Summary: Introduction: Granulocyte and monocyte apheresis (GMA) is an effective treatment strategy for active ulcerative colitis (UC) in Japan. Single needle (SN) apheresis reduces needle puncture pain in patients because it requires only one puncture site. We evaluated whether single-needle apheresis could be a safe and effective means of reducing patient burden.

Method: We performed a retrospective study of active UC patients who were treated with either SN apheresis or conventional double-needle (DN) apheresis at the Kurume university hospital from April 2014 to March 2018. All the patients treated with GMA after September 2016 underwent SN apheresis. Thus, the two groups predominantly belonged to different time periods. We assessed the safety of SN apheresis.

Result: Six patients underwent SN apheresis, and 6 underwent DN apheresis. The average time to the start of apheresis was significantly reduced from 23.1 minutes in the case of DN apheresis to 12.6 minutes for SN apheresis. In addition, the number of difficult punctures was significantly reduced with SN apheresis. There were no differences in adverse events between SN and DN apheresis. Treatment benefits, remission rate and disease activity were similar between SN and DN apheresis.

Conclusion: SN apheresis reduced both the time to treatment initiation and pain during puncture, and there was no difference in the number of blood clotting episodes as compared with DN. Although further comparative studies are needed, SN apheresis may be a safe alternative for patients to reduce the strain of treatment.

Summary: Objective: Although studies have evaluated learning curves for laparoscopic surgery (LS), this issue has not yet been addressed in gynecologic oncologists. The present study aimed to evaluate LS proficiency for early-stage endometrial cancer among gynecologic oncologists.

Methods: We examined 25 cases in which LS with pelvic lymphadenectomy (PLA) for endometrial cancer was performed by two gynecologic oncologists undergoing training in LS. The LS duration, estimated blood loss (EBL), number of dissected pelvic lymph nodes (PLNs), and perioperative complications were assessed as measures of surgical proficiency.

Results: Operators A and B performed 10 and 15 cases, respectively, with median LS durations of 348.5 and 378 minutes, respectively. Although the LS duration and number of procedures did not exhibit a significant correlation, the regression lines for both operators showed decreasing trends. Both operators had a consistently low median EBL (A, 57 ml; B, 60 ml). Operators A and B dissected a median of 21.5 and 22 PLNs, respectively. Although both operators dissected a relatively large number of PLNs, with a median of over 20 per patient after the introduction of LS, this number decreased as the number of LS increased for Operator B (p=0.009). However, no correlation was observed between the LS duration and number of PLNs dissected by Operator B (ρ=0.353, p=0.197). A severe perioperative complication, specifically perforation of the sigmoid colon requiring emergent laparotomy, occurred in one case; however, the association with surgical manipulation was not definitive.

Conclusion: The observed gynecologic oncologists were able to acquire early proficiency in LS for early-stage endometrial cancer.

Summary: Various endogenous mitochondria-associated antioxidants protect mitochondria from oxidative stresses such as Superoxide Dismutase 2 (SOD2), Catalase, Glutaredoxin 2 (GLRX2), educed Glutathione (GSH), Glutathione Peroxidase (GPx), and Thioredoxin 2 (TXN2). They protect mitochondria from Reactive Oxygen Species (ROS). Excess ROS causes mitochondrial DNA damage and respiratory chain dysfunction leading to carcinogenesis. In an earlier study we found complex alterations of mitochondrial antioxidants in different stages of oral squamous cell carcinoma. Here, we profiled mitochondrial antioxidants in different oral potentially malignant disorders such as oral leukoplakia (OL), oral lichen planus (OLP), and oral submucous fibrosis (OSMF). Mitochondria was prepared from oral tissues from OL, OLP, and OSMF patients. Biochemical assays and immunoblotting were performed to investigate expression of various mitochondrial antioxidants. Catalase was expressed as Control> OL > OSMF > OLP. GLRX 2 was expressed as OLP> OL >Control >OSMF. GPX1 and GPX4 were expressed as Control >OSMF> OLP > OL. GSH increased in OL and OSMP, but decreased in OLP. SOD2 was expressed as Control >OSMF> OLP > OL. PRX3 was expressed as OL > OLP > OSMF > Control. TXN2 expression was nearly the same in all groups except OL, which showed elevated expression. We conclude that endogenous mitochondria-associated antioxidants show different levels of expressions in various oral potentially malignant disorders.

