Correction to: Preventive effect of early introduction of everolimus and reduced­exposure tacrolimus on renal interstitial fibrosis in de novo living­donor renal transplant recipients.

In the Original publication of the article, the co-author name has been misspelled as "Yousuke Nakagawa".

Preventive effect of early introduction of everolimus and reduced-exposure tacrolimus on renal interstitial fibrosis in de novo living-donor renal transplant recipients.

BACKGROUND: To improve the long-term outcomes following renal transplantation, prevention of renal-allograft interstitial fibrosis (IF), mainly due to calcineurin inhibitors, is an important therapeutic target. Everolimus (EVR) was reported to have antifibrotic effects. We aimed to investigate the safety, efficacy, and IF of our modified immunosuppressive regimen, which includes early introduction of EVR and reduced-exposure tacrolimus (Tac) (EVR group), and compare it with the standard-exposure tacrolimus-based regimen (Tac group) in de novo living-donor renal recipients. METHODS: In this retrospective, single-center cohort study, we compared the 2-year clinical courses between the two groups according to intention to treat. Additionally, in patients in whom biopsies were obtained at 1 h, 3 months, and 12 months post-transplant, we compared IF between the groups using imaging analysis. RESULTS: Overall, 47 patients were included (EVR group, n = 22; Tac group, n = 25). There were no significant differences in renal function and incidences of rejection and viral infections between the groups at the 2-year post-transplant follow-up. However, pathologic imaging analysis (n = 34) revealed chronological progression of IF in the Tac group during the first year post-transplant and no changes in the EVR group (fibrosis rate at 3 months: 20.8 vs. 13.6%, p < 0.001; at 12 months: 24.7 vs. 14.7%, p < 0.001, respectively). CONCLUSION: Our modified immunosuppressive regimen may have an antifibrotic effect on transplanted kidneys without loss of safety and efficacy.

[A Case of Long-Term Survival Following Two-Stage Surgery for Perforated Advanced Gastric Cancer Caused by Chemotherapy].

A 74-year-old man with bloody vomit was diagnosed as having clinical Stage Ⅳ advanced gastric cancer with lymph node metastasis around the abdominal aorta. Initially, for curative surgery, he was administered neoadjuvant chemotherapy. On day 32, in the second course of chemotherapy containing S-1 after 12 courses of chemotherapy containing S-1 and cisplatin, he developed pan-peritonitis owing to the perforation of gastric cancer caused by chemotherapy, and thus, we performed emergency omental implantation and peritoneal drainage. He was discharged from the hospital after 14 days with no trouble. His gastric cancer was judged to be resectable without retaining metastatic lymph nodes based on intraoperative findings and abdominal computed tomography. Therefore, 3 months after the emergency surgery, he underwent total gastrectomy with D1+(+No. 11d)lymphadenectomy. The postoperative course was uneventful. He rejected adjuvant chemotherapy despite our recommendation. Regrettably, intraabdominal dissemination was observed 15 months after total gastrectomy, and he then received chemotherapy again. He has remained alive for 57 months after the first visit to our hospital.

Intratumoral heterogeneity of HER2 protein and amplification of HER2 gene in salivary duct carcinoma.

Salivary duct carcinoma (SDC) is an aggressive adenocarcinoma of the salivary glands, and accounts for 1-3% of all malignant salivary gland tumors, resembling morphologically invasive ductal carcinoma (IDC) of the breast. In contrast to IDC of the breast and gastric carcinoma (GC), the study of human epidermal growth factor receptor 2 (HER2) in SDC has not progressed. Therefore, we investigated the relationship between HER2 protein expression and amplification of the HER2 gene, and compared them in terms of intratumoral heterogeneity (ITH) in 13 cases of SDC using immunohistochemistry and dual color in situ hybridization. We found seven cases with protein overexpression (53.8%) and five cases with gene amplification (38.5%) in accordance with ASCO/CAP guidelines. ITH of HER2 protein expression was seen in seven cases (53.8%). Interestingly, the ratio of the HER2 gene showed homogenous distribution with or without the presence of ITH of HER2 protein expression. SDC tends to have more ITH of HER2 protein similarly to GC, in contrast to IDC of the breast. ITH of HER2 protein in SDC has no heterogeneity of the HER2 gene amplification. The mechanism of HER2 protein expression in SDC might proceed through a more complex pathway relative to that of IDC of the breast.

