Tokyo-Kita Medical Center

症例は54歳の男性で，検診の上部消化管内視鏡検査にて食道胃接合部に1/3周性のメラノーシスを認めていた．1年後の検診にて同部位に15 mm大の隆起性病変を認め，生検の結果悪性黒色腫と診断された．自覚症状はなく，全身を検索したが他にメラノーシスの所見を認めず，CTでも明らかな遠隔転移がなかったことから，食道胃接合部原発の悪性黒色腫と診断し，幽門側胃切除後であったため，残胃全摘術を施行した．病理組織学的検査の免疫染色検査にてmelan A，PRAME陽性で悪性黒色腫に矛盾せず，深達度はSMで小彎リンパ節転移陽性であった．術後補助療法としてnivolumabの投与を開始したが，術後1年のCTにて多発肝転移を認めたためipilimumabとの併用療法を開始している．食道胃接合部原発悪性黒色腫に対し術後補助療法としてnivolumabを使用した報告は本症例が初である．

Anterior choroidal artery (AChA) infarction typically manifests as the classical triad of contralateral hemiparesis, hemisensory loss, and homonymous hemianopia (Monakow syndrome). We report a rare case of right AChA infarction presenting with fluctuating consciousness and left hemispatial neglect, accompanied by widespread functional suppression of the right cerebral hemisphere. A 65-year-old right-handed man initially exhibited mild dysarthria and left-sided sensory impairment, with no acute lesions on diffusion-weighted MRI. He subsequently developed impaired consciousness and hemispatial neglect. Follow-up MRI demonstrated acute infarcts in the posterior limb of the internal capsule (PLIC) and lateral geniculate nucleus (LGN). Arterial spin labeling (ASL) and N-isopropyl-p-[123I]iodoamphetamine single-photon emission computed tomography (IMP-SPECT) revealed extensive right-hemispheric hypoperfusion, disproportionate to the structural lesion. Recent evidence indicates that the PLIC and LGN function as major network hubs rather than simple relay pathways. Local injury to these hubs may disrupt global network efficiency, producing functional diaschisis. This case highlights the need to consider network-level dysfunction in AChA infarction.

Abstract Background In cases of advanced esophageal cancer and esophageal stenosis following chemoradiotherapy (CRT), oral intake often becomes difficult, significantly reducing patients’ quality of life (QOL). Esophageal bypass surgery is one option to maintain oral intake. To continue chemotherapy, maintaining oral intake and controlling airway complications are crucial. Methods A retrospective analysis was conducted on cases that underwent esophageal bypass surgery (Postlethwait method) at Kobe University and its affiliated hospitals between January 2021 and December 2022. Results The cohort included two male and three female patients. The indications for surgery were passage obstruction after CRT in three cases, stenosis after endoscopic submucosal dissection (ESD) in one case, and mediastinal perforation in one case. Among the five cases, three experienced airway obstruction due to tracheoesophageal fistula or bronchial invasion during the continuation of chemotherapy postoperatively. The remaining two cases did not receive postoperative treatment and ultimately succumbed to other diseases. The mean survival time from the Postlethwait procedure was 528 (285–973) days. Patients were able to maintain a relatively stable QOL, with adequate oral intake until death. Conclusion Esophageal bypass surgery (Postlethwait method) contributes to maintaining patients’ QOL. Even in cases of unresectable esophageal cancer, if oral intake is preserved and airway complications are managed, continued chemotherapy is feasible, potentially leading to a relatively prolonged prognosis.

ObjectivesTo measure the assumed tumour volume in the humerus of patients with multiple myeloma using dual-energy spectral computed tomography (DESCT) and to evaluate the correlation with haematological indicators.MethodsWe retrospectively analysed 82 DESCT examinations of 22 patients diagnosed with multiple myeloma. After extracting the bilateral humeri and removing the bone tissue, we measured the volume of the assumed tumour area using a single threshold based on Hounsfield unit values and double thresholds using material density images. We analysed the correlations between tumour volume and haematological indicators (β2-microglobulin, M-protein, free light chain, albumin, lactate dehydrogenase) and the trends after treatment intervention.ResultsA moderate correlation was identified between the assumed tumour volume in the initial scan and the β2-microglobulin level, with a correlation coefficient of ρ = 0.69 for the volume calculated from a single threshold value of Hounsfield unit and ρ = 0.57 for the volume calculated from a double threshold value of the bone(fat) material density image. No significant correlation was found between the assumed tumour volume and the M-protein or free light chain levels. In patients who underwent three or more follow-up evaluations after the initial examination, there was a similarity in the changes in the assumed tumour volume and β2-microglobulin levels after treatment.ConclusionExtracting assumed tumour volume using DESCT has sufficient potential as a biomarker for multiple myeloma.

