Nagoya Journal of Medical Science

High-dose opioids induce hyperalgesia and tolerance, which negatively affects postoperative recovery. Prolonged surgery inevitably requires higher opioid doses. Ketamine reduces perioperative opioid consumption and prevents opioid-induced tolerance. However, its effects in cases of prolonged surgery remain unknown. This study aimed to evaluate the dose of intraoperative remifentanil, an ultrashort-acting μ-opioid agonist, administered after an intravenous ketamine bolus during prolonged head and neck surgery. This single-center, retrospective, observational study included 251 patients who underwent head and neck surgery (operation time ≥8 h) between January 2015 and December 2019. The participants were stratified into two groups: those who received an intravenous bolus of ketamine and those who did not (ketamine group and non-ketamine group, respectively). Propensity score-matching was used to match patients in a 1:1 ratio between the two groups, based on their covariates. The difference in intraoperative remifentanil dose administered between the two groups was assessed. After 1:1 propensity score-matching, 89 matched patients were selected from each group. The mean ± standard deviation dose of remifentanil administered was significantly lower in the ketamine group than in the non-ketamine group before (0.15±0.05 vs 0.17±0.05 μg/kg/min; P=0.01) and after matching (0.15±0.06 vs 0.17±0.05 μg/kg/min; P=0.03). In conclusion, intravenous ketamine administration may reduce the intraoperative dose of remifentanil required during prolonged head and neck surgery. However, further studies are required to evaluate the effect of this finding on enhanced recovery after surgery.

This study aimed to examine the reliability and validity of using a smartphone to measure the multi-joint range of motion of the lower limbs. We measured the straight leg raise angle, ankle dorsiflexion angle, and hip internal rotation angle in each of the 40 lower extremities of 20 healthy adults. Measurements were compared between a conventional method using a goniometer and a smartphone application method. The intraclass correlation coefficient (ICC) was used to evaluate the reliability of each smartphone measurement, and Bland–Altman analysis was used to examine measurement errors. The criterion-related validity of the two methods was also examined. Intra-rater reliability (ICC 0.668–0.939) was substantial to almost perfect, with no systematic errors found for all items, and the standard errors of measurement were acceptable. Inter-rater reliability (ICC 0.701–0.936) was also substantial to almost perfect, but the straight leg raise angle and hip internal rotation angle showed fixation errors. For these two measurements, with more than one examiner, the limit of agreement of error needs to be considered. No systematic errors were found in the ankle dorsiflexion angle, and the standard error of measurement was within the acceptable range. A moderate to strong correlation (r = 0.626–0.915) was found between the conventional and smartphone methods, demonstrating good criterion-related validity. However, in the ankle dorsiflexion angle measurements, the reliability and validity were shown to be lower than the other two items. This suggested the necessity of changing the measurement conditions in order to use the ankle dorsiflexion angle in clinical practice.

Evaluation of liver fibrosis is necessary to make the therapeutic decision and assess the prognosis of CHB patients. The current study aimed to describe the progression and identify some influencing factors in patients with chronic hepatitis B at a General Hospital in Northern Vietnam. The longitudinal study included 55 eligible subjects diagnosed Hepatitis-B-virus. Dependent variable was the aspartate aminotransferase/platelet ratio index and we collected some demographic variables and disease related and behaviour variables. Bayesian Model Averaging was used to select variables into model. Mixed-effect linear models were used to evaluate the change of the aspartate aminotransferase/platelet ratio index over time and identify related factors. the aspartate aminotransferase/platelet ratio index differences between examinations, age of participants, working status were statistically significant. This pattern indicated that the average the aspartate aminotransferase/platelet ratio index of the population decreased by 0.005 (95% CI=-0.009; –0.001) after each patient’s visit, and increased by 0.013 if the patient’s age increased by 1 year (95% CI=0.005; 0.0219). For non-working patients, the aspartate aminotransferase/platelet ratio index was lower, coefficient was –0.054 (95% CI=-0.108; 0.001). Other variables such as gender, education level, time for disease detection, drinking tea, alcohol consumption, forgetting to take medicine and the aspartate aminotransferase/platelet ratio index were not significantly different. The study showed that the majority of study subjects had average the aspartate aminotransferase/platelet ratio index, and were relatively well controlled and treated during the study. Age and working status are factors that influence the the aspartate aminotransferase/platelet ratio index.

