[A Case of De Novo Stage â £ Breast Cancer Successfully Treated with Surgery and Multiple Endocrine Therapies Over a Long Period of Time].

Here we present a case of de novo Stage Ⅳ breast cancer successfully treated with surgery and multiple endocrine therapies over a long period of time. A 75-year-old female presented with a breast tumor with skin invasion and multiple lung metastases. Diagnosed with infiltrating breast cancer of Luminal A-like subtype, endocrine therapy with anastrozole was initiated. Despite initial response to the treatment in both the primary site and lung metastases, the primary tumor regrew and surgery with lumpectomy was performed. After a 3-year-treatment of tamoxifen, axillary lymphadenopathy and bone metastases developed. The patient was treated with fulvestrant for 5 years, resulting in clinical complete response. The now 88-year-old patient has been free of disease without treatment for a year and a half. Generally, primary tumor resection of Stage Ⅳ breast cancer does not improve prognosis, but in this case it provided good local control and enabled long-term endocrine therapy, resulting in prolonged disease-free survival.

[A Case of Primary Gastric Lymphoma with Spontaneous Perforation].

An 85-year-old female patient presented to the emergency department with the chief complaint of sudden upper abdominal pain. The patient suffered from anorexia and epigastric pain for a month, and a local physician suspected a diagnosis of gastric ulcer. An abdominal computed tomography(CT)scan showed intraperitoneal free air as well as irregular thickening and thinning of the gastric wall. Gastric ulcer perforation was suspected, and an emergency operation was performed. Surgical findings showed thickening of the gastric wall in the pylorus and gastric corpus but partial thinning of areas of the anterior wall of the gastric corpus with a perforation measuring 5 mm. A distal gastrectomy and reconstruction were performed using the Billroth Ⅱ method. The histopathological diagnosis was malignant gastric lymphoma(diffuse large B- cell lymphoma). Considering the patient's age and general condition, chemotherapy was not administered after surgery. The patient was alive without recurrence 8 months after the operation.

[Resectable Pancreatic Cancer Successfully Treated with Neoadjuvant Chemotherapy Regimen Change to Modified FOLFIRINOX-A Case Report].

A 72-year-old woman presented with obstructive jaundice. Computed tomography revealed a 12-mm low-density mass in the head of the pancreas. She was diagnosed as having pancreatic cancer by endoscopic ultrasound-guided fine-needle aspiration. She received gemcitabine plus nab-paclitaxel as preoperative chemotherapy. After 2 courses, hepatoduodenal lymph node metastasis appeared and was accompanied by increased tumor marker levels. The regimen was changed to modified FOLFIRINOX. After 5 courses, the lymph node metastasis was reduced in size and the tumor marker levels were decreased, so subtotal stomach-preserving pancreaticoduodenectomy was performed. Adjuvant chemotherapy was administered postoperatively. The patient was alive and well without recurrence 2 years and 9 months after the surgery, but died of sepsis. Nevertheless, this case highlights that when preoperative chemotherapy for resectable pancreatic cancer appears to be ineffective, a change in regimen may be useful.

[A Case of Pancreatic Invasive Micropapillary Carcinoma That Survived Seven Years after Resection and Chemotherapy].

We present the case of a 47-year-old man who underwent a subtotal stomach-preserving pancreaticoduodenectomy for pancreatic head cancer. Histopathological diagnosis revealed that the majority of the cancer was an invasive micropapillary carcinoma(IMPC). Postoperative adjuvant chemotherapy using S-1 was continued for 4 years, at the end of which, multiple lymph node metastases were identified. Therefore, gemcitabine plus S-1 therapy was initiated. The treatment reduced the lymph node in size and resulted in the maintenance of a partial response for a year and a half. However, increased lymph node metastases recurred, and multiple lung metastases were noted. The patient died 7 years and 2 months after the resection of the primary lesion. Although pancreatic IMPC has a poor prognosis, long-term survival may be achieved by resection of the primary region, the administration of adjuvant chemotherapy and management of recurrent lesions by chemotherapy.

[Locally Advanced HER2-Positive Breast Cancer Successfully Treated with Trastuzumab Emtansine].