Establishment of a primary hepatocyte culture from the small Indian mongoose (Herpestes auropunctatus) and distribution of mercury in liver tissue.

The present study established a primary hepatocyte culture for the small Indian mongoose (Herpestes auropunctatus). To determine the suitable medium for growing the primary hepatic cells of this species, we compared the condition of cells cultured in three media that are frequently used for mammalian cell culture: Dulbecco's Modified Eagle's Medium, RPMI-1640, and William's E. Of these, William's E medium was best suited for culturing the hepatic cells of this species. Using periodic acid-Schiff staining and ultrastructural observations, we demonstrated the cells collected from mongoose livers were hepatocytes. To evaluate the distribution of mercury (Hg) in the liver tissue, we carried out autometallography staining. Most of the Hg compounds were found in the central region of hepatic lobules. Smooth endoplasmic reticulum, which plays a role inxenobiotic metabolism, lipid/cholesterol metabolism, and the digestion and detoxification of lipophilic substances is grown in this area. This suggested that Hg colocalized with smooth endoplasmic reticulum. The results of the present study could be useful to identify the detoxification systems of wildlife with high Hg content in the body, and to evaluate the susceptibility of wildlife to Hg toxicity.

A case of ANCA-negative pauci-immune crescentic glomerulonephritis with lung adenocarcinoma with mediastinal involvement successfully treated by corticosteroid and radiation therapy.

Pauci-immune crescentic glomerulonephritis (PICGN) is one of the pathologies causing rapidly progressive glomerulonephritis, often associated with anti-neutrophil cytoplasmic antibody (ANCA); however, in 10-30% of cases, ANCAs are negative. While a relatively large number of cases of ANCA-positive PICGN complicated with malignancy have been previously reported, the number of cases of ANCA-negative PICGN with malignancy is limited. The prognosis for such cases was poor, and many patients died within a relatively short period. Here, we report the case of ANCA-negative PICGN complicated with malignancy successfully treated by corticosteroid and radiation therapy. A 63-year-old Japanese man was admitted to our hospital due to spiking fevers in the previous 3 months. Based on the findings of imaging and pathological tests, he was diagnosed with locally advanced lung adenocarcinoma with mediastinal involvement. After admission, his renal function rapidly deteriorated, and urinalysis showed heavy proteinuria. In serological tests, serology for autoantibodies, including ANCAs, was negative. The kidney biopsy revealed PICGN with prominent endocapillary proliferation. We administered corticosteroid therapy for glomerulonephritis and subsequent radiation therapy for lung carcinoma, both of which were effective. He has been alive without progression of malignancy or kidney disease for 5 years after discharge. In patients with malignancy presenting with acute deterioration of kidney function, although infrequent, one of the conceivable pathological conditions to consider is ANCA-negative PICGN associated with malignancy. In such cases, even with negative antibodies such as ANCA, pathological examination is warranted, and a combination of anti-tumor therapy and immunosuppressive therapy is expected to be effective.

Bilateral Hilar and Mediastinal Lymphadenopathy as an Initial Manifestation of Amyloidosis.

A 75-year-old male visited our hospital with bilateral hilar lymph node swelling detected on chest radiography during an annual medical checkup. Chest computed tomography revealed swelling of multiple hilar mediastinal lymph nodes. Histopathological and immunohistochemical examinations of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) specimens from the hilar lymph nodes revealed amyloid deposition. Bilateral hilar and mediastinal lymphadenopathies can be the first manifestations of amyloidosis diagnosed using EBUS-TBNA.

