[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.

[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.

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.

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.

[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.

[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.

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.

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.

Intraoperative continuous hemodiafiltration with selective venous drainage of ischemic limbs.

We report two cases of acute limb ischemia with threatened myonephropathic metabolic syndrome (MNMS) in which continuous hemodiafiltration (CHDF) was started before revascularization with selective drainage from the clamped femoral vein of ischemic limb and return of processed blood into the contralateral femoral vein. It was aimed to optimise the removal of metabolites which were produced by myolysis following reperfusion as well as to minimize the deviation of metabolites into the systemic circulation. Both cases had uneventful postoperative course without MNMS and the limbs were salvaged.

Simultaneous detection of T lymphocyte-related antigens (CD4/CD8, CD57, TCRß) with nuclei by fluorescence-based immunohistochemistry in paraffin-embedded human lymph node, liver cancer and stomach cancer.

OBJECTIVE: To develop a method for immunohistochemical staining of three different T lymphocyte antigens (CD4 or CD8, CD57 and TCRß) on the same tissue section and to determine whether tissues have been infiltrated with T lymphocytes expressing these markers. STUDY DESIGN: Commercially available antibodies were tested for immunohistochemical usefulness in a dye-based conventional single-immunostaining method after antigen retrieval on paraffin-embedded human lymph nodes. We searched for the combination of antibodies that could detect T lymphocyte antigens on the same section without any cross-reactivity and that have fluorescent signals robust enough to overcome paraffin autofluorescence. RESULTS: Application of the antigen retrieval technique and the Sudan black B quenching technique enabled staining of paraffin-embedded tissue sections with fluorescent-labeled secondary antibodies. The combination of primary and secondary antibodies that could simultaneously detect the T lymphocyte antigens CD4 or CD8, CD57 and TCRß in histochemical analysis of a paraffin-embedded human lymph node section was established, and was successfully applied to a human tissue section infiltrated with T lymphocytes that express these markers. CONCLUSION: The antibodies listed here would be helpful for histopathologists who wish to investigate T lymphocytes in the paraffin-embedded sections that have accumulated in pathology labs throughout the world.

Iatrogenic Common Femoral Artery Occlusion Caused by a Suture-Mediated Closure System: A Case Report.

Vascular closure devices (VCDs) are useful for reducing bed rest time after percutaneous catheterization procedure without manual compression at the femoral puncture site. Occlusion of the common femoral artery (CFA) related to VCDs has rarely been reported. Although catheter treatment for CFA occlusion may be the first choice, it may be insufficient. Surgical treatment should be performed immediately when catheter treatment for artery occlusion is deemed difficult. We report a case of surgical angioplasty performed for femoral artery occlusion by using a suture-mediated device.

Determining important regulatory relations of amino acids from dynamic network analysis of plasma amino acids.

The changes in the concentrations of plasma amino acids do not always follow the flow-based metabolic pathway network. We have previously shown that there is a control-based network structure among plasma amino acids besides the metabolic pathway map. Based on this network structure, in this study, we performed dynamic analysis using time-course data of the plasma samples of rats fed single essential amino acid deficient diet. Using S-system model (conceptual mathematical model represented by power-law formalism), we inferred the dynamic network structure which reproduces the actual time-courses within the error allowance of 13.17%. By performing sensitivity analysis, three of the most dominant relations in this network were selected; the control paths from leucine to valine, from methionine to threonine, and from leucine to isoleucine. This result is in good agreement with the biological knowledge regarding branched-chain amino acids, and suggests the biological importance of the effect from methionine to threonine.

Use of tissue microarrays and immunohistochemistry to standardize the diagnosis of gastrointestinal stromal tumors.

We assessed the concordance among seven general pathologists with respect to histologic diagnosis and interpretation of c-kit proto-oncogene (KIT) and platelet-derived growth factor receptor alpha (PDGFRA) immunostaining of 36 cases of primary spindle-cell tumor, predominantly of the gastrointestinal tract, mesentery, and retroperitoneum, based on review of a tissue microarray (TMA) subjected to immunohistochemistry with antibodies to KIT/CD117, PDGFRA, vimentin, desmin, smooth muscle action, CD34, and S-100 protein. Tumors included 20 molecularly analyzed gastrointestinal stromal tumors (GISTs), 4 leiomyosarcomas, 4 schwannomas, 4 desmoid-type fibromatoses, and 4 solitary fibrous tumors. The mean overall concordance with original diagnosis for each histologic type was 91.1%, with a mean kappa value of 0.91. With respect to PDGFRA immunostaining, the four GISTs with PDGFRA mutation were interpreted as cytoplasm positive, but the 16 GISTs with c-kit mutation were interpreted as weak or positive. These results indicate that the overall concordance with original diagnosis in mesenchymal tumors with the use of immunohistochemical panels is high, despite the use of TMAs. To some extent, PDGFRA immunophenotyping may be useful in GISTs with PDGFRA mutation, but it was not highly reproducible or specific. Therefore, in KIT-negative or weakly positive GISTs, mutation analysis will be required.

Intraoperative Transesophageal Echocardiography for Coronary Artery Assessment.