Although the prognosis of HER2-positive breast cancer(BC)has been improving than before, that of locally advanced cases is not satisfactory. A 41-year-old female presented with a huge breast lump and massive lymphadenopathy, which was diagnosed as HER2-positive, unresectable, locally advanced BC. The first treatment, consisting of docetaxel, trastuzumab and pertuzumab, had only a limited and temporary effect, with subsequent mass regrowth. After initiation of the second treatment, trastuzumab emtansine(TDM1), the mass gradually shrank, and mastectomy and axillary lymphadenectomy were performed successfully. Histologically, several tiny invasive foci were observed in the mammary gland. No lymph node metastases were observed. The patient subsequently underwent radiation therapy and a 1-year course of TDM1 treatment. The patient has been in remission for 5 years. HER2-positive, locally advanced BC can be successfully treated with multimodal therapy, including anti-HER2 therapy, timely surgery and radiation therapy.

[Total Pancreatectomy for Remnant Pancreatic Cancer with Positive Washing Cytology after Conversion to Negative Cytology Following Gemcitabine plus Nab-Paclitaxel Therapy-A Case Report].

A 53-year-old woman underwent subtotal stomach-preserving pancreaticoduodenectomy(SSPPD)for resectable pancreatic cancer after neoadjuvant chemotherapy. Postoperatively, she received hepatic arterial infusion of 5-FU and S-1 chemotherapy. Two years after SSPPD, abdominal computed tomography showed a 2-cm mass in the remnant pancreas, which was diagnosed as recurrence of cancer by endoscopic ultrasound-guided fine-needle aspiration. Staging laparoscopy was performed and peritoneal washing cytology(CY)was positive. She then received gemcitabine plus nab-paclitaxel chemotherapy for 8 months. After that, staging laparoscopy was performed again and negative CY was confirmed. A total remnant pancreatectomy with splenectomy was performed. She received chemotherapy after pancreatectomy and is now alive and well without recurrence 2 years and 1 month after the second surgery. Although positive CY is a poor prognostic factor, surgery combined with perioperative chemotherapy may contribute to prolonged survival for some patients who have recurrence in the remnant pancreas with positive CY.

Criminal victimization of people with epilepsy: Sixteen criminal judgments in Japan between 1990 and 2019.

Criminal behavior by people with epilepsy (PWE) has often been discussed. However, there are limited studies on criminal victimization of PWE-in particular, how such victimizations occur. We identified criminal cases involving victims with epilepsy using databases containing criminal judgments and found 16 such cases between 1990 and 2019. Seven were homicide cases, including four filicide cases. In the four filicide cases, all the perpetrators had the intention of homicide-suicide; all the victims had intellectual disabilities or cerebral palsy; two of these victims had acted violently toward the family; and two mothers who perpetrated the crime against the victims had depression. It seemed that the comorbidities and problem behaviors of the victims were more strongly related to serious crimes by family caregivers than the epilepsy itself. To prevent victimization caused by family caregivers, reducing their stress levels is important. Defendants sometimes argued against objective evidence of a crime, claiming that epileptic seizure of PWE caused or was related to the death of victims. Legal and medical professionals involved in determining the manner of death need careful evaluation when sudden deaths of PWE occur.

[A Case of Surgical Resection of Anaplastic Carcinoma of the Pancreas(Pleomorphic Cell Type)with Poor Response to Neoadjuvant Chemotherapy].

A 62-year-old man was incidentally found to have a pancreatic tumor by CT. He was diagnosed with pancreatic cancer by EUS-FNAB. Gemcitabine(GEM)plus nab-paclitaxel(PTX)was started as neoadjuvant chemotherapy(NAC)for resectable pancreatic cancer. However, after the end of the second course, the tumor grew rapidly and invaded the stomach, so NAC was discontinued, and surgery was performed. The pathological diagnosis was anaplastic ductal carcinoma of the pleomorphic cell type, and the histological response was Grade 1a. Multiple liver metastases appeared during adjuvant chemotherapy with S-1, so GEM plus nab-PTX and modified FOLFIRINOX were administered, but the therapeutic response was poor, the patient died 9 months after surgery. Anaplastic carcinoma has a poor response to chemotherapy and may be included with cancers showing treatment resistance to NAC, as seen in our case. It is necessary to pay attention to anaplastic carcinoma during the course of NAC for pancreatic cancer.

