Tenri Medical Bulletin
Online ISSN : 2187-2244
Print ISSN : 1344-1817
ISSN-L : 1344-1817
Volume 16, Issue 2
Displaying 1-12 of 12 articles from this issue
Special Article
Original Article
  • Shunzo Maetani, Hitoshi Obayashi, Yoshiaki Segawa, Hideo Banja, Hiroak ...
    Article type: Original Article
    2013 Volume 16 Issue 2 Pages 70-78
    Published: 2013
    Released on J-STAGE: December 25, 2013
    JOURNAL FREE ACCESS
     Overall 5-year survival has long been used as an approximate measure of the proportion of patients cured of a particular cancer under study. For more accurate estimation of the cure rate, we applied the Boag parametric cure model to follow-up data from cancer patients.
     Three datasets were used, comprising 1,410 patients with gastric cancer, 1,754 with colonic cancer and 10,447 with pancreatic cancer; all underwent surgical resections and were followed up. The patients were classified into 14 groups by cancer type and TNM stage and for each group the 5-year survival rate was compared with the cure rate, which was estimated by the maximum likelihood method based on the Boag model. The effects of pathological factors including tumor size, serosal invasion, nodal involvement and venous invasion on the cure rate were evaluated by the Boag model and the Gamel-Boag regression.
     The results showed that, in 11 of the 14 cancer-stage groups, the 5-year survival was greater than the corresponding cure rate. Of the three cancers the pancreatic cancer showed the lowest cure rate: the curable fraction was about 16% with tumor size <= 4 cm. In contrast, patients with colonic cancer were highly curable:75% of them were cured even when their tumor size >4 cm. Only the group with positive venous invasion showed a cure rate less than 75%. This lower curability is explained by the fact that liver metastasis, a common form of relapse of colonic cancer, is preceded by venous invasion. Gastric cancer was intermediate in curability between pancreatic and colonic cancers.
     In conclusion, the estimation of cure rate provides a clear and deep insight into the relationship between patient outcome and prognostic factors, permitting patients and clinicians to make better clinical decisions.
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Case Report
  • Futoshi Iioka, Daiki Shimomura, Katsuyo Tsuda, Masahiko Hayashida , ...
    Article type: Case Report
    2013 Volume 16 Issue 2 Pages 79-88
    Published: December 25, 2013
    Released on J-STAGE: December 25, 2013
    JOURNAL FREE ACCESS
     A 65-year-old man presented with remittent fever and macrocytic anemia. His hemoglobin level was 7.6 g/dL, mean corpuscular volume 105 fL, white blood cell count 2,200/µL, and platelet count 272 × 103/µL. Bone marrow aspirates showed 40% cellularity with marked erythroid hypoplasia and dysplasia of granulocyte- and megakaryocyte-lineage cells. Blasts, comprising 17.8% of nucleated cells, were composed of two populations: type A blasts were myeloperoxidase-positive myeloid precursors, while type B blasts had an eccentric nucleus and abundant cytoplasm, and electron microscopic examination revealed tubuloreticular inclusions. Flow cytometry discriminated a mononuclear cell population that expressed CD4, CD36, CD45RA, CD123, CD303, CD304, and HLA-DR, but lacked CD1a, CD11c, CD34, and CD56 and lineage-specific markers; this phenotype most likely represented type B blasts. G-banding revealed del(5)(q13q33) as the sole cytogenetic abnormality and 79.7% of interphase nuclei, including those of both types of blasts, were found to lack one 5q31 signal by fluorescence in situ hybridization. The patient responded well to daunorubicin-cytarabine induction chemotherapy and successfully underwent allogeneic hematopoietic stem cell transplantation, achieving long-term disease-free survival. We herein describe a rare case of myelodysplastic syndrome, in which blasts differentiated to plasmacytoid dendritic cells in vivo. The biological and clinical significance of this rare condition remains to be clarified.
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  • Satoshi Okamori, Yoshitomo Maesako, Jun Ehara, Kumi Fujita, Kayo Tak ...
