Journal of Nippon Medical School最新文献

Allergic reactions during chemotherapy can lead to a rare condition known as Kounis syndrome, characterized by the simultaneous occurrence of coronary ischemia and allergic manifestations. Herein, we present a case of a 75-year-old woman who developed carboplatin-induced coronary vasospasm, highlighting the importance of comprehensive clinical and immunological evaluations for an accurate diagnosis. During carboplatin infusion, the patient exhibited typical symptoms, including chest pain and electrocardiographic changes. Subsequent investigations revealed elevated serum tryptase and total immunoglobulin E levels along with normal-looking coronary arteries, confirming a diagnosis of Type I Kounis syndrome. Following a safe recovery from the acute anaphylactic episode, the patient's treatment plan was adjusted accordingly based on this definitive diagnosis. Our findings emphasize the significance of recognizing and documenting immune responses in the diagnosis of Kounis syndrome; this can inform therapeutic strategies and improve patient outcomes.

Background: Epithelial ovarian cancer (EOC) is increasingly affecting women of reproductive age. Fertility-sparing surgery (FSS) is an option for patients with early EOC who want to preserve their fertility, but the oncologic safety of FSS requires rigorous evaluation. This study retrospectively compared the oncologic outcomes of FSS with those of radical surgery (non-FSS) for patients with FIGO 2014 Stage I EOC at our institution.

Methods: We retrospectively reviewed the medical records of patients younger than 45 years diagnosed with FIGO 2014 Stage I EOC (April 2010-June 2024). Patients were categorized into FSS (n=11) and non-FSS (n=9) groups. Baseline characteristics, recurrence rates, progression-free survival (PFS), and overall survival (OS) were compared.

Results: Twenty patients were included. The FSS group was significantly younger (median age 29.2 vs 40.8 years, p=0.043). Recurrence was more frequent in the FSS group (36.4% vs 11.1%), although this difference was not significant (p=0.077). Kaplan-Meier analysis showed no significant difference in PFS (HR 3.24, 95% CI: 0.56-18.74, p=0.19) or OS (HR 1.78, 95% CI: 0.18-16.9, p=0.63).

Conclusion: In this small cohort, FSS for Stage I EOC yielded a higher recurrence rate, but no significant difference in survival, as compared with radical surgery. Because of the small size and inherent stage-migration bias from incomplete surgical staging in the FSS group, these findings should be interpreted with extreme caution. Careful patient selection, thorough staging, and strict surveillance are crucial when implementing FSS.

Background: The global increase in endometrial cancer, including in Japan, and a shortage of pathologists and cytotechnologists have increased the diagnostic burden, emphasizing the need for an AI-based diagnostic support model that uses deep learning. We evaluated the clinical application of an improved AI-supported endometrial cytology model.

Methods: Using YOLOv5x and YOLOv7 models evaluated by mean average precision (mAP), we compared two datasets-one annotated for both benign and malignant cell clusters, and one for malignant only. In addition, using the Two One-Sided Tests (TOST) procedure, we assessed the correlation between AI diagnostic accuracy and the level of difficulty perceived by human diagnosticians. Finally, we used Gradient-weighted Class Activation Mapping (Grad-CAM) to visualize and enhance the interpretability of the AI model's decision-making process.

Results: The YOLOv5x model with both benign and malignant annotations had the highest malignant mAP, 0.798, as compared with YOLOv7. The TOST analysis showed no significant difference in perceived diagnostic difficulty between cases that were correctly and incorrectly diagnosed by the AI model, indicating consistent AI accuracy regardless of case difficulty. Grad-CAM visualizations clarified the AI model's decision-making basis; in some cases, the model appeared to focus on regions that differed from those typically attended to by human diagnosticians.

Conclusion: The AI support model showed high and consistent accuracy in endometrial cytological analysis, regardless of diagnostic difficulty as perceived by human diagnosticians. Grad-CAM visualizations revealed diagnostic patterns, and the AI occasionally focused on regions different from those emphasized by human diagnosticians. This study advanced a real-time microscope-integrated AI system toward clinical application.