Mortality and suicide rates in patients discharged from forensic psychiatric wards in Japan.

BACKGROUND: Japanese forensic mental health services for patients with psychiatric disorders under the Medical Treatment and Supervision Act was initiated in 2005; however, the prognosis of those patients is not well-known, particularly regarding mortality and suicide. This study aimed to evaluate the all-cause mortality and suicide rate in forensic psychiatric outpatients who had been discharged from forensic psychiatric wards in Japan. METHODS: Participants included 966 patients who had been discharged from forensic psychiatric wards. Data were collected from July 15, 2005 to July 15, 2018 at 29 of the 33 forensic psychiatric wards in Japan. Only the patients who provided written informed consent were included. We and collaborators at each forensic psychiatric ward identified demographic data of participants from the medical records for the inpatient treatment period. The reintegration coordinators, who belonged to the Ministry of Justice, investigated the prognosis of the participants during the outpatient treatment order period. We then connected demographic data and participants' prognosis for analysis. The crude rates (CRs) and standardized mortality ratios (SMRs) were calculated to analyze all-cause mortality and suicide rates. Univariate analysis was performed to examine the factors associated with all-cause mortality and suicide rates using the Cox proportional hazards ratio model. RESULTS: The participants included 3.3 times as many men (n=739) compared to women (n=227), and their combined mean age was 47.3 (SD=12.9). The most common primary psychiatric diagnosis was psychotic disorders (81.3%). The mean follow-up period was 790.2 days (SD=369.6). The total observation period was 2091.2 person-years. The CR for all-cause death was 812.9 per 100,000 person-years (95% CI [426.5, 1199.4]), while the SMR for all-cause death was 2.2 (95% CI [1.3, 3.5]). The CR for completed suicide was 478.2 per 100,000 person-years (95% CI [181.8, 774.6]). The suicide SMR was 17.9 (95% CI [8.6, 32.9]) overall, 7.7 (95% CI [2.5, 18.0]) for men, and 79.4 (95% CI [25.8, 185.2]) for women. Univariate analysis showed that women had higher completed suicide risk than men (hazard ratio=3.599, 95% CI [1.041, 12.445]). CONCLUSION: The all-cause mortality and completed suicide rates were higher in participants than observed in the general population consistent with the results of previous international studies.

Segmental clamp and distal perfusion technique for reducing myocardial ischemia during coronary onlay grafting on a beating heart.

We present a segmental clamp with distal perfusion technique to reduce myocardial ischemia during onlay grafting, on a beating heart. After a proximal coronary arteriotomy for 2-3 cm, the distal artery is perfused through a cannula, with femoral arterial blood (distal perfusion with external shunt). During proximal and distal coronary snare clamping with distal perfusion, onlay anastomosis is performed, from the heel toward the point of cannula insertion. We then move the proximal clamp to the onlay area and open the graft, to get early proximal coronary reperfusion. The arteriotomy is extended, and this procedure is repeated to achieve complete beating heart onlay anastomosis. We safely performed this procedure on the beating heart off-pump or on-pump in 95 patients with no perioperative myocardial infarction, no intraoperative hemodynamic deterioration, no 30-day mortality. This technique reduces regional myocardial ischemic and secures the safety for onlay grafting on the beating heart.

[A Case of Retroperitoneal Mature Teratoma with Combined Resection of Left Kidney].

A 37-year-old woman with the complaint of stomachache was referred to our hospital because a retroperitoneal tumor was detected in an ultrasound study at another hospital. Magnetic resonance imaging showed a poorly enhanced 14 cm tumor in the left retroperitoneal space suggesting a cyst that contained fat and showed calcification. Abdominal dynamic computed tomography revealed left renal vein stenosis and left ovarian vein dilation caused by tumor compression of the renal vein. The tumor was excised together with the left kidney because the renal vein was adhered to the tumor. The resected specimen weighed 1,300 g, and the histological diagnosis was mature teratoma. The patient has experienced no recurrence at eight months after surgery.

Migrated Hopene Synthases from Colysis pothifolia and Identification of a Migration Switch Controlling the Number of 1,2-Hydride and Methyl Shifts.

