90.7% (95% CI: 87-94%), indicating an apparent decrease in the positive rate of cytology in self-obtained specimens. CONCLUSION: HrHPV test and cytology were performed on parallel samples obtained by the patients with a self-sampling tool and by the physician. The positive rate of cytology was considerably different between these specimens, while almost equivalent results were obtained for hrHPV test in both specimens. It was concluded that hrHPV test may be safely and accurately performed on self-obtained cervicovaginal samples by the help of a self-sampling device in the Japanese population as a first screening tool, with equivalent results to physician-obtained specimens.

[Collision cancer of primary squamous cell carcinoma and adenocarcinoma in the stomach after treatment for a non-Hodgkin's lymphoma of diffuse large B cell type:a case report].

We report the case of a 61-year-old woman with a collision cancer of primary squamous cell carcinoma (SCC) and adenocarcinoma in the stomach that was cured surgically. She achieved complete remission after treatment (R-CHOP and radiation therapy;40.8Gy/22Fr) for a non-Hodgkin's lymphoma of diffuse large B cell type from September 2016 to April 2017. In August 2018, endoscopic findings showed a type 3 tumor with a white coat on the posterior wall of the upper gastric body. A biopsied specimen showed that the tumor was a SCC. Total gastrectomy, distal pancreatectomy, splenectomy, and D2 lymph node dissection were performed. Pathological examination showed a SCC invasion to the spleen, and normal gastric mucosa between the esophagus and SCC of the stomach. Based on the pathological TNM classification, the tumors were T4N1M0 (Stage IIIB) for the SCC and T1N0M0 (Stage IA) for the adenocarcinoma of the stomach. The patient received adjuvant chemotherapy with S-1, and was recurrence free at 9 months after the surgery.

Correction to: Treatment outcomes for acute type A aortic dissection with patent false lumen in patients over the age of 80.

In the original publication of the article, Table 1 was published with errors. The correct Table 1 is given in this correction.

A Case of Coronary Artery Fistula Ligation in Minimally Invasive Mitral Valve Plasty via Right Anterolateral Minithoracotomy.

We report a case of coronary artery fistula treated by ligation with concomitant minimally invasive mitral valve plasty via right anterolateral minithoracotomy. The coronary artery fistula was isolated well under heart beating, and clip-ligation was easily and safely performed. The present method is an effective and safe option for use with minimally invasive cardiac surgery.

Treatment outcomes for acute type A aortic dissection with patent false lumen in patients over the age of 80.

OBJECTIVES: While reports which focus on the outcomes of conservative treatments for acute type A aortic dissection in patients over the age of 80 are worth considering, recently many studies have reported improved outcomes of surgical treatment. Accordingly, we analyzed the outcomes of surgical and conservative treatments for acute type A aortic dissection with patent false lumen in patients over the age of 80. METHODS: We retrospectively investigated 70 patients over 80 years in age out of 248 consecutive patients with acute type A aortic dissection between January, 2010, and May, 2015. Of the 70 patients, 44 underwent surgical treatments (ascending replacement in 33 and total arch replacement in 11) and 23 patients underwent conservative medical treatments. RESULTS: In the surgical treatment, the 30-day mortality rate was 14% (6/44) and the rate of morbidity was 34%. And 17 patients (39%) were discharged home without ambulatory assistance. The actuarial survival rates in the surgical treatment group were 83% and 60% at 1 and 3 years, respectively. The in-hospital death rate of conservative medical treatment was 43% (10/23). Only 26% of the patients having had conservative treatment were discharged home without ambulatory assistance. The actuarial survival rate in the conservative medical group was 8.7% at 1 year. CONCLUSION: Surgical outcomes of acute type A aortic dissection with patent false lumen were satisfactory in patients aged over 80 in this study by meticulously determining operative indications, depending on the background of each patient.

Rare case of idiopathic sclerosing cholangitis, which was difficult to distinguish from cholangiocarcinoma: A case report.

