[Analysis of Prognostic Factors Considering Absolute Lymphocyte Count of Metastatic Breast Cancer Patients with Eribulin Mesylate Therapy-A Retrospective Study in a Single Institution].

Recently, a study for eribulin mesylate(ERI), which is a useful drug for metastatic and recurrent breast cancer, reported that the absolute lymphocyte count(ALC)before administration is a useful prognostic factor. We retrospectively examined whether the results were reproducible in the patients with ERI. We examined the effect of ERI on the overall survival(OS)in 21 patients with HER2-negative metastatic and recurrent breast cancer who underwent treatment with ERI at our hospital. The clinical benefit ratio(CBR)was 57.1%. The median time to treatment failure(TTF)was 5.8 months and median OS was 19.9 months, showing a positive correlation between the TTF and OS. The factors that significantly prolonged the OS in univariate analysis were the TTF(<3 months vs ≥3 months, p<0.001), NLR(<3 vs ≥3, p=0.037), and ALC(<1,000/ µL vs ≥1,000/µL, p=0.008). In the multivariate analysis, TTF and ALC were the prognostic factors. The ERI outcome at our institution was good regardless of the subtype. The results of the multivariate analysis showed that TTF and ALC were factors that prolonged OS, and patients who received ERI for >3 months had good OS. Long-term administration of ERI was assumed to affect the immune microenvironment and prolong OS. Additionally, our data showed that the lymphocyte count before ERI administration is a simple and useful prognostic factor.

Alcohol consumption, hospitalization and medical expenditure: a large epidemiological study on the medical insurance system in Japan.

AIMS: This study investigated the relationship between alcohol drinking habits and the onset of high medical expenditure in a Japanese male population. METHODS: The cohort comprised 94,307 male beneficiaries 40-69 years of age of the Japanese medical insurance system, who had daily alcohol drinking habits. The likelihood of incurring high medical expenditure, defined as the ≥90th percentile of the medical expenditure distribution in the study population 1 year after baseline, as well as the likelihood of undergoing hospitalization that year were compared among the participants grouped according to their alcohol consumption amount (<2, 2-3.9, 4-5.9, ≥6 drinks/day). RESULTS: Participants who ranked in the top 10% medical expenditure group within the 1 year after baseline each incurred at least 2152 euros/year. The top 10% medical expenditure group accounted for 61.1% of the total medical expenditure in the study population. The odds ratios (95% confidence intervals) for ranking in the top 10% group during the 1-year period, compared with the <2 drinks (23 g of alcohol)/day group, were 1.08 (1.02-1.15) for 2-3.9 drinks/day, 1.11 (1.05-1.19) for 4-5.9 drinks/day, and 1.31 (1.18-1.45) for ≥6 drinks/day after adjustment for age, body mass index, and smoking and exercise habits. The adjusted odds ratios for undergoing hospitalization were 1.11 (1.04-1.19), 1.14 (1.06-1.24) and 1.39 (1.24-1.56), respectively. CONCLUSION: The likelihood of incurring high medical expenditure and undergoing hospitalization increased with daily alcohol consumption amount.

Clinicopathological features, postoperative survival and prognostic variables for cancer-related survival in patients with mucinous colorectal carcinoma.

PURPOSE: To investigate the clinicopathological features and postoperative survival of patients with mucinous colorectal carcinoma (MC) and to identify the factors related to long-term survival. METHODS: Twenty-three patients who had undergone resection for MC at Miyazaki University Hospital from 1991 to 2006 were followed up for at least 5 years or until death. The effects of the clinicopathological variables on the 5-year cancer-specific survival were assessed by the univariate analyses. These patients' clinicopathological data were compared with those of 403 non-mucinous carcinoma (NMC) patients (102 well-differentiated adenocarcinomas, 301 moderately differentiated adenocarcinomas). RESULTS: The 5-year cancer-specific survival rate was significantly worse in MC (56.2 %) than in NMC (73.8 %; p = 0.008) cases. Univariate analyses showed the T factor, lymph node metastases, liver metastases, metastases to the distant peritoneum, remote metastases and curative resection to be significant factors predicting the survival. However, there were no significant differences in the postoperative survival in patients with stage II-IV disease. The rates of metastases to the distant peritoneum, M1, T4, a tumor size ≥5 cm and non-curative resection were higher in MC than in NMC patients. CONCLUSIONS: Patients with MC had advanced stage cancer, especially with metastases to the distant peritoneum, more frequently than did the patients with NMC. To improve the survival of these patients, it is therefore important to detect MC at an early stage and to perform curative resection.

