Estimation of the physiologic ability and surgical stress scoring system as a useful predictor of postoperative recurrence in patients with stage II colorectal cancer: a multicenter study.

PURPOSE: We determined the usefulness of the estimation of physiologic ability and surgical stress (E-PASS), initially reported as a predictive factor for postoperative morbidity and mortality, as a prognostic indicator in stage II colorectal cancer (CRC). METHODS: Overall, 739 patients who underwent proctocolectomy for CRC at Tottori University Hospital and affiliated hospitals and histologically diagnosed with stage II CRC were included in the current study. RESULTS: A receiver operating characteristic (ROC) analysis of the five-year recurrence-free survival indicated that the comprehensive risk score (CRS) of E-PASS predicted postoperative recurrence. A multivariate analysis revealed that the presence of preoperative perforation, T4, v ≥ 2, and CRSHigh (≥ 0.2267) were independent predictors of postoperative recurrence. Patients were assigned a score using these factors, as follows: the presence of perforation = 1, the absence of preoperative perforation = 0, T4 = 1, T3 = 0, v2/3 = 1, v0/1 = 0, CRSHigh = 1, and CRSLow = 0 (total score: 0-4). Accordingly, the respective 5-year relapse-free survival rates were 91.0%, 83.6%, 70.3%, and 52.0% among those with scores of 0, 1, 2, and both 3 and 4 (P < 0.001). CONCLUSIONS: The CRS predicts postoperative recurrence in patients with stage II CRC.

Risk factors for recurrence in elderly patients with stage II colorectal cancer: a multicenter retrospective study.

BACKGROUND: Adjuvant chemotherapy for stage II colorectal cancer (CRC) is considered appropriate for patients with risk factors for recurrence, rather than for all patients uniformly. However, the risk factors for recurrence remain controversial, and there is limited information, especially for elderly patients. The Geriatric Nutritional Risk Index (GNRI) is widely used as a simple nutritional screening tool in the elderly and is associated with cancer prognosis and recurrence. This study aimed to investigate the risk factors for recurrence in the elderly with stage II CRC, focusing on the GNRI. METHODS: We enrolled 348 elderly patients (≥ 75 years) with stage II CRC who underwent curative resection at the Department of Surgery, Tottori University and our 10 affiliated institutions. The patients were divided into GNRIhigh (≥ 93.465) and GNRIlow (< 93.465) groups. RESULTS: The GNRIlow group showed a significantly worse overall survival (OS), cancer-specific survival (CSS), and relapse-free survival (RFS) (P < 0.001, P < 0.001, and P < 0.001, respectively). In a multivariate analysis, GNRIlow (hazard ratio [HR]: 2.244, P < 0.001), pathologic T4 stage (HR: 1.658, P = 0.014), and moderate to severe lymphatic or venous invasion (HR: 1.460, P = 0.033) were independent factors affecting RFS. By using these three factors to score the risk of recurrence from 0 to 3 points, the prognosis was significantly stratified in terms of OS, CSS, and RFS (P < 0.001, P < 0.001, and P < 0.001, respectively). The recurrence rate for each score was as follows: 0 points, 9.8%; 1 point, 22.0%; 2 points, 37.3%; and 3 points, 61.9%. CONCLUSIONS: GNRIlow, pathologic T4 stage, and moderate to severe lymphatic or venous invasion are high-risk factors for recurrence in the elderly with stage II CRC. The scoring system using these three factors appropriately predicted their recurrence and outcome.

Long-term outcomes of nasogastric tube with Gastrografin for adhesive small bowel obstruction.