It is often difficult to correctly diagnose patients who present with dilation of the bile duct. Cholangiocarcinoma, primary sclerosing cholangitis (PSC) and immunoglobulin (Ig)G4-related sclerosing cholangitis must be considered as potential diagnoses for these cases. The current study presents a 73-year-old female patient who presented with a high fever and abdominal pain. Contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography revealed stenosis and dilation of the intrahepatic bile duct without solid components. It was suspected that the patient had intrahepatic cholangiocarcinoma. A left liver lobectomy, cholecystectomy and distal gastrectomy combined with a D2 lymph node dissection were performed. A pathological examination of the liver revealed increased fibrosis in the stroma, irregular bile duct dilation and clusters of inflamed lymph cells. No carcinoma or IgG4-positive plasma cells were observed and the typical findings of PSC were not detected. Based on these clinical and pathological results, the diagnosis was idiopathic sclerosing cholangitis, which is particularly rare. It is often difficult to preoperatively differentiate between cholangiocarcinoma and benign bile duct stenosis.

[A Case of Malignant Peritoneal Mesothelioma Treated with Cisplatin and Pemetrexed].

A 65-year-old man was admitted to our hospital complaining of general malaise, anorexia and weight loss. A computed tomography(CT)scan showed massive ascites and multiple peritoneal masses. Although adenocarcinoma was suspected based on the cytology of the ascites, we were unable to determine the site of origin. We next performed a laparoscopy and a biopsy of the tumor on the omentum. The laparoscopy showed small, white, hard nodules that were disseminated throughout the abdominalcavity, and histologicaldiagnosis confirmed malignant peritonealmesothel ioma. The patient was administered chemotherapeutic treatment of cisplatin and pemetrexed. After treatment, the ascites decreased; however, tumor regression was not observed. The patient's performance status gradually decreased, and he died on hospital day 104. Prognosis of malignant peritoneal mesothelioma remains poor, and malignant peritoneal mesothelioma should be considered when diagnosing peritoneal tumors.

Left Atrial Appendage Resection During Minimally Invasive Aortic Valve Surgery via Right Minithoracotomy.

Here, we report concomitant resection of the left atrial appendage through the transverse sinus during minimally invasive aortic valve replacement via right anterolateral thoracotomy. The left atrial appendage was exposed by raising the collapsed ascending aorta and was safely resected using a surgical stapling device. This procedure is a feasible option in elderly patients, for whom a percutaneous procedure would be inappropriate, and could be useful for preventing thromboembolic and hemorrhagic complications.

Multiple organ embolization with vegetation on an elephant trunk graft.

We encountered a rare case of infection in a vascular graft created using the elephant trunk technique. A 65-year-old woman who underwent total arch replacement with the elephant trunk technique was re-admitted with fever. She developed embolization of multiple organs from vegetation attached to the elephant trunk graft which was elucidated by transesophageal echocardiography. Surgery for ruptured jejunal artery aneurysm was performed, and the graft infection healed after long-term antibiotic therapy with the prosthesis left in situ. Graft infection may generate vegetations on an elephant trunk graft. Transesophageal echocardiography is a helpful tool for accurate diagnosis.

Avoidance of Coronary Sinus Injury During Retrograde Cardioplegia.

Coronary sinus injury is a rare but critical complication of retrograde cardioplegia. Even after detection, successful repair with a pericardial patch is not always attained. Malalignment of the infusion cannula relative to the coronary sinus is likely to be partially responsible for the injury. Monitoring the location of the cannula tip can help prevent injury. Transesophageal echocardiography can indicate the vascular structure within which the cannula is located. This finding may be useful in preventing injury to the coronary sinus or middle cardiac vein.

A case of mixed adenoneuroendocrine carcinoma of the stomach.

A 71-year-old man who tested positive in a pepsinogen test also underwent upper gastrointestinal endoscopy. A 0-IIc lesion was identified at the posterior wall of the antrum. Biopsy findings indicated endocrine cell carcinoma. The patient underwent distal gastrectomy, and subsequent histopathological examination of the resected specimens showed a moderately differentiated adenocarcinoma (tub2) in the mucosa with transformation to small cell carcinoma in the submucosal and muscle layers. The final diagnosis was of a mixed adenoneuroendocrine carcinoma. We herein describe a case report of this patient with this rare form of gastric carcinoma.

Multidisciplinary approach for primary cardiac lymphoma associated with hemodynamic failure caused by tricuspid valve obstruction.

