[Indication and Perioperative Management for Esophagectomy in Elderly Patients of Esophageal Cancer].

Esophagectomy is a highly invasive surgery for elderly patients. The incidence of esophageal cancer is relatively high among the aging population in Japan. Therefore, it is crucial to determine the indications for esophagectomy and implement effective pre- and post-operative management strategies, considering the reduced physical function often observed in elderly patients. In our study, approximately 20% of patients with stageⅡ/Ⅲ esophageal cancer underwent esophagectomy. When we assessed thesepatients using the estimation of physiologic ability and surgical stress (E-PASS) scoring system, we found that the E-PASS score was significantly lower in the group that underwent surgery compared to those who received chemotherapy, radiation, or palliative treatment. Evaluating the risk of esophagectomy using tools such as E-PASS or others is crucial in establishing appropriate indications and ensuring patient safety. Regarding the perioperative period, our study revealed that the complication rate did not differ significantly between patients aged 74 years or younger and those aged 75 years or older. However, patients aged 75 years or older experienced significantly longer total and post-hospital stays. This prolonged postoperative stay in elderly patients can be attributed to a decline in activities of daily living (ADL) following esophagectomy, primarily due to their lower physical function. These results emphasize the importance of considering the potential decline in ADL resulting from lower physical function in elderly patients during perioperative management. Establishing multidisciplinary perioperative teams and rehabilitation programs can enhance the quality of life for patients after esophagectomy.

[A Case of Specific Pneumonia Diagnosed as Peritumoral Infiltration during Nivolumab Treatment for Esophageal Cancer].

The patient is a 54-year-old man who was diagnosed with advanced unresectable esophageal cancer. He underwent three courses of FP therapy and was followed up for observation after chemoradiotherapy and PR. Metastasis appeared in the upper lobe of the left lung and new lung metastasis was found in the lower lobe of the right lung despite FP therapy 2 years and 1 month after the start of treatment. Nedaplatin and docetaxel were administered as a second-line chemotherapy; however, the lung metastasis worsened. Consequently, nivolumab was introduced as a third-line chemotherapy. The metastases in the lower lobe of the right lung disappeared with pneumonia after 6 courses of nivolumab, which was diagnosed as a peritumoral infiltration(PTI). PTI is difficult to distinguish from drug-induced lung injury and should be diagnosed carefully because it is an imaging finding that reflects the desired antitumor effect.

[A Case of Unresectable Thoracic Esophageal Cancer Responding Well to Multimodal Therapy Including 5-FU plus CDDP plus Pembrolizumab].

A 51-year-old male presented with swelling on the left side of his neck. A diagnosis of thoracic esophageal cancer(Lt type 5a, squamous cell carcinoma, T3N4[16LN]M1[skin, bone, retroperitoneum, lung], cStage Ⅳb)was made, and treatment with a combination of 5-FU plus CDDP and pembrolizumab was initiated. After the 1st round of chemotherapy, there was an increase in metastases in the left cervical lymph node and skin, along with the development of back pain because of an L3 lumbar spine metastasis. Palliative radiotherapy(Σ24 Gy/6 Fr)was administered for all lesions. Subsequently, pembrolizumab was administered for the persistent decline in white blood cell and neutrophil counts. After 6 courses of pembrolizumab, computed tomography(CT)revealed an absence of lesions. Positron emission tomography/CT demonstrated no significant accumulation, prompting a diagnosis of complete response(CR). The patient is currently under pembrolizumab therapy and continues to remain in a state of CR.

[A Case of Suspected Pure Red Cell Aplasia Due to Nivolumab Treatment for Unresectable Esophageal Cancer].

Immune checkpoint inhibitor(ICI)combination therapy is the first-line of treatment for unresectable or recurrent esophageal cancer. The frequency and mechanism of immune-related adverse events(irAEs)associated with ICI are still unclear and may require differentiation from other diseases. The present study examined a patient with unresectable, advanced esophageal cancer treated with cisplatin plus 5-fluorouracil(CF)plus nivolumab as the first-line treatment. CF therapy was discontinued after 1 course owing to adverse events. Nivolumab was continued, but progressive anemia stemming from pure red cell aplasia(PRCA), an irAE of nivolumab administration, was observed. Nivolumab was discontinued, but later, interstitial pneumonia also developed, and pulse steroid therapy was begun. After steroid tapering, both the PRCA and interstitial pneumonia improved. At present, about 6 months have elapsed since the last nivolumab administration without any PRCA recurrence or evidence of tumor progression.