We propose two methods to evaluate system-related distortion in magnetic resonance imaging (MRI) in radiation therapy treatment planning (RTP) and demonstrate the importance of three-dimensional (3D) distortion correction (DC) by quantitatively measuring the distortion magnitude. First, a small pin phantom was scanned at multiple positions using an external laser guide for accurate phantom placement and combined into one image encompassing a large area. Direct plane images were used for evaluating in-plane distortion and multiplanar reconstruction images for through-plane distortion with no DC, two-dimensional (2D) DC, and 3D DC. Second, a large grid sheet was scanned as the direct plane of the phantom placement. The distortion magnitude was determined by measuring the displacement between the MRI and reference coordinates. The measured distortions were compared between in- and through-plane when applying DC and between the two methods. The small pin phantom method can be used to evaluate a wide range of distortions, whereas data from the entire plane can be obtained with a single scan using the grid sheet without a laser guide. The mean distortion magnitudes differed between the methods. Furthermore, the 3D DC reduced in- and through-plane distortions. In conclusion, the small pin phantom method can be used to evaluate a wide range of distortions by creating a combined image, whereas the grid sheet method is simpler, accurate, repeatable, and does not require a special-order phantom or laser guide. As 3D DC reduces both in- and through-plane distortions, it can be used to improve RTP quality.

COVID-19 is indirectly associated with various mental disorders such as anxiety, insomnia, and depression, and healthcare professionals who treat COVID-19 patients are particularly prone to severe anxiety. However, neither the anxiety of healthcare workers in non-epicenter areas nor the effects of knowledge support have been examined thus far. Participants were 458 staff working at the Toyota Regional Medical Center who completed a preliminary questionnaire of their knowledge and anxiety regarding COVID-19. Based on text mining of the questionnaire responses, participants were offered an online lecture. The effect of the lecture was analyzed using a pre- and post-lecture rating of anxiety and knowledge confidence, and quantitative text mining. The response rates were 45.6% pre- and 62.9% post-lecture. Open-ended responses regarding anxiety and knowledge were classified into seven clusters using a co-occurrence network. Before the lecture, 28.2%, 27.2%, and 20.3% of participants were interested in and anxious about “infection prevention and our hospital’s response,” “infection and impact on myself, family, and neighbors,” and “general knowledge of COVID-19,” respectively. As a result of the lecture, Likert-scale ratings for anxiety of COVID-19 decreased significantly and knowledge confidence increased significantly. These changes were confirmed by analyses of open-ended responses about anxiety, lifestyle changes, and knowledge. Positive changes were strongly linked to the topics focused on in the lecture, especially infection prevention. The anxieties about COVID-19 of healthcare workers in non-epicenter areas can be effectively reduced through questionnaire surveys and online lectures using text mining.

Frailty is a state of reduced muscle strength and activity in older people. DNA methylation is associated with osteoporosis and muscle loss in murine and other animal studies, but there are no epidemiological studies in humans. This study aimed to assess the association of osteoporosis and muscle loss with DNA methylation in community-dwelling older people. This cross-sectional study was performed in a rural part of Japan. We analyzed 204 subjects (98 men and 106 women). In univariate analysis, the two groups were compared according to the presence or absence of osteoporosis and of muscle loss. Logistic regression analysis was performed to determine predictors of frailty in the muscle loss group. We used age, sex, body mass index, smoking history, drinking history, serum albumin and C-reactive protein levels, diabetes, hypertension, hyperlipidemia, heart disease history, and LINE-1 DNA methylation as the factors. Probability values < 0.05 were considered to be statistically significant. The levels of LINE-1 DNA methylation in leukocytes were associated with muscle loss in men over the age of 60. LINE-1 DNA methylation levels were not associated with bone mineral density in either the men or women over the age of 60. LINE-1 DNA methylation levels in leukocytes correlated significantly with the risk of frailty in men over the age of 60. Promoting an understanding of DNA methylation may lead to a better understanding of the pathophysiology of muscle loss.