Primary cardiac lymphoma (PCL) comprises rare cardiac tumors and exhibits rapid growth and poor prognosis. We report the case of a 65-year-old man with PCL associated with unstable hemodynamics caused by tricuspid valve obstruction. Generally, chemotherapy is the first choice of treatment for patients with PCL. This patient required emergency tumor reduction as he was at risk of having acute hemodynamic failure caused by tricuspid valve obstruction. Therefore, he underwent a 2-staged treatment: urgent surgery to avoid sudden death by tricuspid valve obstruction as well as pulmonary embolism during chemotherapy, followed by early chemotherapy. Pathological findings showed diffuse large B-cell lymphoma, and rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, prednisolone (R-CHOP) therapy was initiated to treat any residual tumor infiltrating the myocardial wall. The patient showed a marked clinical improvement. We conclude that surgical tumor reduction and early chemotherapy might be an effective treatment for PCL patients with hemodynamic compromise. .

[Operative Results of Total Arch Replacement with Arch First Technique using a Trifurcated Graft].

In aortic arch surgery, we reconstruct branches before opening the arch to avoid cerebral embolism of the debris derived from the aortic wall. We made a trifurcated graft for branch reconstruction using 10 mm and 8 mm polyester grafts. Cardiopulmonary bypass started under right axillary perfusion and venous drainage through the right atrium. While cooling, the left subclavian artery was clamped and anastomosed to the end of the trifurcated graft. Then the ascending aorta was cross-clamped and cardioplegic solution was infused. At 25 degrees centigrade of the tympanic temperature, the left carotid artery is clamped and anastomosed to the branch of the trifurcated graft with or without perfusion into the left carotid artery. Subsequently the brachiocephalic artery was reconstructed in the same manner. After antegrade cerebral perfusion was established through the trifurcated graft via right axillary perfusion, distal anastomosis of the aortic arch was done with the open distal technique. Graft-graft anastomosis was followed to reperfuse the lower half of the body. Finally proximal anastomosis was performed to complete total arch replacement. Forty-four patients underwent total arch replacement in this technique. In-hospital mortality was 4.5%. Cerebral infarction occurred in 4.5% of the patients probably due to embolization of the debris derived from the branches of the aortic arch.

Maximal blood flow acceleration analysis in the early diastolic phase for in situ internal thoracic artery bypass grafts: a new transit-time flow measurement predictor of graft failure following coronary artery bypass grafting.

OBJECTIVES: Maximal graft flow acceleration (max df/dt) determined by transit-time flowmetry (TTFM) in the diastolic phase was assessed as a possible predictor of graft failure in coronary artery bypass patients. METHODS: Max df/dt was retrospectively measured in 57 in situ left internal thoracic artery grafts. TTFM data were fitted to a 5-polynomial curve, which was derived from the first-derivative curve to measure max df/dt (5-polymial max df/dt). Abnormal TTFM was defined as a mean flow of <15 ml/min, pulsatility index of >5 or diastolic filling ratio of <50%. Postoperative coronary angiography (CAG) or multidetector computed tomography (MDCT) was performed within 1 year after surgery. The grafts were classified into four groups: Normal TTFM/Patent MDCT/CAG (N/P), Normal TTFM/Failing MDCT/CAG (N/F), Abnormal TTFM/Patent MDCT/CAG (Ab-N/P) and Abnormal TTFM/Failing MDCT/CAG graft (Ab-N/F). RESULTS: By TTFM, 34 grafts were normal, 5 of which were occluded on CAG, and 23 grafts were abnormal, six of which were occluded on CAG. There were significant differences in 5-polynomial max df/dt between each group pair (P < 0.05, Mann-Whitney U-test) except for the N/F:Ab-N/P group pair; especially, 5-polynomial max df/dt was significantly lower in the Ab-N/F group compared with the other groups (Ab-N/F: 0.89 ± 0.41 vs N/P: 4.74 ± 3.18, N/F: 2.23 ± 0.65, Ab-N/P: 2.70 ± 1.31 ml/s(2), P < 0.01, Mann-Whitney U-test). The sensitivity and specificity of 5-polynomial max df/dt were, respectively, 72.7 and 80.4% (cut-off value, 1.918 ml/s(2)) for all grafts and 100 and 88.2% (cut-off value, 1.273 ml/s(2)) for abnormal TTFM grafts. CONCLUSIONS: The TTFM 5-polymial max df/dt value in the early diastolic phase may be a promising predictor of future graft failure.

Efficacy of intraoperative HyperEye Medical System angiography for coronary artery bypass grafting.

