ORIGINAL PAPERS
Influence of spinal imbalance on knee osteoarthritis in
community-living elderly adults
Ryoji Tauchi, Shiro Imagama, Akio Muramoto, Masaki Tsuboi, Naoki Ishiguro
and Yukiharu Hasegawa
pg(s) 329 - 337
<Abstract> - < PDF >
Previous studies evaluated various risk factors for knee OA; however, no study has examined the
association between spinal factors, such as total spinal alignment and spinal range of motion (ROM), with
knee OA. The purpose of this study was to examine the influence of spinal factors including total spinal
alignment and spinal ROM on knee OA in community-living elderly subjects. A total of 170 subjects
≥60 years old (mean age 69.4 years, 70 males and 100 females) enrolled in the study (Yakumo study)
and underwent a basic health checkup. We evaluated A-P knee radiographs, sagittal parameters (thoracic
kyphosis angle, lumbar lordosis angle, and spinal inclination angle) and spinal mobility (thoracic spinal
ROM, lumbar spinal ROM and total spinal ROM) as determined with SpinalMouse®. The radiological
assessment of knee OA was based on the Kellgren and Lawrence classification, and the knee flexion angle
was measured while the subject was standing. Spinal inclination angle and thoracic spinal ROM correlated
significantly with knee OA on univariate analyses. Multivariate logistic regression analysis indicated that an
increase in spinal inclination angle (OR 1.073, p<0.05) was significantly associated with knee OA. Spinal
inclination angle had significant positive correlation with knee flexion angle (r=0.286, p<0.001). The spinal
inclination angle is the most important factor associated with knee OA.
Evaluation of the field-in-field technique with lung blocks
for breast tangential radiotherapy
Hidekazu Tanaka, Shinya Hayashi, Yuichi Kajiura, Masashi Kitahara,
Katsuya Matsuyama, Masayuki Kanematsu and Hiroaki Hoshi
pg(s) 339 - 345
<Abstract> - < PDF >
Several studies have reported the advantages of the field-in-field (FIF) technique in breast radiotherapy,
including dose reduction in the lungs by using lung field blocks. We evaluated the FIF technique with
lung blocks for breast tangential radiotherapy. Sixteen patients underwent free breathing (FB) computed
tomography (CT), followed by two CT procedures performed during breath hold after light inhalation
(IN) and light exhalation (EX). Three radiotherapy plans were created using the FIF technique based on
the FB-CT images: one without lung blocks (LB0) and two with lung blocks whose monitor units (MUs)
were 5 (LB5) and 10 (LB10), respectively. These plans were copied to the IN-CT and EX-CT images.
V20Gy, V30Gy, and V40Gy of the ipsilateral lung and V100%, V95%, and the mean dose (Dmean) to the
planning target volume (PTV) were analyzed. The extent of changes in these parameters on the IN-plan
and EX-plan compared with the FB-plan was evaluated. V20Gy, V30Gy, and V40Gy were significantly
smaller for FB-LB5 and FB-LB10 than for FB-LB0; similar results were obtained for the IN-plan and
EX-plan. V100%, V95%, and Dmean were also significant smaller for FB-LB5 and FB-LB10 than for
FB-LB0. The extent of changes in V20Gy, V30Gy, and V40Gy on the IN-plan and EX-plan compared
with the FB-plan was not statistically significant. Lung blocks were useful for dose reduction in the lung
and a simultaneous PTV decrease. This technique should not be applied in the general population.
Preoperative embolization of meningiomas with
low-concentration n-butyl cyanoacrylate
Taiki Yamamoto, Tomotaka Ohshima, Masahiro Nishihori, Shunsaku Goto,
Toshihisa Nishizawa, Shinji Shimato and Kyozo Kato
pg(s) 347 - 353
<Abstract> - < PDF >
The aim of this study was to determine the clinical safety and efficacy of preoperative embolization
of meningiomas with low-concentration n-butyl cyanoacrylate (NBCA). Nineteen cases of hypervascular
intracranial meningiomas were treated by preoperative embolization with 14% NBCA, using a wedged
superselective catheterization of feeding arteries and reflux-hold-reinjection technique. Clinical data of
the patients and radiological and intra-surgical findings were reviewed. All tumors were successfully
devascularized without any neurological complications. Marked reduction of tumor staining with extensive
NBCA penetration was achieved in 13 cases. Perioperative blood transfusion was only required in two
cases. These results indicate that preoperative embolization of meningiomas with low-concentration NBCA
is both safe and effective.
