Harasanshin Hospital

The feasibility of total body irradiation (TBI) delivery using the TomoDirect mode of a TomoTherapy system has been demonstrated. In clinical practice, TomoTherapy-based TBI is typically performed in two parts: upper and lower body. This study aimed to evaluate the dosimetric impact of varying port numbers on dose evaluation indices for lower body irradiation using TomoDirect and to compare these results with those of TomoHelical in a simulation setting. Sixteen patients who underwent myeloablative TBI using TomoHelical between October 2017 and March 2021 were retrospectively analyzed. TomoDirect plans with 2 to 12 ports at approximately equal beam angles were generated (modulation factor=1.5, field width=5.0cm, pitch=0.500). TomoHelical plans used identical parameters except for a pitch of 0.397. The prescribed dose was 12Gy in six fractions. Dose indices (D2, D98, D50, homogeneity index [HI]) and beam-on time were compared. In TomoDirect plans, all dose evaluation indices worsened as the number of ports increased up to five, but changes became minimal beyond eight ports. D2 was significantly improved in all TomoDirect plans compared with those of TomoHelical plan. D98 was significantly lower for the three- and five-port TomoDirect plans, and no TomoDirect plan achieved higher D98 than TomoHelical. The D50 and HI were significantly improved in all TomoDirect plans except the five-port configuration. The two-port TomoDirect plan achieved the most favorable dose indices and the shortest beam-on time. The two-port TomoDirect approach with anterior-posterior beam configuration provides an efficient and clinically reasonable option for lower-body irradiation, offering improved dose homogeneity and reduced treatment time compared with TomoHelical.

To investigate clinical outcomes, treatment, and survival rates of men aged ≥75 years with prostate cancer in Japan. The study used data from the Prostate Cancer Research International: Active Surveillance (PRIAS)-JAPAN, a nationwide, multicentre prospective cohort study of men with clinically localised prostate cancer managed with active surveillance (AS). The original eligibility criteria were clinical stage T1c-T2 disease, prostate-specific antigen (PSA) level ≤10 ng/mL, PSA density (PSAD) <0.20 ng/mL/mL, and Gleason Score ≤3 + 3 with two or fewer positive biopsy cores. In 2021, magnetic resonance imaging use expanded eligibility to include patients with a PSA level ≤20 ng/mL, PSAD <0.25 ng/mL/mL, and Gleason Score ≤3 + 4 with <50% of biopsy cores positive. PSA was monitored every 3-6 months, and biopsies were scheduled at 1, 4, 7, and 10 years, and every 5 years thereafter. The outcomes in those aged ≥75 years (older group) were compared with those aged <75 years (younger group). Of the 1274 eligible patients enrolled by 29 February 2024, 231 were in the older group and 1043 were in the younger group. In the older group, the median age at enrolment was 77 years. At diagnosis, patients in the older group had significantly larger prostate volumes, higher proportion of Gleason Score 3 + 4, and more T2 disease than those in the younger group. The protocol biopsy acceptance rate decreased over time (first: 82.9%, second: 63.6%, third: 42.2%, fourth: 22.4%), with no significant difference between age groups. The 10-year AS persistence rate in the older group was 8.8%. The overall survival was significantly lower in the older group than in the younger group (hazard ratio: 0.32, 95% confidence interval 0.14-0.74); however, the 10-year metastasis-free survival and cancer-specific survival rates in the older group were both 100%. In some patients aged ≥75 years an observation-focused management approach may be appropriate, in which AS is initiated as a structured monitoring phase with planned de-intensification and transition to watchful waiting, to prevent overtreatment while maintaining excellent cancer-specific outcomes.