PURPOSE: When performing coronary artery bypass grafting, anastomotic insufficiency needs to be detected during surgery. We developed a novel indocyanine green angiography system, the HyperEye Medical System (HEMS), which enables color imaging of the bypass flow. This article described the accuracy of HEMS angiography for predicting graft patency. METHODS: A total of 144 grafts in 40 coronary artery bypass grafting patients were assessed by HEMS angiography, a transit time flowmeter (TTF) during surgery and fluoroscopic angiography 1 year after the operation. RESULTS: HEMS angiography showed normal flow in 133 grafts, but abnormal flow in 11. Fluoroscopic angiography showed that 130 of the 133 "normal" grafts were patent (negative predictive value: 97.7%) and that nine of the 11 "abnormal" grafts were occluded (positive predictive value: 81.8%). As a result, 134 grafts were assessed as normal and 10 as abnormal by TTF. Fluoroscopic angiography showed that 124 of these 134 grafts were patent (negative predictive value: 92.5%), whereas two of the 10 grafts were occluded (positive predictive value: 20.0%). For the 127 grafts with compatible results by the HEMS and TTF assessments, the positive and negative predictive values were 100 and 97.6%, respectively. CONCLUSION: HEMS angiography of a bypass graft may provide an accurate prediction of the graft patency after surgery.

[Pacemaker infection in a child; report of a case].

In the treatment for pacemaker infection, removal of infected devices and intensive antibiotics therapy are in principle and new devices should be implanted apart from the infected site. However, there are some problems in the case of children:it is not easy to remove infected devices because epicardial leads are often used for them. If endocardial leads are chosen as a new system, extension of the lead would be concerned with their growth. We report a pediatric case of infection of pacemaker using epicardial leads. It was difficult to cure infection by repeated local treatment leaving epicardial leads and antibiotics therapy was obliged to continue for 9 years to keep infection under control. After growing up, we implanted endocardial leads for her and removed infected devices to cure infection completely.

Development of a new selective coronary perfusion cannula.

The two most common types of coronary perfusion cannulae currently being used are the "balloon type", with a balloon at the tip, and the "fenestrated type", which has holes along the side near the tip. However, on occasion an unusually high perfusion pressure or a considerable amount of leakage is encountered during infusion of the cardioplegic solution. We have examined the properties of a newly developed Kochi Medical School (KMS)-type cannula and compared these to the properties of the balloon-type and fenestrated-type cannulae in an ex vivo experimental model that contains ostia of 4, 3, or 2 mm in diameter. Ejected flow velocity, circuit pressure, and the amount of leakage were measured at an infusion rate of 100 and 200 mL/min, with the latter two parameters measured under the counterpressure of 0 and 50 cmH2O to examine the influence of coronary vascular resistance. Without counterpressure, the balloon type presented with the highest flow velocity (263 cm/s at 200 mL/min) and perfusion pressure (64 mmHg at 200 mL/min) but without leakage. The fenestrated type yielded a considerable amount of leakage (40 % at an ostium size of 2 mm). The KMS type showed a lower flow velocity and circuit pressure with less leakage. Under 50 cmH2O counterpressure, however, only the KMS-type cannula could inject the water to any ostium size at both flow rates. These results suggest that the concept of the KMS-type cannula may be advantageous to achieving a secure infusion to a diseased coronary ostium.

Validity and reproducibility of Ki-67 assessment in gastrointestinal stromal tumors and leiomyosarcomas.

With the aim of standardizing Ki-67 immunohistochemistry, we assessed interobserver and interlaboratory variability of the Ki-67 labeling index and Ki-67 score among eight general pathologists for 24 gastrointestinal stromal tumors (GISTs) and 12 leiomyosarcomas, which were predominantly of the gastrointestinal (GI) tract, mesentery and retroperitoneum, based on a review of a tissue microarrays subjected to immunohistochemistry with antibodies for Ki-67. For Ki-67 immunostaining of mesenchymal tumors of the GI tract, including GISTs, differences were seen in the scores given by regional hospitals. Conversely, for two categories of the Ki-67 labeling index, namely <10% and ≥10%, concordance of the Ki-67 score between microscopic observation and image analysis, and between the observers, was good, but it was not good for the other four categories of the index for <5%, 5-9%, 10-29%, and ≥30%. The concordance of the Ki-67 scores between the observers in two categories was higher using the Ki-67 pre-stained tissue microarrays (TMAs) within each participating institute than that using the Ki-67 stained TMAs between the participating institutes. The reproducibility of a 10% cut-off value for the Ki-67 labeling index to predict the prognosis of GISTs was relatively high, but there is an urgent need to standardize the staining technique.