Medical Terms Learned today

諸君　私は放治が好きだ
諸君　私は放治が大好きだ

根治照射が好きだ
多分割照射が好きだ
CRTが好きだ
予防照射が好きだ
IMRTが好きだ
小線源が好きだ
RALSが好きだ
全身照射が好きだ
姑息照射が好きだ

頭蓋で　脊椎で
喉頭で　咽頭で
乳房で　腋窩で
肺野で　縦隔で
直腸で　子宮で

この人体に行われるありとあらゆる放射線治療が大好きだ

リーフを並べたフォトンの一斉照射が轟音と共に粘膜を焼き尽くすのが好きだ
管腔内部に放り上げられた扁平上皮癌が消化でばらばらになった時など心がおどる

技師の操るLinac の 照射野88 mm （アハトアハト）で癌細胞を撃破するのが好きだ
悲鳴を上げて炎症を起こす肺胞から染み出てきた滲出液を PSL でなぎ倒した時など
胸がすくむような気持ちだった

針先をそろえた小線源治療が舌の側面を蹂躙するのが好きだ
恐慌状態の女医が既に息も絶え絶えの舌を何度も刺入している様など感動すら覚える

敗北主義の後期研修医たちをカンファ上でつるし上げていく様などはもうたまらない
泣き叫ぶ彼らが私の振り下ろしたダメだしとともに金切り声で罵倒され薙ぎ倒されるのも最高だ

哀れな白血病細胞が健気にも立ち上がってきたのを正常骨髄ごと全身照射で木端微塵に粉砕した時など絶頂すら覚える

ターミナルの頭頚部癌に滅茶苦茶にされるのが好きだ
必死に治療するはずだった患者が衰弱し亡くなって行く様はとてもとても悲しいものだ

英米研究費の物量に押し潰されて殲滅されるのが好きだ
英米医学誌（のレフェリー）に重箱の隅をつつかれ害虫のようにリジェクトされるのは屈辱の極みだ

諸君　私は放治を地獄の様な放治を望んでいる
諸君　私に付き従うJASTROの会員諸君
君達は一体何を望んでいる？

更なる放治を望むか？
情け容赦のない糞の様な放治を望むか？
鉄風雷火の限りを尽くし三千世界の鴉を殺す嵐の様な病棟を望むか？

『放治！　　　放治！　　　放治！』
（アールティ　アールティ　アールティ）

よろしい　ならば放治だ


我々は渾身の力をこめて今まさに振り降ろさんとする握り拳だ
だがこの暗い闇の底で半世紀もの間堪え続けてきた我々にただの放治ではもはや足りない！！

過剰照射を！！
一心不乱の過剰照射を！

我らはわずかに国内　500人に満たぬ放射線治療医に過ぎない
だが諸君は一騎当千の古強者だと私は信仰している
ならば我らは諸君と私で総力50万と1人の医集団となる


我々を忘却の彼方へと追いやり眠りこけている厚労省を叩き起こそう
髪の毛をつかんで引きずり降ろし眼を開けさせ思い出させよう
連中に恐怖の味を思い出させてやる
連中に我々のサンダルの音を思い出させてやる

天と地のはざまには奴らの哲学では思いもよらない事があることを思い出させてやる
500人未満の放射線治療医の集団で
癌を燃やし尽くしてやる

「最後の治療医指揮官より全ネーベンへ」
目標米国本土ワシントン・ASTRO会場！！

第二次レジストレーション作戦　状況を開始せよ

Goldstein JA, Gallagher MJ, O'Neill WW, et al.A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007 Feb 27;49(8):863-71.

Malagutti P, Nieman K, Meijboom WB, et al. Use of 64-slice CT in symptomatic patients after coronary bypass surgery: evaluation of grafts and coronary arteries. Eur Heart J. 2007 Aug;28(15):1879-85.

Kobza R, Auf der Maur C, et al. Esophagus imaging for radiofrequency ablation of atrial fibrillation using a dual-source computed tomography system: Preliminary observations. J Interv Card Electrophysiol. 2007 Sep;19(3):167-70.

