Association between the quantity of stroke care units and the complement of neurosurgical and neurology specialists in Japan: A retrospective study.

BACKGROUND: Stroke care units provide advanced intensive care for unstable patients with acute stroke. We conducted a survey to clarify the differences in stroke care units between urban and regional cities and the relationship between the number of stroke care unit beds and neurologists. METHODS: This retrospective observational study was conducted in 2,857 and 4,184 hospitals in urban and regional cities in 47 provinces of Japan, respectively, between January 2020 and August 2023. Tokyo and ordinance-designated cities in provinces were defined as urban cities, and those without such cities were defined as regional cities. The primary endpoint was the presence or absence of a stroke care unit. RESULTS: Multiple linear regression analysis revealed that the presence of stroke care units was significantly associated with the number of neurosurgical specialists. Receiver operating characteristic curve analysis was performed to predict the number of personnel required for stroke care unit installation based on the number of neurosurgical specialists. The area under the receiver operating characteristic curve, Youden index, sensitivity, and specificity were 0.721, 0.483, 0.783, and 0.700, respectively. CONCLUSIONS: Our study underscores the indispensability of SCUs in stroke treatment, advocating for a strategic allocation of medical resources, heightened accessibility to neurosurgical specialists, and a concerted effort to address geographic and resource imbalances. The identified cutoff value of 8.99 neurosurgical specialists per 100,000 population serves as a practical benchmark for optimizing SCU establishment, thereby potentially mitigating stroke-related mortality.

[Fatal invasive pneumococcal disease developed 14 years after allogeneic hematopoietic stem cell transplantation in a patient with myelodysplastic syndrome].

Invasive pneumococcal diseases (IPDs) after allogeneic hematopoietic stem cell transplantation have high fatality rates and often develop late after transplantation. The patient was a 58-year-old female. Fourteen years ago, she underwent bone marrow transplantation from a HLA-DR 1-antigen mismatched unrelated donor for myelodysplastic syndrome. She developed pneumonia, chronic graft-versus-host disease, and hypogammaglobulinemia. She received 23-valent pneumococcal capsular polysaccharide vaccine 11 and 6 years earlier. She was presented to our emergency room with fever. Her blood culture was positive for pneumococcus, and she was diagnosed with an IPD. The patient received antibiotic treatment but died on the third day of hospitalization. Because of its seriousness, pneumococcal infection should receive attention even 10 or more years after transplantation. Preventive approaches such as vaccination and early intervention at the time of diagnosis are important.

Underbody blankets have a higher heating effect than overbody blankets in lithotomy position endoscopic surgery under general anesthesia: a randomized trial.

BACKGROUND: Surgery under general anesthesia results in temperature decrease due to the effect of anesthetics and peripheral vasodilation on thermoregulatory centers. Perioperative temperature control is therefore an issue of high importance. In this study, we aimed to compare the warming effect of underbody and overbody blankets in patients undergoing surgery in the lithotomy position under general anesthesia. METHODS: From September 2018 to October 2019, 99 patients undergoing surgery for colorectal cancer in the lithotomy position were included in this randomized controlled trial and assigned to the intervention group (underbody blanket) or control group (overbody blanket). RESULTS: The central temperature was significantly higher in the underbody blanket group than in the overbody blanket group at 90 min after the beginning of the surgery (p = 0.02); also in this group, the peripheral temperature was significantly higher 60 min after the beginning of the surgery (p = 0.02). Regarding postoperative factors, the underbody blanket group had a significantly lower frequency of postoperative shivering (p < 0.01) and a significantly shorter postoperative hospital stay (p = 0.04) than the overbody blanket group. CONCLUSIONS: We recommend the use of underbody blankets for intraoperative temperature control in patients undergoing surgery in the lithotomy position under general anesthesia. Underbody blankets showed improved rise and maintenance of central and peripheral temperature, decreased the incidence of postoperative shivering, and shortened the postoperative length of hospital stay.

Feasibility and Safety of Oral Nutritional Supplementation with High-Density Liquid Diet After Total Gastrectomy for Gastric Cancer.