A rare case of synchronous multiple primary malignancies of breast cancer and diffuse large B-cell lymphoma that responded to multidisciplinary treatment: a case report.

BACKGROUND: Multiple primary malignancies of breast cancer and diffuse large B-cell lymphoma (DLBCL) are rare. Here, we report a case of advanced breast cancer and DLBCL managed with multidisciplinary therapy preceded by surgery with a successful outcome. CASE PRESENTATION: During a medical examination, a 71-year-old woman was diagnosed with a right breast mass, enlarged lymph nodes throughout the body, and a splenic tumor. The results of the clinical examination and imaging were suggestive of widely spread breast cancer with lymph node metastasis and malignant lymphoma with systemic metastasis. The histological evaluation of the biopsied breast tissue revealed human epidermal growth factor receptor 2 (HER2)-positive breast cancer, whereas the histological evaluation of the excised inguinal lymph node revealed DLBCL. 18F-FDG PET/computed tomography was performed, and it was determined that both breast cancer and DLBCL were in an advanced stage. Thus, mastectomy was performed, and the axillary lymph nodes showed mixed metastasis of breast cancer and DLBCL. Soon after, the R-CHOP therapy was initiated (375-mg/m2 rituximab, 2-mg/m2 vincristine, 50-mg/m2 doxorubicin, 750-mg/m2 cyclophosphamide, and 125-mg methylprednisolone). After irradiation of the spleen, trastuzumab was administered for 1 year. CONCLUSIONS: We experienced a case of combined breast cancer and DLBCL, which was difficult to treat because both were in advanced stages. Thorough staging of the malignancy and discussion by a multidisciplinary team are necessary to determine the optimal treatment strategy.

A case of poorly differentiated adenocarcinoma with lymphoid stroma originated in the ascending colon diagnosed as lymphoepithelioma-like carcinoma.

An 86-year-old woman's stool sample was positive for blood. Computed tomography (CT) showed wall thickening of the ascending colon at the hepatic flexure. Colonoscopy showed near-complete obturation by colon cancer. Since she was asymptomatic, elective surgery was planned. Laparoscopic right hemicolectomy was performed. Histopathological examination showed poorly differentiated carcinoma cells proliferating in a solid pattern with marked lymphocyte infiltration. The diagnosis was lymphoepithelioma-like carcinoma (LELC) associated with Epstein-Barr virus (EBV) infection; however, EBV-encoded small RNA-in situ hybridization was negative. Microsatellite instability was not assessed. The postoperative course was uneventful and she was discharged on the 15th postoperative day. She remains recurrence-free at 2 years after surgery. Past reports note that colorectal carcinomas with dense lymphoid stroma may be related to LELC or medullary carcinoma (MC). Gastrointestinal LELC is rare, with some reports on LELC of the esophagus and stomach. Reports on LELC of the large intestine are very rare. MC of the large intestine is relatively new concept, firstly described in the WHO Classification of Tumours of the Digestive System 3rd Edition in 2000. We herein present a case of lymphoepithelioma-like carcinoma of the ascending colon and relevant case reports about LELC and MC of the large intestine.

An unusual variant of a left paraduodenal hernia diagnosed and treated by laparoscopic surgery: report of a case.

An 80-year-old woman who had undergone both a cholecystectomy and an appendectomy presented with intermittent abdominal pain. Computed tomography (CT) revealed an encapsulated circumscribed cluster of jejunal loops in the left upper quadrant. The hernia orifice was adjacent to the left side of the superior mesenteric artery and vein. An upper gastrointestinal series also revealed a cluster of jejunal loops, suggesting the possibility of an internal hernia. Laparoscopic surgery was performed. The hernia orifice was found to be caused by abnormal adhesion between the transverse mesocolon and the jejunum mesentery. An adhesiotomy reduced the jejunum entrapped in the hernia. The hernia space was a large mesocolic fossa composed of transverse mesocolon and mesentery, continuing to the splenic flexure. The hernia was classified as a variant of paraduodenal hernia.

[Prognostic factors and usefulness of chemotherapy with S-1 in patients received gastrectomy for stage IV gastric cancer].