Long-term effects of tolvaptan in patients requiring recurrent
hospitalization for heart failure
Hayato Ogawa, Masayoshi Ajioka, Hideki Ishii, Takahiro Okumura,
Yosuke Murase, Hiroyuki Osanai, Yoshihito Nakasima, Hiroshi Asano,
Kazuyoshi Sakai and Toyoaki Murohara
pg(s) 355 - 362
<Abstract> - < PDF >
Although reports suggest that tolvaptan does not reduce survival or subsequent hospitalization rates
in heart failure patients, its continuous use has shown good outcomes in some patients who cannot be
effectively managed with high doses of loop diuretics. Therefore, we investigated the association of patient
characteristics and continued tolvaptan use in heart failure patients with changes in the frequency and
annual duration of patient hospitalization due to heart failure. We carefully reviewed the medical records
of patients hospitalized due to heart failure who began tolvaptan therapy and continued with outpatient
treatment between December 2010 and November 2013 (tolvaptan group); patients hospitalized for heart
failure between May 2008 and March 2009 served as controls. We set the reference dates as the start
of tolvaptan therapy (tolvaptan group) or as the date of admission (control group). The changes in
hospitalization frequency and total hospitalization time due to heart failure, before and after the reference
dates, were not significantly different between the tolvaptan and control groups. In the tolvaptan group, a
high estimated glomerular filtration rate was a predictor of decreased hospitalization. Continuous tolvaptan
use did not decrease hospitalization duration in all heart failure patients, but good renal function was
predictive of a good response.
The prognostic impact of pulmonary metastasectomy
in recurrent gynecologic cancers:
a retrospective single-institution study
Manabu Adachi, Mika Mizuno, Hiroko Mitsui,
Hiroaki Kajiyama, Shiro Suzuki, Ryuichiro Sekiya,
Fumi Utsumi, Kiyosumi Shibata, Tetsuo Taniguchi,
Koji Kawaguchi, Kohei Yokoi
and Fumitaka Kikkawa
pg(s) 363 - 372
<Abstract> - < PDF >
The aim was to examine the impact of pulmonary metastasectomy in patients with recurrent gynecologic
cancers. Thirty-seven patients with isolated lung metastases (< 3 nodules) in recurrent epithelial gynecologic
cancers were treated at Nagoya University Hospital between 1985 and 2013. The clinicopathological data
for the 23 patients who underwent surgical resection were retrospectively analyzed, and their survival
was compared with patients who received chemotherapy only. The median age at the time of surgery
was 56 years (range 28–77). The studied population comprised 7 patients with 2 or 3 nodules and 8
patients with chemoresistant tumors, including fourteen cervical, 4 endometrial, and 5 ovarian primary
tumors, with 5-year overall survivals (OSs) after surgery of 61, 100, and 100%, respectively. The survival
of recurrence-free interval after initial treatment (>2 years) was significantly favorable (5-year OS 100%
vs. 41.7%, p=0.006). Among the 6 patients with re-recurrence of lung metastases, 5 patients underwent a
second pulmonary metastasectomy, and all of the patients are currently alive without disease. None of the
29 operations yielded severe complications. Although the survival rate showed a tendency to be higher in
the surgery group than in the chemotherapy-only group, no significant difference was observed (5-year OS
81.7% vs. 49.5%, p=0.072). Our results indicate that pulmonary metastasectomy contributed to long-term
survival with a low-risk of complications. Surgery to remove isolated lung metastases might provide a
favorable prognosis for patients with long recurrence-free intervals and for patients with chemoresistant
or re-recurrent tumors.
Background parenchymal enhancement in preoperative breast
MRI
Satoko Kohara, Satoko Ishigaki, Hiroko Satake, Akiko Kawamura, Hisashi Kawai,
Toyone Kikumori and Shinji Naganawa
pg(s) 373 - 382
<Abstract> - < PDF >
We aimed to assess the influence of background parenchymal enhancement (BPE) on surgical planning
performed using preoperative MRI for breast cancer evaluation. Between January 2009 and December 2010,
91 newly diagnosed breast cancer patients (mean age, 55.5 years; range, 30−88 years) who underwent
preoperative bilateral breast MRI followed by planned breast conservation therapy were retrospectively
enrolled. MRI was performed to assess the tumor extent in addition to mammography and breast ultrasonography.
BPE in the contralateral normal breast MRI at the early dynamic phase was visually classified
as follows: minimal (n=49), mild (n=27), moderate (n=7), and marked (n=8). The correlations between
the BPE grade and age, menopausal status, index tumor size, changes in surgical management based on
MRI results, positive predictive value (PPV) of MRI, and surgical margins were assessed. Patients in the
strong BPE groups were significantly younger (p=0.002) and generally premenopausal (p<0.001). Surgical
treatment was not changed in 67 cases (73.6%), while extended excision and mastectomy were performed
in 12 cases (13.2%), each based on additional lesions on MRI. Six of 79 (7.6%) patients who underwent
breast conservation therapy had tumor-positive resection margins. In cases where surgical management was
changed, the PPV for MRI-detected foci was high in the minimal (91.7%) and mild groups (66.7%), and
0% in the moderate and marked groups (p=0.002). Strong BPE causes false-positive MRI findings and
may lead to overly extensive surgery, whereas MRI may be beneficial in select patients with weak BPE.
