Background: The serum level of carcinoembryonic antigen (CEA) is a marker of malignant disease but can also be increased in benign diseases. Patients with allergic bronchopulmonary aspergillosis (ABPA) have bronchial asthma showing a wide variety of radiological findings. We measured serum CEA levels in patients with ABPA and evaluated the relationships of serum CEA levels with peripheral blood eosinophil counts, total blood levels of immunoglobin (Ig) E, and findings of computed tomography (CT) in ABPA.
Methods: The subjects were 13 patients (6 men and 7 women aged 34 to 76 years) who had been treated for ABPA at our hospital. Serum levels of CEA, peripheral blood eosinophil counts, total blood IgE levels, and CT findings were examined before and after treatment with prednisolone.
Results: Before the start of the treatment 7 of 13 patients had serum CEA levels higher than the upper limit of normal. The serum CEA level was not correlated with eosinophil counts or total IgE values. Serum CEA levels were examined after treatment in 9 patients and were found to have significantly decreased as pulmonary consolidation improved. Furthermore, serum CEA levels before treatment in patients with pulmonary consolidation were significantly higher than those in patients without consolidation.
Conclusion: Serum CEA levels are elevated in some patients with ABPA; these elevations might be associated with consolidation in the lung. Elevated serum CEA levels decrease as the consolidation decreases after treatment. The elevation of serum CEA might be attributed to the presence of local inflammation in the lung.

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Aims: This study aimed to evaluate the relationship between aortic arch calcification (AAC) detectable on chest X-ray films and plasma diacron-reactive oxygen metabolites (d-ROMs) in patients with type 2 diabetes but without cardiovascular disease.
Methods: Forty-nine patients with type 2 diabetes but without cardiovascular disease were evaluated with chest X-ray examinations and divided into those with AAC (n=26) and those without AAC (n=23). Biochemical variables, including plasma levels of d-ROMS, high-sensitivity C-reactive protein (hsCRP), plasminogen activator inhibitor-1 (PAI-1), and lipoprotein(a) (Lp(a)), were evaluated after an overnight fast. The relationships of AAC with both inflammation and oxidative-stress variables were evaluated.
Results: The plasma level of d-ROMs in subjects with AAC was significantly higher than that in subjects without AAC, whereas plasma levels of hsCRP, PAI-1, and Lp(a) in subjects with AAC were higher, but not significantly so, than those in subjects without AAC. Multivariate linear regression analysis with AAC grade as the dependent variable and plasma levels of d-ROMs, hsCRP, PAI-1, or Lp(a) as independent variables demonstrated a significant association of AAC grade with plasma levels of d-ROMs but not with plasma levels of hsCRP, PAI-1, or Lp(a).
Conclusions: The plasma level of d-ROMs is associated with AAC in patients with type 2 diabetes but without cardiovascular disease. Hence, the results of the present study suggest that AAC in these patients is strongly associated with oxidative stress. Furthermore, patients with type 2 diabetes and AAC may be at high risk for the development and progression of various diabetic complications induced by oxidative stress.

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The prognostic value of heart rate variability (HRV) in patients with cardiac conditions has been investigated for many years. However, the HRV is superior to annual health examinations for predicting the longevity of very elderly residents of long-term care facilities is unknown. Annual health examinations and subsequently ambulatory Holter ECG recording were performed in 2008 for 71 very elderly subjects, who were then followed up for 3 to 48 months. The patients were divided into 2 groups on the basis of whether they were alive (86 ± 14 years, n=37) or deceased (90 ± 16 years, n=34) at end of follow-up. To assess cardiac autonomic function, HRV was obtained with the MemCalc/Chiram software program after Holter ECG. Age, sex, body-mass index, plasma levels of C-reactive protein and albumin, and the low-frequency/high-frequency ratio did not differ between the 2 groups. However, the standard deviation of all NN intervals (SDNN) and the coefficient of variation of RR intervals (CVRR) were higher in living subjects than in deceased subjects (SDNN: 73.2 ± 13.5 milliseconds vs. 53.2 ± 9.8 milliseconds, CVRR: 9.3% ± 1.7% vs. 7.6% ± 1.3%, p<0.05). The relative risks with an SDNN <65 milliseconds was 1.85 (p<0.05) and that with a CVRR <8% was 1.84 (p<0.05). Kaplan Meier analysis showed that SDNN and CVRR were useful markers for the longevity of very elderly subjects. The present data suggest that annual health examination data does not predict longevity, but that HRV does. The modulation of parasympathetic tone in daily activities plays an important role in the longevity of very elderly residents of long-term care facilities.