Ferns are known to produce triterpenes, derived from squalene, that are synthesized by squalene cyclases (SCs). Among these, Colysis species produce onoceroids, the bis-cyclic skeleton of which can be cyclized from both termini of squalene. To gain insight into the molecular basis of triterpene structural diversity, cDNA cloning of SCs from C. elliptica and C. pothifolia was performed; this leads to the isolation of five SC cDNAs. Functional analysis of these clones revealed their enzymatic products to be hop-22(29)-ene, α-polypodatetraene, and hop-17(21)-ene. One of these clones (CPF) is a transcribed pseudogene with a 22-nucleotide deletion causing a nonsense mutation. To predict the inherent function of CPF, we constructed an insertion mutant of CPF that successfully converted inert CPF to the active SC, the product of which is fern-9(11)-ene. Subsequent mutations identified active-site residues that control the number of 1,2-hydride and methyl shifts.

[Etoposide and Carboplatin Effective for Treatment of Small Cell Carcinoma of Prostate : A Report of Two Cases].

Case 1 : A 76-year-old man consulted a physician because of pollakisuria, decline of urinary stream. A high level of serum prostate specific antigen (PSA) was detected and he came to our hospital. He was diagnosed to have prostate cancer, cT3aN0M1b, and was treated with combined androgen blockage (CAB). Two years and nine months later, postrenal failure appeared and serum level of neuron-specific enolase (NSE) was 162 ng/ml. We performed re-biopsy of prostate, and pathological examination indicated small cell carcinoma of the prostate. We treated him with combination chemotherapy comprised of etoposide and carboplatin, which was effective. Serum level of NSE was decreased and computed tomography showed reduction of the prostate volume and metastasis. Case 2 : An 84-year-old man was treated at a hospital with radiation therapy and CAB, because of prostate cancer. He came to our hospital with bladder tamponade. We performed transurethral coagulation and transurethral biopsy. Pathologically it proved to be small cell carcinoma of the prostate. The stage was cT4N1M1a, NSE and pro-gastrin-releasing peptide (Pro-GRP) levels were high. The same treatment given to him as in case 1, effectively decreased the metastasis and the level of serum NSE.

[A Subcutaneous Metastasis from Renal Pelvic Carcinoma Growing Rapidly after radical Nephrectomy : A Case Report].

A 78-year-old man was admitted to our department for a right renal mass detected by computed tomography which was accompanied by right hypochondriac pain. Dynamic computed tomography demonstrated a 7cm hypovascular right renal mass invading the liver. No metastatic disease was evident. Transabdominal nephrectomy and partial hepatectomy were performed under the diagnosis of right renal cell carcinoma in July 2014. Pathological examination revealed right renal pelvic carcinoma with liver invasion. After the operation, a subcutaneous nodule in the right forearm rapidly grew in one week. A needle biopsy revealed that it was a metastasis of the urothelial carcinoma. Additionally, lung metastases and lymph node swelling were detected. The patient received two courses of combination chemotherapy (gemcitabine, carboplatin) in August 2014. The subcutaneous metastasis was decreased, but it was not effective for other metastases. Two courses of another combination chemotherapy (methotrexate, vinblastine, epirubicin, calboplatin) were performed. It was effective for all metastatic lesions. During the third course, the patient developed melancholia and rejected additional therapy. He died in March 2015 due to disease progression.

Neurophysiological modulation of rapid emotional face processing is associated with impulsivity traits.

BACKGROUND: Sensori-perceptual processing of emotional stimuli under attentive conditions effectively prevents response disinhibition. This is observed saliently in low-impulsive people, because of their high sensitivity to warning signals, such as emotional faces. Results from human neurophysiological studies have been used to develop a dual detector model for early sensori-perceptual processing. A transient detector mechanism is related to automatic neurophysiological arousal in response to warning signals, which is reflected by early frontal event-related potential effects. The memory-based detector mechanism is associated with subsequent mismatch negativity (MMN), which reflects a short-term memory trace of signals. Based on previous findings, we predicted that impulsivity affects functional associations among the dual detector mechanisms, and modulates early frontal and/or MMN activities. In the present study, we recorded electroencephalograms for twenty-one healthy adults using a visual oddball paradigm with neutral faces as frequent stimuli, and angry and happy faces as infrequent stimuli. We measured the impulsivity traits by a self-report scale (the Barratt Impulsiveness Scale, 11th version). RESULTS: Main findings were that only happy faces increased early frontal negativity and subsequent occipital visual MMN (vMMN) for emotional change, and these neurophysiological effects positively correlated with each other in a temporally causal manner. However, an impulsivity sub-trait positively correlated selectively with vMMN for the happy faces. CONCLUSION: These findings demonstrate that higher impulsivity is associated with attenuated vMMN for emotional change detection in healthy populations, potentially because of weakened fronto-occipital functional connection that is responsible for the dual detector mechanism.