Evaluation of patients who underwent percutaneous transhepatic portal vein embolisation by Tc-99m GSA scintigraphy.

PURPOSE: To analyse the correlation between the fold change in residual liver volume (RLV) and residual liver uptake at 15 (RLU15) before and after percutaneous transhepatic portal vein embolisation (PTPE). MATERIAL AND METHODS: Between August 2010 and December 2016, 20 patients who underwent PTPE were retrospectively selected. Before and three weeks after PTPE, contrast-enhanced computed tomography (CECT) and Tc-99m GSA scintigraphy were performed to analyse the fold changes in RLV and RLU15, respectively, as well as their correlation. RESULTS: After PTPE, a significant increase was observed in the RLV (before: 464 ±â€…99 ml; after: 573 ±â€…118 ml, p = 0.004) and the RLU15 (before: 11.0 ±â€…2.9%; after: 17.7 ±â€…3.8%, p = 5 × 10-7). The fold increase of RLV and RLU15 in all patients was 1.25 ±â€…0.15 and 1.66 ±â€…0.33, respectively. No significant correlation was observed in the fold increase in both RLV and RLU15 (r = 0.14, p = 0.66). In patients no. 3 and 9, who were outliers, the increase in RLV was minimal and RLU15 increased greatly, and these 2 patients underwent radical hepatectomy after PTPE. CONCLUSIONS: No correlation was observed between the fold increase in RLV and RLU15 before and after PTPE. In order to accurately evaluate the residual liver function, it should be considered necessary to evaluate not only by morphological CECT volumetry, but also by functional outcome of Tc-99m GSA scintigraphy.Residual liver volume may not necessarily reflect RLF. It may be possible to improve the radical resection rate by detecting the potential increase of RLF with RLU15 of Tc-99m GSA scintigraphy.

[Outcomes of Staging Laparoscopy in Eight Patients with Positive Peritoneal Washing Cytology after S-1 Administration].

AIM: The aim of this study was to clarify the clinical outcomes of staging laparoscopy(SL)for patients with positive peritonealwashing cytology(CY1P0)after S-1 administration. PATIENTS AND METHODS: Since 2007, eight CY1P0 patients who underwent SL after S-1 administration were enrolled. S-1 was administered according to the ACTS-GC and SL was performed after 8 courses of S-1 treatment. RESULTS: SL was ended with adequate observation of intra-abdominalcavity in allthe patients with a median time of 68 minutes(range: 52-76 minutes). The timing of SL was after 8 courses of S-1 administration in 6 patients, after 11 courses in 1, and 12 courses in 1. Based on the SL results, CY0P0 was attained in 6 patients; CY1P0, in 1 and CY1P1, in 1. For the 6 patients who attained CY0P0, S-1 administration was completed. For the 2 patients who attained CY1P0 and CY1P1, chemotherapy was continued. Only 1 of the patients who attained CY0P0 had peritoneal recurrence 3 months after completion of S-1 administration. CONCLUSION: When CY0P0 is detected by using SL, S-1 administration may be completed. More cases need to be studied to determine the suitable courses or timing of S-1 administration for CY0P0 patients.

Nivolumab Rechallenge After Immune-related Adverse Events in Patients With Unresectable Advanced or Recurrent Esophageal Cancer.

BACKGROUND/AIM: Rechallenge with immune checkpoint inhibitors following immune-related adverse events (irAEs) during the treatment of certain cancers reportedly has good efficacy. However, the subsequent clinical course of esophageal cancer remains unclear. This study investigated the nature of irAEs and the efficacy of a nivolumab rechallenge for patients with esophageal cancer. PATIENTS AND METHODS: This study retrospectively analyzed 44 patients with unresectable advanced or recurrent esophageal cancer who were treated with nivolumab as a second-line or later regimen and developed irAEs between February 2020 and May 2022. The cohort was divided into continuation, rechallenge, and discontinuation groups based on nivolumab administration after the occurrence of irAEs. The proportion of each group was investigated according to the type of irAEs. The progression-free and overall survival periods were retrospectively analyzed for each group. RESULTS: Among patients with skin-related irAEs, 78.6% continued nivolumab administration, 14.3% rechallenged, and 7.1% discontinued nivolumab. Among patients with gastrointestinal disorders, 30.8% continued, 46.2% rechallenged, and 23.1% discontinued nivolumab. Among patients with interstitial pneumonia, none continued, 55.6% rechallenged, and 44.4% discontinued nivolumab. In those with endocrine disorders, 83.3% continued, none rechallenged, and 16.7% discontinued nivolumab. The median progression-free survival after irAE occurrence in the continuation, rechallenge, and discontinuation groups was 210, 333, and 72.5 days, respectively (p=0.022), while the median overall survival after irAE occurrence was 714, 848, and 223 days, respectively (p=0.008). CONCLUSION: Rechallenge with nivolumab may be considerably effective, depending on the type and severity of irAEs, and may improve the prognosis of patients with unresectable advanced or recurrent esophageal cancer.