BACKGROUND: We had previously reported that the administration of Gastrografin through a nasogastric tube (NGT-G) followed by long tube (LT) strategy could be a novel standard treatment for adhesive small bowel obstruction (ASBO); however, the long-term outcomes after initial improvement remain unknown. This study aimed to analyze the long-term outcomes of first-line NGT-G. METHODS: Enrolled patients with ASBO were randomly assigned to receive LT or NGT-G between July 2016 and November 2018. Thereafter, the cumulative surgery rate, cumulative recurrence rate, and overall survival (OS) rate were analyzed. In addition, subset analysis was conducted to determine the cumulative recurrence rate according to colonic contrast with Gastrografin at 24 h. RESULTS: A total of 223 patients (LT group, n = 111; NGT-G group, n = 112) were analyzed over a median follow-up duration of 550 days. The cumulative 1-year surgery rates, cumulative 1-year recurrence rates, and 1-year OS rates in the LT and NGT-G groups were 18.8% and 18.1%, 30.0% and 31.7%, and 99.1% and 96.6%, respectively; no significant differences were observed between both groups. In the NGT-G group, a negative colonic contrast at 24 h demonstrated a higher tendency for future recurrence compared with a positive colonic contrast at 24 h (1-year recurrence rate: negative contrast, 46.9% vs positive contrast, 27.6%). CONCLUSIONS: Gastrografin through a nasogastric tube followed by LT can be a promising treatment strategy for ASBO, with long-term efficacies equivalent to initial LT placement.

[A Case of Pembrolizumab Therapy Markedly Effective for Advanced Recurrent Colorectal Cancer].

We report a case of pembrolizumab therapy as the fourth-line therapy for colorectal cancer and multiple lymph node recurrence with high-frequency microsatellite instability(MSI-High). The patient was a 75-year-old woman diagnosed with ascending colon cancer(pT4aN2bM0, Stage Ⅲc)and underwent laparoscopic right hemicolectomy, D3 dissection, and functional end-to-end anastomosis after inserting a self-expandable metallic stent. Postoperative adjuvant chemotherapy was performed, and the patient was followed. Postoperative 1 year 8 months, lymph node recurrence was indicated, and FOLFOX plus panitumumab therapy was introduced. FOLFIRI plus ramucirumab therapy and FTD/TPI were introduced as the second-line and third-line treatments, respectively; however, recurrent lymph nodes were further exacerbated and showed treatment resistance. Lymph node biopsy confirmed MSI-High, and pembrolizumab therapy was initiated as the fourth-line treatment. After the therapy, the lymph nodes reduced markedly. The patient remains undergoing chemotherapy without any adverse events.

Optimal definition of coagulation syndrome after colorectal endoscopic submucosal dissection: a post hoc analysis of randomized controlled trial.

PURPOSE: Endoscopic clipping closure after colorectal endoscopic submucosal dissection (ESD) did not reduce the incidence of post-ESD coagulation syndrome (PECS) in our recent randomized controlled trial (RCT); however, the definition of PECS is still controversial. The aim of this study is to establish optimal definition of PECS with additional analysis of RCT based on another definition. METHODS: In this multicenter, single-blind RCT, individuals were randomly assigned to colorectal ESD followed by endoscopic clipping closure or non-closure. In this post hoc analysis, the definition of PECS was modified as both localized abdominal pain on visual analogue scale and inflammatory response (fever or leukocytosis), from either localized abdominal pain or inflammatory response in the original study. All participants underwent a computed tomography after ESD, and PECS was classified into type I, conventional PECS without extra-luminal air, and type II, PECS with peri-luminal air. RESULTS: A total of 155 patients (84 in the non-closure group and 71 in the closure group) were analyzed. As a result of criteria modification, 21 type I PECS and four type II PECS cases in the original study, which included patients with clear pain and inflammatory response, were downgraded to no adverse event and simple peri-luminal air, respectively. The frequency of PECS showed no significant difference between non-closure and closure groups. CONCLUSION: Clipping closure after colorectal ESD does not reduce the incidence of PECS regardless of the diagnostic criteria. Either localized abdominal pain or inflammatory response might be optimal criteria of PECS (UMIN000027031). TRIAL REGISTRATION NUMBER: UMIN000027031 DATE OF REGISTRATION: April 18, 2017.

Non-Contact Heart-Rate Measurement Method Using Both Transmitted Wave Extraction and Wavelet Transform.

Continuous monitoring of heart-rate is expected to lead to early detection of physical discomfort. In this study, we propose a non-contact heart-rate measurement method which can be used in an environment such as driver heart-rate monitoring with body movement. The method is based on the electric field strength transmitted through the human body that changes with the diastole and systole of the heart. Unlike conventional displacement detection of the skin surface, we attempted to capture changes in the internal structure of the human body by irradiating the human body with microwaves and acquiring microwaves that pass through the heart. We first estimated the electric field strength transmitted through the heart using three receiving sensors to reduce the body movement effect. Then we decomposed the estimated transmitted electric field using stationary wavelet transform to eliminate significant distortion due to body movement. As a result, we achieved an estimation accuracy of heart-rate as high as 98% in a verification experiment with normal body movement.