Bessell-Browne R, O'Malley ME. CT of pheochromocytoma and paraganglioma: risk of adverse events with i.v. administration of nonionic contrast material. AJR Am J Roentgenol. 2007 Apr;188(4):970-4.

Bettmann MA. Frequently asked questions: iodinated contrast agents.
Radiographics. 2004 Oct;24 Suppl 1:S3-10. http://radiographics.rsnajnls.org/cgi/content/full/24/suppl_1/S3

Aspelin P, Aubry P, Fransson SG, et al. Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med. 2003 Feb 6;348(6):491-9. http://content.nejm.org/cgi/content/abstract/348/6/491

http://www.esur.org/fileadmin/Guidelines/ESUR_2007_Guideline_6_Kern_Ubersicht.pdf
(ESUR造影検査のガイドライン)

Thomsen HS, Morcos SK. Contrast-medium-induced nephropathy: is there a new consensus? A review of published guidelines.
Eur Radiol. 2006 Aug;16(8):1835-40.

Einstein AJ, Henzlova MJ, Rajagopalan S.　Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography.　JAMA. 2007 Jul 18;298(3):317-23.

MDCT of coronary artery: Feasibility of low dose CT. 2008 AJR in publishing

Molecular Targeting Therapy in Lung Cancer
Speaker: Dr. Adi Gazdar, from UT Southwestern Medical Center.

Gefinitib "Lazarus" Response
www.aacr.org/page4369.aspx
"...Dr. Tom Lynch at Massachusetts General Hospital in Boston called the “Lazarus response.” Lazarus was brought back from the dead in the Bible. In a similar manner, there was the occasional patient who came to the clinic in a wheelchair on oxygen, and after taking this pill once a day for a couple of months, will now come into the clinic walking, with clear lungs on the CT scan."

Janus of DNA repair gene.
Zhong Z, et al.
DNA Synthesis and Repair Genes RRM1 and ERCC1 in Lung Cancer
New Engl j Med 356:800-808, 2007.(Link)
Expression of RRM1 correlated with good prognosis.

Gazdar A.
DNA Repair and Survival in Lung Cancer — The Two Faces of Janus
New Engl j Med 356:771-773, 2007.(Link 1, 2)
However, expression of RRM1 preedicts
poor response to gemcitabine and platinum compounds.

Bild AH, et al. Oncogenic pathway signatures in human cancers as a guide to targeted therapies
Nature 439:353-357, 2006. (Link)

Japanese Status of "Bevacizumab (BV: Avastin)" in Advanced colorectal cancer.
Speaker: Dr. Toshihiko Doi, from National Cancer Center East Hospital.

Practical Use of Imatinib in CML Patients: Results from Shomofusa Study Group.
Speker: Dr. Hisashi Wakita, from Narita Red Cross Hospital.

Aggressive Surgery for Hilar Cholangiocarcinoma
Speaker: Dr. Peter Neuhaus, from Charité - Berlin University School of Medicine, Campus Virchow-Klinikum.
Bismuth Classification.
Neoadjuvant therapy + transplantation 5 yr survival 82%. Transplant only lower than HCC survival.
Expression of VEGF-C (lymphangiogenesis) expression correlate with poor prognosis.
Pitt HA, Nakeeb A, Abrams RA, et al. Perihilar cholangiocarcinoma. Postoperative radiotherapy does not improve survival.
Ann Surg. 221:788-97, 1995.(Link)
*Conflicting results.

Eckel F, Schmid RM. Chemotherapy in advanced biliary tract carcinoma: a pooled analysis of clinical trials.
Br J Cancer. 96:896-902, 2007. Gemcitabine + platinum compounds provisionaly standards chemotherapy.

LiMAX rather than ICG correlate well with liver function.
Pre- EPO, post-insulin+glucose
HGF/EGF increases hepatic regeneration.