INTRODUCTION: Patients requiring total gastrectomy for gastric cancer experience a decrease in food intake leading to severe body weight loss after surgery. This loss may be prevented using a high-density liquid diet of high caloric content and minimal volume. This phase II study evaluated the feasibility and safety of a high-density liquid diet (UpLead®; Terumo Corporation, Tokyo, Japan) after total gastrectomy. METHODS: UpLead® (1 pack, 100 mL, 400 kcal/day) was administered after surgery for 28 days. The primary endpoint was the % relative dose intensity of 28 days of UpLead intake®. The secondary endpoint was % body weight loss at 1 and 3 months after surgery. The sample size was 35 considering expected and threshold values of 80 and 60%, respectively, with a one-sided alpha error of 10% and statistical power of 80%. RESULTS: Among 35 patients enrolled before surgery between April 2018 and December 2019, 29 patients who could initiate UpLead® after surgery were analyzed. Seven patients had interrupted UpLead® intake due to taste intolerance (n = 6) and due to a duodenal stump fistula (n = 1). The remaining 22 patients completed 28 days of UpLead® intake, including temporary interruption, with no associated adverse events. The median relative dose intensity was 25.8% (95% confidence interval: 20.6-42.0%). The median body weight loss at 1 and 3 months after surgery was 7.2% (range: 3.2-13.9%) and 13.1% (range: 2.5-20.4%), respectively. CONCLUSIONS: Oral nutritional supplementation with a high-density liquid diet (UpLead®) was safely administered but was not feasible after total gastrectomy for gastric cancer. Clinical trial registration number UMIN000032291.

[Successful outcome of allogeneic hematopoietic stem cell transplantation for systemic mastocytosis complicated with acute myeloid leukemia].

A 60-year-old woman developed a fifth thoracic spine fracture with progressive paraplegia and underwent posterior spine fusion in June 2018. Based on the histopathological analysis of the surgical specimen, she was diagnosed with KIT D816V-positive systemic mastocytosis (SM). In June 2019, peripheral blood examination revealed remarkable eosinophilia. She was given prednisolone, which resulted in the resolution of eosinophilia. In May 2020, she developed acute myeloid leukemia (AML). Induction therapy was initiated and complete remission achieved. Subsequently, she received one course of consolidation therapy and allogeneic hematopoietic stem cell transplantation (allo-SCT). Although the residual mast cell tumor aggravated during chemotherapy for AML, the tumor regressed after allo-SCT, suggesting a graft-versus-mastocytosis effect. Nine months after the transplantation, the patient is alive and healthy without recurrence of AML and SM.

Association between preoperative toe perfusion index and maternal core temperature decrease during cesarean delivery under spinal anesthesia: a prospective cohort study.

BACKGROUND: The main mechanism of body temperature decrease during cesarean delivery under spinal anesthesia is core-to-peripheral redistribution of body heat, attributable to vasodilation. Perfusion index (PI) obtained with a pulse oximeter helps to assess peripheral perfusion dynamics by detecting the change in peripheral vascular tone. This study aimed to examine whether preoperative toe PI could predict the decrease in core temperature induced by spinal anesthesia during cesarean delivery. METHODS: Parturients undergoing scheduled cesarean delivery under combined spinal-epidural anesthesia from September 2019 to March 2020 were enrolled in this single-center prospective cohort study. All parturients received 0.5% hyperbaric bupivacaine (10 mg) with fentanyl (15 µg) intrathecally. A pulse oximeter probe was placed on the left second toe for continuous PI measurement. The 3 M™ Bair Hugger™ Temperature Monitoring System placed over the right temporal region was used to record core temperature over time. We evaluated the association between the maximum core temperature decrease, which is the primary outcome, and the preoperative toe PI at operating room (OR) admission using a segmented regression model (SRM) and a generalized additive model (GAM). The maximum core temperature decrease was defined as the difference between core temperature at OR admission and minimum intraoperative core temperature. RESULTS: Forty-eight patients were evaluated. In the SRM, the slope for the association between the maximum core temperature decrease and the preoperative toe PI changed from 0.031 to 0.124 after PI = 2.4%. Likewise, with the GAM, there was a small core temperature decrease when preoperative toe PI was greater than 2.0 to 3.0%. CONCLUSIONS: Low preoperative toe PI was associated with maternal core temperature decrease during cesarean delivery under spinal anesthesia. Preoperative toe PI is a simple, non-invasive, and effective tool for the early prediction of perioperative core temperature decrease during cesarean delivery. TRIAL REGISTRATION: UMIN Clinical Trials Registry (registry number: UMIN000037965 ).

[A Long‒Term Survival Case of Advanced Rectal Cancer with Liver and Lung, Para‒Aortic Lymph Nodes Metastasis That Responded to Multidisciplinary Therapy].