[A case of advanced gastric cancer responding to S-1 therapy, leading to pathologically complete response].

Our patient was a 74-year-old man with abdominal pain. A gastrofiberscope revealed type 2 advanced gastric cancer. An abdominal computed tomography(CT)demonstrated liver and lymph node metastases. The No. 8a lymph node was 7 cm in diameter, and it invaded the head of the pancreas. Since a curative operation was deemed impossible, S-1 was administered orally for 28 consecutive days with a 14-day interval. After 2 courses of monotherapy, CT showed that metastatic lymph nodes were reduced and that liver metastases had mostly disappeared. After 8 courses, the primary lesion was scarred and the lymph node metastases were remarkably reduced. Therefore, we conducted distal gastrectomy and lymph node resection (D2). Histological findings revealed that there were no cancer cells in either the primary tumor or the lymph nodes, meaning that the resected lesions were Grade 3 in pathology. This rare case showed that S-1 monotherapy enabled curative surgery of unresectable gastric cancer with pathological CR.

Left thoracoscopic approach in the supine position for torsion of the residual esophagus after esophagectomy: a case report.

BACKGROUND: Anastomotic stenosis can occur after esophagectomy and gastric tube reconstruction. The effective surgical treatment for refractory anastomotic stenosis, which seems difficult to resolve with endoscopic treatment, has not been established. We report a case of refractory stenosis due to esophageal torsion in which reconstructive surgery was possible using a left thoracoscopic approach in the supine position. CASE PRESENTATION: A 72-year-old man who underwent thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstruction for esophageal cancer 6 months previously presented to us. Postoperative endoscopy revealed that the residual esophagus was twisted approximately 360°, just above the anastomotic site. Conservative endoscopic treatment failed to improve the condition due to severe passage obstruction, and reconstructive surgery was repeated. Surgery was performed in the supine position using a left thoracoscopic approach. The entire circumferences of the gastric tube and residual esophagus were dissected from the inferior mediastinum to the top of the sternum, with focus on preserving the right gastroepiploic vein and gastric-tube wall. Subsequently, laparoscopic surgery was performed to remove the gastric tube from the thoracoabdominal junction. After separating the esophagus on the oral side of the torsion from the left cervical wound, the abdomen was opened, the gastric tube was pulled out through the abdominal wound, and adhesions in the abdominal cavity were peeled off to raise the gastric tube cranially via the retrosternal route. An end-to-side anastomosis was performed using a circular stapler, and the esophageal torsion and previous anastomosis were resected. Oral intake was resumed on the 7th postoperative day, and the patient was discharged on the 38th day. CONCLUSIONS: After subtotal esophagectomy and retrosternal gastric tube reconstruction, the left thoracoscopic approach is one of the most minimally invasive approaches and is especially useful for preserving the right gastroepiploic artery and veins and for mobilizing the gastric tube wall.

Comparison of Liver Fibrosis and Function Indices with Extracellular Volume Using Dual-energy CT: A Retrospective Study.

BACKGROUND: Dual-Energy Computed Tomography (DECT) enables the direct measurement of iodine accumulation in the extracellular space. OBJECTIVE: To compare measures of liver fibrosis and function with Extracellular Volume (ECV) from iodine/water images using DECT. METHODS: Data was obtained from 119 consecutive patients who underwent abdominal DECT. A region of interest was set in the right lobe of the liver, pancreas, spleen, and aorta on iodine density images. ECV was calculated using the following formula: ECV = (1 - hematocrit) × [iodine concentration in the liver (or pancreas, spleen) / iodine concentration in the aorta]. The severity of liver fibrosis was estimated using the aminotransferase/platelet ratio index (APRI) and the Fibrosis-4 (FIB-4) index. Liver function was assessed by the Child-Pugh classification and albumin-bilirubin (ALBI) grade. Data were analyzed by the Spearman rank correlation coefficient, one-way analysis of variance, and post hoc analysis. RESULTS: The correlation between ECV and fibrosis indices (APRI and FIB-4) was only significant, with a weak magnitude for liver ECV quantification at the equilibrium phase (r=0.25 and r=0.20, respectively). The correlations between liver function index and ECV quantification were more robust than with fibrosis index. The highest correlations (r=0.50) were found between ALBI grade and liver ECV at the equilibrium phase. Liver ECV values at the equilibrium phase had a significant difference between ALBI grade 1 vs. 2 and grade 1 vs. 3. CONCLUSION: Liver ECV quantification by DECT is more suitable for evaluating liver function than liver fibrosis severity.