Although lipoma is the most common soft tissue tumor, lipoma in the infrapatellar fat pad (IFP) is rare. Herein, we report three cases of lipoma in the IFP that penetrated the joint capsule and extended subcutaneously. All patients presented with unusual MRI findings. Patients 1, 2, and 3 were 63, 74, and 64 years old, respectively, and all were female. Their chief complaint was a knee mass; however, they did not experience pain or limitations in range of motion. The interval from initial awareness of the mass to first consultation was long (3, 8, and 13 years, respectively). MRI revealed that the mass had extended subcutaneously from the IFP through the lateral, medial, and bilateral joint capsules of the patellar tendon, respectively. On MRI, the masses appeared as lipomatous tumors with scattered low signal areas on T1-weighted imaging. The tumors excised after biopsy had long axes of approximately 6, 7, and 7 cm, respectively. Histological examination revealed lipomas with partial fibrosis in all three tumors and cartilage metaplasia in the tumor from patient 3. Lipomas in IFPs often exhibit secondary changes, such as fibrosis and cartilage metaplasia, resulting in MRI findings that differ from those of typical lipomas. In the present cases, biopsy was necessary to differentiate them from atypical lipomatous tumors or Hoffa disease.

A 78-year-old man was diagnosed as having a submucosal gastric mass (diameter 4 cm). Preoperative findings from endoscopic ultrasound-guided fine needle aspiration suggested a diagnosis of gastric neuroendocrine neoplasm. Total gastrectomy with excision of a metastatic liver lesion and dissection of gastric lymph nodes was performed. Analysis of frozen sections indicated adenocarcinoma of the peritoneum, which suggested the possibility of a mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN), based on the presence of solid tubules, metastatic spread, and lymphovascular invasion. However, the smooth gastric mucosal surface, organoid architecture with rare atypia or necrosis, immunopositivity for neuroendocrine markers, a Ki-67 index of 21%, and the presence of somatostatin receptor 2 expression confirmed a final pathological diagnosis of grade 3 gastric neuroendocrine tumor (NETG3) with glandular formation. NETG3 with glandular formation can be difficult to distinguish from MiNEN because their histological features overlap. However, gastric NETG3 with glandular formation is distinguishable from MiNEN by the presence of a submucosal tumor with a histological organoid pattern without frequent mitoses and/or necrosis, immunopositivity for neuroendocrine markers, and the absence of an adenocarcinoma or neuroendocrine carcinoma component within the tumor, as determined by immunohistochemistry for somatostatin receptor 2 expression, Ki-67, and Rb1.

Introduction: Because of its lower risk of mediastinal complications, the retrosternal route is commonly used for reconstruction after subtotal esophagectomy. However, cases of postoperative gastric conduit obstruction at the thoracic inlet have been reported, as has passage disturbance at the feeding jejunostomy site. These obstructions are often managed by surgical treatment, but few reports have described endoscopic treatment.

Case presentation: A 75-year-old man with advanced mid-thoracic esophageal cancer underwent three courses of DCF chemotherapy, followed by robotic esophagectomy with gastric conduit reconstruction via the retrosternal route and feeding jejunostomy. Preoperative CT showed no thoracic inlet stenosis. On postoperative day (POD) 7, a barium swallow test revealed cervical esophageal dilation and narrowing of the gastric conduit due to external compression at the thoracic inlet. In addition, a passage disturbance at the feeding jejunostomy site developed later. Endoscopic balloon dilation was performed at both sites on POD 26 and 31, resulting in resolution of both obstructions. The patient resumed adequate oral intake and was discharged without the need for reoperation.

Conclusions: This case suggests that endoscopic balloon dilation is an effective, minimally invasive alternative to surgery for managing postoperative gastric conduit and jejunostomy obstructions after esophagectomy.

Leptomeningeal metastasis (LM) from colorectal cancer is rare. LM is characterized by rapid progression, making diagnosis and treatment challenging, and are associated with a poor prognosis. A 63-year-old man undergoing chemotherapy with bevacizumab for colorectal cancer was admitted to our hospital with loss of appetite. On admission, he experienced frequent episodes of loss of consciousness. Imaging to identify the underlying cause revealed no abnormalities. Cytological examination of cerebrospinal fluid confirmed LM. Because of worsening symptoms, the patient had difficulty communicating, thus preventing continuation of chemotherapy. He died at 3 weeks post-admission. In patients with cancer who exhibit central nervous system symptoms without abnormal imaging findings, LM should be considered even if the primary tumor is in the transverse colon. In such cases, cytological examination of cerebrospinal fluid and imaging studies should be conducted. This rare case of LM from colorectal cancer after resection and chemotherapy with molecularly targeted agents yielded insights that might guide future treatment strategies.