Assessment of endovascular coil configuration for
embolization of intracranial aneurysms using
computational fluid dynamics
Tomotaka Ohshima, Shigeru Miyachi, Ichiro Takahashi and Katsuya Ishii
pg(s) 383 - 388
<Abstract> - < PDF >
Endovascular coil embolization of arterial aneurysms is often complicated by reduced blood flow to
branching arteries. To determine the optimal coil configuration for safe embolization of endovascular
aneurysms without compromising blood flow in branching arteries. A 3-dimensional voxel model, built
based on an unruptured vertebral artery–posterior inferior cerebellar artery (VA–PICA) aneurysm, predicted
to show impairment of flow in the PICA during endovascular coil embolization (Case 0). Six different
models of final coil configuration were generated and applied to this aneurysm. Case 1 was a round coil
mass. Case 2 was designed with a stent assist. Cases 3, and 4 were designed with a neck remnant and
Cases 5 and 6 incorporated a balloon neck remodeling technique. Computational fluid dynamics was used
to analyze the flow in the PICA in each model. The average outflow to the PICA was highest in Case 0
and lowest in Case 2 (in descending order, Case 0, 5, 4, 6, 1, 3, and 2). There was better preservation
of outflow to the PICA in the balloon neck remodeling models than in the neck remnant models. In a
model of endovascular coil embolization, we found considerable differences in outflow to the branching
artery with small changes in coil configuration. Careful preoperative planning is important to minimize
the risk of thromboembolic events during and after endovascular coil embolization.
The number of cardiovascular surgeries in Japan may
decrease after 2020
Akihiko Usui, Tomonobu Abe, Yoshimori Araki, Yuji Narita,
Masato Mutsuga and Hideki Oshima
pg(s) 389 - 398
<Abstract> - < PDF >
The expected future number of cardiovascular operations is estimated based on the predicted Japanese
population and the rate of cardiovascular surgery performance calculated from 16845 cases treated by the
Nagoya University group of hospitals between 2001 and 2013. The population of <20-year-old individuals
has decreased since 1990, while that of 20–64-year-old individuals has also decreased since 2000.
The population of 65–79-year-old individuals is expected to peak in 2020, with only the population of
≥80-year-old individuals expected to increase until 2040. The performance rate of cardiovascular surgery
per 100,000 population is low in the 20–64-year-old group and increases to reach a peak in the elderly
population of 70–74-year-old individuals in valvular heart disease (55.5), ischemic heart disease (54.5) and
thoracic aortic aneurysm (31.9) and decreases to about half those values in the ≥80-year-old age group.
The number of cardiovascular operations (all types) per 100,000 was 40.6 in 2002, 42.1 in 2006 and 46.6
in 2010. The total number of expected cardiovascular operations is increasing slightly and will reach a
peak in 2020 with an estimated 61,506 operations. It then decreases gradually to reach 55966 in 2035,
on the premise that the cardiovascular surgery performance rate does not change from the present time.
In order to maintain and expand to meet the medical needs of cardiovascular surgery, it is crucial that an
effort be made to increase the cardiovascular surgery performance rate, especially in octogenarian patients.
Gel phantom study of a cryosurgical probe with a
thermosiphon effect and liquid nitrogen-cooled aluminum
thermal storage blocks
Haruo Isoda, Yasuo Takehara, Hitoshi Fujino, Kazuya Sone,
Takeshi Suzuki, Yoshinari Tsuzaki, Kouji Miyazaki, Michio Fujie,
Harumi Sakahara and Yasuaki Maekawa
pg(s) 399 - 407
<Abstract> - < PDF >
Cryosurgery is a minimally invasive treatment for certain types of cancers. Argon-based cryosurgical
devices are available at present, however a large compressed gas cylinder with the pressure of 300 atmospheres
is needed. To overcome these drawbacks, we developed a new cryosurgical probe measuring about
50 cm in length with separate lumens inside for liquid and gaseous ethylene to be used as a thermosiphon
and liquid nitrogen-cooled aluminum thermal storage blocks. The probe needle was 8 cm in length and 3
mm in outer diameter. To investigate the freezing capabilities of our new cryosurgical system we inserted
the needle 5cm into a poly-acrylamide gel phantom warmed to 36.5 °C. Thermal storage blocks made of
aluminum, cooled at –196 °C in liquid nitrogen, were attached to the condenser of the probe and replaced
with thermal storage blocks every 4 to 5 minutes to compensate for warming. We took digital camera
images of the ice ball at the needle and measured the temperature in certain locations of the cryoprobe.