The patient was a 59‒year‒old woman. In 2005, she underwent low anterior resection plus D2 dissection for rectal cancer (pT4aN2aM0, pStage Ⅲb). In 2007, she underwent hepatic S8 subsegment resection for liver metastasis. After that, FOLFIRI therapy was performed as chemotherapy for recurrence of the right upper lung lobe and para‒aortic lymph node(PALN). CR was once obtained in both(of)PALN and lung, but PALN re‒expansion and left ovary enlargement were observed in 2009, and resection of PALN plus left ovariectomy was performed. Histological examination showed PALNs were metastases from rectal cancer and the ovary was benign. Eleven years after the first operation, she stayed alive without recurrence.

[A Case of Laparoscopy-Assisted Surgery for Intestinal Malignant Lymphoma with Bowel Obstruction].

An 83-year-old woman visited our emergency department with a chief complaint of abdominal pain and vomiting. Abdominal computed tomography showed thickening of the wall of the small intestine in the right middle abdomen and marked bowel dilation and fluid retention in the oral side of the small intestine. The patient was diagnosed with adhesive bowel obstruction and hospitalized for conservative treatment. However, the treatment was unsuccessful, and laparoscopic surgery was performed. The intraoperative findings included thickening of the wall and hardening of the obstructed part, suggestive of an intestinal tumor; thus, this part was resected. A histopathological examination revealed diffuse infiltration of large-sized atypical lymphocytes in the tumor, and diffuse large B-cell lymphoma was diagnosed through immunochemical staining. The postoperative course was uneventful, and the lymphoma has not recurred. Intestinal malignant lymphoma rarely causes bowel obstruction without invagination. Here, we report this case and review the literature.

Association Between Lymph Node Ratio and Survival in Patients with Pathological Stage II/III Gastric Cancer.

BACKGROUND: Lymph node ratio (LNR), defined as the ratio of metastatic nodes to the total number of examined lymph nodes, has been proposed as a sensitive prognostic factor in patients with gastric cancer (GC). We investigate its association with survival in pathological stage (pStage) II/III GC and explore whether this is a prognostic factor in each Union for International Cancer Control pStage (7th edition). PATIENTS AND METHODS: We retrospectively examined 838 patients with pStage II/III GC who underwent curative gastrectomy between June 2000 and December 2018. Patients were classified into low-LNR (L-LNR), middle-LNR (M-LNR), and high-LNR (H-LNR) groups according to adjusted X-tile cutoff values of 0.1 and 0.25 for LNR, and their clinicopathological characteristics and survival rates were compared. RESULTS: The 5-year recurrence-free survival (RFS) and overall survival (OS) rates postsurgery showed significant differences among the groups (P < 0.001). Multivariate analysis demonstrated that LNR was a significant predictor of poor RFS [M-LNR: hazard ratio (HR) 3.128, 95% confidence interval (CI) 2.254-4.342, P < 0.001; H-LNR: HR 5.148, 95% CI 3.546-7.474, P < 0.001] and OS (M-LNR: HR 2.749, 95% CI 2.038-3.708, P < 0.001; H-LNR: HR 4.654, 95% CI 3.288-6.588, P < 0.001). On subset analysis stratified by pStage, significant differences were observed between the groups in terms of the RFS curves of pStage II and III GC (P < 0.001 and < 0.001, respectively) and OS curves of pStage II and III GC (P = 0.001 and < 0.001, respectively). CONCLUSIONS: High LNR is a predictor of worse prognosis in pStage II/III GC, including each substage.

A mutant MATR3 mouse model to explain multisystem proteinopathy.

Mutations in the Matrin 3 (MATR3) gene have been identified as a cause of amyotrophic lateral sclerosis (ALS) or vocal cord and pharyngeal weakness with distal myopathy (VCPDM). This study investigated the mechanism by which mutant MATR3 causes multisystem proteinopathy (MSP) including ALS and VCPDM. We first analyzed the muscle pathology of C57BL/6 mice injected with adeno-associated viruses expressing human WT or mutant (S85C) MATR3. We next generated transgenic mice that overexpress mutant (S85C) MATR3, driven by the CMV early enhancer/chicken ß-actin promoter, and evaluated their clinicopathological features. Intramuscular injection of viruses expressing WT and mutant MATR3 induced similar myogenic changes, including smaller myofibers with internal nuclei, and upregulated p62 and LC3-II. Mutant MATR3 transgenic mice showed decreased body weight and lower motor activity. Muscle histology demonstrated myopathic changes including fiber-size variation, internal nuclei and rimmed vacuoles. Spinal cord histology showed a reduced number of motor neurons, and activation of microglia and astrocytes. Comprehensive proteomic analyses of muscle demonstrated upregulation of proteins related to chaperones, stress response, protein degradation, and nuclear function. Overexpression of WT and mutant MATR3 similarly caused myotoxicity, recapitulating the clinicopathological features of MSP. These models will be helpful for analyzing MSP pathogenesis and for understanding the function of MATR3. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Feasibility and safety of laparoscopy-assisted distal gastrectomy performed by trainees supervised by an experienced qualified surgeon.