[A Case of Retroperitoneal Tumor in the Adrenal Area Turned Out to Be Schwannoma Mimicking an Adrenal Malignant Tumor].

A 76-year-old woman was found to have bilateral suprarenal tumors, 6.5 cm in diameter on the right side, and 2.4 cm in diameter on the left side, by ultrasonography, computed tomography, and magnetic resonance imaging. Strong accumulation of fluorodeoxyglucose in these tumors was found on positron emission tomography. Since it mimicked an adrenal malignant tumor, we performed right adrenalectomy. The pathological diagnosis of the removed mass was benign schwannoma, consistent of the Antoni type A. The left suprarenal tumor was not removed and she has been followed up for 18 months without any recurrence or tumor increase.

[Epithelioid Angiomyolipoma of the Kidney: A Case Report].

Herein we report a case of epithelioid angiomyolipoma of the kidney which is a rare subtype of angiomyolipoma. A 68-year-old man without a history of tuberous sclerosis complex (TSC) was referred to our department with a 40 × 84 mm left renal tumor incidentally detected by computed tomography. Computed tomography demonstrated a left renal heterogeneous mass which was enhanced at the early phase and washed out at the late phase. A tumor thrombus was seen extending into the main renal vein. No metastatic disease was evident. Thus, on the diagnosis of renal cell carcinoma, the patient underwent a left radical nephrectomy. Pathological examination showed that this tumor was composed predominantly of epithelioid cells, with a few blood vessels and adipose tissue and was diagnosed as epithelioid angiomyolipoma. He shows no disease progression for 6 months after the operation.

[A Case of Long-Term Survival of a Patient with Liver Metastasis of Colon Cancer and Suspected Inferior Vena Cava Invasion].

A 58-year-old woman was diagnosed with a sigmoid colon cancer and synchronous liver metastasis. Because an obstruction of the sigmoid colon was identified, the patient underwent sigmoidectomy. Computed tomography(CT)findings suggested possible vena cava and hepatic vein invasion. Therefore, the decision was made to offer systemic chemotherapy. The patient underwent 6 courses of chemotherapy with 5-fluorouracil, Leucovorin, and oxaliplatin (mFOLFOX6). After 4 courses of chemotherapy, CT scans showed a significant reduction of the liver metastasis (reduction rate of 5 0%; a partial response) and demonstrated improved exclusion of the inferior vena cava and hepatic vein. After 6 courses of chemotherapy, we performed right trisegmentectomy of the liver and resection of the inferior vena cava and diaphragm. Postoperative pathological findings revealed negative margins, and no invasion of the inferior vena cava. The pathological response grade of the tumor after chemotherapy was determined to be Grade 2. Adjuvant chemotherapy was not performed because of the patient 's poor performance status. The patient was alive with no recurrence 8 years after resection of the liver metastasis.

[A case of effective neoadjuvant chemotherapy (MVEC) against right ureteral cancer involving bladder (cT4N1M0)].

Poorly differentiated ureteral cancer has a poor prognosis, and tumor recurrence is frequent even after nephroureterectomy. We performed neoadjuvant chemotherapy to prevent postoperative recurrence. A 74-year-old man was diagnosed with ureteral cancer (3 cm) by magnetic resonance imaging (MRI). The clinical stage was T4N1M0. Histological examination by transurethral biopsy revealed an urothelial carcinoma, G3, pT1. After a month, the tumor size increased from 3.0 cm to 4.0 cm. With two cycles of neoadjuvant chemotherapy consisting of methotrexate, vinblastine, epirubicin and cisplatin (MVEC) partial remission (regression rate : 87%) was achieved, Following MVEC, right retroperitoneoscopy-assisted nephroureterectomy, total cystectomy, and ileal conduit were performed. Pathological stage was pT0. After two years, postoperative recurrence has not appeared.