Over-expression of BACH2 is related to ongoing somatic hypermutation of the immunoglobulin heavy chain gene variable region of de novo diffuse large B-cell lymphoma.

The basic region-leucine zipper (bZip) factor BTB, CNC homology 2 (BACH2) is known to have important roles in class switch recombination and somatic hypermutation (SHM) of the immunoglobulin (Ig) gene. In this study, we investigated the relationship between the expression of BACH2 and the status of SHM of the Ig heavy chain gene variable region (IgHV) for SHM in diffuse large B-cell lymphoma (DLBCL). We examined 20 cases of DLBCL, 13 of which were germinal center B-cell (GCB) DLBCL and 7 were non-GCB DLBCL. Seven cases were negative, 6 were positive (cytoplasmic expression) and 7 were strongly positive (both nuclear and cytoplasmic expression) for BACH2. Confirmed mutation (CM) was identified in 8 cases and the CM index (number of confirmed mutations per 10 subclones) was distributed from 0 to 5. A CM index of 7 strongly positive (over-expression) cases with BACH2 were distributed from 0 to 5, and that of 7 negative and 6 positive cases were distributed from 0 to 1. Over-expression of BACH2 was statistically related to CM index (P = 0.008). In conclusion, over-expression of BACH2 is critical for ongoing SHM of IgHV in DLBCL, and our data suggest that BACH2 may play an essential role for SHM of the Ig gene in B-cell lymphoma.

A Case of Phlebolith in the Tip of Tongue.

The differential diagnosis of a tongue mass containing calcified bodies includes a phlebolith associated with vascular lesions, such as hemangioma and vascular malformation, and diseases such as neoplasm, osseous choristoma and hypercalcemic states, including hyperparathyroidism. The appearance of the calcified bodies on plain radiographs may help to differentiate these entities. Computed tomography, magnetic resonance imaging, and ultrasonography are also useful for differentiating these soft tissue lesions. We report a 40-year-old man with a small mass containing a calcified body in the tip of tongue. The mass was surgically resected and histologically evaluated, confirming the diagnosis of phlebolith. Our case was a rare phlebolith that did not involve a vascular lesion.

The Main Suppressing Factors of Dry Forage Intake in Large-type Goats.

In large-type goats that were fed on dry forage twice daily, dry forage intake was markedly suppressed after 40 min of feeding had elapsed. The objective of this study was to determine whether or not marked decreases in dry forage intake after 40 min of feeding are mainly caused by the two factors, that is, ruminal distension and increased plasma osmolality induced thirst produced by dry forage feeding. Six large-type male esophageal- and ruminal-fistulated goats (crossbred Japanese Saanen/Nubian, aged 2 to 6 years, weighing 85.1±4.89 kg) were used in two experiments. The animals were fed ad libitum a diet of roughly crushed alfalfa hay cubes for 2 h from 10:00 to 12:00 am during two experiments. Water was withheld during feeding in both experiments but was available for a period of 30 min after completion of the 2 h feeding period. In experiment 1, saliva lost via the esophageal fistula was replenished by an intraruminal infusion of artificial parotid saliva (RIAPS) in sham feeding conditions (SFC) control, and the treatment was maintained under normal feeding conditions (NFC). In experiment 2, a RIAPS and non-insertion of a balloon (RIAPS-NB) control was conducted in the same manner as the SFC control of experiment 1. The intraruminal infusion of hypertonic solution and insertion of a balloon (RIHS-IB) treatment was carried out simultaneously to reproduce the effects of changing salt content and ruminal distension due to feed entering the rumen. The results of experiment 1 showed that due to the effects of multiple dry forage suppressing factors when feed boluses entered the rumen, eating rates in the NFC treatment decreased (p<0.05) after 40 min of feeding and cumulative dry forage intake for the 2 h feeding period reduced to 43.8% of the SFC control (p<0.01). The results of experiment 2 indicated that due to the two suppressing factors of ruminal distension and increased plasma osmolality induced thirst, eating rates in the RIHS-IB treatment were, as observed under NFC, reduced (p<0.05) and cumulative dry forage intake for the 2 h feeding period decreased to 34.0% of the RIAPS-NB control (p<0.01). The combined effects of ruminal distension and increased plasma osmolality accounted for 77.5% of the suppression of dry forage intake 40 min after the start of dry forage feeding. The results indicate that ruminal distension and increased plasma osmolality induced thirst are the main factors in the suppression of dry forage intake in large-type goats.