BACKGROUND: Laparoscopic gastrectomy is becoming more commonly performed, but acquisition of its technique remains challenging. We investigated whether laparoscopy-assisted distal gastrectomy (LDG) performed by trainees (TR) supervised by a technically qualified experienced surgeon (QS) is feasible and safe. METHODS: The short-term outcomes of LDG were assessed in patients with gastric cancer between 2008 and 2018. We compared patients who underwent LDG performed by qualified experienced surgeons (QS group) with patients who underwent LDG performed by the trainees (TR group). RESULTS: The operation time was longer in the TR group than in the QS group (median time: 270 min vs. 239 min, p < 0.001). The median duration of the postoperative hospital stay was 9 days in the QS group and 8 days in the TR group (p = 0.003). The incidence of postoperative complications did not differ significantly between the two groups. Grade 2 or higher postoperative complications occurred in 18 patients (12.9%) in the QS group and 47 patients (11.7%) in the TR group (p = 0.763). Grade 3 or higher postoperative complications occurred in 9 patients (6.4%) in the QS group and 17 patients (4.2%) in the TR group (p = 0.357). Multivariate analysis showed that the American Society of Anesthesiologist Physical Status was an independent predictor of grade 2 or higher postoperative complications and that gender was an independent predictor of grade 3 or higher postoperative complications. The main operator (TR/QS) was not an independent predictor of complications. CONCLUSIONS: Laparoscopy-assisted distal gastrectomy performed by trainees supervised by an experienced surgeon is a feasible and safe procedure similar to that performed by experienced surgeons.

Relationship Between the Waiting Times for Surgery and Survival in Patients with Gastric Cancer.

BACKGROUND: Surgery for gastric cancer should be performed as soon as possible after diagnosis. However, sometimes the waiting time for surgery tends to be longer. The relation between the waiting time for surgery and survival in patients with gastric cancer remains to be fully investigated. METHODS: This retrospective, single-center cohort study evaluated patients with gastric cancer who underwent curative surgery from 2006 through 2012 at Kanagawa Cancer Center in Japan. Patients who received neoadjuvant chemotherapy were excluded. The waiting time for surgery was defined as the time between the first visit and surgery. We investigated whether the waiting time for surgery has a linear negative impact on outcomes by using a Cox regression model with clinical prognostic factors. RESULTS: In total, 801 patients were eligible. The median waiting time was 45 days (range 10-269 days). The restricted cubic spline regression curve showed that the adjusted time-specific hazard ratios of waiting times did not indicate a linear negative trend on survival between 20 and 100 days (p = 0.759). In the Cox model with a quartile of waiting times, waiting times in the 32-44-day group, 43-62-day group, and ≥63 day groups were not associated with poorer overall survival as compared with the ≤31 day group (HR: 1.01, 95% CI 0.63-1.60, p = 0.984, HR: 1.17, 95% CI 0.70-1.94, p = 0.550, HR: 1.06, 95% CI 0.60-1.88, p = 0.831, respectively). CONCLUSIONS: There was no negative relation between the waiting time for surgery (within 100 days) and survival in patients with gastric cancer.

Postoperative D-dimer elevation affects tumor recurrence and the long-term survival in gastric cancer patients who undergo gastrectomy.