    Article type: Case Report
    2013 Volume 16 Issue 2 Pages 89-100
    Published: December 25, 2013
    Released on J-STAGE: December 25, 2013
    JOURNAL FREE ACCESS
     A 64-year-old man was admitted to our institution due to anasarca and lymphadenopathy. His blood pressure was 100/60 mmHg under vasopressor support and oxygen saturation was 85% despite oxygen supplementation. Blood tests showed anemia and hypoalbuminemia, and soluble interleukin-2 receptor was 47,920 U/mL. Computed tomography demonstrated marked subcutaneous edema and a large volume of pleural fluid in the thoracic cavity associated with lung atelectasis. A biopsy of the axillary lymph node revealed anaplastic lymphoma receptor tyrosine kinase-positive (ALK+) anaplastic large cell lymphoma (ALCL); ALK was expressed solely in the cytoplasm. G-banding revealed two marker chromosomes derived from chromosome 2, determined as inv(2)(p23q35) and der(2)inv(2)(p23q35)del(2)(p21) by combination with fluorescence in situ hybridization using the Vysis ALK probe. ATIC-ALK fusion mRNA was confirmed by reverse transcriptase-mediated polymerase chain reaction and sequencing. The patient was emergently admitted to the intensive care unit to be treated by mechanical ventilation and continuous hemodiafiltration. However, he responded poorly to chemotherapy and died of disease progression. Postmortem examination revealed that the lymphoma had disseminated predominantly in the lung; multiple nodular lesions composed of lymphoma cells were distributed in the organizing lung parenchyma and associated with bronchovascular bundles. The alveoli and small airways around the nodules were filled with collagenous fibrous tissue. This report indicates that ALK+ ALCL can occur in older individuals and the clinical outcome may be poor in elderly patients. It is possible that the presenting symptoms (i.e., anasarca and cardiopulmonary failure) resulted from systemic capillary leak syndrome, and that the disseminated lung involvement of ALCL affected the organizing process of the lung parenchyma.
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  • Masahiro Fukushima , Masahiko Matsumura, Takeshi Shiba, Shinichiro Yos ...
    Article type: Case Report
    2013 Volume 16 Issue 2 Pages 101-105
    Published: December 25, 2013
    Released on J-STAGE: December 25, 2013
    JOURNAL FREE ACCESS
     A 1-year and 9-month-old boy presented with fever, red eyes, redness of his lips, rash on his trunk and erythema around a BCG scar. On the 8th day of illness, he was diagnosed with incomplete Kawasaki disease and received intravenous immunoglobulin at a dose of 2 g per kilogram. The fever subsided the next day, but his ECG showed second-degree atrioventricular (AV) block (Wenckebach type). Because he was not able to sit up and was not active, he was transferred to our hospital on the 11th day of illness. He was followed up with oral aspirin therapy and his diagnostic symptoms of Kawasaki disease were relieved without any coronary artery abnormality. Second-degree AV block disappeared on the 13th day of illness and first-degree AV block disappeared on the 16th day of illness. He was able to sit up on the 16th day of illness and to walk around on the 18th day, and was discharged on the 19th day.
     Several types of arrhythmia have been reported as one of the complications of Kawasaki disease. We studied the frequency of arrhythmias in Kawasaki disease patients in our hospital. During fifteen years, 5 out of 100 Kawasaki disease patients had arrhythmias. This result is lower than in previous reports. Although the prognosis of arrhythmias associated with Kawasaki disease is generally good, it is necessary to be careful of the development of arrhythmias.
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Mini-symposium for resident physicians of Tenri Hospital
  • Hitoshi Ohno
    Article type: Mini-symposium for resident physicians of Tenri Hospital
    2013 Volume 16 Issue 2 Pages 106-110
    Published: December 25, 2013
    Released on J-STAGE: December 25, 2013
    JOURNAL FREE ACCESS
     On February 2, 2013, a mini-symposium entitled: “Hodgkin Lymphoma: Case Presentation and Treatment Outcome in Tenri Hospital” was held in Nara Royal Hotel. The key feature of this symposium was that it was specifically aimed at providing a platform for resident physicians of Tenri Hospital to present their knowledge and understanding of Hodgkin lymphoma obtained through the management of their own patients with this particular disease. The symposium attracted clinical hematologists, radiologists, and pathologists working in Nara Prefecture involved in the diagnosis and treatment of hematological tumors. In this meeting report, we briefly present a biography of Dr. Thomas Hodgkin, who first described the disease bearing his name, 180 years ago. Next, we highlight some of the most significant findings reported by the young and talented physicians-in-training of Tenri Hospital.
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  • Shunsuke Nishimura, Takashi Akasaka, Futoshi Iioka, Yoshimasa Kamoda, ...
