Background: In daily medical practice, there are many decisions to be made; wrong decision-makings may result in serious outcomes for the patient. Even if the outcome appears to be desirable for the physician, it may be undesirable for the patient in the era of patient-centered medicine; we studied clinical decision-making under uncertainty on the basis of the teachings of great names in history and their works.

Methods: We cited the Maxim by the Hippocrates School, the Ojoyoso by Genshin, Zoshi by Toyo Yamawaki, and the Introduction of the Study of Experimental Medicine by Claude Bernard. We evaluated their effects on advances in medical decision-making.

Results: Even earlier than 2000, the School of Hippocrates recognized the difficulty of decision-making, the danger of physician’s experience, and the elusive nature of opportunity. Genshin (a Buddhist priest in the Heian Era) taught people that life is valued as equal to death, being full of agony and pain; comfort is only gained in the paradise after death. Thus, he dramatically changed the order of outcome values. Toyo Yamawaki and Claude Bernard discouraged theoretical or hypothetical approaches in medical science and advocated evidence-based outcome approaches. They contributed to the evolution of surgical research, clinical decision analysis, and evidence-based medicine.

Conclusion: It is not only Genshin and his followers who believe that life is full of agony and pain, and wish that their lives might be better if shortened by sudden Pokkuri death, rather than be prolonged. Physicians should take such wishes into consideration.

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 We present a 63-year-old male patient with acute myeloid leukemia (AML). His hemoglobin level was 10.0 g/dL, white cell count was 16.78 × 10³/μL with 94.6% blasts, and platelet count was 91 × 10³/μL. The bone marrow had 20% cellularity with 87.0% blasts. Approximately 20% of blasts in the peripheral blood exhibited cup-like nuclear morphology, and many mitochondria were concentrated within the nuclear pocket under electron microscopy. The blasts were negative for myeloperoxidase, but expressed CD13 and CD33. CD34 was positive and HLA-DR was weak. The cells demonstrated normal G-banding cytogenetics, and lacked FMS-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD) and nucleophosmin 1 (NPM1) gene mutation. The patient relapsed shortly after a response to initial chemotherapy and died 9 months after presentation. To date, we have encountered a total of 6 cases of cup-like AML in our institution. The ages ranged from 62 to 80 and male to female ratio was 3 to 3. Two had French-American-British M0, one had M1, two had myelomonocytic/monocytic leukemia, and the remaining one had hypoplastic leukemia. Two presented with marked leukocytosis, while the other two had leukopenia. All cases exhibited expression of myeloid antigens, and weak or negative expression of CD34 and/or HLA-DR. All cases carried a normal karyotype, and four had FLT3-ITD or NPM1 mutations, or both. In the nuclear indentation, a condensed collection of mitochondria was observed in all. At present, it remains to be determined whether cup-like nuclear morphology represents a distinctive AML subtype associated with particular clinical features, genetic abnormality, or treatment outcome.

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 We report a 13-year-old boy who had experienced recurrent stomatitis from the age of 3. On admission, he complained of abdominal pain in the right lower quadrant and the anus, and exhibited 11 kilograms of weight loss during the last 3 weeks. His mother and his cousin on his mother side were diagnosed with Behçet's disease. There were aphthous ulcerations in his mouth and an erosion around the anus, and spiralshaped ulcerative lesions with a white-coating were observed in the ileocecal region by colonoscopy. He was diagnosed with an incomplete form of intestinal-type Behçet's disease according to the criteria. His symptoms as well as laboratory abnormalities improved in response to nutritional treatment for inflammatory bowel disease and oral administration of prednisolone, colchicine, and mesalazine. It appears that this case represents inherited Behçet's disease because of the rich family history.

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 The application of laparoscopic surgery in pregnant woman is currently increasing. Many case reports attest to the safety of laparoscopic surgery over laparotomy during pregnancy. In most cases, laparoscopic surgery is performed within 12 to 16 weeks of pregnancy, and in some rare cases, it may be performed at a later gestational age. We report four pregnant women who underwent laparoscopic ovarian cystectomy at 16 to 18 weeks of gestation. The tumor diameters ranged from 7.5 to 9 cm. Pathological diagnosis was mature cystic teratoma in three and serous cystadenoma in one. Operation times ranged from 157 to 232 minutes, with longer times for operations performed at a later gestational age. No intraoperative or postoperative maternal or fetal complications occurred. As the uterus is enlarged during pregnancy, the trocar sites should be placed on the umbilicus and at a more cephalad level on the same side of the tumor. Laparoscopic surgery can be performed safely at 16 or more weeks of pregnancy.