Abstract Background Patients with advanced renal cell carcinoma (RCC) undergoing hemodialysis are often excluded from clinical trials. We aimed to evaluate real-world outcomes of first-line molecular targeted therapy (MTT) and immuno-oncology (IO) combination therapies in patients with advanced RCC receiving hemodialysis. Methods We retrospectively analyzed data from 88 patients undergoing hemodialysis who received first-line systemic therapy for advanced RCC at 18 institutions in Japan between 2008 and 2023. Patients were divided into three groups by first-line regimen: MTT (n = 53), IO–IO (n = 18), or IO-tyrosine kinase inhibitor (IO–TKI, n = 17). Treatment response, progression-free survival (PFS), overall survival (OS), and treatment-related adverse events (TRAEs) were evaluated. Prognostic factors were identified using univariate and multivariate Cox regression analyses. Results The median PFS and OS were 3.9 and 18.9 months, respectively. IO–IO and IO–TKI groups achieved significantly longer PFS than the MTT group (median PFS 3.5, 5.4, and 7.5 months, respectively; p = 0.003); OS did not differ significantly among groups. Grade ≥ 3 TRAEs occurred in 30.2%, 33.3%, and 41.2% of MTT, IO–IO, and IO–TKI groups, respectively. Multivariate analysis identified poor Eastern Cooperative Oncology Group performance status, longer hemodialysis duration (≥ 10 years), and first-line regimen as independent PFS predictors. International Metastatic RCC Database Consortium risk classification and hemodialysis duration independently predicted OS. Conclusions Systemic therapy, including MTT and IO combination therapy such as IO–IO and IO–TKI, demonstrated acceptable safety profiles for patients with advanced RCC undergoing hemodialysis. IO combination therapy significantly improved PFS, supporting its utility as a first-line treatment option.

Fragility hip fracture (FHF) has been frequently seen in trauma of older people, resulted in decreased mobility and a loss of independence. This study retrospectively assessed the long-term health-related quality of life (HRQOL) and living arrangement in older patients following FHF, and evaluated the factors associating with long-term EuroQol 5D (EQ5D) for 5years or more. This study included 203 Japanese patients (male 26, female 177) with FHF over the age of 60years. We examined the long-term EQ5D and life style at final follow-up, and identified the factors affecting with EQ5D. The mean age at baseline of 79years, the mean observation duration was 6years, and the average value of EQ5D at final follow-up was 0.65. Multivariate analysis presented that EQ5D at final follow-up was significantly predicted by serum albumin, trochanteric fracture, comorbidity stroke, higher BI at post-admission, less length of stay hospital, and living at home at final follow-up. The people living at home at final follow-up (148/203 [72.9%]) was less than the people at baseline (190/203 [93.6%]). In multivariate analysis, the people living at home at final follow-up were younger age at baseline, and higher BI at post-admission. In conclusion the long-term EQ5D after FHF was decreased in patients with lower serum albumin at baseline, with trochanteric fracture, with stroke comorbidity, and with lower BI at post-admission. The people living at home after FHF were young age at baseline and high BI at post-admission.

BackgroundOs acromiale is an accessory bone resulting from the nonunion of the acromial ossification center, with a reported prevalence of approximately 2%. While os acromiale is often asymptomatic, when symptomatic, it has been reported to be strongly associated with rotator cuff injuries. This multicenter study aimed to determine the prevalence of and the factors associated with os acromiale in the Japanese population.MethodsWe analyzed 6,842 shoulder magnetic resonance imaging scans for shoulder disabilities obtained at 10 facilities between April 2018 and March 2023. The average age was 63.7 years, with 3,483 male and 3,359 female shoulders. This study assessed the prevalence of os acromiale, its location (pre-acromion, meso-acromion, and meta-acromion), size (length, width, and thickness), acromion shape (square tip, intermediate, and cobra), and the association between os acromiale and rotator cuff injuries. Statistical analysis was performed using Fisher's exact test with a significance level set at P < .05.ResultsA total of 76 cases of os acromiale (1.1%) were identified. There were 58 shoulders with pre-acromion, 18 with meso-acromion, and none with meta-acromion. The dimensions were as follows: pre-acromion (length 7.5 mm, width 10.5 mm, and thickness 5.3 mm), and meso-acromion (length 20.1 mm, width 20.8 mm, and thickness 8.5 mm). Acromial shapes included a square tip in 13 shoulders, intermediate tip in 38 shoulders, and cobra shape in 25 shoulders. The presence of os acromiale was significantly associated with rotator cuff injury (P < .001).ConclusionThe study supports previous findings that os acromiale is associated with rotator cuff injuries. In addition, the prevalence of os acromiale in the Japanese population was lower than that in non-Asian populations, and the size of os acromiale tended to be smaller than in European populations.