Extended hepatectomy (R0) good prognosis.
Ebata T, Nagino M, Kamiya J, et al. Hepatectomy with portal vein resection for hilar cholangiocarcinoma: audit of 52 consecutive cases. Ann Surg. 238:720-7, 2003.(Link)
About lymph node status
N+ 53%,
N- 5yr 32%, #16 micrometastases 29%.
Kitagawa Y, Nagino M, Kamiya J, et al. Lymph node metastasis from hilar cholangiocarcinoma: audit
of 110 patients who underwent regional and paraaortic node dissection. Ann Surg. 233:385-92, 2001.
(Link)
Virchow's node
Lancet 03/11/2007 - 02:01
A 70-year-old man presented to his primary care physician with postprandial epigastric pain. He was prescribed antacids, which were ineffective; his weight then decreased by 11 kg in 3 months. Oesophagogastroduodenoscopy showed a mass in the antrum; histopathological analysis of a biopsy sample established that the mass was a signet-ring adenocarcinoma. Even before the biopsy was analysed, examination of the neck supported the diagnosis of cancer: the left supraclavicular lymph node was firm and enlarged (). The left supraclavicular lymph node is near the junction of the thoracic duct and the left subclavian vein, where the lymph from much of the body drains into the systemic circulation. An enlarged node can be the first sign of gastric cancer—and is often called Virchow's node, because the association between left supraclavicular lymphadenopathy and gastric cancer was first described by the German pathologist Rudolf Virchow (1821–1902). Virchow lectured and practised at the Charité Medical School of the Humboldt University of Berlin, where he discovered several facts fundamental to modern medicine.

Clinical Management of Cancer Therapy
Speaker: Dr. Richard S. Zimmerman, from Mayo clinic.
Can We deliver good practice?
Dissociation between medical research and real world.
Hawthorne effect (Link1, 2)

Evaluation of Process
Fonarow GC, Abraham WT, Albert NM, et al.Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 297:61-70, 2007. (Link1)
"Assessment of quality of care in heart failure has focused on the development and use of process-based performance measures, with the presumption that these processes are associated with improved clinical outcomes. However, this link remains largely untested."

Publication bias and so on. Is the good results can be directly translated into the clinical practice??
Ioannidis JP. Contradicted and initially stronger effects in highly cited clinical research. JAMA. 294:218-28, 2005.　href="http://jama.ama-assn.org/cgi/content/full/294/2/218">(Link)

"16% contraindicated later, 16% shows stronger effect"

Pros and cons of megatrial.
Mammoscreening risk up down 0.05%, up 0.5%!
Avoid casual Benchmarking.

・PIDのパラダイムシフト　common, sporadic, adult, spontaneously improving, other specific, # of phenotype/episode low, nonhematopoietic, penetrance incomplete, germ line de novo or somatic. IL-12p40 IL-12Rβ1-mycobacterium, IL-1 receptor associated kinase 5 (IRAK-4)-pneumococcal, UNC-93B and TLR3 -HSE.

Skull of Schiller を調べる。1805年・４５歳時に結核で死亡、共同墓地に埋葬される。
サルは音楽より静寂を好む、音楽を楽しむのは人特有か。

Lancet

１）May 25, 2007

A mimic of sarcoidosis
from The Lancet by Larisa Dzirlo
In June, 1998, a 48-year-old man presented to the University Hospital of Vienna with large, red, partly ulcerated cutaneous plaques on the anterior surfaces of his lower legs. He also described shortness of breath on exertion. He had no other medical history of note.　Whipple disease による皮膚病変、縦隔リンパ節腫大。ステロイドで軽快せず、後にタンパク漏出胃腸症で診断された。PAS陽性。Tropheryma whipplei が原因。

9 years of recurrent dysphagia
from The Lancet by Krishna P Basavaraju
A 46-year-old man was referred with a 9-year history of recurrent, intermittent, painful dysphagia, mainly for solids. His appetite was good and his weight remained steady. The results of his barium swallow, gastroscopy, oesophageal manometry, and 24-hour oesophageal pH study were unremarkable. In view of the patient's continued dysphagia, gastroscopy was repeated 4 months later, when it revealed multiple concentric rings in the upper and middle oesophagus (); the gastroscope could not be advanced beyond 28 cm. A biopsy of the oesophagus showed dense eosinophilic infiltration, consistent with eosinophilic oesophagitis. The patient's symptoms settled with a 3-month course of steroids. 5 months after the end of the course, his symptoms recurred, but responded equally well to 10 mg of montelukast daily, on which he has remained symptom-free for a year.　好酸球性食道炎で膜状構造

２）May 28, 2007.