INTRODUCTION: We retrospectively evaluated the blood coagulation activity using the D-dimer level in the early period after gastrectomy and investigated whether postoperative hypercoagulation affects tumor recurrence and long-term survival in gastric cancer patients. METHODS: The study involved 650 patients who underwent curative resection for gastric cancer at Kanagawa Cancer Center between July 2009 and July 2013. They were divided into a low-D-dimer group (LD group) and high-D-dimer group (HD group) according to the median D-dimer level on postoperative day (POD) 7. The risk factors for overall survival (OS) and relapse-free survival (RFS) were identified. RESULTS: Of the 448 enrolled patients, 218 were classified into the LD group and 230 into the HD group. The 5-year OS rates after surgery were 90.8% and 81.3% in the LD and HD groups, respectively (p < 0.001). The 5-year RFS rates after surgery were 89.9% and 76.1% in the LD and HD groups, respectively (p < 0.001). A high D-dimer level on POD 7 (≥ 4.9 µg/ml) was identified as an independent predictive factor for both the OS (hazard ratio [HR] 1.955, 95% confidence interval [CI] 1.158-3.303, p = 0.012) and RFS (HR 2.182, 95% CI 1.327-3.589, p = 0.002). Furthermore, hematological recurrence was significantly more frequent in the HD group than in the LD group (p = 0.014). CONCLUSION: A high D-dimer level on POD 7 may predict tumor recurrence and the long-term survival in patients who undergo gastrectomy for locally advanced gastric cancer. Patients with an elevated postoperative D-dimer level need careful observation and diagnostic imaging to timely detect tumor recurrence.

A Randomized Phase 2 Trial of Antibiotic Prophylaxis Versus No Intervention for Muscle Biopsy in A Neurology Department.

Muscle biopsy can be used to confirm the diagnosis of neuromuscular diseases. However, it is unclear whether antibiotic prophylaxis prior to muscle biopsy is needed to prevent surgical site infection (SSI). We are conducting a phase 2, single-center, open-labeled, prospective randomized trial to clarify the need for antibiotic prophylaxis in patients at low risk for SSI undergoing muscle biopsy. Patients will be randomized to an antibiotic prophylaxis group or a control group, and the incidence of SSI will be compared between the groups. Our findings will clarify the need for antibiotic prophylaxis in this patient population.

Risk factors analysis and stratification for microscopically positive resection margin in gastric cancer patients.

BACKGROUND: Cancer cells are often found postoperatively at surgical resection margins (RM) in patients with gastric cancer because of submucosal infiltration or hesitation to secure adequate RM. This study was designed to evaluate risk factors for microscopic positive RM and to clarify which patients should undergo intraoperative frozen section diagnosis (IFSD). METHODS: Patients who underwent R0/1 gastrectomy for gastric adenocarcinoma between 2000 and 2018 in a single cancer center in Japan were studied. We divided the patients into a positive RM group and negative RM group according to the results of definitive histopathological examinations. We performed multivariate analysis to analyze risk factors for positive RM by and used the identified risk factors to risk stratify the patients. RESULTS: A total of 2757 patients were studied, including 49 (1.8%) in the positive RM group. The risk factors significantly associated with positive RM were remnant gastric cancer (odds ratio [OR] 4.7), esophageal invasion (OR 6.3), tumor size ≥80 mm (OR 3.9), and a histopathological diagnosis of undifferentiated type (OR 3.6), macroscopic type 4 (OR 3.7), or pT4 disease (OR 4.6). On risk stratification analysis, the incidence of positive RM was 0.1% without any risk factors, increasing to 0.4% with one risk factor, 3.1% with two risk factors, 5.3% with three risk factors, 21.3% with four risk factors, and 85.7% with five risk factors. CONCLUSIONS: The risk of macroscopically positive RM increased in patients who have risk factors. IFSD should be performed in patients who have four or more risk factors.

[A Case of Port-Site Herniation from an Eight mm Port after Robot-Assisted Distal Gastrectomy].

A 63-year-old-woman was diagnosed with gastric cancer cStage ⅠA after ESD, and then, underwent robot-assisted distal gastrectomy. She vomited on the postoperative day 2 and then was inserted nasogastric tube. The amount of drainage from the tube was increased on the postoperative day 5, therefore, abdominal computed tomography scan was performed, which showed herniation of small bowel at the 8 mm port site in the left upper abdomen. The emergent surgery was performed because of difficulty in manual reduction. Intraoperative findings showed that small intestine was incarcerated at the left 8 mm port-site. The intestine was released by incising the fascia of hernia orifice, then, the fascia was repaired. There was no recurrence of gastric cancer and port-site hernia for 34 months after surgery. In general, the fascia of over 10 mm port site is sutured and closed to avoid port-site hernia, however, it is unclear whether the fascia of 8 mm port-site should be closed after robotic surgery. Since we experienced this case, we have also performed fascia suture on the 8 mm port-site in all cases. And then, we could prevent occurrence of port-site hernia in the 8 mm port-site.

[A Case of Malignant Melanoma Metastasized to the Small Intestine].

