Otsu Municipal Hospital

Immune checkpoint inhibitors are widely used in treating metastatic urothelial carcinoma and metastatic renal cell carcinoma. However, the incidence, timing, and clinical impact of immune-related adverse events in real-world practice remain unclear. This study aimed to investigate their onset patterns and outcomes. We retrospectively analyzed 210 patients with metastatic urothelial carcinoma (n=127) or metastatic renal cell carcinoma (n=83) treated with immune checkpoint inhibitors between 2017 and 2023 at a single academic institution. Events were graded using Common Terminology Criteria for Adverse Events version 5.0. Associations with progression-free and overall survival were assessed. We also evaluated cumulative incidence, corticosteroid or immunosuppressant use, and outcomes after rechallenge. Immune-related adverse events occurred in 78 patients (37.1%), more frequently in metastatic renal cell carcinoma (47.0%) than in metastatic urothelial carcinoma (30.9%). Overall, grade ≥3 events occurred in 22.0% of patients, with higher incidence in renal cell carcinoma (27.7%) than in urothelial carcinoma (17.3%). In metastatic urothelial carcinoma, their presence was linked to longer survival; no difference was seen in metastatic renal cell carcinoma. Most events developed within six months; only 3.4% occurred after one year. High-dose corticosteroids were administered in 13.8% of patients, and 72.4% of them successfully completed tapering. Immunosuppressants were used in 1.4%. Eleven patients underwent rechallenge, of whom two experienced recurrence. Immune-related adverse events showed distinct incidence and prognostic relevance between urothelial and renal cell carcinoma. These findings underscore the need for treatment-specific monitoring and provide practical insights into managing toxicities and decisions regarding immunotherapy rechallenge.

<title>Abstract</title> Purpose Although image-enhanced endoscopy (IEE) is useful, its benefit over white light imaging (WLI) for the detection of superficial non-ampullary duodenal epithelial tumors (SNADETs) remains unclear. We evaluated whether narrow-band imaging (NBI) and texture and color enhancement imaging (TXI) could improve SNADET visibility compared to WLI under CO ₂ insufflation and underwater conditions. Methods We conducted a post-hoc analysis using a prospectively collected image database from patients with SNADET enrolled in a multicenter observational study. We used the EVIS X1 system with a GIF-H290Z or GIF-EZ1500 endoscope to compare the visibility scores for the recognition of SNADETs. We also measured the color difference (ΔE*), saturation difference (ΔC*), and lightness difference(ΔL*) between the tumor and background mucosa. Results We analyzed 50 lesions, comprising 46 intramucosal adenocarcinomas and 4 adenomas. Under CO ₂ insufflation, TXI provided a significantly higher visibility score than the WLI (2.7 ± 0.8 vs 2.5 ± 0.9, <italic>P</italic> = 0.002); however, no significant differences were observed between TXI and NBI (2.7 ± 0.8 vs 2.6 ± 0.7, <italic>P</italic> = 0.072). Underwater conditions yielded significantly higher visibility scores than CO ₂ insufflation across the three modes (WLI, 3.1 ± 0.6 vs. 2.5 ± 0.9, <italic>P</italic> &lt; 0.001; NBI, 2.9 ± 0.7 vs. 2.6 ± 0.7, <italic>P</italic> &lt; 0.001; TXI, 3.2 ± 0.5 vs. 2.7 ± 0.8, <italic>P</italic> &lt; 0.001). The ΔC* in TXI was significantly higher than that in WLI under CO ₂ insufflation (8.5 ± 6.0 vs 5.9 ± 3.9, <italic>P</italic> &lt; 0.001) and underwater condition (9.2 ± 5.6 vs 6.6 ± 3.5, <italic>P</italic> &lt; 0.001). Conclusion TXI significantly improved SNADET visibility compared to WLI under CO ₂ insufflation and underwater conditions, likely due to the increased saturation difference.

The associations between symptom characteristics and patients' interpretations and sources of knowledge about acute coronary syndrome (ACS) remains unclear. We enrolled 81 patients with ACS. Patients who misinterpreted their symptoms more frequently reported atypical features such as tenderness (13.3% vs 0%; P=0.028) and syncope (11.8% vs 0%; P=0.011). Common knowledge sources among patients who correctly interpreted their symptoms included television, healthcare professionals, and the internet without social media. Patients experiencing atypical symptoms often misinterpret them. Most knowledge sources for those who interpreted correctly were traditional.

