Here, we report 19 consecutive patients who were diagnosed with adult T-cell leukemia and lymphoma (ATLL) and treated at Hyogo Prefectural Amagasaki Hospital between January 2008 and June 2011. Seven had the acute, 8 had the lymphoma, and 4 had the chronic type of the disease. The age range was 53 to 95, with a median of 67. The male to female ratio was 17 to 2. Sixteen of 17 were born in Southwest Japan and had moved to the Hanshin industrial area during their young adulthood. Acute-type patients showed the most aggressive clinical behavior, including a poor performance status, hepatosplenomegaly, pleural fluid/ascites, and high levels of lactate dehydrogenase, soluble interleukin-2 receptor, and serum calcium. Diagnosis of the acute type was readily established in the laboratory on the basis of the characteristic morphology of the circulating neoplastic lymphocytes and activated mature T-cell immunophenotype by flow cytometry, while the histopathological features of lymph nodes overlapped with those of other types of peripheral T-cell lymphoma or Hodgkin lymphoma. Cytogenetic studies revealed a complex karyotype in 8 cases and add(14)(q32) in 2. Five acute and 5 lymphoma-type patients were initially treated with the LSG15 or mLSG15 chemotherapy regimen. Six patients achieved a partial or better response, and 4 lymphoma-type patients showed >1 year survival. The marked male predominance most likely reflects the unique demographic configuration of the Amagasaki area. As the aging of patients with ATLL seems to be a nationwide trend within Japan, the development of a treatment strategy that can be tolerated by elderly patients is required.

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 The objective of this study is to evaluate the change in the quality of care provided by physicians-in-training in Japan for common diseases after the 2004 post-graduate medical education (PGME) reforms. Physicians who were training at eight Japanese teaching hospitals participated in this study. The physicians completed clinical performance vignettes involving outpatients with four common conditions (diabetes mellitus, chronic obstructive pulmonary disease, vascular disease, and depression). Their responses were judged against a master list of explicit evidence-based quality criteria to give a percentage of correct answers. We compared the scores obtained in 2003 with those recorded in 2008 to evaluate whether they improved after rotating curricula had been put in place. In 2003, 141 (70.1%) students consented to participate, whereas in 2008, 237 (72.3%) consented to participate. We did not observe any significant change in the quality of care score after adjusting for possible confounders (change in the total score from 2003 = 1.9, 95% CI: -1.8 to 5.8). The quality of care score improved by 3.1 percentage points at the institutes whose pre-reform curricula were specialty-oriented, which was significantly greater than the 1.4 point increase observed at the institutions whose pre-reform curricula involved rotation (p-value for interaction, 0.03). The quality of care provided by physicians-in-training for diseases that are commonly encountered by general internists did not change after the 2004 PGME reforms.

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 We report a 19-year-old male with Philadelphia chromosome (Ph)-positive acute myelocytic leukemia (AML) showing the French-American-British M2 morphology. The karyotype was 46,XY,t(9;22)(q34;q11.2)[17]/46,XY[3] and real-time polymerase chain reaction detected chimeric mRNA consisting of the minor cluster of the BCR gene and the ABL oncogene. The patient failed to respond to treatment with either imatinib or dasatinib, and died of AML progression. Fluorescence in situ hybridization of interphase nuclei revealed that t(9;22)/Ph+ cells comprised a fraction of AML blasts, suggesting that the translocation was a secondary abnormality. It appeared that, in this case, t(9;22)/Ph and expression of the p190 BCR-ABL oncoprotein played a limited role in the development and progression of AML.

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 We describe a 57-year-old woman who presented with a bulky tumor of the iliosacral region. Bone marrow biopsy and computer tomography-assisted needle biopsy of the tumor revealed infiltration of lymphoma cells showing high-grade cytology with a mature B-cell immunophenotype and high proliferation index determined by Ki-67 immunohistochemistry. Cytogenetic studies of bone marrow specimens revealed two distinct karyotypes involving chromosomes 3, 14, and a marker chromosome. A series of fluorescence in situ hybridization studies of metaphase and interphase nuclei revealed a three-way translocation, t(3;12;14)(q27;p12;q32), leading to a BCL6-immunoglobulin heavy chain (IgH) fusion gene, and two distinct c-MYC translocations involving either the IgH or a non-Ig gene as partners. With multiple cycles of chemotherapy, the patient finally achieved complete response. We concluded that this case fulfills the criteria of doublehit lymphoma carrying both c-MYC and BCL6 translocations, and that the lymphoma be placed into the category of the WHO 2008 classification “B-cell lymphoma unclassifiable with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma".