Ice ball formation started at one minute after cooling. The sizes (longest diameter × minimum diameter) at
10, 20 and 30 minutes after the start of the procedure were 4.5×2.1, 4.5×3.1 and 4.6×3.7 cm, respectively.
During the procedure the minimum temperature of the condenser was –85 °C and the needle was –65 °C.
This newly developed compact cryosurgical probe with thermosiphon effect and cooled thermal storage
blocks created an ice ball that can be used for cryosurgery within 20 minutes.
Utility of endoscopic diagnosis for postoperative small-bowel
lesions in patients with Crohn’s disease at double-balloon
endoscopy
Koji Yamada, Yoshiki Hirooka, Osamu Watanabe, Masanao Nakamura,
Takeshi Yamamura, Kohei Funasaka, Eizaburo Ohno, Ryoji Miyahara,
Hiroki Kawashima and Hidemi Goto
pg(s) 409 - 415
<Abstract> - < PDF >
Double-balloon endoscopy (DBE) has enabled precise diagnosis and endoscopic intervention deep within
the small bowel. In this study, we determine the factor related to the risk of endoscopic and clinical
recurrences in the diagnosis of postoperative lesions including anastomosis for the patients with Crohn’s
disease. Forty-eight patients (40 men and 8 women) had undergone small bowel resection previously and
anastomotic sites were evaluated by Rutgeerts’ endoscopic scoring. The factors related to endoscopic and
clinical recurrences at anastomosed sites were investigated. The analyzed items included the disease type,
anastomosis procedure, frequency of surgery, time to endoscopy after surgery, the presence or absence of
treatment with 5-aminosalicylic acid (5-ASA), immunomodulators, steroids, maintenance administration of
infliximab, and an elemental diet that required the ingestion of 900 kcal or more per day. Outcome of the
anastomosed lesions was analyzed in the groups treated with and without postoperative anti-TNFa antibody
including infliximab and adalimumab. DBE was performed 133 times, and 168 anastomosed lesions were
observed for enrolled patients. Univariate analysis showed that time to DBE after surgery of 1.5-year or
longer and the absence of 5-ASA administration were found to be significant factors leading to both endoscopic
and clinical recurrences. The results of Kaplan-Meier estimate and the log rank test demonstrated
that the clinical recurrence was avoided more often in the anti-TNFa antibody-treated group compared with
the non-treated group. In conclusion, DBE was useful for accurate diagnosis of small-bowel lesions after
surgery. Anti-TNFa antibody may help to decrease the postoperative recurrence rate of Crohn’s disease.
Trends in smoking rates among urban civil servants in
Japan according to occupational categories
Takahiro Higashibata, Hiroko Nakagawa, Rieko Okada, Kenji Wakai
and Nobuyuki Hamajima
pg(s) 417 - 423
<Abstract> - < PDF >
Occupation could affect the distribution of smoking status of workers, and the success of smoking
cessation among workers depends partly on worksite conditions. Blue collar workers have been identified
as a high-risk group for smoking. The aim of the present study was to examine trends in smoking rates
among urban civil servants in Japan according to occupational categories. Subjects were urban civil servants
aged 30–59 years. They annually reported smoking status in a questionnaire in a worksite health check-up
each year from 2004 to 2011. Urban civil servants reported substantially lower current smoking rates
than national smoking rates in Japan (20.2%, 23.8%, and 27.0% for males in their 30s, 40s, and 50s and
2.4%, 6.3%, and 9.5% for females, respectively, in 2011). In analysis by occupational categories, current
smoking rates declined among all groups except female white collar workers in their 50s. The current
and persistent smoking rates (number of current smokers/[number of ex-smokers and current smokers])
among blue collar workers were higher than those among white collar workers at almost all time points
in all age and gender groups. This study found relatively lower current smoking rates among urban civil
servants than the national average and higher current and persistent smoking rates in blue collar workers
than in white collar workers among them. These results would help to make suitable worksite smoking
cessation policies for each occupational category.