Treating chronic hepatitis C virus infection with direct-acting antivirals (DAAs) results in a sustained virological response (SVR) in most cases, but hepatocellular carcinoma (HCC) can occur in some patients after achieving SVR. Thus, this study comprehensively assessed the risk factors associated with the development of HCC during long-term follow-up in patients who achieved SVR. Furthermore, we aimed to identify a group of patients without prior HCC treatment who are at extremely low risk for HCC long after achieving SVR. This retrospective cohort study included patients who achieved SVR after DAA therapy, and predictors contributing to the incidence of HCC were determined via Cox regression analysis. Specifically, we evaluated the factors contributing to the incidence of HCC among patients without previous HCC treatment later than 5 years after achieving SVR, and these were used to construct a predictive scoring system for HCC. Overall, 267 cases of HCC were observed during follow-up. Male sex, older age, previous HCC treatment before starting DAA therapy, excessive alcohol use, diabetes mellitus, elevated γ-GTP, low albumin, and low platelet count were independent predictors of HCC. Since previous HCC treatment strongly influenced the incidence of HCC after SVR, we further analyzed the risk factors for HCC among patients without previous HCC treatment. In that cohort, parameters at 5 years after achieving SVR that contributed to the incidence of HCC later than 5 years after SVR were an age of ≥ 70 years, diabetes mellitus (DM), and fibrosis-4 index(Fib-4) of ≥ 2.67. These three factors were used to create a scoring system, with scores of 0 to 3 predicting a 0.8%, 2.7%, 11.9%, and 28.8%, respectively, cumulative incidence rate of HCC later than 5 years after SVR. Using long-term follow-up data, we investigated the risk factors for HCC among patients who achieved SVR after DAA therapy. Previous HCC treatment strongly predicted HCC after SVR. Although this was a retrospective cohort study, among patients without previous HCC treatment, those younger than 70 years, without DM and with a Fib-4 index of < 2.67 had a very low risk of developing HCC later than 5 years after SVR.

A 67-year-old male with a history of interstitial pneumonia presented with embolic stroke of undetermined source (ESUS) in the right middle cerebral artery territory. Initial workup revealed a large right-to-left shunt (RLS) suggestive of patent foramen ovale (PFO) due to bubble inflow occurring within three heartbeats after releasing the Valsalva maneuver. However, PFO was ruled out when guidewire passage through the atrial septum failed, and pulmonary angiography showed no evidence of pulmonary arteriovenous fistula or malformation. Ultimately, intrapulmonary arteriovenous anastomoses (IPAVA) were considered as the source of the RLS. It was hypothesized that numerous small IPAVA combined to form a large RLS, which, despite its size, could not be the embolic source. This case highlights the importance of thorough evaluation of RLS in patients with lung diseases, as even large shunts may originate from IPAVA rather than from intracardiac shunts such as PFO.

The aim of this study was to analyze the data from a cohort study of community-dwelling older people to clarify the impact of low tongue pressure on the onset of malnutrition. The analysis was divided into a baseline and a longitudinal analysis. The baseline analysis included 765 people (median age: 74 years; 276 men and 489 women), and the longitudinal analysis included 100 people (median age: 72 years; 33 men and 67 women). The baseline analysis showed that tongue pressure and the diagnosis of low tongue pressure using a cut-off of 30kPa were associated with the risk of malnutrition (tongue pressure: odds ratio [OR] = 0.972, 95% confidence interval [95% CI] = 0.953-0.992, p = 0.006; the diagnosis of low tongue pressure: OR = 1.555, 95% CI = 1.050-2.302, p = 0.027). In the longitudinal analysis, tongue pressure and the diagnosis of low tongue pressure at baseline were associated with the onset of the risk of malnutrition after 4 years (tongue pressure: OR = 0.952, 95% CI = 0.907-0.998, p = 0.041; the diagnosis of low tongue pressure: OR = 2.698, 95% CI = 1.148-6.341; p = 0.023). In community-dwelling older people, low tongue pressure could increase the risk of future malnutrition.