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 Carcinosarcoma of the uterine cervix is rare and generally regarded as a very aggressive tumor with a poor prognosis.However, there could be very unusual reported cases in which cervical carcinosarcoma has a good prognosis. We present a case of cervical carcinosarcoma with invasion of the endometrium and fallopian tubes in a patient who is alive with no recurrence more than 3 years after the initial surgery. A 61-year-old nulligravida with post-menopausal genital bleeding visited our outpatient clinic. Transvaginal sonography and magnetic resonance imaging revealed an endometrial tumor and adnexal cysts with solid components on either side of the uterus. Endometrial malignancy was diagnosed, and she underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and adjuvant chemotherapy with cisplatin and ifosfamide for 6 months. Gross examination of the surgically resected specimen revealed it to be a polypoid and bulky tumor (5 × 4.5 cm) arising from the endocervix. Apart from this, a polypoid sessile tumor adhering to the endometrium and both tubal lumina was detected. Histologically, the tumor had arisen exophytically from the endocervix;it had adenocarcinomatous and chondrosarcomatous components. Malignant epithelial tumors resembling the epithelial component of the endocervical tumor were also detected in the endometrium and fallopian tubes. Despite the predicted poor prognosis, the patient is currently alive and free of disease more than 36 months after the initial surgery. It is likely that the biological behavior and prognosis of these tumors are different than those expected. Therefore, cervical carcinosarcoma may show better prognosis than endometrial carcinosarcoma.

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 A 58-year-old woman presented with protracted fever and absolute monocytosis in the peripheral blood. Imaging studies suggested an inflammatory condition of the terminal ileum and colonoscopic examination revealed multiple ileocecal ulcers. The patient was treated with prednisolone, leading to not only resolution of inflammatory symptoms but also a favorable hematological response; during the response, the patient successfully underwent endoscopic submucosal dissection for coexistent early gastric cancer. The disease finally evolved into florid acute monocytic leukemia (AMoL), which responded well to induction chemotherapy consisting of cytarabine and idarubicin. Fluorescence in situ hybridization showed that nuclei of monocytes at presentation carried the split signal pattern of the MLL gene and, in combination with a reverse transcriptase-mediated polymerase chain reaction, cells were clonally marked with t(11;19)(q23;p13.1), generating the MLL-ELL fusion gene. The karyotype obtained at progression was 47,XX,+8,t(11;19)(q23;p13.1).ish t(11;19)(5′MLL;3′MLL), indicating that trisomy 8 appeared in association with the evolution to AMoL. We concluded that the disease met the criteria of chronic myelomonocytic leukemia (CMMoL), and the ileocecal lesion represented a paraneoplastic inflammatory condition associated with CMMoL/AMoL.

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 An 8-year-old girl was admitted to our hospital with fever and purpura. Laboratory examinations showed that the white cell count was 1,300/μl (segmented neutrophil 4.0%, band neutrophil 3.5%, lymphocyte 90.0%, monocyte 1.0%, eosinophil 1.5%), platelet count 2,000/μl, red cell count 363×10⁴/μl, reticulocyte count 1.09×10⁴/μl, and the hemoglobin (Hb) level 10.1 g/dl. Hepatitis and Fanconi anemia were not suspected on the basis of her current medical history, physical examinations and laboratory data, and she was diagnosed with very severe idiopathic aplastic anemia. As she had no brother or sister, she received immunosuppressive therapy with rabbit antithymocyte globulin (ATG) and cyclosporine. The side effects on her skin and bulbar conjunctiva were treated with methylprednisolone. Neutrophil and platelet counts and Hb levels increased to partial remission 3 months later and to complete remission 6 months later. It took more than 5 months to reach a lymphocyte count 500/μl. Since horse ATG is not available at present and there are few reports of using rabbit ATG as a first line therapy, this case presents valuable data that may help overcome some of the remaining problems in the therapeutic use of rabbit ATG.

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 Lipoma occurring in the parotid gland is relatively rare among all parotid gland tumors. Lipoma is observed in about 1% of all parotid gland tumors. We report three cases of lipoma in the parotid gland treated at Tenri Hospital between 1997 and 2011. Computed tomography and magnetic resonance imaging were useful for the diagnosis of lipoma, however fine- needle aspiration could not give an accurate cytological diagnosis preoperatively. The parotid gland tumor was surgically removed. The parotid tumor occurred from a deep lobe in one case and from a superficial lobe in two cases. There was neither facial palsy nor recurrence of tumors after surgery.

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 We report here a case of acute type-A aortic dissection complicated by rupture into the left thoracic cavity and hypoperfusion of the lower extremities, which was treated with total aortic arch replacement followed by thoracic endovascular aortic repair (TEVAR) within a single day. The patient was a 45-year-old man who presented with severe back pain. A computed tomographic scan using contrast media revealed a type A aortic dissection. Although the disease was complicated by severe hemothorax and hypoperfusion of the legs, his vital signs did not reach the level of shock. We first performed total aortic arch replacement, and to prevent postoperative re-dissection and improve perfusion of the legs, we then performed TAVERA using two pieces of a Gore-Tex TAG^® stent graft on the same day. On postoperative day 2, the patient developed delayed postoperative paraplegia; the patient was treated with cerebrospinal fluid drainage and the administration of naloxone and high-dose corticosteroids, resulting in the resolution of neurological symptoms. He was ambulant at discharge on postoperative day 40. We reviewed the literature regarding the treatment of acute type A aortic dissection associated with intra-thoracic rupture and delayed postoperative paraplegia.