ObjectiveThis study aimed to evaluate the feasibility and safety of neurointerventional procedures performed via transradial access (TRA) using a sheathless 8 Fr Optimo balloon guide catheter (BGC).MethodsWe retrospectively analyzed 100 consecutive neurointerventional procedures performed via TRA using a sheathless 8 Fr Optimo BGC at a single center. Technical success was defined as the successful delivery of the BGC to the target vessel without conversion to an alternative access site or catheter system, along with the completion of the planned procedure.ResultsA total of 100 procedures were performed in 95 patients (median age: 75 years; 63% male). The most common interventions were aneurysm coiling or flow diversion (45%) and carotid artery stenting (36%). Target vessels for BGC placement included the right carotid (59%), left carotid (31%), right vertebral (4%), and left vertebral (6%) arteries. The median BGC navigation time was 12 min (interquartile range: 7-20). Technical success was achieved in 95% of procedures. In five cases, conversion to transulnar, transbrachial, or transfemoral access was required; nevertheless, all planned procedures were completed successfully. Balloon inflation was utilized in 37% of procedures for distal embolic protection, rupture management, or device delivery support. No major access-related complications were observed. Symptomatic non-access-related periprocedural complications occurred in 3% of cases. The overall mortality rate was 2%.ConclusionsNeurointerventional procedures performed via TRA using a sheathless 8 Fr Optimo BGC appear to be feasible and safe, offering a high technical success rate and a low incidence of access-related complications.

Covered self-expandable metal stents are commonly used for unresectable malignant distal biliary obstruction. Partially covered self-expandable metal stents have uncovered sections at both ends; however, their anti-migration effect remains unclear. The objective of this study was to evaluate that effect by comparing such stents with fully covered self-expandable metal stents for patients with unresectable malignant distal biliary obstruction. This was a multicenter, retrospective comparative study of partially covered stents with fully covered stents for unresectable malignant distal biliary obstruction. Stent migration, recurrent biliary obstruction, and the time to recurrent biliary obstruction were compared between them. Thirty-nine patients with partially covered stents were included and compared with 42 patients with fully covered stents. The partially covered group had a significantly lower stent migration rate (3%vs. 36%; p<0.001). The recurrent biliary obstruction rate was significantly lower in the partially covered group (21%vs. 43%; p=0.036). The non-recurrent biliary obstruction rate at 6 months was 90% and 68% in the partially and fully covered groups, respectively. The time to recurrent biliary obstruction was significantly longer in the partially covered group (Gray's test, p=0.016). Only partially covered stent placement was significantly associated with a lower risk of stent migration (subdistribution hazard ratio=0.077; 95% confidence interval=0.01-0.60; p=0.014) in the multivariable analysis. The anti-migration effect of partially covered self-expandable metal stents was associated with a reduced recurrence of biliary obstruction and prolonged time to such obstruction.

We evaluated the outcomes of canalplasty for external auditory canal cholesteatoma (EACC) using an inferior-pedicled periosteal flap to cover the eradicated diseased bone. Retrospective chart review. Tertiary referral center. Thirty-one ears in 30 patients surgically treated for stages III and IV primary EACC. Canalplasty using an inferior-pedicled periosteal flap with or without tympanoplasty. Disease recurrence, hearing, and clinical factors influencing the time taken to achieve complete epithelization of the external auditory canal. The 31 ears with EACC required 2 to 40 weeks (mean, 7.8 wk; median, 4 wk) to achieve complete epithelization. After epithelization, 84% of the ears became self-cleaning ear canals without any local treatment. Two patients with renal dysfunction experienced recurrence of EACC in the anterior-superior bony canal wall and needed additional treatment. Younger patients took a significantly shorter time to achieve epithelization than older patients ( p < 0.001). Patients with renal dysfunction tended to need longer periods for epithelization than those without renal dysfunction ( p = 0.092). Canalplasty for stages III and IV EACC using an inferior-pedicled periosteal flap achieved good postoperative results, with 86% of ears becoming self-cleaning ear canals in a short healing time. Special attention must be paid to the patients with renal dysfunction to create a pedicled flap of sufficient size to cover the bone and maintain a good blood supply.