BackgroundGastrointestinal neuroendocrine tumors (GI-NETs) are slow-growing tumors with the potential for malignancy that originate from neuroendocrine cells. Therefore, early diagnosis and treatment of GI-NETs are necessary to prevent metastasis. The widespread use of colonoscopy, which allows early detection of rectal neuroendocrine tumors (rNETs) that are small enough to be treated endoscopically, has resulted in an increasing rate of endoscopic resection of rNETs. However, whether the long-term prognosis of endoscopically resected rNETs is favorable has not yet been determined. This study aimed to assess whether endoscopically resected rNETs affect the long-term prognosis of patients.MethodsWe retrospectively reviewed the medical records of 163 consecutive patients with rNETs who underwent endoscopic resection at 11 hospitals in Japan between 1999 and 2012. The primary analysis focused on 47 patients with 51 rNETs who underwent ≥ 10 years of follow-up. The secondary analysis focused on patients who underwent less than 10 years of follow-up.ResultsThe median follow-up period of patients included in the primary analysis was 12.3 years (range, 10–19.1 years). The median lesion size was 5 mm (range, 2–12). Three lesions were treated using conventional endoscopic mucosal resection (EMR). Twenty-nine lesions were treated using modified EMR. Nineteen lesions were treated using endoscopic submucosal dissection. The R1 resection rate and lymphovascular invasion rate were 15.7% and 25.5%, respectively. The curative resection (CR) rate and non-CR rate were 66.7% and 33.3%, respectively. Two patients with lesions treated with non-CR underwent radical surgery. None of the 47 patients experienced lesion recurrence during the 10-year follow-up period. Two patients whose lesions were treated with CR died of other diseases.ConclusionsDeath attributable to rNETs did not occur among patients who underwent at least 10 years of follow-up after endoscopic resection.

Retrospective case-control study. To determine risk factors for recurrence of pediatric lumbar spondylolysis at L5 after return to sport in patients who achieved bone union with conservative treatment. Pediatric lumbar spondylolysis is a stress fracture commonly observed in adolescent athletes, particularly at the L5 vertebra. Because some patients experience a recurrence of spondylolysis after bone fusion with conservative treatment, identifying risk factors for recurrence may help athletes continue sports activities, maintain performance levels, and preserve mental health. Of the 375 pediatric patients (below 18yr of age) who received conservative treatment for lumbar spondylolysis at L5 between 2015 and 2021, 296 patients who achieved bone fusion and returned to their original sports activities were analyzed. Recurrence rate, sports, pathologic stage of spondylolysis at initial examination, presence of spina bifida occulta (SBO), duration of conservative treatment for initial spondylolysis, and radiologic parameters including lumber lordosis, L5-S1 lordosis, and sacral slope were examined. Recurrence and nonrecurrence groups were compared using univariate and multivariate analyses to investigate risk factors for recurrence. A receiver operating characteristic (ROC) curve was drawn to determine cutoff values of the parameters to predict spondylolysis recurrence. Recurrence was observed in 52 of 296 patients (17.6%). Multivariate logistic regression analysis revealed that a large L5-S1 lordosis was a significant independent risk factor for recurrence. ROC analysis demonstrated a cutoff value of 24.5° for L5-S1 lordosis. Age, sex, SBO, and duration of conservative treatment for initial spondylolysis were not significant predictors of recurrence. We identified large L5-S1 lordosis as an independent risk factor for recurrence of pediatric lumbar spondylolysis at L5 following conservative treatment. Intensive athletic rehabilitation to prevent recurrence and follow-up measures to monitor and detect recurrence are recommended for patients with large L5-S1 lordosis.