Clinicopathological factors influencing the survival and the effect of chemotherapy with special reference to S-1 were retrospectively analyzed in 41 patients who underwent gastrectomy for stage IV gastric cancer. Significantly better outcomes were observed in patients with H0, P0 or M0 than those with H1, P1 or M1, respectively. Curability B surgery showed a significantly better result than curability C. A significantly better result was demonstrated in patients treated with S-1 alone than those treated with chemotherapy other than S-1 or in patients without chemotherapy. Multivariate analysis revealed that H0, M0 and chemotherapy with S-1 were significant and independent prognostic factors. Moreover, the patients treated with S-1 for more than 12 months showed a significantly better outcome than those treated with S-1 for less than 12 months. It is concluded that curative resection (curability B) and the longer period of postoperative chemotherapy with S-1 is the treatment of choice to improve the outcome of patients with stage IV gastric cancer.

[A case of recurrent gastric cancer during adjuvant chemotherapy with S-1, treated by S-1 combination chemotherapy].

A 59-year-old man was admitted to our hospital for the treatment of gastric cancer with synchronous and multiple metastatic liver tumors. After total gastrectomy in February 2005, partial resection of the posterior segment of the liver was carried out in the next month. Pathological study of both the resected specimens showed moderately differentiated adenocarcinoma. The postoperative treatment with S-1 was initiated without any evidence of recurrence. However, CT scans showed recurrent multiple liver tumors after 4 courses of treatment with S-1. Subsequently, a combination chemotherapy of S-1 (80 mg/m(2) over day 1-14 with a 2-week rest) and paclitaxel (PTX) (120 mg/m(2), day 1 and 15) was applied. After 3 courses, CT scans showed reduced liver metastases, judged as a partial response(PR)on Response Evaluation Criteria in Solid Tumors (RECIST). However, metastatic liver tumors showed progressive disease (PD) after 7 courses of treatment. The treatment was changed to combination chemotherapy with S-1 (80 mg/m(2) over day 1-21 with a 2-week rest) and CPT-11 (80 mg/m(2) day, day 1 and 15) for 6 courses, but the legions showed PD. He was then treated with combined chemotherapy with S-1 (70 mg/m(2) over day 1-14 with a 1-week rest)and cisplatin (CDDP) (10 mg/m(2), day 1 and 8). However, his condition became worse and he was treated at the palliative care unit. There were no adverse effects greater than grade 4 throughout the treatment period, and his treatment was continued as an outpatient for more than two years. This case suggests that after failure of S-1 therapy, S-1 combination chemotherapy might be an effective treatment for recurrent gastric cancer.

Comparative effect of lymph node metastasis classified by the anatomical site or by the number of nodes involved on prognosis of patients with gastric cancer.

BACKGROUND/AIMS: Lymph node metastasis (pN) is one of the most significant prognostic factors in patients with gastric cancer. The pN classification of the Japanese Gastric Cancer Association (JGCA) is based on the anatomical site of metastatic nodes from the primary tumor, whereas that of the International Union Against Cancer (UICC) is based on the number of nodes involved. The purpose of this study was to determine which system is more useful for predicting patient outcomes. METHODOLOGY: From 1992 to 2002, a total of 318 patients at our hospital underwent surgical resection with lymph node dissection for primary gastric cancer. Their medical records were examined, and the overall survival rates were compared between the two pN classification systems. RESULTS: Under the JGCA system, there was a significant difference in patient survival between pN0 and pN1 and between pN1 and pN2 but not between pN2 and pN3. Under the UICC-TNM system, there was a significant difference in patient survival between all pN classes. When the JGCA-pN1 and JGCA-pN2 classes were regrouped as UICC-pN1 and UICC-pN2-3, respectively, the survival rate was still better for the UICC-pN1 class than for the UICC-pN2-3 class. CONCLUSIONS: The better differentiation of outcomes by the UICC-pN system suggests that the number of metastatic lymph nodes is more important than the anatomical site in predicting outcomes.

Circular tumor growth: a prognostic factor in stage II colorectal carcinoma.