A case of 69-year-old man underwent resection for the plantar surface of left foot malignant melanoma and received a sentinel biopsy of left inguinal lymph node. Two years and 10 months later, a mass of 30 mm in diameter in the ileum was detected by contrast-enhanced computed tomography, which showed abnormal uptake using FDG positron emission tomography. The partial intestinal resection was performed, and then, the mass was diagnosed as metastasis of malignant melanoma by pathological examination. Malignant melanoma is highly malignant disease that frequently shows distant metastasis. Although the malignant melanoma with distant metastasis shows poor prognosis, previous studies reported the prognosis could be improved when the patient could receive curative resection for single intraabdominal metastasis. Therefore, surgical resection should be considered for the single metastasis of malignant melanoma. We report a case of malignant melanoma with ileum metastasis resected curatively with literature review.

Mitochondrial localization of PABPN1 in oculopharyngeal muscular dystrophy.

Oculopharyngeal muscular dystrophy (OPMD) is a late-onset disorder characterized by ptosis, dysphagia, and weakness of proximal limbs. OPMD is caused by the expansion of polyalanine in poly(A)-binding protein, nuclear 1 (PABPN1). Although mitochondrial abnormality has been proposed as the possible etiology, the molecular pathogenesis is still poorly understood. The aim of the study was to specify the mechanism by which expanded PABPN1 causes mitochondrial dysfunction in OPMD. We evaluated whether transgenic mouse model of OPMD, by expressing expanded PABPN1, indeed causes mitochondrial abnormality associated with muscle degeneration. We also investigated the mechanism by which expanded PABPN1 would cause mitochondrial dysfunction in the mouse and cell models of OPMD. Mitochondrial localization of PABPN1 was observed in the muscle fibers of patients with OPMD. Moreover, abnormal accumulation of PABPN1 on the inner membrane of mitochondria and reduced expression of OXPHOS complexes were detected in the muscle fibers of the transgenic mice expressing expanded human PABPN1 with a 13-alanine stretch. In cells expressing PABPN1 with a 10-alanine or 18-alanine stretch, both types of PABPN1 accumulated in the mitochondria and interacted with TIM23 mitochondrial protein import complex, but PABPN1 with 18-alanine stretch decreased the cell viability and aggresome formation. We proposed that the abnormal accumulation of expanded PABPN1 in mitochondria may be associated with mitochondrial abnormality in OPMD.

Muscle pathology of hereditary motor and sensory neuropathy with proximal dominant involvement with TFG mutation.

BACKGROUND: Hereditary motor and sensory neuropathy with proximal dominant involvement (HMSN-P) is characterized by adult onset, a slowly progressive course and autosomal dominant inheritance. It remains unclear whether myopathic changes occur histopathologically. METHODS: We encountered 2 patients in a family with a heterozygous p.P285L mutation in TRK-fused gene (TFG), which is known to cause HMSN-P. The affected individuals developed proximal-dominant muscle weakness in their 40s, which slowly progressed to a motor neuron disease-like phenotype. RESULTS: Muscle biopsy showed myopathic pathology including fiber size variability, increased internal nuclei, fiber splitting, and core-like structures, associated with neurogenic changes: large groups of atrophic fibers and fiber type-grouping. Immunohistochemistry revealed sarcoplasmic aggregates of TFG, TDP-43, and p62 without congophilic material. CONCLUSIONS: The present study demonstrates myopathic changes in HMSN-P. Although the mechanisms underlying the skeletal muscle involvement remain to be elucidated, immunohistochemistry suggests that abnormal protein aggregation may be involved in the myopathic pathology.

[A Case of Hepatocellular Carcinoma Treated with Transdiaphragmatic Radiofrequency Ablation under Thoracotomy].

The patient was a 73-year-old man. A liver tumor was found in the posterior segment(S6)during the follow-up period post the interferon treatment for hepatitis C in September 1999. An S6 sub-segmentectomy was performed. The tumor was diagnosed as a moderately differentiated carcinoma, hepatocellular carcinoma(HCC)with pT2N0M0, pStage Ⅱ(UICC TNM 7th edition). The tumor recurred twice post-surgery. The recurrent tumors were treated with local therapies such as transcatheter arterial chemoembolization(TACE), percutaneous ethanol injection(PEI)and radiofrequency ablation(RFA). The third recurrence was found in the posterior segment(S7)in April 2009. RFA was unsuccessful because an appropriate puncture route could not be found. Then, a transdiaphragmatic RFA under thoracotomy was performed as an alternative treatment, which led to an optimal outcome. We report a case of HCC that could not be treated with percutaneous RFA but with a transdiaphragmatic RFA under thoracotomy.