Neurofibromatosis type 1 (NF1), also known as von Recklinghausen's disease, is an autosomal dominant disorder characterized by multiple café-au-lait macules and cutaneous neurofibromas. Although neurofibromas are common in NF1, involvement of the urinary tract is rare, with the bladder being the most frequently affected site. Urachal neurofibromas are extremely rare, and their diagnosis and management remain challenging due to nonspecific imaging characteristics and their often asymptomatic presentation.We report the case of a 30-year-old man with clinical features of NF1 in whom a 5-cm mass at the bladder dome was incidentally identified on MRI performed during evaluation for spinal cord symptoms. Imaging revealed a cone-shaped mass in the urachal region, and cystoscopy showed no mucosal abnormalities. Urinalysis and urine cytology were unremarkable. A transabdominal needle biopsy confirmed the diagnosis of a neurofibroma. Given the tumor’s size (>5 cm) and deep-seated location in the trunk, both known risk factors for malignant transformation, surgical excision was performed, including resection of the urachus and bilateral umbilical ligaments. Histopathological analysis confirmed a plexiform neurofibroma consistent with NF1. The postoperative course was uneventful, with no evidence of recurrence during 36 months of follow-up.This case highlights the rare presentation of a urachal plexiform neurofibroma in a patient with NF1. To reduce the potential risk of malignant transformation associated with plexiform neurofibromas larger than 5 cm and located in deep trunk regions, accurate diagnosis and timely surgical intervention are essential, even in asymptomatic cases.

Abdominoperineal resection with permanent colostomy has historically been performed for very low rectal cancer located near the anal canal. Anus-preserving surgeries, such as intersphincteric resection (ISR) and low anterior resection (LAR), have recently become more common. However, postoperative anal function is a concern in these surgeries when the anastomosis is very low. The aim of this study was to examine changes in anal function and factors that worsen anal function after surgery for rectal cancer. A multicentre (47 facilities), non-randomized, single-arm phase II trial was conducted prospectively using the Wexner score questionnaire between 2014 and 2017. A total of 278 patients who underwent laparoscopic surgery for clinical Stage I very low rectal cancer were analysed using a mixed-effects model. Anal function temporarily worsened 3 months after surgery, but gradually recovered and spontaneously returned to an acceptable level in 3 years. In a comparison of surgical procedures, anal function was significantly better after LAR than after any type of ISR. There was little difference in anal function after total ISR, subtotal ISR and partial ISR. In the mixed-effects model analysis, ISR and older age (≥75 years) were identified as independent factors that worsened postoperative anal function. The results showed early deterioration of anal function followed by gradual improvement to an acceptable level after surgery. There is a higher risk of poor postoperative anal function after ISR and in older patients, and these risk factors should be communicated to patients when obtaining consent for the surgery.

Introduction: The imaging findings of elastosis, a subtype of fibrous components, have hardly been investigated in breast cancer to date. Case Presentation: A 70-year-old woman visited the Rinku General Medical Center for the evaluation of her left palpable breast tumor. Mammography (MMG) showed an irregular mass with segmental distribution of pleomorphic calcifications. The tumor was more clearly depicted on cranio-caudal (CC) MMG than on medio-lateral-oblique (MLO) MMG. Ultrasound showed a lobulated mass with low internal echoes, echogenic spots, and at least focally enhanced posterior echoes. Magnetic resonance imaging of the tumor showed low signal intensity on T1-weighted images and no high signal intensity on T2-weighted images and a rim enhancement pattern on subtraction images. Pathological examination of the core needle biopsy specimen showed atypical cells growing in a tubule-forming fashion. The patient underwent mastectomy and, due to the cytologically proven lymph node metastasis, axillary dissection. Postoperative pathological study showed that the tumor had large elastosis areas encompassed by malignant cells. Conclusion: Diagnostic physicians should note that breast cancer-related elastosis is more clearly depicted on CC MMG than on MLO MMG, has possible enhanced posterior echoes, and shows low and no high signal intensities on T1- and T2-weighted images, respectively.