This study explores the differences in factors associated with hypertension between younger and older subjects in an urban slum community in Bangladesh. We analyzed the data of 1,008 men and 1,001 women obtained from a cross-sectional survey conducted between October 2015 and April 2016. Multivariable logistic regression models were stratified by age (18 to 44 and 45 to 64 years) in men and women separately. The multivariable model included age (continuous) and the following categorical variables simultaneously: education duration, marital status, tobacco smoking, smokeless tobacco use, total physical activity, body mass index (BMI), waist circumference, and the blood levels of glycated hemoglobin (HbA1c), triglycerides, high- and low-density lipoprotein (HDL and LDL) cholesterol. Hypertension was defined as the presence of either blood pressure ≥140/90 mmHg or the use of antihypertensive medication. The prevalence of hypertension was 13.0% (younger men), 14.6% (younger women), 35.6% (older men), and 38.7% (older women). In younger men, higher waist circumference and increased LDL cholesterol levels were significantly associated with hypertension. In older men, physical activity was the only significant factor that was inversely associated with hypertension. In younger women, higher BMI, increased HbA1c, triglycerides, and LDL cholesterol levels were associated with hypertension. In older women, a higher HbA1c was the only factor significantly associated with hypertension. These findings suggest that public health interventions to prevent hypertension may require different approaches according to sex and age groups within the poor urban population in Bangladesh.

More than 40% of Japanese patients with multiple myeloma (MM) are over 75 years of age at diagnosis. Regardless of the treatment benefits, complications and relapses obstruct long-term survival. We conducted a phase II, open-label, single-arm, multicenter clinical trial to assess the efficacy and safety of alternating bortezomib-dexamethasone (Bd) and lenalidomide-dexamethasone (Ld) (Bd/Ld) treatment in MM patients aged over 75 years (MARBLE trial). Patients received Bd therapy from days 1 to 35 and Ld therapy from days 36 to 63. For Bd therapy, patients were administered bortezomib 1.3 mg/m² and oral dexamethasone 20 mg on days 1, 8, 15, and 22. For Ld therapy, they were administered lenalidomide 15 mg from days 36 to 56 and dexamethasone 10 mg on days 36, 43, 50, and 57. They underwent six treatment cycles in total, each consisting of a 63-day regimen. In total, 10 patients were enrolled, with a median age of 81 years. Efficacy was not evaluated because the patients were fewer than planned. The overall response rate was 80.0% and complete response rate 40.0%. Seventy percent of patients completed the study treatment. Progression-free survival and overall survival at 2 years were 40.0% and 80.0%, respectively. Adverse events of grade 3 or higher, including anemia, decreased lymphocyte count, neutropenia, and hypokalemia, were observed in eight patients. Alternating chemotherapy with Bd/Ld might be feasible, but its efficacy should be verified further.