Book: Too busy to have cancer?
from The Lancet by Priya Shetty
“What happens when a shoe-crazy, lipstick-obsessed, wine-swilling, pasta-slurping, fashion-fanatic, madly-in-love, single-forever, about-to-get-married big city girl cartoonist with a fabulous life finds…A LUMP IN HER BREAST!?” She writes a darkly funny graphic memoir of her fight with breast cancer through an alter ego “Cancer Vixen”—replete with 5-inch gold heels and sassy slogan: “cancer, I'm gonna kick your butt!” In Marisa Acocella Marchetto's New York life “B.C.” (Before Cancer), her biggest problems were which fashionable party to go to next, a rivalry with another female cartoonist, and the models vying for her rakish Italian restaurateur fiancé's attention. Finally, aged 43, having found the man she wants to marry, and with her cartoons in demand by the likes of The New Yorker, she is diagnosed with breast cancer. In her words, “now is not a good time!” What happens next is the story she relates in Cancer Vixen.

Radiotherapy and the heart
from The Lancet by Matthias Bramkamp
In June, 2006, a 47-year-old man was admitted to our emergency department with chest pain. There was ST segment elevation on his ECG, and his troponin T concentration was raised at 0·24 μg/L (normal <0·10 μg/L). His LDL cholesterol concentration was marginally raised at 3·1 mmol/L, but his total cholesterol concentration was within the normal range, as was his blood pressure. He was a non-smoker, and had been working as an instructor in a gymnasium. His medical history had only one notable feature: in his teens, he had been diagnosed with Hodgkin's lymphoma, for which he had undergone mediastinal radiotherapy at a total dose of 40 Gy ().冠動脈疾患
リスクファクターが僅かな47歳男性。心筋虚血で来院。10代の頃HDで胸部照射の既往あり。
それによる冠動脈疾患が疑われた。

２）Science　May 11, 2007.
A Common Variant in the FTO Gene Is Associated with Body Mass Index and Predisposes to Childhood and Adult Obesity
Timothy M. Frayling, Nicholas J. Timpson, Michael N. Weedon, Eleftheria Zeggini, Rachel M. Freathy, Cecilia M. Lindgren, John R. B. Perry, Katherine S. Elliott, Hana Lango, Nigel W. Rayner, Beverley Shields, Lorna W. Harries, Jeffrey C. Barrett, Sian Ellard, Christopher J. Groves, Bridget Knight, Ann-Marie Patch, Andrew R. Ness, Shah Ebrahim, Debbie A. Lawlor, Susan M. Ring, Yoav Ben-Shlomo, Marjo-Riitta Jarvelin, Ulla Sovio, Amanda J. Bennett, David Melzer, Luigi Ferrucci, Ruth J. F. Loos, Inês Barroso, Nicholas J. Wareham, Fredrik Karpe, Katharine R. Owen, Lon R. Cardon, Mark Walker, Graham A. Hitman, Colin N. A. Palmer, Alex S. F. Doney, Andrew D. Morris, George Davey Smith, The Wellcome Trust Case Control Consortium, Andrew T. Hattersley, and Mark I. McCarthy
Science 11 May 2007: 889-894.
Bat Flight Generates Complex Aerodynamic Tracks

A. Hedenström, L. C. Johansson, M. Wolf, R. von Busse, Y. Winter, and G. R. Spedding
Science 11 May 2007: 894-897.
The wake of small flying bats shows multiple vortices when traced, suggesting that their flight is based on somewhat different principles than that of birds.