Abdominal Organ Enhancement in Dynamic MRI using 1 M Gadobutrol vs 0.5 M Meglumine Gadoterate in Liver of Hemangioma Patients.

BACKGROUND: The utility of gadobutrol (GAD) which is higher r1 value contrast media for evaluating abdominal solid organ have not been fully evaluated. OBJECTIVE: To compare the contrast enhancement of abdominal organs on dynamic MRI using 0.1 mmol/kg 1.0 M GAD or 0.5 M meglumine gadoterate (MG) in patients with a liver hemangioma. METHODS: A phantom study was performed at different concentrations (0.05, 0.1, 0.3, 0.5, 0.7, 0.9, 1.0, 5.0 and 10 mmol/L) of GAD and MG. Sixty-two patients with a liver hemangioma were enrolled. Contrast media was injected at a rate of 2 mL/s followed by 40 mL of saline. Two arterial phases, a portal phase and an equilibrium phase were obtained. One certified radiologist set regions of interest on the abdominal aorta, liver, pancreas, spleen and the liver hemangioma. The relative enhancement ratio (RER) was calculated. RESULTS: In the phantom study the signal intensity of both contrast media was similar at lower concentrations. However, the signal intensity of MG was higher at concentrations of more than 5.0 mmol/L. In the clinical study the RER of the abdominal viscera during the portal and equilibrium phases was higher with GAD. The hemangioma had a higher equilibrium phase enhancement with GAD. The aortic RER was equivalent during all phases and the liver RER during the 2nd arterial phase was higher with GAD. The arterial phase during GAD imaging might have been measured later than was optimal. CONCLUSION: When the same injection protocol was used for an abdominal dynamic MRI, arterial phase imaging was late when GAD was used. The higher T1 relaxation value was significantly higher in the abdominal viscera during the portal and equilibrium phases, while the liver hemangioma also had significantly higher contrast enhancement during the equilibrium phase. CLINICAL TRIAL REGISTRATION NUMBER: 3186.

Perilesional Lymph Node Swelling Might be a Radiologic Clue for Appendiceal Schwannoma: A Case Report.

BACKGROUND: Gastrointestinal schwannoma is not a common type of tumor, and lesions originating from the appendix are extremely rare. Herein, we report a patient with appendiceal schwannoma characterized by lymph node swelling. CASE REPORT: A 67-year-old male patient who had diabetes complained of weight loss. A computed tomography scan revealed a mass in the right side of the pelvic cavity. Moreover, a contrast-enhanced computed tomography scan showed perilesional lymph node swelling measuring up to 28 mm. A low-intensity mass was observed on T1-weighted imaging, heterogeneous high-intensity mass on T2-weighted imaging, and restricted diffusion on diffusion-weighted imaging. There were no abnormal findings on colonoscopy. Based on a preoperative examination, a differential diagnosis of either appendiceal schwannoma, carcinoid, or gastrointestinal stromal tumor was considered. During surgery, a large appendiceal mass and multiple swollen perilesional lymph nodes were observed. Therefore, ileocecal resection and D3 lymph node dissection were performed. Pathological and immunohistochemical analyses confirmed the diagnosis of appendiceal schwannoma. There were numerous swollen lymph nodes in the mesenteric region. The lymph nodes revealed reactive lymphoid hyperplasia, with enlarged follicles of various sizes and shapes with an irregular distribution. Almost all lymphocytes, except those at the germinal centers, were small. CONCLUSION: Gastrointestinal schwannoma is characterized by lymph node swelling. Appendiceal schwannoma may have characteristics, including peritumoral lymph node swelling, similar to other types of gastrointestinal schwannoma such as that in the stomach. Thus, this characteristic can be a diagnostic clue for appendiceal schwannoma.