Prediction of background parenchymal enhancement on
breast MRI using mammography, ultrasonography, and
diffusion-weighted imaging
Akiko Kawamura, Hiroko Satake, Satoko Ishigaki,
Mitsuru Ikeda, Reiko Kimura, Kazuhiro Shimamoto
and Shinji Naganawa
pg(s) 425 - 437
<Abstract> - < PDF >
This retrospective study assessed the effects of menopausal status and menstrual cycle on background
parenchymal enhancement (BPE) of breast magnetic resonance imaging (MRI), and investigated whether the
degree of BPE can be predicted by findings of mammography, ultrasonography (US), and diffusion-weighted
MR imaging (DWI). There were 160 study patients (80 premenopausal, 80 postmenopausal). Degree of
BPE was classified into minimal, mild, moderate, or marked. Mammographic density was classified into
fatty, scattered, heterogeneously dense, and extremely dense. BP echotexture on US and BP intensity on
DWI were visually classified as homogeneous or heterogeneous. Apparent diffusion coefficient (ADC)
values of normal breast tissue were measured. Associations of the degree of BPE with menopausal status,
menstrual cycle, or imaging features were evaluated by univariate and multivariate analyses. No significant
correlation was found between mammographic density and BPE (p=0.085), whereas menopausal status
(p=0.000), BP echotexture (p=0.000), and BP intensity on DWI (p= 0.000), and ADC values (p=0.000)
showed significant correlations with BPE. Multivariate analysis showed that postmenopausal status was
an independent predictor of minimal BPE (p=0.002, OR=3.743). In premenopausal women, there was no
significant correlation between menstrual cycle and BPE, whereas BP echotexture was an independent
predictor of whether BPE was less than mild or greater than moderate (p=0.001, OR=26.575). BPE on
breast MRI is associated with menopausal status and the findings of US and DWI. Because premenopausal
women with heterogeneous BP echotexture may be predicted to show moderate or marked BPE, scheduling
of breast MRI should preferentially be adjusted to the menstrual cycle.
The prevalence of homebound individuals in the elderly
population: a survey in a city area in Japan
Hiroyuki Umegaki, Madoka Yanagawa, Hirotaka Nakashima, Taeko Makino
and Masafumi Kuzuya
pg(s) 439 - 446
<Abstract> - < PDF >
Being homebound has been reported to be associated with a number of conditions. In the current study,
the incidence of homebound individuals was surveyed in an urban city area in Japan. The city office
randomly enrolled 5,000 residents of Nagoya City aged 65 and over. A questionnaire was sent to their
principal caregivers by mail, and 3,444 (68.9 %) subjects returned the survey. The investigators obtained
the totally anonymous data from the city office. This study was approved by the Ethics Committee of
Nagoya University Graduate School of Medicine. In the present study, the data of 3,053 (61.1 %) subjects
for whom complete sets of data were available were employed for statistical analysis. The questionnaire
included the following items: age, sex, the status of public long-term care insurance certification (none,
support-level, care-level), self-rated health (good, fair, poor, very poor), states of living (single living, with
only spouse, with other family members), and the frequency of outside excursions per a week (every day,
once in a few day, one a week, rarely). An individual was defined as being homebound if his or her
frequency of outside excursions was less than once per week. he incidence of the homebound elderly in
the elderly population over 65 years old was 14.4 % in the current study. The status of certification in
public long-term care insurance was associated with being homebound. Self-rated health was significantly
worse in homebound individuals than in those non–homebound. The current survey found 14.4 % of the
elderly was home-bound in a large city in Japan.
Gamma knife radiosurgery of craniopharyngioma: results of
30 cases treated at Nagoya Radiosurgery Center
Tatsuya Kobayashi, Takahiko Tsugawa, Manabu Hatano, Chisa Hashizume,
Yoshimasa Mori and Yuta Shibamoto
pg(s) 447 - 454
<Abstract> - < PDF >
Evaluation of 30 cases of craniopharyngioma treated by Gamma Knife at Nagoya Radiosurgery Center
(NRC), Nagoya Kyoritsu Hospital since July, 2004 has been made. The mean volume of the tumor was
2.64 ml, which was treated with the marginal dose of 11.7 Gy. Mean follow-up period was 79.9 months.
The effects were evaluated by MRI findings, neuro-endocrine and hypothalamic signs and symptoms,
complications and KPS every 3~6 months. As the results, complete remission was obtained in 8, partial
remission in 12, no change in 6, progression in 3, in which two died by hypothalamic invasion. Tumor
response rate was 68.9% and control rate 87.9%. Actuarial survival was 96% at 5 and 86% at 10 years.
However, progression free survival was 76% and 76%, respectively. Using marginal dose of 11.7Gy to a
smaller tumor, better control without complications has been obtained. KPS was excellent in 14, good in
9, fair in 2, poor in 1 and unknown in a case. Finally, there were three deaths, where two were died of
tumor progression and one by infirmity. The progression of hypothalamic symptoms other than diabetes
insipidus were found in two cases. Volume reduction and effective dose setting will be important for the
improvement of QOL and survival after combined microsurgery and radiosurgery of craniopharyngioma.
Leg lengthening of more than 5 cm is a risk factor for
sciatic nerve injury after total hip arthroplasty
for adult hip dislocation
Yoshitoshi Higuchi, Yukiharu Hasegawa and Naoki Ishiguro
pg(s) 455 - 463
<Abstract> - < PDF >
Total hip arthroplasty (THA) in patients with high hip dislocation is challenging and technically
demanding. Nerve injury is a problem associated with leg lengthening after THA. The purpose of this study
was to identify the risk factors for sciatic nerve injury after THA in patients with high hip dislocation.