This prospective, cross-sectional, cohort observational study was conducted to evaluate the associations between sedentary behavior and arteriosclerosis-related vascular issues in community-dwelling frail older adults. We included 116 Japanese community-dwelling older adults (92 females and 24 males) who availed daycare at two long-term care insurance facilities in the cities of Yokkaichi and Handa between 2017 and 2019. An unpaired t-test and the chi-square test were used for intergroup comparisons. Logistic regression analysis was conducted with cardio–ankle vascular index as the dependent variable, sedentary behavior as the explanatory variable, and the other evaluated factors as covariates. Long-time sedentary behavior (based on the median value for all participants) was associated with high cardio–ankle vascular index after adjusting for age, sex, body mass index, ankle–brachial index, and walking MET-minutes in 1 week (odds ratio 3.086, 95% confidence interval 1.275–7.467, p=0.012). After adjusting for other variables (care needs certificate, skeletal muscle mass index, body fat percentage, grip strength, 4-m walking duration, etc), there was a significant association between long-time sedentary behavior and high cardio–ankle vascular index values (odds ratio 4.977, 95% confidence interval 1.497–16.554, p=0.009). The results study confirmed an association between long-time sedentary behavior in frail older adults and the degree of arterial stiffness assessed by the cardio–ankle vascular index. Interventions in older adults that focus on daily sedentary time to prevent the onset and exacerbation of geriatric syndromes secondary to the progression of arteriosclerosis warrant further investigation.

It was aimed to evaluate the relationship between frailty and inflammation in people receiving home health care. It was a cross-sectional study. Edmonton Frail Scale was used to determine the level of frailty and, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio were used to determine inflammation. Of 332 people included in the study, 54.82% were females and 45.18% were males. Participants’ ages were between 65 and 106. When we examined the frailty of the participants according to the Edmonton Frail Scale, the mean score was 9.403 ± 2.032. The mean neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio of the participants were 4,397±5,038 and 169,363±101,461 respectively. Accordingly, neutrophil-to-lymphocyte ratio was high in men, frail elderly, 75–84 age range, hypertension patients, malnutrition patients; and neutrophil-to-lymphocyte ratio was low in diabetes mellitus, dementia, cerebrovascular accident and hemiplegia. Platelet-to-lymphocyte ratio, another inflammatory marker, was high in men, non-frail elderly, 75–84 age range, hypertension patients and cerebrovascular accident patients; it was low in hemiplegia, malnutrition, dementia, diabetes mellitus. In the study, no statistically significant difference was found between Edmonton Frail Scale and inflammatory markers. More studies are needed on this subject. In addition, we think that examining NLR and PLR values will be useful for monitoring inflammation in frail elderly.

The purpose of this study was to determine the most appropriate seed arrangement by comparing two different methods (linked seeds and loose seeds). A total of sixty-one patients (28 linked seed brachytherapy cases and 33 loose seed brachytherapy cases) with clinically localized prostate cancer were treated with I-125 permanent prostate brachytherapy. Modified peripheral loading was the method used for seed placement. The parameters evaluated were as follows: prostate D90, V100, and V150; urethral D90, D10, and D5; and rectal V100 (RV100) and D2 (RD2). Coefficient parameters (r and r²) were assessed by regression analysis. Prostate V150, urethral D90, urethral D10, urethral D5, and RD2 showed significant correlations between both methods in all patients. Urethral D90, urethral D10, urethral D5, and RD2 showed significant correlations in patients who received linked seed brachytherapy. Prostate V150, urethral D90, urethral D10, urethral D5, RV100, and RD2 showed significant correlations in patients who received loose seed brachytherapy. Urethral D90, urethral D10, urethral D5, and RD2 showed significant correlations in the linked seed and loose seed brachytherapy analyses. In contrast, prostate D90 and prostate V100 showed no correlation. Parameters of normal organ damage showed good correlations between intraplan and postplan parameters. These parameters may be useful to determine normal organ damage during guided brachytherapy with two different methods (linked seeds and loose seeds).