３）Other
Most Osteomalacia-associated Mesenchymal Tumors Are a Single Histopathologic Entity: An Analysis of 32 Cases and a Comprehensive Review of the Literature.

Original Article
American Journal of Surgical Pathology. 28(1):1-30, January 2004.
Abstract:
colon; Oncogenic osteomalacia (OO) is a rare paraneoplastic syndrome of osteomalacia due to phosphate wasting. The phosphaturic mesenchymal tumor (mixed connective tissue variant) (PMTMCT) is an extremely rare, distinctive tumor that is frequently associated with OO. Despite its association with OO, many PMTMCTs go unrecognized because they are erroneously diagnosed as other mesenchymal tumors. Expression of fibroblast growth factor-23 (FGF-23), a recently described protein putatively implicated in renal tubular phosphate loss, has been shown in a small number of mesenchymal tumors with known OO. The clinicopathological features of 32 mesenchymal tumors either with known OO (29) or with features suggestive of PMTMCT (3) were studied. Immunohistochemistry for cytokeratin, S-100, actin, desmin, CD34, and FGF-23 was performed. The patients (13 male, 19 female) ranged from 9 to 80 years in age (median 53 years). A long history of OO was common. The cases had been originally diagnosed as PMTMCT (15), hemangiopericytoma (HPC) (3), osteosarcoma (3), giant cell tumor (2), and other (9). The tumors occurred in a variety of soft tissue (21) and bone sites (11) and ranged from 1.7 to 14 cm. Twenty-four cases were classic PMTMCT with low cellularity, myxoid change, bland spindled cells, distinctive "grungy" calcified matrix, fat, HPC-like vessels, microcysts, hemorrhage, osteoclasts, and an incomplete rim of membranous ossification. Four of these benign-appearing PMTMCTs contained osteoid-like matrix. Three other PMTMCTs were hypercellular and cytologically atypical and were considered malignant. The 3 cases without known OO were histologically identical to the typical PMTMCT. Four cases did not resemble PMTMCT: 2 sinonasal HPC, 1 conventional HPC, and 1 sclerosing osteosarcoma. Three cases expressed actin; all other markers were negative. Expression of FGF-23 was seen in 17 of 21 cases by immunohistochemistry and in 2 of 2 cases by RT-PCR. Follow-up (25 cases, 6-348 months) indicated the following: 21 alive with no evidence of disease and with normal serum chemistry, 4 alive with disease (1 malignant PMTMCT with lung metastases). We conclude that most cases of mesenchymal tumor-associated OO, both in the present series and in the reported literature, are due to PMTMCT. Improved recognition of their histologic spectrum, including the presence of bone or osteoid-like matrix in otherwise typical cases and the existence of malignant forms, should allow distinction from other mesenchymal tumors. Recognition of PMTMCT is critical, as complete resection cures intractable OO. Immunohistochemistry and RT-PCR for FGF-23 confirm the role of this protein in PMTMCT-associated OO.

Easy node to miss
Facial, parotid, delphian (pre-laryngeal), suboccipital, Rouvier, supraclavicular, paratracheal
Wide FOV
Subtle focal defect
Cutaneous lesions
Pull shoulders using strap
Dont miss second-thrird-fourth primary ca.
For laryngeal ca., slice thickness and gantry titlting are important.
Time delay-several minutes later may be better
Puffed-cheek technique.
Retention cysts are very common.
Variant-accessory parotid, unusually prominent pterygoid venous plexus.
Sebaceous cyst mandibular tori.
L/N mimics-Posterior belly digastric muscle, levator scapulae, anterior scalene, Levator claviculae muscle which assist thoracic respiration (seen in 1-2% of the pop) almost always on the left side, behind the SCM or bilateral.
External ear fake-out (not written in the book)
Posterior condylar vein present unilaterally in 80%. Anastamotic vein between jug bulb and suboccipital venous plexus
Insect bite mimiching subcutanoues tumor.
Don't miss thrombosed IJV as necrotic lymph node.
Laryngocele mimics laryngeal tumor.
Vocal cord Teflon Injection
Montgomery thyroplasty
Denerved muscle enhances.
Nu-gauze packing and xeroform gauze bolster for maxillectomy defect.
Tru-soft obturator prosthesis for separating oral cavity from nasal cavity.-removable prosthesis.
Prosthesis may hide recurrence.
Sialocele after parotidectomy may mimic abscess or recurrence.
Compensatory hypertrophy of lavator scapulae accompanying spinal accessory denervation after neck dissection.
Some thyroid tissue may be left after "total" thyroidectomy.
Dental extraction may mimic destructive mandibular lesion.