BACKGROUND/AIMS: Almost all patients with stage II colorectal cancer are spared adjuvant chemotherapy, yet a considerable number of these patients die from the disease. The aim of this retrospective study was to identify factors negatively affecting survival of patients with stage II colorectal cancer treated by curative resection. METHODOLOGY: Study subjects were 88 patients who had undergone curative resection for stage II colorectal cancers at Miyazaki University Hospital during the period from 1987-1999. Patients were followed up for a minimum of 5 years or until death. The influence of clinical and pathologic variables on 5-year cancer-specific survival was assessed by uni variate and multivariate analyses. RESULTS: The 5-year cancer-specific survival rate was 83.4%. Univariate analysis showed circular tumor growth to be significantly associated with decreased survival (p=0.0047). Furthermore, multivariate analysis showed that circular tumor growth significantly affected long-term cancer-specific survival of patients with stage II colorectal cancer (hazard ratio 1.184, p=0.025). CONCLUSIONS: Circular tumor growth is an independent prognostic factor for patients with stage II colorectal cancer. The long-term prognosis of stage II colorectal cancer patients with circular-type carcinoma appear to be poor.

Surgical treatment for gastric GIST with special reference to liver metastases.

BACKGROUND/AIMS: Gastrointestinal stromal tumor (GIST) is recently defined as a tumor expressing c-kit and sometimes showing liver metastasis. We investigated the outcomes of gastric GIST with special attention to the effect of repeated treatment for the patients with liver metastases. METHODOLOGY: Fourteen gastric GISTs were retrospectively reviewed and the significance of the NIH stratification system was examined. RESULTS: Liver metastasis was found in 4 of the 14 patients with gastric GISTs. Three of the 4 patients had metachronous liver metastases and underwent repeated hepatectomies after the initial operation for gastric GIST. The other patient had a synchronous liver metastasis and underwent total gastrectomy and partial resection of the liver as the initial treatment. Two of the 4 patients have received treatments 6 times, including hepatic resection, microwave coagulation therapy (MCT), radiofrequency ablation (RFA), or by imatinib. All 4 patients with hepatic metastases are alive after the first hepatectomy with a mean survival time of 64.8 months with or without imatinib treatment. None classified to very low risk and low risk groups by the NIH system showed liver metastasis, while 43% of the patients classified to the high risk showed liver metastasis. CONCLUSIONS: Repeated surgical and medical treatments for liver metastases from gastric GIST improve survival. Special attention should be paid to be the high risk group categorized by the NIH classification system.

Video monitoring and slide and video presentations as tools for surgical education.

BACKGROUND/AIMS: To provide medical students with good visualization and understanding of surgical procedures, we used video monitoring (Monitor) in the operating room and slide (Slide) and video (Video) presentation in the conferences. The purpose of this study was to evaluate the effect of these visual aids on surgical education. METHODOLOGY: One hundred and twenty-nine fifth- and sixth-year medical students completed a questionnaire regarding their visualization of, understanding of, and interest in all surgical procedures observed and procedures pertaining to their assigned patients. The score was collected on a Likert-type scores ranged from 1 for "poor" to 5 for "excellent". RESULTS: Visualization and understanding scores were significantly lower for direct observation than for Monitor (p<0.01 and p<0.001), Slide (p<0.001 and p<0.001) and Video (p<0.001 and p<0.001). Interest scores did not differ between observation methods. For all observation methods, understanding of and interest in the surgical procedures were significantly greater in relation to assigned patients than in relation to all patients observed. CONCLUSIONS: Video monitoring and slide and video presentations enhance students' understanding of and interest in surgical procedures. Contributing to the care of assigned patient also increases understanding of and interest in general surgery.

Medical students' attitudes to laparoscopic surgery.

BACKGROUND/AIMS: The purpose of the present study was to evaluate the attitude of medical students to laparosocopic surgery. METHODOLOGY: Two hundred and seven medical students completed a questionnaire regarding their visualization of, understanding of, and interest in observation of laparoscopic surgery via laparoscopic monitor (laparoscopic observation) and of open surgery, either directly (open direct observation), or via video monitor observation (open monitor observation). They were also asked about their willingness to become an operator (operator). Responses to each item were given as Likert-type scores ranging from 1 to 5. RESULTS: The visualization score was significantly lower for open direct observation than for open monitor observation (P<0.001) and laparoscopic observation (P<0.001), with the significantly lower score for open monitor observation than for laparoscopic observation (P<0.001). The understanding score was significantly lower for open direct observation than for open monitor observation (P<0.01) and laparoscopic observation (P<0.01). Interest scores did not differ between the three observation methods. The operator score was significantly higher for open surgery than for laparoscopic surgery. CONCLUSIONS: Laparoscopic surgery provides good visualization of the operative field. However, students' interest in laparoscopic surgery is similar to those of open surgery.