    Article type: Mini-symposium for resident physicians of Tenri Hospital
    2013 Volume 16 Issue 2 Pages 111-118
    Published: December 25, 2013
    Released on J-STAGE: December 25, 2013
    JOURNAL FREE ACCESS
     A 58-year-old man was immediately hospitalized in our department because of generalized lymphadenopathy and recurring fever. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) revealed marked FDG accumulation within enlarged lymph nodes from the neck through to the inguinal region, while the axial and proximal appendicular skeleton showed diffuse and homogeneous FDG uptake. The level of hemoglobin was 12.8 g/dL, white blood cell count 6,300/μL, including 20.0% lymphocytes, and platelet count 205×103/μL. Serum albumin was 3.3 g/dL, lactate dehydrogenase 507 IU/L, aspartate aminotransferase 570 IU/L, alanine aminotransferase 419 IU/L, alkaline phosphatase 1,172 IU/mL, total bilirubin 2.3 mg/dL, ferritin 2,075 ng/mL, C-reactive protein 12.4 mg/dL, and soluble interleukin-2 receptor 6,305 U/mL. A biopsy of the left supraclavicular lymph node showed the features of the mixed cellularity subtype of classical Hodgkin lymphoma. Examination of May-Giemsa-stained smear slides of bone marrow (BM) aspirates revealed 1.4% Reed-Sternberg (RS)/Hodgkin (H) giant cells associated with monocytes/macrophages ingesting blood cells. The BM biopsy specimen contained foci of pleomorphic cellular infiltrates, and immunohistochemistry highlighted CD30-positive RS/H cells, corresponding to the “certain” category of the histopathological criteria of BM involvement. The disease responded well to ABVd chemotherapy, and the patient achieved a complete response. This case report indicates that the BM test is still mandatory to detect BM disease, and 18F-FDG PET cannot be a substitute for BM aspiration/biopsy.
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  • Tsutomu Wada, Futoshi Iioka, Yoshimasa Kamoda, Yoshitomo Wada, Takashi ...
    Article type: Mini-symposium for resident physicians of Tenri Hospital
    2013 Volume 16 Issue 2 Pages 119-125
    Published: December 25, 2013
    Released on J-STAGE: December 25, 2013
    JOURNAL FREE ACCESS
     A 63-year-old man was admitted to our institution due to loss of 6 kilograms in body weight during the past 2 months. There was no surface lymphadenopathy, and the spleen was palpated 3 finger-breadths below the left costal margin. The hemoglobin level was 11.1 g/dL, white blood cell count 7,100/µL, including 13.0% lymphocytes, and platelet count 121×103/µL. Serum albumin was 3.4 g/dL, C-reactive protein 18.0 mg/dL, erythrocyte sedimentation rate 78 mm/hr, and soluble interleukin-2 receptor 7,107 U/mL. Computed tomography of the body demonstrated an enlarged spleen containing multiple nodules and marked para-aortic lymphadenopathy, as well as supraclavicular lymph node swelling, and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) revealed strong uptake within the enlarged lymph nodes and spleen. A paraaortic lymph node biopsy showed the nodular sclerosis (NS) subtype of classical Hodgkin lymphoma (CHL), and infection with Epstein-Barr virus (EBV) was determined based on the positivity of EBV-encoded small RNAs and polymerase chain reaction amplification of the virus fragment. The patient was diagnosed with CSIII-2B disease of NSCHL and treated with ABVD combination chemotherapy. An 18F-FDG PET scan performed after 2 cycles of ABVD showed resolution of 18F-FDG-avid lymphadenopathy and splenomegaly. The patient finally achieved a complete response after the completion of 6 cycles of ABVD. The pathogenesis of the present case of EBV-positive NSCHL involving an older man may not be identical to that of EBV-negative NSCHL that predominantly develops in younger patients. Despite the presence of risk factors before treatment, an early complete metabolic response determined by 18F-FDG PET suggests long-term progression-free survival.
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Brief Report
  • Katsuhiro Fukutsuka, Kayo Takeoka, Masahiko Hayashida, Fumiyo Maekawa, ...
    Article type: Brief Report
    2013 Volume 16 Issue 2 Pages 126-132
    Published: December 25, 2013
    Released on J-STAGE: December 25, 2013
    JOURNAL FREE ACCESS
     An acquired mutation in the Janus kinase 2 (JAK2) gene, V617F, is identified in subtypes of myeloproliferative neoplasms (MPNs) at high frequency and is one of the diagnostic criteria for MPNs. To detect the JAK2 V617F mutation, melting curve (MC) and amplification refractory mutation system (ARMS) assays have been developed. We first applied a dilution series of mutated DNA in wild-type DNA for each assay to determine the analytical sensitivities. The result showed that MC assay with inspection of the melting curves identified the mutated population at >5%, while ARMS detected the mutation with a limit of 1%. We next subjected DNA extracted from the peripheral blood in cases of MPN or other hematologic diseases to MC and ARMS assays. Of 11 cases of polycythemia vera (PV), all cases were positive for the mutation by both assays, including one with “mixed type” by MC but “mutant” by ARMS. Of 8 cases of essential thrombocytosis (ET), 5 by MC and 6 by ARMS showed the “mixed-type” pattern, while “mutant” cases were absent. One discordant case with ET,in which MC was negative but ARMS was positive, was estimated to contain a 3% mutated population at initial assay, while the percentage increased to 14.3% after 2 years. Two cases of myelodysplastic syndrome were mutation-positive. Our study showed that MC assay is sufficient to detect JAK2 V617F mutation in PV. However, high-sensitivity ARMS assay should be applied to ET, in which the mutated population may comprise a small fraction of the test material, when MC assay is negative.
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