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Background: Whether hepatic resection is indicated for elderly patients with hepatocellular carcinoma (HCC) remains controversial.
Methods: This retrospective study evaluated surgical outcomes and prognostic factors in elderly patients with HCC who underwent hepatectomy. Overall survival rates and disease-free survival rates after hepatectomy were compared between 63 patients with HCC who were 75 years or older (elderly group) and 353 patients with HCC who were younger than 75 years (younger group). Prognostic factors in the elderly group were evaluated by means of multivariate analysis with a Cox's proportional-hazards model.
Results: Overall survival rates at 3 and 5 years were respectively 56.2% and 40.2% in the elderly group and 63.4% and 46.6% in the younger group. Disease-free survival rates at these times were 34.9% and 34.9% in the elderly group and 30.8% and 21.5% in the younger group. These differences were not significant. Multivariate analysis revealed a significant association between Child-Pugh class and outcomes (P=0.01).
Conclusions: The safety and survival benefits of hepatectomy in carefully selected elderly patients with HCC are similar to those in younger patients.

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Objective: With an aging society, elderly patients increasingly require long-term placement of urethral balloon catheters. In this study, we investigated if Memokath^TM urethral stents, when inserted from the bladder neck to distal to the urethral sphincter in elderly men being treated with urethral balloon catheters, induce incontinence, which would then be managed with adult briefs.
Patients and Methods: Of all outpatients who were being managed with urethral balloon catheters at our institution from September 2011 through March 2012, 4 patients who had had problems with the catheters were included in the study. Exclusion criteria were a performance status of 1 or 2 and the ability to urinate after standard placement of the stent. After application of local anesthesia to the urethra, the Memokath^TM stent was placed distal to the urethral sphincter under radiographic guidance in all patients.
Results: After stent placement, all patients had total incontinence and were catheter-free. Although 2 patients were receiving anticoagulant therapy before the procedure, no intraprocedural or postprocedural anticoagulant-related complications were noted.
Conclusions: Memokath^TM stent-induced incontinence is a safe and effective treatment for patients requiring long-term placement of urethral balloon catheters who are expected to have continuing urination difficulties.

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Background: In most cases of pancreatic head cancer, surgery often results in noncurative resection, which is frequently related to inadequate clearance of the mesopancreas.
Purpose: The aim of this report is to introduce the surgical technique of left posterior approach pancreaticoduodenectomy (PD) with total mesopancreas excision and circumferential lymphadenectomy around the superior mesenteric artery (SMA) (LPA-PD) and to examine whether this procedure increases the rate of true curative resection and decreases the rate of locoregional recurrence.
Patients and Methods: Nineteen patients underwent standard PD, and 19 patients underwent LPA-PD. The demographic characteristics, intraoperative outcomes (mean operative time and mean blood loss), postoperative outcomes (complications, type of recurrence and survival), and pathological findings (R number, number of removed regional lymph nodes and positive resection margins) were evaluated.
Results: The patient characteristics did not differ significantly between the groups. The mean blood loss in the LPA-PD group was significantly less than that in the standard PD group (p<0.05). The incidence rate of postoperative complications did not differ between the groups. No surgery-related deaths occurred in either group. The number of removed regional lymph nodes around the superior mesenteric artery in the LPA-PD group was significantly greater than that in the standard PD group (p<0.01). The R0 resection rate in the LPA-PD group was higher, although not significantly so, than that in the standard PD group. The resection margin of the mesopancreas was negative in all patients of the LPA-PD group. The rate of locoregional recurrence in the LPA-PD group was significantly lower than that in the standard PD group (p<0.01). The postoperative survival rate did not differ significantly between the groups.
Conclusion: Our method of LPA-PD helps secure the negative margin of the mesopancreas and enables complete circumferential lymphadenectomy around the SMA. Therefore, LPA-PD may increase the true curative resection rate and decrease the locoregional recurrence rate compared with standard PD.