Intraoperative enteroscopy in minimally invasive surgery.

PURPOSE: The purpose of this study was to assess the efficacy and safety of intraoperative enteroscopy (IOE) in patients undergoing minimally invasive surgery. METHODS: Twelve patients underwent minimally invasive surgery and IOE at Miyazaki University Hospital. Patients included 11 men and 1 woman. After extraction of the intestine via minilaparotomy, enterotomy was performed, and a sterilized enteroscope was inserted. RESULTS: Length of the skin incision was 5.7+/-0.2 cm (mean+/-standard error). Length of the small intestine observed enteroscopically was 334+/-19 cm. Distance from the ligament of Treitz to the orally observed jejunum was 11.8+/-3.6 cm. In 5 of 9 patients with Crohn disease, additional lesions were found by IOE that were not found by preoperative examination. One additional tumor was found in 1 patient with ileal tumor. Postoperative complications occurred in 2 patients. CONCLUSION: IOE is efficacious in patients undergoing minimally invasive surgery.

Internal herniation through the mesenteric opening after laparoscopy-assisted right colectomy: report of a case.

We discuss a rare complication in a patient who underwent laparoscopic colectomy. A 69-year-old woman underwent laparoscopy-assisted right colectomy for cancer of the ascending colon. Two months after the operation, bowel obstruction developed. Decompression with a long intestinal tube failed to resolve the obstruction. Thus, surgery was performed. Abdominal exploration revealed a strangulated ileal loop caused by herniation through the mesenteric opening at the anastomotic site. The mesenterium had not been sutured during the previous operation. The anastomotic segment had twisted semicircularly and adhered to the retroperitoneum, so the mesenteric opening had narrowed.

Signal of proteinase-activated receptor-2 contributes to highly malignant potential of human pancreatic cancer by up-regulation of interleukin-8 release.

Proteinase-activated receptor-2 (PAR-2) is expressed in various tissues, including cancer lesions. However, the functional consequences of PAR-2 expression in cancer cells, especially in pancreatic cancer cells, are poorly understood. To clarify the biological significance of PAR-2 signaling in pancreatic cancer, we examined the production of growth factors and cytokines, such as IL-6, IL-8, bFGF, TGF-beta1, and VEGF, by specific ELISAs. Two human pancreatic cancer cell lines, SUIT2 and MiaPaCa2, which have been shown to express PAR-2, were stimulated by trypsin and PAR-2 activating peptide (PAR-2AP: SLIGKV-NH2). After 24 h, the culture supernatants were collected and specific ELISAs were performed. Although no significant changes were observed in the release of IL-6, bFGF, TGF-beta1, or VEGF, that of IL-8 was significantly up-regulated by PAR-2 agonists in a dose-dependent manner. In addition, IL-8 receptor expression was found in pancreatic cancer cells and fibroblasts. These results suggest that the PAR-2 signal up-regulates IL-8 release from pancreatic cancer cells. This up-regulated IL-8 has an effect on the pancreatic cancer cells in an autocrine manner and on the fibroblasts in a paracrine manner. Thus, this signal might contribute to tumor progression and characteristic fibrosis in pancreatic cancer.

Sum of the longest diameters of metastatic liver tumors is a possible new prognostic factor after hepatectomy in patients with colorectal liver metastases.

BACKGROUND/AIMS: Although the size and number of the metastatic liver tumors have been considered to be prognostic factors after hepatectomy in patients with colorectal liver metastases, the importance of these parameters is still controversial. The aim of this study was to evaluate the importance of the new factor, namely, the sum of longest diameters of the metastatic liver tumors (SLD). METHODOLOGY: The medical records of 59 patients who had undergone hepatic resection for colorectal liver metastases were abstracted and these patients were completely followed-up. RESULTS: The overall 5-year survival rate after hepatectomy was 38.5%, and median survival time was 25.9 months. The significant prognostic factors by the univariate analysis were the extents of vessel permeation and lymph node metastasis of primary colorectal carcinoma, the presence of extrahepatic metastasis, the longest diameter and SLD of the liver tumor, surgical margin of the liver, and the serum level of carcinoembryonic antigen. Multivariate analysis showed that SLD (P=0.026) and extrahepatic distant organ metastasis (P=0.008) were the independent prognostic factor. CONCLUSIONS: SLD is a useful and significant predictor for survival after hepatectomy in patients with colorectal liver metastases.