A Physiological Stimulating Factor of Water Intake during and after Dry Forage Feeding in Large-type Goats.

When ruminants consume dry forage, they also drink large volumes of water. The objective of this study was to clarify which factor produced when feed boluses enter the rumen is mainly responsible for the marked increase in water intake in the second hour of the 2 h feeding period in large-type goats fed on dry forage for 2 h twice daily. Six large-type male esophageal- and ruminal-fistulated goats (crossbred Japanese Saanen/Nubian, aged 2 to 6 years, weighing 85.1±4.89 kg) were used in two experiments. In experiment 1, the water deprivation (WD) control and the water availability (WA) treatment were conducted to compare changes in water intake during and after dry forage feeding. In experiment 2, a normal feeding conditions (NFC) control and a feed bolus removal (FBR) treatment were carried out to investigate whether decrease in circulating plasma volume or increase in plasma osmolality is mainly responsible for the marked increase in water intake in the second hour of the 2 h feeding period. The results of experiment 1 showed that in the WA treatment, small amounts of water were consumed during the first hour of feeding while the majority of water intake was observed during the second hour of the 2 h feeding period. Therefore, the amounts of water consumed in the second hour of the 2 h feeding period accounted for 82.8% of the total water intake. The results of experiment 2 indicated that in comparison with the NFC control, decrease in plasma volume in the FBR treatment, which was indicated by increase in hematocrit and plasma total protein concentrations, was higher (p<0.05) in the second hour of the 2 h feeding period. However, plasma osmolality in the FBR treatment was lower (p<0.05) than compared to the NFC control from 30 min after the start of feeding. Therefore, thirst level in the FBR treatment was 82.7% less (p<0.01) compared with that in the NFC control upon conclusion of the 30 min drinking period. The results of the study indicate that the increased plasma osmolality in the second hour of the 2 h feeding period is the main physiological stimulating factor of water intake during and after dry forage feeding in large-type goats.

Clinicopathological features of PD-L1 protein expression, EBV positivity, and MSI status in patients with advanced gastric and esophagogastric junction adenocarcinoma in Japan.

This real-world study examined the prevalence of programmed death ligand-1 (PD-L1) expression and assessed the frequency of microsatellite instability-high (MSI-H) status and Epstein-Barr virus (EBV) positivity in Japanese patients with advanced gastric and gastroesophageal junction (GEJ) adenocarcinoma. This multicenter (5 sites), retrospective, observational study (November 2018-March 2019) evaluated Japanese patients with advanced gastric and GEJ adenocarcinoma after surgical resection (Stage II/III at initial diagnosis) or unresectable advanced cancer (Stage IV). The primary objectives were prevalence of PD-L1 expression (combined positive score [CPS] ≥1), MSI status, and EBV positivity. Tumor specimens of 389/391 patients were analyzed (male, 67.1%; mean age, 67.6 ± 12.2 years); 241/389 (62%) were PD-L1 positive, 24/379 (6.3%) had MSI-H tumors, and 13/389 (3.3%) were EBV positive. PD-L1 expression was higher in tumor-infiltrating immune cells than in tumor cells for lower CPS cutoffs. Among patients with MSI-H tumors and EBV-positive tumors, 19/24 (79.2%) and 9/13 (69.2%), respectively, were PD-L1 positive. A greater proportion of patients with MSI-H tumors (83.3% [20/24]) were PD-L1 positive than those with MSI-low/stable tumors (60.8% [216/355]; p = .0297); similarly, an association was observed between history of H pylori infection and PD-L1 expression. A higher proportion of patients with MSI-H tumors demonstrated PD-L1 expression with a CPS ≥10 (66.7% [16/24]) vs those with MSI-low/stable tumors (24.8% [88/355]; p < .0001). The prevalence of PD-L1 positivity among Japanese patients was comparable to that in previous pembrolizumab clinical trials and studies in gastric cancer. Particularly, higher PD-L1 expression was observed in MSI-H tumors.