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Laparoscopic hepatectomy has become a widespread procedure in Japan, now that the national medical insurance system covers partial resection and lateral segmentectomy. An important procedure during laparoscopic hepatectomy is the division of the vascular pedicles. In this paper we report a practical and useful method for vascular division with an Endo Mini-Retract^TM retractor and a shortened Nelaton catheter (2.5-mm-diameter) developed in our department.

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We treated a patient who had gastrointestinal perforation during chemotherapy with docetaxel and S-1 which was successfully treated with percutaneous drainage. A 66-year-old man was admitted to our hospital with complaints of abdominal pain. Gastric cancer (T3N1M0) had been diagnosed 3 years earlier, and distal gastrectomy had been performed. Two years later, intrapelvic recurrence of the cancer was diagnosed. We administered docetaxel and S-1. After 3 courses of chemotherapy, he complained of abdominal pain of sudden onset. Computed tomography showed free air and limited ascites, and gastrointestinal perforation was diagnosed. We performed percutaneous drainage. The abdominal pain improved 3 days later, and he was able to eat meals 15 days after the onset of abdominal pain. He was discharged 27 days after admission. Because the patient's general condition was poor, we started providing best supportive care only. He died 10 months after the perforation was found.

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A case of herpes simplex virus (HSV) encephalitis in a neonate after delivery from a woman whose genital HSV infection had been treated with acyclovir is reported. The main approach to prevent genital HSV infection in the neonate is interruption of transmission at the time of delivery. Guidelines for prophylactic therapy with acyclovir have been established, but the risk of neonatal infection remains. A fever began to develop in a male neonate delivered vaginally from a 35-year-old woman. Treatment with intravenous acyclovir was started on the basis of a diagnosis of HSV encephalitis, because polymerase chain reaction was positive for HSV in the cerebrospinal fluid. The mother had had a first genital HSV infection during the second trimester, but treatment with injected acyclovir had caused the blisters and erosion to resolve by the time of delivery. Important steps for preventing neonatal HSV infection are the appropriate treatment of mothers with a history of genital HSV infection, the assessment of delivery methods, and the appropriate treatment of neonates.

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A liver tumor metastatic from a sigmoid colon carcinoma was diagnosed in a 70-year-old man. Because hepatectomy was not indicated, the patient was treated with a combination of oxaliplatin, levofolinate, and fluorouracil (5-FU) (modified FOLFOX 6 regimen). After 15 cycles of chemotherapy, this regimen was considered to have been ineffective; therefore, treatment was started with the topoisomerase inhibitor irinotecan and an intravenous infusion of 5-FU and levofolinate (FOLFIRI). After receiving irinotecan and levofolinate, the patient had chills, a severe cough, and dyspnea. We diagnosed pulmonary edema as a side effect due to oxaliplatin, and the chemotherapeutic regimen was changed from FOLFIRI to FOLFOX plus bevacizumab. After the third cycle of oxaliplatin and levofolinate, pulmonary edema recurred, and a preshock state developed again. We suspected that either oxaliplatin or irinotecan had caused the pulmonary edema and, therefore, administered levofolinate, 200 mg/m²; 5-FU, 400 mg/m²; and bevacizumab, 330 mg/m²; intravenously on day 1, followed by 5-FU, 2,400 mg/m², as a continuous intravenous infusion at 46 hours without either of oxaliplatin, levofolanate, and bevacizumab. After being treated with levofolinate again, the patient suddenly complained of severe dyspnea; this symptom confirmed that levofolinate had caused the pulmonary edema. To our knowledge, severe pulmonary edema caused by levofolinate has not been reported previously. This adverse effect was clinically significant because it led to the patient's death.