Relevance of diffusion-weighted imaging with background body signal suppression for staging, prognosis, morphology, treatment response, and apparent diffusion coefficient in plasma-cell neoplasms: A single-center, retrospective study.

Accurate staging and evaluation of therapeutic effects are important in managing plasma-cell neoplasms. Diffusion-weighted imaging with body signal suppression magnetic resonance imaging (DWIBS-MRI) allows for acquisition of whole-body volumetric data without radiation exposure. This study aimed to investigate the usefulness of DWIBS-MRI in plasma-cell neoplasms. We retrospectively analyzed 29 and 8 Japanese patients with multiple myeloma and monoclonal gammopathy of undetermined significance, respectively, who underwent DWIBS-MRI. We conducted a histogram analysis of apparent diffusion coefficient values. The correlations between each histogram parameter and staging, cell maturation, prognosis, and treatment response were evaluated. We found that the apparent diffusion coefficient values in patients with monoclonal gammopathy of undetermined significance were lower than those in patients with multiple myeloma. Pretreatment apparent diffusion coefficient values of immature myeloma were lower than those of mature myeloma. Moreover, these values decreased in proportion to stage progression in Durie-Salmon classification system but showed no significant correlation with other staging systems or prognosis. Patients were stratified as responder, stable, and non-responder based on the International Myeloma Working Group criteria. The magnitude of changes in apparent diffusion coefficients differed significantly between responders and non-responders (0.154 ± 0.386 ×10-3 mm2/s vs. -0.307 ± 0.424 ×10-3 mm2/s, p = 0.003). Although its usefulness has yet to be established, DWIBS-MRI combined with apparent diffusion coefficient measurement allowed for excellent response evaluation in patients with multiple myeloma. Furthermore, apparent diffusion coefficient analysis using DWIBS-MRI may be useful in predicting cell maturation and total tumor volume.

[A case of rectal cancer with liver metastases successfully treated with modified FOLFOX6 therapy].

We report a case of a 71-year-old male with rectal cancer accompanied by liver metastases. Abdominal CT scan revealed a hepatic tumor (S2, 3) about 4 cm in diameter. We performed a Mile's operation and planned to resect the liver metastases after chemotherapy of modified FOLFOX6(mFOLFOX6)regimen: l-leucovorin (200 mg/m2) and oxaliplatin (85 mg/m/2) were given as a 2-hour infusion followed by bolus injection of 5-FU 400 mg/m2 and a 46-hour infusion 5-FU 2,400 mg/m2 every 2 weeks. An abdominal CT scan 6 months later demonstrated regression of the liver metastases. Hepatectomy was performed after chemotherapy, and no viable tumor cells were seen.

Successful recanalization of acute extensive portal vein thrombosis by aspiration thrombectomy and thrombolysis via an operatively placed mesenteric catheter: a case report.

Portal vein thrombosis (PVT) after hepatobiliary surgery is rare but can cause lethal and severe complications. If early diagnosis and recanalization can be achieved, the PVT is expected to be eliminated. A 70-year-old male was diagnosed as having hepatocellular carcinoma occupying the right lobe of the liver. As oligometastatic lung tumors were simultaneously detected on contrast-enhanced CT (CECT), hepatectomy was not indicated. However, the primary tumor was very large, and as large tumor size can be associated with an unfavorable prognosis, and owing to the strong desire of the patient, he underwent right lobe hepatectomy. Jaundice appeared on post-operative Day (POD) 2 and CECT displayed slight intraheptatic bile duct dilation. However, a PVT did not exist at this time. Percutaneous transhepatic biliary drainage was performed and Doppler echo displayed intrahepatic and extrahepatic PVT on post-operative Day 5. Emergent thrombectomy was performed using a Vasplyser PlusTM thrombus aspiration catheter (Johnson & Johnson K.K. Medical Company, Tokyo, Japan) via the ileocolic vein under laparotomy. The mesenteric catheter was placed at the distal point of the residual PVT. Thrombolysis and anticoagulant therapy were performed using heparin and urokinase. In the CECT performed 16 days after the additional operation, the PVT had disappeared and the portal vein was completely recanalized. The mesenteric catheter was removed on the same day and oral anticoagulant therapy was continued. At the time of writing, 14 months have passed with no recurrence of PVT. Early diagnosis of PVT enables treatment with emergent thrombectomy, thrombolysis, and anticoagulant therapy. These treatments result in the improvement of portal vein flow and the complete disappearance of PVT.