The enhanced-view totally extraperitoneal technique (eTEP) has gained popularity as a novel minimally invasive ventral hernia repair approach. However, this procedure becomes technically demanding once the view is no longer maintained, due to incidental pneumoperitoneum caused by peritoneal injury during the surgery. In an attempt to overcome this technical issue, we report laparoscopic extraperitoneal repair with upfront coring out of hernia defect (LERCO) where the intraperitoneal coring out of the hernia defect precedes the regular eTEP for the treatment of midline incisional ventral hernia. A total of nine patients with midline incisional ventral hernia were treated by LERCO. In the first step, 3 ports are inserted into the peritoneal cavity. The half circumference of the hernia defect is cored out and the extraperitoneal space is further dissected. Then, an additional 3 ports are inserted in the dissected extraperitoneal space. The remaining half circumference of the hernia defect is cored out and the dissection of the extraperitoneal space around the hernia defect is completed. Subsequently, the hernia defect as well as posterior sheath and peritoneum are reapproximated and the mesh is deployed in the extraperitoneal space. In this series of patients, there was no open conversion during the surgery nor severe postoperative complications including hernia recurrence. LERCO secures the procedure under the optimal field of view during midline incisional ventral hernia repair. Although our results are promising, further accumulation of clinical experiences is warranted.

Peptide-binding motif (PBM) model, a hierarchical clustering of HLA class I based on their binding specificity, was developed to predict immunopeptidome divergence. The effect of PBM mismatches on outcomes is unknown in HLA-haploidentical haematopoietic cell transplantation with post-transplant cyclophosphamide (PTCy-haplo). We therefore conducted a retrospective study using national registry data in PTCy-haplo. Overall, 1352 patients were included in the study. PBM-A bidirectional mismatch was associated with an increased risk of overall mortality in multivariable analysis (hazard ratio, 1.26; 95% confidence interval, 1.06 to 1.50; p = 0.010). None of relapse, non-relapse mortality (NRM) and graft-versus-host disease showed significant differences according to PBM-A bidirectional mismatch status in the entire cohort. The impact of PBM-A bidirectional mismatch on overall survival (OS) was preserved within the HLA-A genotype bidirectional mismatch population, and their lower OS stemmed from higher relapse rate in this population. The worse OS due to high NRM with PBM-A bidirectional mismatch was prominent in lymphoid malignancies receiving reduced-intensity conditioning. The PBM model may predict outcomes more accurately than HLA genotype mismatches. In conclusion, this study demonstrated that the presence of PBM-A bidirectional mismatch elevated the risk of mortality of PTCy-haplo. Avoiding PBM-A bidirectional mismatch might achieve better outcomes in PTCy-haplo.

Lymphangiomas in the peritoneal cavity are rare in adults, with most cases occurring in children. We present the case of a 49-year-old woman who was admitted with severe lower abdominal pain. The diagnostic assessment revealed a multiloculated cystic structure in the mesentery of the distal ileum, suggesting a lymphangioma. The patient underwent laparotomy and resection, with successful removal of the mass. Histopathological examination confirmed the diagnosis of intestinal lymphangioma, a rare benign vascular neoplasm of the small bowel. Postoperatively, the patient experienced resolution of postoperative ileus and mild back and abdominal pain, with no complaints during follow-up. Awareness of this uncommon condition is crucial for accurate diagnosis and appropriate treatment. Surgical resection, supported by radiological and histopathological investigations, is the primary treatment modality for symptomatic lymphangioma. Regular follow-up with imaging may be necessary to monitor recurrence.