A multicenter, single-blind randomized controlled trial of endoscopic clipping closure for preventing coagulation syndrome after colorectal endoscopic submucosal dissection.

BACKGROUND AND AIMS: Post endoscopic submucosal dissection coagulation syndrome (PECS) occasionally occurs after colorectal endoscopic submucosal dissection (ESD), presenting with localized abdominal pain and inflammation. We conducted a randomized controlled trial (RCT) to assess the usefulness of endoscopic clipping closure to prevent PECS and delayed perforation (DP). METHODS: This is a multicenter, single-blind RCT. Prospectively enrolled patients undergoing colorectal ESD were randomly allocated to endoscopic clipping closure and nonclosure after ESD, stratifying by institution and tumor size. All participants underwent a computed tomography scan after ESD. PECS was defined as visual analog scale (VAS) ≥30 mm, an increase in VAS ≥20 mm from baseline, body temperature ≥37.5°C or white blood cells ≥10,000/µL after colorectal ESD. DP was defined as PECS accompanied by extraluminal air. The preplanned sample size was 320 patients, and the primary endpoint was the rate of PECS/DP. RESULTS: At the planned interim analysis, this trial was terminated by recommendation of the independent data and safety monitoring committee because conditional power with superiority was lower than the preplanned futility limit. Finally, 155 patients were analyzed. The rate of PECS/DP was 16% (95% confidence interval [CI], 8%-23%) in the nonclosure group and 24% (95% CI, 14%-34%) in the closure group (P = .184). All cases of DP were within minor criteria, and all PECS/DP patients were managed conservatively without surgical treatment. Simple periluminal air without PECS was observed in 16% (95% CI, 8%-23%) in the nonclosure group and 10% (95% CI, 3%-17%) in the closure group. CONCLUSION: Endoscopic clipping closure could not reduce the high incidence of PECS/DP after colorectal ESD. (University Hospital Medical Network Clinical Trials Registry number: UMIN000027031.).

[A Case of Drug-Induced Lung Injury Associated with Paclitaxel plus Bevacizumab Therapy].

A 61-year old woman with recurrent breast cancer received combined treatment with paclitaxel (PTX) and bevacizumab (BV) as the third-line chemotherapy. During the administration of PTX in the 3 courses of chemotherapy, she suddenly developed respiratory failure, and both chest X-ray and CT revealed bilateral pulmonary infiltrates. Symptoms and radiographic findings responded dramatically to steroid pulse therapy. The history of onset and laboratory data showed no evidence of infection; therefore, we made a diagnosis of acute lung injury induced by the chemotherapy. It should be noted that lung injury may be induced by both PTX and BV, and is one of the important adverse events despite the low frequency of occurrence.

[Breast Cancer Patient with Bone Metastases Who Was Able to Return Home without Using Opioids after Administration of Strontium-89 Chloride].

A 46-year-old woman underwent mastectomy for right inflammatory breast cancer.Three years later, she was diagnosed with multiple bone metastases and was treated with systemic chemotherapy and zoledronic acid.Six years after the mastectomy, she complained of severe sacral pain, and 40 Gy external radiotherapy was applied to the sacral metastases.Oxycodone was also administered, but dose escalation was difficult because of severe nausea and fatigue.A bone scan showed increased uptake of Tc99m in an area consistent with the painful regions, and an injection of 89SrCl2 was administered.Five weeks after the injection, her severe pain was relieved and she was able to discontinue the use of opioids completely.She successfully lived at home for 100 days without using opioids.In this case, radionuclide therapy with 89SrCl2 led to remarkable pain relief with an improvement in the quality of life of the patient.

[A case report of recurrent small bowel adenocarcinoma successfully treated with monoclonal antibody against EGFR and S-1].