Submitting data compliant with the Clinical Data Interchange Standards Consortium (CDISC) standards is mandatory for new drug applications (NDAs). The standards set by CDISC are widely adopted in the pharmaceutical business world. Introduction of CDISC standards in academia can be necessary to reduce labor, resolve the shortage of data managers in academia, and gain new knowledge through standardized data accumulation. However, the introduction of CDISC standards has not progressed in communities within the academia that do not apply for NDAs. Therefore, herein, we created study data tabulation model (SDTM)-compliant datasets within the academia, without outsourcing, to reduce costs associated with investigator-initiated clinical trials. First, we input data from paper case report forms (CRFs) into an electronic data capture system with minimal function for paper CRFs, “Ptosh,” which is compatible with SDTM. Then, we developed a generic program to convert data exported from Ptosh into fully SDTM-compliant datasets. The consistency was then verified with an SDTM validator, Pinnacle21 Community V3.0.1 (P21C). This resulted in generation of SDTM datasets, resolving all “Rejects” in P21C, thereby achieving the required quality level. Although Ptosh directly exports data in SDTM format, manual mapping of items on CRFs to SDTM variables prepared in Ptosh is necessary. SDTM mapping requires extensive knowledge and skills, and it was assumed that mapping is challenging for the staff without in-depth knowledge of CDISC standards and datasets. Therefore, for CDISC dissemination in academia, it is crucial to secure the staff, time, and funding to acquire the knowledge.

Amongst 942 out-patients who consulted our male infertility division between 2016 to 2020, 85 (9.0%) patients suffered from secondary infertility. Of these, in 59 (69.4%) subjects, the first pregnancy was achieved by natural conception. 81 subjects were evaluated for semen quality except for two subjects who at the time were undergoing cancer treatment and another of two ejaculatory dysfunction (EjD). Semen analysis revealed 16 subjects (19.8%) were azoospermic, whereas 9 (11.1%) were cryptozoospermic at median three years of infertility. Left varicocelectomy had been undertaken in a total of 17 oligoasthenozoospermic and cryptozoospermic cases in order to improve semen quality. For achieving natural pregnancy, microscopic vasoepididymostomy was performed in 3 subjects of obstructive azoospemia and patency was achieved in two of three. 11 azoospermic subjects and two of the EjD underwent sperm retrieval surgery for intracytoplasmic sperm injection (ICSI). Motile sperm recovery was obtained by microscopic epididymal sperm aspiration (5/5=100%), microscopic testicular sperm extraction (micro-TESE, 2/6=33.3%), and retrograde vasal sperm aspiration (2/2=100%). Natural pregnancy was obtained in two subjects following varicocelectomy, and in one following vasoepididymostomy. Seven pregnancies were achieved by ICSI using cryopreserved sperm and surgically retrieved sperm. Even if the first pregnancy occurred naturally, 30.9% subjects showed azoospermia or cryptozoospermia at median duration of three years. We would like to emphasize that earlier urological assessment especially semen analysis is necessary if pregnancy later in life is desired.

In this paper, the author explores the clinical ethical issue of the withdrawal and withholding of life-prolonging treatment, surveying 2,848 lawyers and 2,469 doctors as medical and legal professionals in Japan on a variety of points for discussion. The main survey items are: (1) systems that should be used in the withdrawal and withholding of life-prolonging treatment at the end of life; (2) problems in determining treatment strategy at the end of life; (3) assessment of suspension of life support systems (extubation); and (4) strategies for better end-of-life care. While 42.2% of lawyers cited legislature and judiciary and 54.9% cited academic society guidelines as the system that should respond to the withdrawal and withholding of life-prolonging treatment, 23.3% of doctors cited the legislature and the judiciary, and 65.4% academic society guidelines. In relation to current end-of-life care, 81.3% of lawyers and 69.3% of doctors responded that there was room for improvement. Strategies for doing so included ensuring the transparency of and publishing decision procedures, and notification to government. It is important for medical institutions to normalize end-of-life care by making decisions with reference to guidelines and the like, ensuring the transparency of decision-making procedures, and being managed by a public institution.