Thirty-seven patients (41 THAs) with Crowe type IV hips were consecutively treated. The average leg
lengthening (LL) was 3.2 cm. The average Harris hip score was improved from 57.5 points to 83.1 points
at the final follow-up. The clinical outcomes after an average 6.4-years follow-up were satisfactory. Sciatic
nerve injury was observed in two joints. LL in the two joints (two patients) with sciatic nerve injury was
5.2 cm and 6.7 cm, respectively. Leg lengthening of >5 cm was a risk factor for sciatic nerve injury.
Therefore, leg lengthening of >5 cm should be avoided to prevent sciatic nerve injury.
Effects of the health insurance coverage extension on the use
of outpatient services among small children in rural China
Nobuo Kawazoe, Guoxiang Liu, Chifa Chiang, Yan Zhang and Atsuko Aoyama
pg(s) 465 - 474
<Abstract> - < PDF >
A new public health insurance scheme has been gradually introduced in rural provinces in China since
2003. This would likely cause an increment in the use of health services. It is known that the association
between health insurance coverage and health service utilization varies among different age groups. This
study aims to examine the association between extending health insurance coverage and increment in
outpatient service utilization of small children in rural China, and to identify other factors associated with
the outpatient service utilization.
A household survey was conducted in 2 counties in north China in August 2010, targeting 107 selected
households with a child aged 12–59 months. The questionnaire included modules on demographic information
such as ages of children and parents, enrollment status of health insurance, the number of episodes
of illness as perceived by parents, month of incidence of episode and outpatient service utilization at each
episode. Based on the utilization at each episode of illness, a random effects logistic regression model
was employed to analyze the association.
It was found that eligibility for the reimbursement of outpatient medical expenses was not significantly
associated with decision to seek care or choice of health facility. This might be in part due to the low
level of reimbursement which could discourage the use of insured, and to the close relationship with
village clinic workers which would encourage the use of uninsured. Three other factors were significantly
associated with increment in the outpatient service utilization; age of children, mother’s education, and
number of children in a household.
Which variables should be considered in patients with
stage II and III non-small cell lung cancer after
neoadjuvant therapy?
Naoki Ozeki, Koji Kawaguchi, Takayuki Fukui, Koichi Fukumoto, Shota Nakamura,
Toshiki Okasaka and Kohei Yokoi
pg(s) 475 - 480
<Abstract> - < PDF >
This study was designed to elucidate the predictive usefulness of the response evaluation criteria
in solid tumors (RECIST), a volume response (VR; a > 50% reduction in the tumor volume) and the
post-neoadjuvant therapy maximum standardized uptake value (post-SUVmax) in patients with non-small
cell lung cancer (NSCLC) after neoadjuvant therapy. Between December 2006 and June 2012, 33 patients
with clinical stage II and III NSCLC who underwent pulmonary resection following neoadjuvant therapy
were enrolled. The relationships between the variables and a pathological complete response (pCR), the
disease-free survival (DFS) and the overall survival (OS) were analyzed. As neoadjuvant therapy, 24
patients received chemoradiotherapy, five patients received chemotherapy and four patients were given
radiation therapy. Based on the RECIST, 12 tumors were classified as having a partial response and 21
tumors were classified as stable disease. Twenty-one tumors showed a VR and 12 did not. Twenty-five
tumors had a post-SUVmax ≤7.5 and eight had a post-SUVmax >7.5. Eight tumors had a pCR. In the
multivariate Cox regression analysis, both a non-VR and a post-SUVmax >7.5 were significant variables
predicting the DFS (p = 0.0422 and 0.0127, respectively), but either was not for OS. The post-SUVmax
was also a significant variable for the pCR rate (p = 0.0067). The post-treatment SUVmax can be a
valid alternative variable that can be used to predict the effect of neoadjuvant therapy and the survival of
patients with stage II and III NSCLC.
CASE REPORTS
Hemorrhagic lumbar synovial cyst: case report
and literature review
Gregory Cannarsa, Shannon W. Clark, Norah Chalouhi,
Mario Zanaty and Joshua Heller
pg(s) 481 - 492
<Abstract> - < PDF >
Intraspinal synovial cysts are infrequent causes of back and radicular leg pain. Commonly associated
with degenerative spinal disease, the majority of synovial cysts appear in the lumbar spine. Rarely, intracystic
hemorrhage can occur through an unclear mechanism. Similarly rare, cysts may also become migratory.