UCLA to Ronald Reagan UCLA medical center.

Nonrecurrent laryngeal nerve 3-8% in the population Vast majority are on the right accompanying aberrent right subclavicular artery.
Judge it by posttracheal line. Watanabe A et al., Laryngoscope 2001.111.1756-
post-"traumatic" changes creates pseudomass.
Fibrous lingual septum in the midline is good for piercing.
IAC lipoma is "do nothing" lesion since symptom may be worsening after resection.
Normal bone marroe and neuritis may mimic small schwannoma. Do not operate stable small lesion of the VIII nerve.
Always obtain pre contrast T1WI.

PET/CT muscle, brown fat, benign parotid mass uptake may be false positive.
False negative cancer-well diff.

１
a 分枝型と主膵管型を確実に区別できるか？
主膵管型の癌化率は57-92%、分枝型は6-46% で区別する意義はあるが時として術前診断できなかった混合型というものは存在する。

b 病理組織学的には殆どの IPMN で分枝と主膵管の両方にまたがって乳頭状増殖があるが混合型という分類は必要か？分枝型の進行形とみなすべきか？
画像的に分枝型とされたものは小さく乳頭状増殖も低く胃型の上皮 (gastric/foveolar)をもつ良性腺腫の可能性が高い。「～優位型」という解釈がより正確であろう。分類基準が明らかとなるまで混合型は残しておいた方が良いだろう。

c MCN の組織学的診断に卵巣様間質の存在は必要不可欠か？
必要不可欠。閉経後、男性で卵巣様間質を有するMCNはまれ。MCN様で卵巣様間質の無いものは「分類不能の粘液産生嚢胞性膵腫瘍」としておくことを提案する。

d MCN と IPMN の区別に実地臨床上の区別は必要か？
MCNとIPMNでは病因、多発性(分枝型IPMNでは多発30%, MCN は単発）、経過観察の必要性(IPMNでは断端陰性でも再発１０％)、発癌の頻度(MCNでは 6-27%)に違いがあるので臨床的意義はある。


２
a 術前に IPMN と MCN を確実に鑑別できるか？

不可能な例もあるが殆どの例では可能。女性、40-50歳、膵体尾部、共通被膜、石灰化、オレンジ状、Cysts in cyst, 主膵管圧排は MCNであるし、男性(70%）、60-70歳、頭部、共通被膜・石灰化が無く、葡萄の房状・ cyst by cyst 、主膵管との交通あるいは拡張を伴うものは
IPMN の可能性が高い。もちろん、主膵管との交通は粘液により証明されないこともあるし、まれにはMCNで主膵管と交通があり、SCTでも主膵管と交通がある例もあるので全例で可能とは言えない。

b IPMN あるいは MCN 由来の微小浸潤癌を診断できるか？

顕微鏡レベルの話であり、いずれも不可能。

３
a 主膵管型は全例手術適応か？

b 分子型は全例手術適応か？そうでないならどのように区別するか？

c MCN は全例手術適応か？

４
a MCN あるいは IPMN ゆらいの非浸潤癌におけるリンパ節郭清は？
b MCN IPMN における縮小手術の意義
c 多発分枝型IPMNの治療方針は？高齢者に於ては膵全摘を回避すべく最大の病変のみを切除することは許容できるか？

５
a IPMN と MCN の切除術における術中迅速診断の意義は？粘液上皮が断端にあったら？
b MCN や IPMN の切除標本には特別な注意が必要か？
c