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Graves' disease and Hashimoto's thyroiditis are the most common autoimmune thyroid diseases. Hypothyroidism can develop in patients with Graves' disease, either spontaneously or as a result of radioactive iodine therapy or surgery. However, it is rare for patients with Hashimoto's thyroiditis to subsequently develop Graves' disease. We report a case of alopecia areata associated with Graves' disease in a 41-year-old woman who had previously been diagnosed with Hashimoto's disease. Alopecia areata is an autoimmune disease associated with other autoimmune diseases such as thyroid disorders, anemia, and other skin disorders.

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True splenic cysts are uncommon and are associated with elevated serum and intracystic tumor marker CA 19-9 levels. A 33-year-old woman presented to our hospital with a chief complaint of epigastralgia. Computed tomography of the abdomen showed a 10-cm cystic lesion in the spleen. The serum carbohydrate antigen (CA) 19-9 level was 3,347 U/mL (normal, <37 U/mL). Total laparoscopic splenectomy was performed, and the serum level of CA 19-9 had normalized 2 weeks later. Pathological examination showed a benign true epidermal cyst of the spleen with strong immunohistological staining for CA 19-9. Splenic epidermoid cysts most often occur in young women, and laparoscopic surgery to remove cysts of this type is minimally invasive. Thus, laparoscopic surgery should be the method of first choice for most cases of splenic benign true cyst.

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Introduction: A case of mucosa-associated lymphoid tissue (MALT) lymphoma, the most frequent of the various conjunctival lymphoproliferative disorders, in which the initial biopsy was inconclusive but the second biopsy provided a definitive diagnosis, is reported.
Case Report: A 26-year-old woman with a 3-month history of bilateral conjunctival swelling was referred by a local physician for suspected MALT lymphoma. A salmon-pink elastic swelling was found to involve both eyes and to extend from the lower palpebral conjunctiva to the bulbar conjunctiva. Tonsillar swelling was also found, and ophthalmologic (left eye) and otolaryngologic biopsies were therefore performed simultaneously under general anesthesia. The otolaryngologic diagnosis was chronic tonsillitis. Light microscope examination of the conjunctival tissue showed proliferation of lymphocytes and small aggregates of small to medium-sized atypical lymphocytes. On immunohistochemical studies, atypical lymphocytes were positive for CD20 and CD79a, but differentiation to plasmacytes was not prominent, and neither Dutcher bodies nor evidence of immunoglobulin light chain restriction was found. The results were not incompatible with MALT lymphoma but were not definitive. A second biopsy of the right eye was therefore performed 3 months later. Staining with hematoxylin and eosin showed proliferation of small lymphocytes and monocytoid B cells and differentiation to plasmacytes. The hyperplastic cells were positive for CD19, CD79a, and CD20, and their cytoplasm were positive for Bcl-2 and slightly positive for Bcl-6. Cells positive for CD38 were noted where differentiation to plasmacytes and immunoglobulin light chain κ restriction was evident on immunohistochemical studies and in situ hybridization. The Ki-67-positivity rate was approximately 5%. The results of paraffin-embedded tissue section fluorescence in situ hybridization were negative for MALT-1 (18q21). A diagnosis of MALT lymphoma was made, and treatment with rituximab was started.
Discussion: Few findings lead directly to a definitive diagnosis of MALT lymphoma, and its differential diagnosis from benign lymphoproliferative disorders is difficult. In the present case definitive diagnosis was possible only after a second biopsy. This case suggests repeated biopsy may be necessary when a single biopsy is not definitive.

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Preventing infectious diseases in patients with cancer receiving palliative care is extremely important. However, little is known about the factors causing infection in these patients. The aim of this study was to clarify the factors contributing to infection in patients with cancer receiving palliative care. The medical records of each patient were reviewed, and patient characteristics were recorded. Factors that correlated significantly with infection, as revealed by univariate analysis, were performance status, the fall risk assessment score, and venous catheters. Our present study provides further evidence that the fall risk assessment score is a risk factor for infection. Critical infections might be prevented in patients with cancer receiving palliative care by monitoring the above 3 factors.

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