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 The incidence of arterial rupture following irradiation of head and neck cancer is frequently reported, but it is rare in gynecological cancer. We report a 66-year-old woman who survived rupture of the external iliac artery sixteen months after whole pelvic irradiation for recurrent ovarian cancer. She had undergone abdominal total hysterectomy and bilateral salpingo-oophorectomy for stage IA ovarian cancer, and received adjuvant chemotherapy. However, a cystic tumor recurred in the pelvis. Four regimens of chemotherapy could not effectively control the recurrent mass and she received 54 Gy of whole pelvic irradiation. Radiotherapy was effective, but sixteen months after radiotherapy, a tumor-rectal fistula formed and caused an abscess in the tumor. Thus, we performed fenestration surgery by cutting the vaginal stump under general anesthesia. Although blood loss during the surgery was low, marked genital bleeding occurred immediately after extubation and the patient went into hemorrhagic shock. Emergency angiography was performed and we observed rupture of the right external iliac artery. We therefore placed an endovascular stent graft in the ruptured artery and stopped the bleeding. Following irradiation of gynecological cancer as well as head and neck cancer, arterial rupture can occur. Computed tomography is useful to estimate its incidence. When it occurs, immediate endovascular treatment should be considered.

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 An 84-year-old male smoker, who underwent left upper lobectomy for a lung adenocarcinoma six years earlier, was admitted to our institution due to loss of appetite and exertional dyspnea. Computed tomography scanning demonstrated a tumor shadow in the upper lobe of the right lung, mediastinal lymphadenopathy, and tumor shadows in the liver. His blood test revealed anemia (hemoglobin, 9.9 g/dL), thrombocytopenia (platelet count, 32 × 10³/µL), and increased serum levels of lactate dehydrogenase (2,391 IU/L) and soluble interleukin-2 receptor (6,954 U/mL). Examination of the bone marrow smear showed large neoplastic cells, comprising 70% of nucleated cells, and the cells lacked expression of lymphoid and myeloid antigens on flow cytometry analysis. A bone marrow biopsy demonstrated that the marrow space was replaced by the proliferation of large neoplastic cells, and some areas exhibited an organoid nesting pattern. Immunohistochemistry revealing that neoplastic cells were positive for synaptophysin and chromogranin established the diagnosis of large-cell neuroendocrine carcinoma (LCNEC). This replacement of bone marrow with carcinoma cells is a rare presentation of LCNEC and abnormalities in laboratory test results resembled those in hematolymphoid tumors.

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 A 65-year-old woman presented with marked hepatomegaly and polyclonal hypergammaglobulinemia. Her total serum protein was 8.9 g/dL with 35.6% albumin and 40.2% (35.8 mg/mL) γ globulin. Alkaline phosphatase was 730 IU/L. The cranio-caudal liver span measured on computed tomography was 24.2 cm. A biopsy of the liver revealed replacement of the liver parenchyma with amorphous eosinophilic materials that were stained positive with Congo red and showed the apple-green birefringence of amyloid; amyloid deposits were also observed in the gastric mucosa and bone marrow (BM). Although immunofixation of the serum and urine detected no monoclonal component, the serum free light chain (FLC) assay revealed an excess of FLC-κ (FLC-κ, 1,290 mg/L; FLC-λ, 86 mg/L). The BM contained 10.4% clonal plasma cells carrying the CCND1-immunoglobulin heavy chain fusion gene. She was diagnosed with AL amyloidosis and treated with bortezomib-based chemotherapy, readily leading to the hematological response fulfilling the criteria of very good partial response. The hepatomegaly was steadily resolved in response to persistent administration of bortezomib for >2 years. It is possible that the hypergammaglobulinemia reflected a reactive process against amyloid deposits in the liver. This report suggests that plasma cell-targeting therapy can reduce the amyloid deposits from the involved organs, potentially reversing their dysfunction.

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 Anti-N-methyl-D-aspartate (NMDA)-receptor encephalitis is a type of autoimmune limbic encephalitis that occurs in young women. We report a case of laparoscopic surgery in a young woman suspected to have anti-NMDA-receptor encephalitis associated with ovarian teratoma.
 A 21-year-old woman presented with fever, headache, and unusual behavior that developed a month before her hospital visit. Two weeks later, she was admitted to a psychiatric hospital with a diagnosis of schizophrenia. Despite receiving antipsychotic therapy, her consciousness deteriorated and symptoms of involuntary movement developed. Ten days later, she was admitted to the department of neurology, and a CT scan detected a tumor in her left ovary. Since anti-NMDA-receptor encephalitis was suspected, she was referred to our hospital to undergo surgery.
 The patient underwent laparoscopic left salpingo-oophorectomy and received methylprednisolone (mPSL) + intravenous immunoglobulin (IVIG) for immunosuppressive therapy. The pathological diagnosis was a mature teratoma. After 35 days, anti-NMDA-receptor antibodies were detected in the cerebrospinal fluid and the diagnosis of anti-NMDA-receptor encephalitis was confirmed. Her impaired consciousness significantly improved, and she was discharged 50 days after the operation.
 The clinical course of anti-NMDA-receptor encephalitis is severe and has a characteristically long recovery period. Early diagnosis and surgery are important for the prompt recovery of anti-NMDA-receptor encephalitis associated with ovarian teratoma. It is necessary for clinicians including psychiatrists, neurologists, and gynecologists to be aware of this disease.

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