The pathogenesis of hemorrhagic synovial cysts remains uncertain and their potential for migration also
remains unclear. A 36 year-old male presented to the clinic with 5 months of back pain and leg pain that
began after a work-related injury. An initial MRI obtained by another surgeon 3 month prior demonstrated
an epidural cystic mass with T1 hypointensity and T2 hyperintensity at L2-L3. With worsening pain, the
patient came to our clinic for a second opinion. A second MRI demonstrated resolution of the L2-L3
epidural cystic mass and formation of a new epidural cystic mass at L3-L4 causing compression of the
thecal sac. The patient subsequently underwent decompressive hemilaminectomy with cyst removal. We
present a case of two lumbar synovial cysts, separated over time and a vertebral level and giving the
appearance of a single, migratory cyst. This is the first case of an “occult migratory” synovial cyst with
repeat MR imaging capturing spontaneous resolution of the initial cyst and formation of a hemorrhagic
cyst one level below. We also present a summary of the 44 cases of hemorrhagic synovial cysts reported
in the literature and propose a mechanism that may account for the hemorrhagic and migratory progression
in some patients.
Skull involvement in a pediatric case of chronic recurrent
multifocal osteomyelitis
Toru Watanabe, Hiroyuki Ono, Yoshitaka Morimoto, Yoshiro Otsuki, Masami Shirai,
Akira Endoh, Masaaki Naito, Yoshiya Inoue and Teruaki Hongo
pg(s) 493 - 500
<Abstract> - < PDF >
An 11-year-old boy was diagnosed with chronic recurrent multifocal osteomyelitis (CRMO) and
presented with right sacro-femoral and occipital lesions. Initially, a tumor was suspected. However, the
bone biopsy showed osteomyelitis with a negative bacterial culture. Bone scintigraphy revealed inflammatory
changes on multiple bone lesions. The slight elevation in inflammatory markers such as C-reactive
protein was of little clinical value. He was diagnosed with CRMO by sacral biopsy, and the clinical course
progressed, with the presence of a new occipital lesion observed after the 1-year follow-up. The administration
of non-steroidal anti-inflammatory drugs successfully improved his clinical symptoms. The presence of
a skull lesion in the occipital bone of a pediatric patient with CRMO has not been previously reported.
Accessory scrotum with perineal lipoma diagnosed prenatally:
case report and review of the literature
Naruhiko Murase, Hiroo Uchida and Kiyoshi Hiramatsu
pg(s) 501 - 506
<Abstract> - < PDF >
We report a case of accessory scrotum (AS) in the perineal region with peduncular lipoma, diagnosed
prenatally. A male fetus of 31 weeks’ gestation was referred to our department with a perineal mass.
Prenatal ultrasonography and magnetic resonance imaging showed a mass of 1.0 × 1.2 cm located posterior
to the scrotum. No other abnormalities were noted during pregnancy. The patient was delivered vaginally
at 38 weeks of gestation. On physical examination, a soft peduncular mass with a rugged and pigmented
swelling was located between the normally developed scrotum and the anus. There were no specific
symptoms or any other associated congenital anomalies. We completely excised the mass at one month of
age. A histological examination revealed lipoma, with tissue suggestive of scrotum, so a definite diagnosis
of AS was made. AS is a rare congenital anomaly of the scrotum. We review the literature.
Fatal case of cervical blunt vascular injury with cervical
vertebral fracture: a case report
Kazuyoshi Kobayashi, Shiro Imagama, Toshiaki Okura, Hisatake Yoshihara, Zenya Ito,
Kei Ando, Junichi Ukai, Ryuichi Shinjo, Akio Muramoto, Tomohiro Matsumoto,
Hiroaki Nakashima and Naoki Ishiguro
pg(s) 507 - 514
<Abstract> - < PDF >
Blunt cerebrovascular injury (BCVI) is usually caused by neck trauma that predominantly occurs in
high-impact injuries. BCVI may occur due to damage to both the vertebral and carotid arteries, and may
be fatal in the absence of appropriate treatment and early diagnosis. Here, we describe a case of cerebral
infarction caused by a combination of a lower cervical spinal fracture and traumatic injury to the carotid
artery by a direct blunt external force in a 52-year-old man. Initially, there was no effect on consciousness,
but 6 hours later loss of consciousness occurred due to traumatic dissection of the carotid artery that resulted
in a cerebral infarction. Brain edema was so extensive that decompression by emergency craniectomy
and internal decompression were performed by a neurosurgeon, but with no effect, and the patient died
on day 7. This is a rare case of cerebral infarction caused by a combination of a lower cervical spinal
fracture and traumatic injury to the carotid artery. The case suggests that cervical vascular injury should
be considered in a patient with a blunt neck trauma and that additional imaging should be performed.