A man in 30s was admitted to our hospital with a complaint of abdominal and back pain. Abdominal CT scan showed a large mass and double balloon endoscopy detected a tumor of the jejunum. The pathological diagnosis of biopsy samples was poorly differentiated adenocarcinoma. After radical resection, adjuvant chemotherapy with mFOLFOX6 was administered, however, a recurrent lesion developed. Although the lesion was successfully removed again, it did not react to the combination therapy with irinotecan and cisplatin. Because the tumor showed a high percentage of epidermal growth factor receptor (EGFR) expression and also had a wild-type KRAS status, a therapeutic strategy targeting EGFR was selected. The patient started on panitumumab associated with S-1 and obtained a complete response on CT 6 weeks later. Small bowel adenocarcinoma is an aggressive malignancy with a poor prognosis and little information about its definitive chemotherapy. Analysis of molecular characterization, an increase in reported experience, and prospective trials are needed to improve a prognosis.

Utility of unsupervised deep learning using a 3D variational autoencoder in detecting inner ear abnormalities on CT images.

BACKGROUND AND PURPOSE: To examine the diagnostic performance of unsupervised deep learning using a 3D variational autoencoder (VAE) for detecting and localizing inner ear abnormalities on CT images. METHOD: Temporal bone CT images of 6663 normal inner ears and 113 malformations were analyzed. For unsupervised learning, 113 images from both the malformation and normal cases were used as test data. Other normal images were used for training. A colored difference map representing differences between input and output images of 3D-VAE and the ratio of colored to total pixel numbers were calculated. Supervised learning was also investigated using a 3D deep residual network and all data were classified as normal or malformation using 10-fold cross-validation. RESULTS: For unsupervised learning, a significant difference in the colored pixel ratio was seen between normal (0.00021 ± 0.00022) and malformation (0.00148 ± 0.00087) cases with an area under the curve of 0.99 (specificity = 92.0%, sensitivity = 99.1%). Upon evaluation of the difference map, abnormal regions were partially and not highlighted in 7% and 0% of the malformations, respectively. For supervised learning, which achieved 99.8% specificity and 90.3% sensitivity, a part of and no abnormal regions were highlighted on interpretation maps in 34% and 8% of the malformations, respectively. Abnormal regions were not highlighted in 4 malformation cases diagnosed as malformations and were highlighted in 6 cases misdiagnosed as normal. CONCLUSIONS: Unsupervised deep learning of 3D-VAE precisely detected inner ear malformations and localized abnormal regions. Supervised learning did not identify whole abnormal regions frequently and basis for diagnosis was sometimes unclear.

Eosinophilic pancreatitis presenting as rupture of a pancreatic cystic lesion into the chest cavity.

A 71-year-old man was receiving follow-up examination because of a retention cyst in the pancreatic body that extended to the dorsal extrahepatic area, but presented to the Emergency Department at our hospital with dyspnea and cough. Chest X-ray showed a large amount of left-sided pleural effusion and abdominal computed tomography (CT) showed reduction in size of the cystic lesion. Biochemical testing of the pleural effusion revealed high levels of pancreatic enzymes. We, therefore, diagnosed rupture of the pancreatic cystic lesion into the chest cavity. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated stenosis of the pancreatic duct and leakage of contrast medium at the cystic lesion. CT after ERCP revealed leakage of contrast medium from the cystic lesion through the dorsal extrahepatic area into the chest cavity. Endoscopic naso-pancreatic drainage was performed, but the cystic lesion and pleural effusion remained unimproved. Distal pancreatectomy was, therefore, performed. Microscopic examination revealed eosinophilic infiltration of the pancreatic parenchyma, leading to a diagnosis of eosinophilic pancreatitis (EP). Pancreatic retention cyst secondary to chronic pancreatitis associated with eosinophilic infiltration was considered to have ruptured into the chest cavity. EP is a rare etiology of pancreatitis and few cases have been reported. This case was thus considered valuable.

Fracture strength of secondary crown with different taper and thickness in zirconia double crown attachments.

The objective of this study was to clarify the influences of zirconia materials, one-half taper angle, and thickness of the secondary crown on the fracture strength of the secondary crown. For the primary and secondary crowns, Y-TZP and Ce-TZP/Al2O3 were used, respectively. Samples were prepared at one-half taper angles of 2° and 4°, and a secondary crown thickness of 0.5 and 1.0 mm (n=8). Regarding the fracture strength, the secondary crown was restored on the primary crown, all specimens were loaded until fracture using a universal testing machine. The load value added at the time of secondary crown fracture was regarded as fracture strength. Based on the analysis of variance, the fracture strength of Ce-TZP/Al2O3 was significantly higher than that of Y-TZP with regard to the material and that at 1.0-mm thickness was significantly higher than that at 0.5-mm thickness, but the taper angle had no influence.