Expression of proteinase-activated receptor-2 in human pancreatic cancer: a possible relation to cancer invasion and induction of fibrosis.

The proteinase-activated receptor-2 (PAR-2) is a G protein-coupled receptor that is cleaved and activated by trypsin. To clarify the presence of PAR-2 in human pancreatic cancer, the expression of PAR-2 was analyzed by RT-PCR, immunoblotting and immunocytochemistry using 5 human pancreatic cancer cell lines. And to evaluate the biological significance, immunohistochemical expression of PAR-2 in malignant and non-malignant human pancreatic tissues was examined using paraffin-embedded sections. The presence of PAR-2 was confirmed in all 5 pancreatic cancer cell lines and all 21 paraffin-embedded specimens from human pancreatic cancer examined. The expression of PAR-2 was found to be higher in the tissues with infiltrative growth pattern than those with expansive growth pattern. Moreover, significantly higher expression of PAR-2 was observed in the tissues which were accompanied by severe fibrosis. Even in the same specimen, the intensity of immunoreactivity tended to be stronger in the part with severe fibrosis than that with mild fibrosis. Similarly, the higher expression of PAR-2 was observed in chronic pancreatitis with severe fibrosis than with mild fibrosis. Taken together, these results suggest that the activation of PAR-2 is involved in cancer invasion and the induction of fibrosis in human pancreatic cancer.

Primary, solitary, adult T-cell leukemia / lymphoma of the descending colon.

We herein report a patient with adult T-cell leukemia/lymphoma (ATLL) of the descending colon. A 64-year-old man was admitted to our hospital complaining of left lower abdominal pain. Endoscopic examination revealed an ulcerative tumor in the descending colon that was diagnosed as T-cell lymphoma by biopsy. Neither distant organ metastasis nor lymph node swelling was observed by radiographic examinations. Curative excision with left hemicolectomy and regional lymph node dissection was performed. Surgical sections contained ulcerative and superficially elevated lesions; these were continuous with each other. Histological examination revealed diffuse proliferation of medium-sized abnormal lymphoid cells. Immunohistochemically, these lymphoid cells were positive for UCHL-1/CD45RO and CD3 and negative for CD79a, indicating that the tumor was a primary malignant T-cell lymphoma of the descending colon. Integration of the proviral DNA of human T-lymphotropic virus type 1 (HTLV-1) was confirmed by Southern blotting analysis.

Treated and untreated hypertension, hospitalization, and medical expenditure: an epidemiological study in 314622 beneficiaries of the medical insurance system in Japan.

OBJECTIVE: This study investigated the effect of hypertension on hospitalization risk and medical expenditure according to treatment status in a Japanese population. METHODS: A total of 314 622 beneficiaries of the medical insurance system in Japan, aged 40-69 years, without a history of cardiovascular, cerebrovascular, or end-stage renal disease were classified into seven blood pressure categories. These categories were used to compare the risk of undergoing hospitalization in the 1 year after the baseline survey and to examine the percentage of inpatient medical expenditure attributable to overall hypertension relative to total medical expenditure in the study population. RESULTS: During the follow-up period, 6.6% of men and 5.1% of women were hospitalized. In men and women aged 40-54 years, cases of hypertension, especially grade 3 untreated hypertension, led to more frequent hospitalization, compared with optimal blood pressure. Individuals who were hospitalized, especially long-term, incurred considerably higher medical expenditure compared with those who were not hospitalized, regardless of their hypertension status. In women aged 55-69 years, there was little variation in hospitalization risk across blood pressure categories. The inpatient medical expenditure attributable to overall hypertension represented 7.2 and 6.9% of the total medical expenditure for men aged 40-54 and 55-69 years, whereas it represented 2.8 and 3.8% for women, respectively. CONCLUSION: Although cases of hypertension were an economic burden especially in men, grade 3 untreated hypertension was more likely to incur extremely high medical expenditure as a result of hospitalization, compared with other cases.