We reviewed the outcomes of meconium peritonitis and evaluated the safety and feasibility of primary radical surgery for meconium peritonitis. A total of 21 cases of meconium peritonitis between 2006 and 2020 were retrospectively reviewed. The patients were classified into two groups based on the type of surgery: group I (primary radical surgery, n = 16) and group II (multistage surgery; drainage only or ileostomy, followed by elective surgery, n = 5). Patient backgrounds and surgical outcomes were compared between the two groups. The term of prenatal diagnosis, preoperative white blood cell count, and preoperative catecholamine use were not significantly different between the two groups. Group I included more mature neonates than group II (gestational age at birth, 35w1d vs 30w1d, p = 0.02; birth weight, 2.5 kg vs 1.1 kg, p < 0.01). Preoperative C-reactive protein was significantly lower in group I (0.37 mg/dL vs 2.8 mg/dL, p < 0.05). Operation time, blood loss, time to enteral feeding, and complication rates were not significantly different between the two groups. The surgical outcomes of primary radical surgery were comparable to those of multistage surgery, although the patients’ backgrounds were different. Our strategy of selecting one-stage or multiple-stage surgery for treatment of meconium peritonitis, depending on the patient’s general condition and degree of intestinal ischemia, was reasonable.

The purpose of this study is to examine trends in spine surgeries at ten facilities over 15 years, and to analyze relationships with the number of spine surgeons at these facilities. The subjects were patients who underwent spine surgery at the ten facilities from 2003 to 2017. Data were collected every year via a questionnaire designed to obtain clinicopathological and surgical information. There were 37,601 spine surgeries (60.2% male) recorded in the registry at 9 facilities in the Nagoya Spine Group (NSG) between 2003 and 2017, with an increase in the annual number of surgeries by 2.4 times over 15 years. On the other hand, the number of spine surgeons has increased by just under 1.5 times. Instrumentation surgeries increased from 959 in 2003 to 2,276 in 2017 (2.3 times). There was a particularly marked increase in surgeries for spinal degenerative disease from 1,075 in 2003 to 2,821 in 2017 (2.6 times). The number of surgeries performed per surgeon increased from 61.4 in 2003 to 102.8 in 2017, while the average number of spine surgeons per hospital increased from 2.6 in 2003 to 3.7 in 2017. In conclusion, with heavier burden on spine surgeons and the major changes in the spine surgery environment, training and increasing surgeons with advanced expertise and skills will become increasingly important.

Volatile anesthetics (VAs) protect myocardial cells during cardiovascular surgeries, including cardiopulmonary bypass (CPB). In CPB, blood is gradually transferred from the body to a CPB unit until the target cardiac index is achieved, following which human lung (HL) ventilation is stopped. This pilot study aimed to evaluate changes in the blood sevoflurane concentrations 5 min after the start of CPB when its delivery to the oxygenator began after HL ventilation with sevoflurane was completed. Six patients were recruited and participated in this study. For each patient, the equilibrated blood sample, collected 20 min after starting the delivery of 1.7% sevoflurane (HL group), and another blood sample, collected 5 min after starting the CPB, were analyzed using gas chromatography equipped with a flame ionization detector. The mean (± standard deviation) sevoflurane concentrations in the HL and 5 min after starting CPB groups were 58.6 ± 4.7 and 14.5 ± 5.0 μg/ml, respectively (P < 0.01). In conclusion, the equilibrated blood sevoflurane concentrations showed a rapid decrease when switching from sevoflurane ventilation for the HL to CPB unless it was introduced to the oxygenator until completion of the switch.

Ulcerative colitis (UC) is an incurable, chronic inflammatory disease of the large bowel whose etiology and pathogenesis have not yet been comprehensively explained. Tofacitinib is a small molecule Janus kinase inhibitor that was introduced for treating refractory UC. We aimed to examine the efficacy and safety of tofacitinib for the treatment of 18 patients with UC. Continuous treatment rates were 50, 38, and 33% at 8, 24, and 52 weeks, respectively. Overall, 83.3% of these patients showed tumor necrosis factor (TNF) antibody failure status. When the effective status was defined as a Lichtiger index (LI) that decreased by 3 points or more or was less than 4 points and remission status was defined as an LI less than 4 points, the effective and remission rates (%) at 2, 8, and 16 weeks were 55.5 (10/18) and 22.2 (4/18), 38.8 (7/18) and 33.3 (6/18), and 38.8 (7/18) and 38.8 (7/18), respectively. Background characteristics of 2-week responders and non-responders were compared. C-reactive protein level in responders was significantly lower than that in non-responders, and the hemoglobin level in responders was significantly higher than that in non-responders. This study provides preliminary results of the effectiveness of tofacitinib even for TNF antibody and tacrolimus failure patients.