Spinal cord herniation with characteristic bone change:
a case report
Tasuku Imai, Yukimi Nakane, Eiji Tachibana and Koichiro Ogura
pg(s) 515 - 520
<Abstract> - < PDF >
Spinal cord herniation (SCH) is a rare disease characterized by herniation of the thoracic spinal cord
through an anterior dural defect, presenting with progressive myelopathy. A case of a 69-year-old woman
who presented with Brown-Sequard syndrome and a bone defect, in which an osteophyte created a
hemisphere-like cavity with spinal cord herniation, is presented. The strangled spinal cord was released, and
the defect was closed microsurgically using an artificial dural patch to prevent re-herniation. Postoperatively,
the patient experienced gradual improvement in neurologic function. The SCH mechanism and surgical
strategy are discussed.
Bilateral internal thoracic artery grafting during David
procedure complicated with coronary insufficiency
Suguru Ohira, Kiyoshi Doi and Hitoshi Yaku
pg(s) 521 - 524
<Abstract> - < PDF >
A 47-year-old woman diagnosed with Marfan syndrome underwent valve-sparing aortic root replacement
for aortic regurgitation and annulo-aortic ectasia. Her cardiac function was normal. Preoperative
coronary angiography did not demonstrate any stenosis. The David reimplantation procedure with a 28-mm
Valsalva graft was performed. Both coronary orifices were reconstructed in a button fashion with Teflon
felt reinforcement. After aortic declamping, marked bleeding was noted from the left coronary button,
requiring a second pump run. Graft interposition using the great saphenous vein was performed for left
coronary artery reconstruction. The reconstructed right coronary button was also damaged due to the
fragile tissue, and interposed by the vein graft in the same fashion. After the aorta was declamped, the
global left ventricular wall motion was significantly impaired, and did not improve with time. Coronary
insufficiency was considered. Beating-heart coronary artery bypass grafting with the in-situ bilateral internal
thoracic arteries was performed. After revascularization, the left ventricular function was improved. In
certain emergent situations compromised with coronary insufficiency, this procedure could be an option
to revascularize the coronary arteries.
Utility of a 3-dimensional full-scale NaCl model for rib strut
grafting for anterior fusion for cervicothoracic kyphosis
Kazuyoshi Kobayashi, Shiro Imagama, Akio Muramoto, Zenya Ito, Kei Ando,
Hideki Yagi, Tetsuro Hida, Kenyu Ito, Yoshimoto Ishikawa, Mikito Tsushima
and Naoki Ishiguro
pg(s) 525 - 530
<Abstract> - < PDF >
In severe spinal deformity, pain and neurological disorder may be caused by spinal cord compression.
Surgery for spinal reconstruction is desirable, but may be difficult in a case with severe deformity. Here,
we show the utility of a 3D NaCl (salt) model in preoperative planning of anterior reconstruction using
a rib strut in a 49-year-old male patient with cervicothoracic degenerative spondylosis. We performed
surgery in two stages: a posterior approach with decompression and posterior instrumentation with a
pedicle screw; followed by a second operation using an anterior approach, for which we created a 3D
NaCl model including the cervicothoracic lesion, spinal deformity, and ribs for anterior reconstruction.
The 3D NaCl model was easily scraped compared with a conventional plaster model and was useful for
planning of resection and identification of a suitable rib for grafting in a preoperative simulation. Surgery
was performed successfully with reference to the 3D NaCl model. We conclude that preoperative simulation
with a 3D NaCl model contributes to performance of anterior reconstruction using a rib strut in a case
of cervicothoracic deformity.
A new modification of laparoscopic percutaneous
extraperitoneal closure procedure for repairing pediatric
femoral hernias involving a special needle and a wire loop
Takahisa Tainaka, Hiroo Uchida, Yasuyuki Ono, Akihide Tanano, Chiyoe Shirota,
Kazuki Yokota, Naruhiko Murase, Satoshi Makita and Ryo Shirotsuki
pg(s) 531 - 535
<Abstract> - < PDF >
Femoral hernias are relatively rare in children, and more than half of pediatric femoral hernias are
misdiagnosed. A 3-year-old boy was treated for an indirect inguinal hernia at the age of 2, but he exhibited
an inguinal bulge one month after the operation. He underwent laparoscopy, and a right femoral hernia
was detected. The femoral hernia was laparoscopically repaired via two small incisions: a 1.0-cm umbilical
incision for a 3-mm 30° laparoscope and 3-mm grasping forceps and a 5-mm right lateral incision for
3-mm grasping forceps. After the hernia sac had been reflected into the abdominal cavity and resected, the
iliopubic tract was sutured to Cooper’s ligament using a laparoscopic percutaneous extracorporeal closure
(LPEC) needle and 2–0 non-absorbable sutures. Laparoscopy enables the accurate diagnosis of rare and
often missed pediatric femoral hernias. Our laparoscopic technique for treating femoral hernias is easy
and effective. Although these early results are encouraging, more cases involving longer follow-up periods
should be accumulated to confirm the efficacy of our technique.