Prediction of Visual Prognosis after Epiretinal Membrane Surgery Using Regression Tree Analysis.

Background and Objective: Confounding factors should be considered when predicting visual prognosis after epiretinal membrane (ERM) surgery. We aimed to predict visual acuity after ERM surgery using regression tree analysis.Patients and Methods: We retrospectively reviewed 343 eyes of 343 patients who underwent vitrectomy for idiopathic ERM. Regression tree analysis was performed to predict best-corrected visual acuity (BCVA) at 6 months postoperatively.Results: Patients were first divided into two groups based on preoperative BCVA. Age, central macular thickness, and axial length were associated with visual prognosis in patients with specific preoperative BCVAs. When patients were subdivided into groups 1-8, BCVA was significantly better in group 1 than in groups 4-8 (p≤0.001), and in groups 2-5 and 7 than in groups 6 and 8 (p≤0.002).Conclusion: Surgical prognosis in eyes with ERM should be evaluated based on a comprehensive assessment of preoperative characteristics.

Duodenal stenosis after transcatheter arterial embolization for rupture of an inferior pancreaticoduodenal aneurysm.

A 64-year-old man presented with epigastric pain and underwent contrast-enhanced computed tomography. Ruptured aneurysm of the inferior pancreaticoduodenal artery was diagnosed. TAE was successfully accomplished using coils, but vomiting appeared 9 days later. Duodenal stenosis was diagnosed from contrast-enhanced computed tomography and upper gastrointestinal endoscopy and was attributed to edematous changes in the duodenum. Conservative management led to successful recovery and discharge.

[Role of palliative chemotherapy and shift from anticancer therapy to palliative care in patients with advanced or recurrent breast cancer].

We examined the role of palliative chemotherapy and the shift from anticancer therapy to palliative care in 30 patients who had died of advanced or recurrent breast cancer. Patients who received more than four chemotherapy regimens had a longer survival and started analgesics later than those who received less than three regimens. In addition, median survival time was prolonged in patients treated with both anthracycline- and taxane-containing regimens. Presence of bone metastases did not influence survival time, but extended the period of last hospitalization. In the average process of advanced or recurrent breast cancer, use of analgesics was started on the 500 th day and the last hospitalization was on the 760 th day from the diagnosis. Last chemotherapy was performed 29 days before death, and the median survival length was 811 days. Patients were treated as outpatients in 94% of the period from their recurrence until death. Therefore, it is especially important to support outpatients physically and mentally from the early stage of recurrence.

Prospective Comparison of Intraocular Lens Dynamics and Refractive Error between Phacovitrectomy and Phacoemulsification Alone.

PURPOSE: To compare intraocular lens (IOL) dynamics and refractive prediction errors between eyes that underwent phacovitrectomy and eyes that underwent phacoemulsification alone. DESIGN: Prospective, nonrandomized, comparative, observational study. PARTICIPANTS: Sixty eyes of 60 patients who underwent 25-gauge phacovitrectomy without gas injection for macular pathology and 60 eyes of 60 patients who underwent phacoemulsification alone for cataract were enrolled. METHODS: Preoperative optical biometry was performed using the IOLMaster 700 (Carl Zeiss Meditec, Inc, Dublin, CA) to calculate the IOL power with the Barrett Universal II formula. Monofocal, nontoric, single-piece foldable aspherical IOLs were implanted in each patient. Comprehensive ocular examinations, including CASIA2 (Tomey Corp, Nagoya, Japan) evaluations of the preoperative crystalline lens and postoperative IOL positions (i.e., decentration, tilt, and aqueous depth), were performed before and 3 days, 1 month, and 3 months after surgery. MAIN OUTCOME MEASURES: Refractive prediction errors and IOL dynamics. RESULTS: Mean refractive prediction errors at 3 days, 1 month, and 3 months after phacovitrectomy were 0.51±0.59 diopters (D), 0.11±0.40 D, and 0.05±0.41 D, respectively, whereas those after phacoemulsification alone were 0.43±0.38 D, 0.11±0.37 D, and 0.07±0.34 D, respectively. There was no significant difference in the refractive error between the 2 groups at any time point. A myopic shift of -0.50 D or more negative refractive error occurred in 4 (6.7%) of 60 eyes with phacovitrectomy and 3 (5.0%) of 60 eyes with phacoemulsification alone; there was no significant between-group difference. At 3 months postoperatively, refractive errors within ±0.50 D and ±1.00 D were achieved in 49 (81.7%) and 58 (96.7%) of 60 eyes in the phacovitrectomy group and 52 (86.7%) and 60 (100.0%) of 60 eyes in the phacoemulsification alone group, again without any significant between-group differences. There were no significant differences in the preoperative lens and postoperative IOL positions between the 2 study groups, except for a significantly deeper mean aqueous depth at 3 days after surgery in the phacovitrectomy group. CONCLUSIONS: Neither myopic shift nor IOL displacement occurs after 25-gauge phacovitrectomy with a single-piece IOL without gas injection for macular pathology compared with phacoemulsification alone.