A 71-year-old man with stage IIB (Union for International Cancer Control, 8^th edition) non-small cell lung cancer underwent intensity-modulated radiation therapy with a dose of 66 Gy administered in 33 fractions concomitant with carboplatin and paclitaxel therapy. On computed tomography after completion of radiation therapy, ground-glass opacity, which was larger on the contralateral side, was observed, but it was not observed in the high-dose area on the ipsilateral side. Although the adverse event theoretically shows dose dependency, it was finally diagnosed as radiation pneumonitis. The presence of an atypical distribution of radiation pneumonitis should be recognized to improve the diagnosis, and it is suggested that the relative volume of the normal contralateral lung receiving a dose of ≥5 Gy is a possible risk factor for radiation pneumonitis.

Juvenile idiopathic arthritis (JIA) can lead to joint deformity and bone destruction, which can cause gait disturbances. To the best of our knowledge, there are no case reports with over 10 years of follow-up on quadruple joint arthroplasties (QJA) for bilateral hip and knee ankylosis associated with JIA. We present the case of a 29-year-old woman with JIA. The patient suffered from bilateral ankylosis of the hips and knees and developed a swing gait requiring double crutches. We performed staged QJA with careful attention to postoperative rehabilitation and her physical features, which included excessive pelvic anteversion, poor bone quality, and short statue of bones. Twelve years after surgery, the patient was able to walk without any support and showed good clinical functional scores. In addition, no radiological loosening following QJA was observed. We hereby introduce a surgical strategy for total hip arthroplasty for excessive pelvic anteversion, which involves two methods to calculate pelvic tilt on a pelvic anteroposterior radiograph. These methods were able to approximately predict postoperative pelvic changes.

Surgical resection is the mainstay of treatment for retroperitoneal liposarcoma (RPLS). Herein, we describe a case of dedifferentiated RPLS successfully treated with an extended surgical approach with adjuvant chemotherapy. A 61-year-old male was referred to our hospital with a chief complaint of chest tightness. Abdominal computed tomography revealed a large retroperitoneal tumor, 11 cm in diameter, extensively invading the surrounding organs: the celiac axis, the splenic artery, the pancreatic body and tail, the lesser curvature of the stomach and the left adrenal gland. Endoscopic ultrasound-guided fine-needle aspiration biopsy confirmed dedifferentiated liposarcoma, suggesting aggressive tumor biology. We performed total gastrectomy combined with distal pancreatectomy with celiac axis and left adrenal gland resection with a curative intent. The postoperative course was almost uneventful. As the pathological findings indicated a positive margin with a well-differentiated liposarcoma component, we added adjuvant chemotherapy with four cycles of doxorubicin and ifosfamide (AI). Five years after primary surgery, regular follow-up CT demonstrated a pulmonary hilar lymph node enlargement and a tumor at paraesophageal locations. After downsizing chemotherapy with eribulin followed by pazopanib, he underwent partial esophagectomy with dissection of the paraesophageal tumor. The pathological findings indicated recurrence of dedifferentiated liposarcoma with a tumor-free surgical margin. He is currently alive without any evidence of recurrence almost 7 years after the first surgery and 15 months after the second surgery. The long-term survival gained in this patient indicates that extended resections and adjuvant chemotherapy could prolong survival in patients even with RPLS with dedifferentiated tumor histology.