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 The patient was a 43-year-old female who had received repeated open surgery for adhesive bowel obstruction due to underlying Crohn's disease. Seven years earlier, as enteral feeding became unfeasible, long-term indwelling catheter was installed through the right subclavian vein to perform total parenteral nutrition (TPN). One month before the presentation, she showed spiking fever, and methicillin-resistant Staphylococcus aureus was isolated from the blood. Echocardiography and magnetic resonance images revealed that thrombi filled the right subclavian, internal jugular, and innominate veins through the superior vena cava (SVC), and formed a tumor of 20 mm in diameter within the right atrium. As vancomycin was not effective to control the infection, we performed surgical treatment for the thrombi complicated by catheter-associated bloodstream infection. We started the heart surgery via a median sternotomy approach under general anesthesia. When the right atrium was incised obliquely, we found that organized thrombi tightly adhered to the wall of the right atrium and SVC. We carefully removed the thrombi as much as possible and finally withdrew the catheter. We next reconstructed the SVC and right atrium by using autologous pericardial patch and Prolene running suture. She had an uneventful postoperative course and infective symptoms quickly resolved. The patient is currently receiving TPN by using the replaced central venous catheter through the right subclavian vein. Six months after the surgery, reconstructed SVC is patent. Nevertheless, the long-term patency of SVC reconstructed using autologous pericardial patch remains to be determined.

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 For the past several decades, much progress has been made in the assessment of prognosis in various diseases. Formerly, prognosis was often graded using stages or adjectives (e. g., grave or favorable). Now it is usually assessed quantitatively in terms of probability of event or time to event and these outcome measures are statistically related to treatment and other prognostic factors. Unfortunately, it was found that even the results of some randomized controlled trials (RCT), which had been defended by evidence-based medicine, did not agree with the long-term clinical outcomes (e. g., Acute Leukemia Group B trial evaluating 6MP and Dutch Gastric Cancer Group trial evaluating extended lymphadenectomy). Such discrepancies may have resulted from the inappropriate use of statistical models. The purpose of this report was to review commonly used statistical models from the clinician's point of view, and to study whether they agree with the long-term observations, and whether their parameters provide useful information for clinicians and patients.
 The statistical models we checked included the logistic model, probit model, and accelerated failure time model, with special reference to the Boag lognormal model with cured fraction and its extensions, and the Cox proportional hazards model and its extensions as well as simulation of RCT using the Boag model and independent competing risk model.
 The results of our studies show that the most commonly used proportional hazards model does not necessarily derive useful information for clinicians and patients and may occasionally misguide them into favoring a suboptimal therapy if follow-up is terminated prematurely.
 In conclusion, as far as statistical models are used to estimate prognosis, error is unavoidable. In order to minimize error, the validation of the model should not be left to statisticians alone. Instead, clinicians should participate in this process with life-long follow-up of patients.

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 The human chromosome consists of 22 autosome pairs and one pair of sex chromosomes. Chromosome preparations processed by G-banding reveal the characteristic banding pattern of each chromosome, and each chromosomal band is numbered by the International System for Human Cytogenetic Nomenclature (ISCN). Chromosome abnormalities in clude numerical (i.e. gain or loss of a whole chromosome) and structural (e.g. translocation, inversion, and deletion) abnormalities, and each abnormality is designated by symbols and abbreviated terms defined by the ISCN. A karyotype describes the total number of chromosomes, followed by sex chromosome constitution, and numerical/structural abnormalities of sex chromosomes and/or those of autosomes. Research into cytogenetic abnormalities in leukemia started with the discovery of the Philadelphia (Ph) chromosome in chronic myelocytic leukemia. J. D. Rowley in Chicago subsequently found that the Ph chromosome was generated by reciprocal chromosomal translocation between chromosomes 9 and 22 with the breakpoint on 9q34 and 22q11.2, respectively. The BCR-ABL fusion gene is generated on the Ph chromosome, thereby encoding the BCR-ABL chimeric oncoprotein. Many recurrent chromosome abnormalities have been identified in acute myelocytic leukemia, including t(8;21)(q22;q22), inv(16)(p13.1q22)/t(16;16)(p13.1;q22), t(15;17)(q22;q12), and t(9;11)(p22;q23), and leukemia-associated genes have been cloned on each breakpoint. On the other hand, -5/del(5q) and -7/del(7q) have been found in secondary leukemia and are associated with myelodysplastic morphology. Fluorescence in situ hybridization has been introduced into the laboratory to identify specific chromosomal translocations and deletions, and is applicable to not only metaphase spreads but also interphase nuclei. As chromosome abnormalities are closely associated with the morphology of leukemic cells and treatment outcomes of patients, cytogenetic analysis is one of the crucial tests for the diagnosis and treatment of leukemia.

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