Two cases of sclerosing angiomatoid nodular transformation of the spleen with gradual growth: usefulness of diffusion-weighted imaging.

Sclerosing angiomatoid nodular transformation (SANT) is a recently recognized and rare, nonneoplastic lesion of the spleen. Some papers have reported an increased SANT diameter during the follow-up period. We present two cases of SANT whose size increased during the follow-up period. Diffusion-weighted magnetic resonance imaging (DWI) findings correlated well with the pathological findings of SANT, the multinodular high-intensity area as the angiomatoid nodules and the peripheral low-intensity area as fibrous tissues. Therefore, DWI may be a useful imaging tool.

Ureteral intussusception associated with a fibroepithelial polyp: a case report.

We present a case of a 67-year-old man with intussusception of the right ureter associated with a fibroepithelial polyp. The concentric sign and line sign are characteristic radiological findings in intussusception, and these findings could be seen in the present case. Although this entity is rare, its radiological findings are specific. Multidetector row computed tomography and its multiplanar reconstruction make the diagnosis feasible, although the qualitative diagnosis of the tumor was difficult.

Laparoscopic partial hepatectomy of focal nodular hyperplasia.

Focal nodular hyperplasia is a benign liver lesion incidentally discovered with increasing frequency because of the proliferation of imaging studies. Radiographic characterization can diagnose this pathologic lesion and nonoperative therapy is the standard of care. However, surgical resection may be required for diagnostic reasons or symptomatic patients. Depending on the anatomic location of the lesion, biopsy and/or resection can be performed laparoscopically. We herein report the case of a 26-year-old Japanese woman with a hepatic tumor who required a medical examination. Her medical history was negative for alcohol abuse, oral contraceptive administration and trauma. Clinical examination showed no significant symptoms. Ultrasonography, computed tomography and magnetic resonance imaging showed a mass located in the left lateral segment of the liver with a diameter of about 40 mm. It was difficult to diagnose the tumor definitively from these imaging studies, so we performed laparoscopic partial hepatectomy with successive firing of endoscopic staplers. The histopathological diagnosis was focal nodular hyperplasia. Surgical procedures and postoperative course were uneventful and the patient was discharged from the hospital on postoperative day 5.

Assessment of bone scans in advanced prostate carcinoma using fully automated and semi-automated bone scan index methods.

OBJECTIVE: As metastasis of prostate carcinoma occurs in approximately 80 % of terminal prostate carcinoma patients, the prognostic value of the prediction of prostate carcinoma by bone scintigraphy is important. We compared the automated and semi-automated bone scan index (BSI) system with extent of disease (EOD) grade if there is a possibility to substitute for EOD grading. MATERIALS AND METHODS: We evaluated the bone scintigraphic images of 158 prostate carcinoma patients (mean age, 69.2 years old; range 50-97). Bone scans were obtained approximately 3 h after the intravenous injection of 740 MBq technetium-99 m-methylene diphosphonate. EOD grade was evaluated by 2 experienced radiologists using bone scintigraphy, magnetic resonance imaging, and computed tomography. We calculated the BSI using the Bonenavi(®) system (Fujifilm RI Pharma Co., Ltd.), utilizing data from a Japanese database. The semi-automated BSI of the patients was obtained by modifying the automated BSI independently by 3 radiologists (referred to as "observers" in this study) with 25, 10, and 4 years of experience. We then compared the EOD with the corresponding 4 independent BSIs for each patient. We used the Steel-Dwass test for multiple comparisons of the BSI among different EOD groups of patients. We analyzed the receiver-operating characteristics (ROC) curve to determine the cutoff values of sensitivity and specificity, which were both set at 95 %. RESULTS: There were significant correlations observed among the mean EOD and BSI scores as determined using the Bonenavi(®) system for every patient group for all observers and the automated method. There was also a statistically significant difference in the mean BSI among all EOD groups (grades 0, 1, or 2-4) for all observers and the automated method. Each ROC curve showed an ideal shape and was within the optimal cutoff range. CONCLUSION: On the basis of the present results, BSI as calculated using the Bonenavi(®) system significantly correlated with EOD. Sensitivity and specificity as measured by the fully automated method were lower than those of semi-automated BSI with modification by radiologists. Therefore, semi-automated BSI is considered to have the possibility to substitute for EOD grading to predict the survival of prostate carcinoma patients with bone metastases, with only slight interobserver variation.