Background: In surgical aortic valve replacement (SAVR), coronary arteries are routinely assessed by transesophageal echocardiography (TEE) to prevent undesirable complications. This study evaluated the capabilities and pitfalls of TEE assessment. Methods and Results: Of 147 consecutive SAVR patients undergoing aortic stenosis, the TEE records for 130 patients, in which the procedures were conducted by a single examiner, were analyzed retrospectively regarding data acquisition and the accuracy of detecting an anomalous origin, high or low takeoff, ostial diameter, and short left main truncus (LMT). The left and right coronary arteries could be visualized in every patient. A left coronary ostium >5 mm was found in 33 patients (25.4%). TEE revealed an anomalous origin in 2 patients (1.5%) that had not been diagnosed, but missed it in another patient. High takeoff was noted in 11 patients (8.3%), often associated with aortic disease necessitating aortic repair. In one such patient, occlusion of the right coronary artery was detected, necessitating coronary revascularization. Short LMT was found in 15 patients (11.8%) but misdiagnosed due to artifact in 1. During selective cardioplegia, malperfusion of the left anterior descending artery due to deep cannula placement was detected. Conclusions: TEE provides fairly accurate assessment in SAVR, including detection of undiagnosed pathologies or pitfalls related to coronary arteries, although misdiagnosis due to artifacts should be kept in mind.

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.

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.

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.

Genotyping of human papillomaviruses by a novel one-step typing method with multiplex PCR and clinical applications.

We describe here a rapid, high-throughput genotyping procedure that allows the simultaneous detection of 16 high- and low-risk genital human papillomavirus (HPV) types by multiplex PCR in a single reaction tube. Multiplex PCR is based on the amplification of HPV DNA by sets of HPV genotype-specific primers, and the genotypes of HPV are visually identified by the sizes of amplicons after they are separated by capillary electrophoresis. The procedure does not include a hybridization step with HPV-specific probes and is rapid and labor-saving. We detected all 16 HPV genotypes (types 16, 58, 52, 51, 56, 31, 18, 39, 66, 59, 6, 33, 30, 35, 45, and 11) with a high sensitivity and a high degree of reproducibility. By using this newly developed method, we conducted a pilot study to examine the correlation between the prevalence and genotype distributions of HPV and the cytological group classifications for 547 cervical samples. Compared with the group of samples considered normal (14.7%), there was a significant increase in the prevalence of HPV in women with atypical squamous cells of unknown significance (61.3%), low-grade intraepithelial lesions (75.8%), and high-grade intraepithelial lesions (HSILs) (82.2%). The prevalence and distribution of type 58 were correlated with cytological malignancies, with the highest prevalence in women with HSILs. In conclusion, the novel multiplex PCR method described appears to be highly suitable not only for the screening of cervical cancer precursor lesions but also for the characterization of genotype distributions in large-scale epidemiological studies and HPV vaccination trials.

Utility of 18F-fluoro-deoxyglucose emission tomography/computed tomography fusion imaging (18F-FDG PET/CT) in combination with ultrasonography for axillary staging in primary breast cancer.

BACKGROUND: Accurate evaluation of axillary lymph node (ALN) involvement is mandatory before treatment of primary breast cancer. The aim of this study is to compare preoperative diagnostic accuracy between positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (18F-FDG PET/CT) and axillary ultrasonography (AUS) for detecting ALN metastasis in patients having operable breast cancer, and to assess the clinical management of axillary 18F-FDG PET/CT for therapeutic indication of sentinel node biopsy (SNB) and preoperative systemic chemotherapy (PSC). METHODS: One hundred eighty-three patients with primary operable breast cancer were recruited. All patients underwent 18F-FDG PET/CT and AUS followed by SNB and/or ALN dissection (ALND). Using 18F-FDG PET/CT, we studied both a visual assessment of 18F-FDG uptake and standardized uptake value (SUV) for axillary staging. RESULTS: In a visual assessment of 18F-FDG PET/CT, the diagnostic accuracy of ALN metastasis was 83% with 58% in sensitivity and 95% in specificity, and when cut-off point of SUV was set at 1.8, sensitivity, specificity, and accuracy were 36, 100, and 79%, respectively. On the other hand, the diagnostic accuracy of AUS was 85% with 54% in sensitivity and 99% in specificity. By the combination of 18F-FDG PET/CT and AUS to the axilla, the sensitivity, specificity, and accuracy were 64, 94, and 85%, respectively. If either 18F-FDG PET uptake or AUS was positive in allixa, the probability of axillary metastasis was high; 50% (6 of 12) in 18F-FDG PET uptake only, 80% (4 of 5) in AUS positive only, and 100% (28 of 28) in dual positive. By the combination of AUS and 18F-FDG PET/CT, candidates of SNB were more appropriately selected. The axillary 18F-FDG uptake was correlated with the maximum size and nuclear grade of metastatic foci (p = 0.006 and p = 0.03). CONCLUSION: The diagnostic accuracy of 18F-FDG PET/CT was shown to be nearly equal to ultrasound, and considering their limited sensitivities, the high radiation exposure by 18F-FDG PET/CT and also costs of the examination, it is likely that AUS will be more cost-effective in detecting massive axillary tumor burden. However, when we cannot judge the axillary staging using AUS alone, metabolic approach of 18F-FDG PET/CT for axillary staging would enable us a much more confident diagnosis.