A transgender (trans) man is a trans person who was assigned female sex at birth. Some trans men undergo gender-affirming surgical procedures, particularly mastectomy. We present a case of keloid formation after gender-affirming mastectomy that highlights the importance of choosing the most appropriate mastectomy technique in patients at risk of keloid and the most effective therapeutic strategies for anterior-chest keloids. A 40-year-old Japanese trans man developed keloids along inverted-T mastectomy-induced anterior-chest scars. The keloids were completely excised, and the defects were closed by primarily using a layered technique. Starting the next day, the wounds were treated with radiotherapy over 3 consecutive days. The wounds/scars were carefully monitored and treated with continuous taping fixation for 1 year. There was no recurrence, and aesthetic outcomes at 18 months were good. To prevent keloids after gender-affirming mastectomy, surgeons must estimate individual risk of keloid formation. If the patient is young, of Asian or African descent, or has a personal or family history of keloids, surgical methods that leave long lateral scars on the anterior chest (e.g., the inverted T procedure) should be avoided. Tensionless or tension-reducing surgical techniques should also be used, along with postoperative radiotherapy, long-term taping or compression, close follow-up to detect early signs of keloid formation, and referral to a plastic surgery department if any scar induration or elevation is observed. Surgeons performing gender-affirming mastectomy can potentially reduce the risk of keloid formation by carefully considering these factors.

Unlike Langerhans cell histiocytosis (LCH) involving the skull, LCH of the vertebrae and lungs requires careful long-term follow-up because of the risks of motor and respiratory dysfunction; however, few reports have addressed this issue. A boy aged 7 years 7 months presented with bilateral shoulder pain and neck pain. Initial imaging revealed C6 vertebral bone lysis, a mass spanning C5-C7, C6 vertebral body flattening, and epidural extension. Chest radiographs and CT scans showed diffuse reticular and funicular shadows, ground-glass opacities, interlobular septal thickening, and swollen hilar lymph nodes. Bone scintigraphy showed cervical accumulation, while gallium scintigraphy revealed diffuse lung uptake. Lung biopsy confirmed LCH (CD1a, S-100, langerin positivity), confirming a diagnosis of multisystem LCH involving lung, bone, skin, and soft tissue. Treatment with cytarabine, vincristine, and prednisolone, in accordance with the Japan LCH Study Group-02 protocol, resulted in rapid respiratory improvement, withdrawal of oxygen, and resolution of neck pain. Seven years after completing chemotherapy, the patient had no neck discomfort and satisfactory cervical motion, normal respiratory function, and no respiratory symptoms. A cervical MRI scan at 1.5 years after the end of chemotherapy showed persistent C6 vertebral flattening from the compression fracture, which remained clinically stable throughout follow-up, with no herniation, mass formation, or epidural recurrence. Chest imaging at a 7-year follow-up examination showed no abnormalities. These findings suggest that timely diagnosis and appropriate chemotherapy yield favorable long-term outcomes in multisystem LCH with vertebral and pulmonary involvement, and avoid major sequelae.

A 76-year-old woman was referred to our hospital for evaluation of markedly high intraocular pressures (IOPs): ≥40 mmHg in both eyes. No intraocular inflammation, pseudoexfoliation, or glaucomatous optic neuropathy was observed on ophthalmological examination. The 24-hour IOP fluctuations, measured with a Goldmann tonometer in the sitting position at 8, 12, 16, 20, and 24 o'clock, were 22/17, 33/28, 41/33, 30/22, and 30/24 mmHg, respectively, and showed a peak in the afternoon. The patient was diagnosed with ocular hypertension, and microhook trabeculotomy (μLOT) (right eye with lens reconstruction, left eye initially pseudophakic) was performed. After μLOT surgery in both eyes (4 days postoperatively in the right eye and 1 day postoperatively in the left eye), IOP decreased in both eyes to 12/15, 11/14, 12/15, 10/11, and 10/10 mmHg, and the fluctuation range was suppressed. At 3 months postoperatively (measured at 8, 12, 16, 20, 24, and 4 o'clock), the effect was maintained at 14/15, 15/19, 14/19, 11/12, 13/14, and 13/13 mmHg, respectively, but was slightly attenuated. In a patient with marked 24-hour IOP fluctuation, μLOT was effective in reducing IOP values and fluctuation.