Summary: Combined hepatocellular-cholangiocarcinoma (CHC) is a relatively rare tumor with an incidence range of 1.0-4.7%. CHC is defined as a tumor containing unequivocal, intimately mixed components of both hepatocellular carcinoma and intrahepatic cholangiocarcinoma. The recent development of biochemical methodologies and cancer stem cell theory have paved the way for a clearer understanding of the histogenesis of CHC. The latest edited WHO classification published in 2010 adopted the concept of stem cell/hepatic progenitor cells in the pathological classification of CHC. Although this classification includes novel and unique concepts of histogenesis and facilitates the recognition of CHC, there are several problems with it in practice. To reduce confusion, an international group of hepatic pathologists, radiologists, surgeons, and clinicians formulated a nomenclature for CHC and issued a consensus article in 2018. In this review article, we discuss the problems with the latest WHO classification and introduce recent topics concerning CHC from pathologic and genetic points of view.

Summary: High-dose chemotherapy and autologous stem cell transplantation is too toxic for elderly patients with relapsed or refractory (DLBCL). Therefore, tolerable and efficient salvage regimens for elderly patients are greatly needed.

In this study, therapy with rituximab, gemcitabine, dexamethasone, and cisplatin (R-GDP) will be performed every 4 weeks, and an interim evaluation will be performed after the completion of the 3^rd course. If a complete response (CR) is achieved at the time of interim evaluation, 1 course of R-GDP therapy and 2 courses of monotherapy with rituximab will be additionally performed. If a partial response (PR) is achieved, 3 courses of R-GDP therapy will be additionally conducted. In patients without a PR or CR by the time of the interim evaluation, treatment will be discontinued. Treatment will also be discontinued at any point if disease progression is observed during protocol treatment. After the completion of the final course of R-GDP therapy, final effects of the regimen will be evaluated. A primary endpoint is the efficacy of R-GDP therapy (CR and response rates).

This is the first multicenter phase II clinical study of R-GDP therapy to examine post-treatment activities of daily living in addition to the safety and efficacy of treatment in elderly patients with relapsed or refractory transplantineligible DLBCL.

Summary: This multicenter phase II N-DOCC-F-C-1701 trial is being planned in order to investigate the efficacy and safety of CPT-11+S-1 +Ramucirumab (IRIS+Rmab), which is anticipated to have a stronger anti-tumor effect than IRIS+Bmab in patients with metastatic colorectal cancer (mCRC) previously treated with oxaliplatin (L-OHP) containing regimen, in consideration of the result of RAISE, FIRIS and some phase II trials of IRIS+Bevacicizumab (Bmab). The number of patients is set at 38 for the statistical analysis, assuming an expected median PFS of 5.0 months (threshold: 3.0 months). The primary endpoint of the study is the progression free survival (PFS), and the secondary endpoints are the overall response rate (ORR), overall survival (OS), adverse events (AE), quality of life (QOL) and review of nausea and vomiting. This trial is registered in the UMIN Clinical Trials Registry as UMIN000028170. We intend to start conducting the trial in September 1, 2017. If this trial meets the endpoint, IRIS+Rmab might be supported as a new optional standard regimen for mCRC.

Summary: Herein we present a case of a horseshoe kidney with crossed fused renal ectopia. Both of these pathologies are congenital anomalies; however, to date, there are few cases that present with both. In this case, discovered during routine dissection, the fused kidney was mostly left-sided and very low in the pelvis. No renal artery arose from the right wall of the abdominal aorta, and the right renal vein drained into the lower part of the inferior vena cava (IVC) where the right and left common iliac veins joined. It is essential for clinicians and surgeons to understand these types of congenital anomalies, as they could impact patient care.