Immunohistochemical Marker Expression in Temporal Bone Squamous Cell Carcinoma.

BACKGROUND: The correlation between genomic mutations (or the overexpression of abnormal proteins) and prognosis in temporal bone squamous cell carcinoma (TBSCC) is not clear. We investigated the overexpression of EGFR and p53 as a pathological biomarker for predicting the clinical course of patients with TBSCC. METHODS: We performed a retrospective review of 22 TBSCC cases treated in Tokai University Hospital between January 2005 and October 2016. We assessed the overexpression of EGFR and p53 in TBSCC patients through immunohistochemical staining. We also evaluated the association between the overexpression of these proteins and clinicopathological variables, including survival outcomes. RESULTS: The primary lesion in all patients was the external auditory canal. Nine (40.9%) patients were EGFR positive, and 9 (40.9%) were p53 positive. The 5-year overall survival rate for EGFR-positive patients (55.6%) was significantly lower (p = 0.043) than that of the EGFR-negative patients (92.3%). CONCLUSION: EGFR overexpression in TBSCC patients may be a prognostic biomarker.

A p16 Positive M1 Oral Tongue Cancer Completely Responsive to the EXTREME Regimen: A Case Report.

METHODS: A 42-year-old woman presented to our clinic with tongue pain and dysarthria. She had a smoking history of 22 pack-years and no history of alcohol consumption. A deep ulcer at the left side of the tongue and induration across the whole tongue were observed. The bilateral cervical lymph nodes were palpable. A biopsy from the ulcer revealed squamous cell carcinoma. PET/CT showed sternal bone metastasis resulting in the final diagnosis of left-sided oral tongue cancer (cT4aN2cM1). Systemic chemotherapy treatment involving 6 courses of the EXTREME regimen followed by weekly cetuximab administration was indicated. RESULTS: After the first two courses, diminished tongue pain and improved dysarthria were observed; complete response was obtained after 6 courses. Re-examination of the biopsy specimen showed that the tumor was p16 positive. The p16 protein is a surrogate marker for HPV, but in this case HPV in-situ hybridization was negative. Locoregional or distant failure were not observed during the 5-year follow-up period. CONCLUSIONS: The treatment regimen unexpectedly proved successful. It may be beneficial to examine p16 expression in oral tongue cancer to identify patients that are more likely to benefit from the EXTREME treatment regimen.

Sonographic appearance of syphilitic induration mimicking squamous cell carcinoma in the lower lip: a case report.

BACKGROUND: Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum. Recently, its incidence has been increasing worldwide. We encountered a young woman who presented with induration mimicking squamous cell carcinoma in the lower lip, without major medical conditions. CASE PRESENTATION: A 25-year-old Japanese woman presented with a 1-month history of a painless induration in her lower lip. Because squamous cell carcinoma was suspected, a preoperation work up was performed, including laboratory tests, an ultrasonographic examination, and a biopsy. The ultrasonography findings showed an oval-shaped 17 × 11 × 12 mm tumor-like lesion with heterogeneous internal echo and an indistinct border. A pressure test and color Doppler sonography revealed that the lesion was soft with a very abundant blood flow. These findings suggested the possibility of underlying inflammatory causes rather than a neoplastic tumor. Serology tests for syphilis, including the anti-Treponema pallidum antibody and reactive rapid plasma reagin tests, were positive. The biopsy revealed no malignancy. Finally, she was diagnosed as having primary syphilis and treated with amoxicillin for 28 days. The rapid plasma reagin value gradually decreased and the initial induration in her lower lip disappeared. CONCLUSION: This case highlights the need for prompt examinations for possible underlying infective causes, such as syphilis, when seeing a painless induration with ulcer in the lip. Ultrasonography was helpful in the differential diagnosis of a tumor-like lesion and should be included in addition to syphilis serology tests, such as anti-Treponema pallidum antibody and rapid plasma reagin tests.