Reasons for Undergoing CT During Childhood: Can CT-Exposed and CT-Naive Populations Be Compared?

Several epidemiological studies suggested an increased risk of cancer and other tumors in individuals undergoing computed tomography (CT) examination during childhood; however, it was questioned whether the group undergoing CT was comparable to that not undergoing CT. To address this issue, we investigated the reasons for undergoing CT in 763 children aged 0 to 19 years in 2013. Their medical records were fully evaluated and symptoms, underlying conditions, reasons for CT, and clinical courses after CT were investigated. Among the 763 children, 66.1% underwent repeat CT after the first examination, and 19.3% underwent CT 8 times or more. Among all the examined children, 8.8% had cancer and 4.7% had cancer-prone conditions such as Down syndrome, tuberous sclerosis, and cirrhosis. Only 11.4% of the 763 children underwent CT because of trauma, and 32.2% of the children had some types of congenital anomaly. The rate of trauma decreased with an increase in the frequency of CT examinations. Since the incidence of congenital anomalies is below 2.5% in the general population, it was concluded that the population of children undergoing CT is completely different from that not undergoing CT. The 2 groups should not be compared.

Five new 2-(2-phenylethyl)chromone derivatives from agarwood.

Agarwood has been used as an incense and in traditional medicines as aphrodisiac, sedative, cardiotonic, and carminative. In this study, five new 2-(2-phenylethyl)chromones (2, 13-16) and eleven known compounds (1, 3-12) were isolated from the agarwood. The structures of the new compounds were determined by 1H-, 13C-, and two-dimensional NMR together with electronic circular dichroism (ECD) spectroscopy. All isolated compounds were evaluated for the phosphodiesterase (PDE) 3A and 5A1 inhibitory activity by the fluorescence polarization method. Dimeric 2-(2-phenylehyl)chromones (13, 14, 16) had potent inhibitory activity to PDE 5A1 with IC50 values of micro molar range (13: 4.2 µM, 14: 7.9 µM, 16: 4.3 µM), whereas they had weak activity to PDE 3A. In contrast, compound (15), which has a phenylpropionic acid moiety instead of the 2-(2-phenylethyl)chromone moiety in the dimers, showed moderate inhibition of both PDE 3A (IC50: 42.6 µM) and PDE 5A1 (IC50: 15.1 µM).

Evaluation of Thin-slice Coronal Single-shot Turbo Spin-echo Diffusion-weighted Imaging of the Hand: A Comparison with Conventional Echo-planar Diffusion-weighted Imaging.

We prospectively evaluated thin-slice coronal turbo spin-echo (TSE) diffusion-weighted imaging (DWI) covering a larger area with the recently-developed techniques on a 3T MRI scanner, compared with echo-planar imaging (EPI)-DWI in patients undergoing routine hand MRI. Visual score assessment and apparent diffusion coefficient (ADC) measurement were performed for patients with suspected hand tumors. TSE-DWI was superior to EPI-DWI, with less image distortion. The visual score and ADC comparison assessments proved that the image noise of TSE-DWI was acceptable.