Summary: A 78-year-old man who had worked in the building industry visited our hospital because of groundglass opacity with smoothly thickened, intralobular interstitial lines and interlobular septal lines on chest high-resolution computed tomography (HRCT). HRCT image also showed a focal area of reticulation and pleural thickening. Lung specimens obtained by surgical lung biopsy showed accumulations of intra-alveolar periodic acid-Schiffpositive materials, usual interstitial pneumonia (UIP)-like subpleural lung fibrosis and asbestos bodies (1 body/cm2 in high-power field, ×400). Serum granulocyte-macrophage colony stimulating factor autoantibody was positive. The patient was diagnosed as having autoimmune pulmonary alveolar proteinosis (PAP) and needed differential diagnosis from secondary PAP caused from pulmonary asbestosis and UIP. Careful observation of the manifestations of pulmonary asbestosis and the progression of fibrosis using HRCT will be necessary in this patient.

Summary: Anterior shoulder dislocations following an epileptic event are considered rare. An extremely rare case of a 41 year old female suffering from bilateral anterior shoulder dislocation with concomitant greater tuberosities fractures after an epileptic seizure is presented. The patient presented to the out-patient orthopaedic clinic due to persistent pain and restriction of shoulders movement, 4 weeks after an epileptic seizure. Clinical examination and radiological evaluation established the diagnosis of bilateral anterior shoulder dislocation with concomitant greater tuberosities fractures. Closed reduction was performed under general anesthesia. There are 12 such cases in the literature, including the present one. Thirty percent of these cases had a delayed diagnosis. It is of paramount importance to have a high clinical suspicion for myoskeletal injuries and especially for shoulder dislocations following an epileptic episode, even in the absence of a traumatic event.

Summary: We present a pulmonary sarcoidosis patient with specific elevation of serum Krebs von den lungen-6 (KL-6) levels, who was successfully treated with inhaled corticosteroids. Pulmonary sarcoidosis was initially identified as a chest radiograph abnormality during a routine medical examination, and subsequently confirmed by a high serum level of soluble interleukin 2 receptor. The patient was started on high-dose inhaled budesonide because of high serum levels of angiotensin-converting enzyme (ACE) and KL-6. Following treatment, radiographic findings improved, ACE levels normalized, and serum KL-6 levels markedly decreased. No recurrence was detected at 100 months with a budesonide dosage of 800 μg/day. This case demonstrates the efficacy of highdose inhaled corticosteroids for the initial treatment of pulmonary sarcoidosis.

Summary: In the treatment of open depressed skull fracture in pediatric cases, it is preferable to use the patient’s own bone material rather than artificial material. However, there are occasions when self-material reconstruction may be impossible. In such cases the safe option is to leave the defect until future replacement of the skull becomes possible, however this often causes such children to experience severe limitations to school life. We present two thought-provoking cases in which we solved such issues by early stage cranioplasty using a titanium mesh. The first case involved a 9-year-old boy who sustained a depressed fracture in the right temporal region after falling down a riverbank. Although he underwent surgical repair, bacterial infection forced removal of the bone flap postoperatively. His school life was severely restricted and sports activities were prohibited due to the residual regional bone defect. Cranial reconstruction with a titanium mesh made it possible for him to enjoy a more active lifestyle. The second case involved a 7-year-old boy who sustained a right frontal depressed fracture in a traffic accident. The fractured skull was promptly replaced by a titanium mesh at the initial surgery due to the extreme degree of bone fragmentation. Both boys returned to school life enjoying normal activities and without any complications for up to 8 years now. The cases presented here indicate that early cranioplasty even using artificial material is not only safe but enables school age patients to participate in physical activities. From the standpoint of physical and psychological development, early stage cranioplasty with titanium mesh may be a valuable treatment option for pediatric open depressed skull fracture.

Summary: Diverticular pouch in the oral cavity is a rare disease, and its etiology is unclear. The authors present a rare case of diverticular pouch in the buccal mucosa. A 79-year-old man visited our hospital with a chief complaint of food impaction in the right buccal mucosa. Intraoral examination revealed a pouch just inferior to the parotid papilla. Histopathological examination after excisional biopsy showed that the epithelial cells lining the pouch were continuous with the mucous membrane and a diagnosis was made of diverticular pouch of the buccal mucosa. Twenty-five months after the patient’s initial visit no recurrence has been noted. Further clinico-pathological studies are required to understand diverticular disease in the buccal mucosa. This case might help dentists to become more aware of these lesions and collect data for further investigations.