Myxofibrosarcoma that Developed Rapidly in the Breast of an Elderly Man and Recurred Early after Surgery: A Case Report.

BACKGROUND: Myxofibrosarcoma is a rare disease occurring subcutaneously in the limbs. We report a case of a rapidly growing myxofibrosarcoma in the breast of an elderly man that recurred early after surgery. CASE PRESENTATION: A 73-year-old man presented with a breast mass. Physical findings showed a large tumor in the right breast, and malignancy was suspected on ultrasonography. Computed tomography (CT) revealed tumor invasion into the pectoralis major and pectoralis minor muscles. Positron emission tomography/CT showed no abnormality in other organs. Needle biopsy results excluded breast cancer but did not provide a definitive diagnosis. However, the tumor grew rapidly before further results were available, so emergency mastectomy was performed. The final pathological diagnosis was high-grade myxofibrosarcoma. Postoperative radiotherapy was started because of remnant tumor. The wound became worsened and swollen, and needle biopsy 10 days after the start of therapy indicated recurrence. Radical resection and thoracoplasty were performed. Postoperative pathological specimens showed no residual tumor. Radical radiation therapy was resumed. The patient has shown no recurrence after an year. CONCLUSIONS: It is important to consult a soft tissue oncologist for tumors in the breast and perform appropriate examination and treatment if soft tissue tumors cannot be ruled out.

Sinusoidal tumor angiogenesis is a key component in hepatocellular carcinoma metastasis.

Hepatocellular carcinoma (HCC) has a tendency for intravascular dissemination leading to a poor prognosis. The importance of the sinusoidal structure of the tumor vasculature in HCC has been implicated in the metastasis formation. To clarify the role of tumor angiogenesis in HCC metastasis, we morphologically investigated the interaction of HCC cells with blood vessels during the sequential process of metastasis. Autopsy specimens of 80 patients with HCC were examined with immunohistochemistry using a specific antibody against CD31, a marker for endothelial cells. The most frequent sites of metastasis were the liver (82.5%) and lung (43.8%). In most cases, the metastatic process was initiated by vascular involvement where tumor nests surrounded by sinusoidal vessels extend into the portal and hepatic veins. Subsequently, these endothelial-coated tumor emboli enter the circulation, embolize at distant organs, proliferate within the blood vessel and ultimately form metastatic foci. These steps are indicative of an invasion-independent pathway. Our findings in animal models and now in human cases suggest that sinusoidal angiogenesis may represent a novel target for therapeutic strategies to limit HCC metastasis. In combination with primary tumor treatment, perturbation of tumor emboli may reduce dissemination of disease.

An entire clinical course of mediastinal myxofibrosarcoma treated by surgery and radiation.

A woman in her 70s with an 8.6-cm tumor in the anterior mediastinum underwent tumor excision by median sternotomy, which combined resection of the fifth and sixth ribs. The pathological diagnosis was myxofibrosarcoma, and pathologically curative resection was accomplished. Local recurrence was detected at 10, 19, 23 and 28 months after the initial surgery. After repeated surgical resection, radiation therapy for the fourth unresectable recurrence resulted in failure. She died 34 months after the initial surgery. There have been 3 case reports of mediastinal myxofibrosarcoma. With regard to prognosis, control over local recurrence by surgical resection might be essential to achieve a long survival. However, the clinical course of mediastinal myxofibrosarcoma has not been reported in detail. This is the first description on the entire clinical course of mediastinal myxofibrosarcoma.