Deep UV-excited fluorescence microscopy installed with CycleGAN-assisted image translation enhances precise detection of lymph node metastasis towards rapid intraoperative diagnosis.

Rapid and precise intraoperative diagnosing systems are required for improving surgical outcomes and patient prognosis. Because of the poor quality and time-intensive process of the prevalent frozen section procedure, various intraoperative diagnostic imaging systems have been explored. Microscopy with ultraviolet surface excitation (MUSE) is an inexpensive, maintenance-free, and rapid imaging technique that yields images like thin-sectioned samples without sectioning. However, pathologists find it nearly impossible to assign diagnostic labels to MUSE images of unfixed specimens; thus, AI for intraoperative diagnosis cannot be trained in a supervised learning manner. In this study, we propose a deep-learning pipeline model for lymph node metastasis detection, in which CycleGAN translate MUSE images of unfixed lymph nodes to formalin-fixed paraffin-embedded (FFPE) sample, and diagnostic prediction is performed using deep convolutional neural network trained on FFPE sample images. Our pipeline yielded an average accuracy of 84.6% when using each of the three deep convolutional neural networks, which is a 18.3% increase over the classification-only model without CycleGAN. The modality translation to FFPE sample images using CycleGAN can be applied to various intraoperative diagnostic imaging systems and eliminate the difficulty for pathologists in labeling new modality images in clinical sites. We anticipate our pipeline to be a starting point for accurate rapid intraoperative diagnostic systems for new imaging modalities, leading to healthcare quality improvement.

Identifying the Optimal Arm Priming Exercise Intensity to Improve Maximal Leg Sprint Cycling Performance.

Priming exercises improve subsequent motor performance; however, their effectiveness may depend on the workload and involved body areas. The present study aimed to estimate the effects of leg and arm priming exercises performed at different intensities on maximal sprint cycling performance. Fourteen competitive male speed-skaters visited a lab eight times, where they underwent a body composition measurement, two V̇O2max measurements (leg and arm ergometers), and five sprint cycling sessions after different priming exercise conditions. The five priming exercise conditions included 10-minute rest (Control); 10-minute arm ergometer exercise at 20% V̇O2max (Arm 20%); 10-minute arm ergometer exercise at 70% V̇O2max (Arm 70%); 1-min maximal arm ergometer exercise at 140% V̇O2max (Arm 140%); and 10-min leg ergometer exercise at 70% V̇O2max (Leg 70%). Power outputs of 60-s maximal sprint cycling, blood lactate concentration, heart rate, muscle and skin surface temperature, and rating of perceived exertion were compared between the priming conditions at different measurement points. Our results showed that the Leg 70% was the optimal priming exercise among our experimental conditions. Priming exercise with the Arm 70% also tended to improve subsequent motor performance, while Arm 20% and Arm 140% did not. Mild elevation in blood lactate concentration by arm priming exercise may improve the performance of high-intensity exercise.

Reduced port laparoscopic subtotal cholecystectomy for Mirizzi syndrome with a bilio-biliary fistula: A case report.

A 65-year-old male diagnosed with Mirizzi syndrome with a bilio-biliary fistula was referred to our department and underwent single-incision laparoscopic surgery with an assistant trocar. As typical laparoscopic cholecystectomy could not be performed due to the coexistence of a bilio-biliary fistula, we performed laparoscopic subtotal cholecystectomy as a bail-out procedure according to the recommendation of the recent Tokyo Guidelines (TG18). The neck of the remnant gallbladder could be easily sutured with the effective use of an assistant trocar, and the surgery was completed without any complications. The patient was discharged 5 days after surgery without any complications. While little has been reported on the efficacy of reduced port surgery for Mirizzi syndrome, our surgical approach, i.e. reduced port surgery with an assistant trocar, enabled secure and easy suturing as a bail-out procedure and seemed to be an efficient method that is both less-invasive and safe.

LONG-RANGE ATMOSPHERIC TRANSPORT OF RADON IN EAST ASIA AND DEPOSITION OF ITS PROGENIES IN JAPAN.

A three-dimensional long-range atmospheric transport model for 222Rn and its progenies was applied to simulate 210Pb deposition in Japan and its adjacent waters. Monthly precipitation and 210Pb deposition simulated by the model for winter months were favorably compared with observational data although they were exceptionally underestimated in Aomori. The large monthly deposition along the Japan Sea coast lines during winter was successfully simulated by the model to be nearly 200 Bq m-2, which was contrasted by about 10-fold smaller deposition in other regions. It was also pointed out that the heavy deposition areas formed a narrow band structure along the coastline with width of several tens of kilometers and 210Pb deposition amount positively correlated with the height of mountains located leeward of the heavy deposition areas.

[Two Cases of Lower Rectal Cancer in Which Temporary Ileostomy Could Be Avoided by Using the Pull Through Procedure].

We report 2 cases of lower rectal cancer in which temporary ileostomy was avoided by using the Pull through procedure. Case 1 was a 59-year-old man with a BMI of 29.67 who was diagnosed as having lower rectal cancer after a positive stool occult blood test. He had a strong refusal to use a ileostomy and was obese, so he underwent laparoscopic intersphincteric resection using the Pull through procedure. Reconstruction was performed on the 7th postoperative day. He was discharged from the hospital on the 14th day after the initial surgery. Case 2 was a 65-year-old woman with a BMI of 27.65 who was referred to our department for additional resection after ESD for a lesion in the lower rectum. As in the previous case, she was obese and refused to use a ileostomy, so we chose to perform a laparoscopic intersphincteric resection using the Pull through procedure. Reconstruction was performed on the 7th postoperative day, and she was discharged on the 25th day after the initial surgery. Patient satisfaction was high, and the Pull through procedure may be an option for patients with lower rectal cancer who have difficulty in undergoing temporary ileostomy.

[A Case of Surgical Resection for Ascending Colon Cancer with Protein-Losing Gastroenteropathy].

An 84-year-old man visited our department for further examination of anemia and elevation of tumor marker levels. Colonoscopy revealed a huge circumferential type 3 tumor in the ascending colon. Significant hypoalbuminemia was observed at 1.1 g/dL, and prolonged hypoalbuminemia was considered to be caused by protein-losing gastroenteropathy due to the large tumor. In this case, we performed right hemicolectomy, and performed single-stage anastomosis. The resected specimen showed a huge type 3 lesion with a diameter of 140×120 mm in the ascending colon, which directory invaded to the cecum and ileum. After the operation, there were no particular complications, and albumin levels gradually improved. Although hypoalbuminemia is one of the risks of anastomotic leakage, there are many reports with one-stage anastomosis and with a good course, including our case. Therefore, it was considered necessary to examine each case regarding the surgical procedure.

[A Case of Low-Grade Appendiceal Mucinous Neoplasm with Extra-Appendiceal Mucin Extrusion Successfully Treated with Laparoscopic Surgery].

A 49-year-old male patient, who presented with abdominal pain, was suspected of having acute appendicitis. Abdominal computed tomography revealed a swollen appendix, accompanied by a 40 mm low-density mass located behind the appendix. He was diagnosed with an appendiceal mucinous neoplasm, and laparoscopic ileocecal resection was performed. A soft tumor was found proximal to the swollen appendix and was adhered tightly to the iliopsoas muscle. The tumor cells were exfoliated carefully, and the tumor was excised en bloc without any injury. Histopathological examination revealed a low- grade appendiceal mucinous neoplasm(LAMN)accompanied by extra-appendiceal mucin extrusion due to the lack of epithelial lining. Because LAMN is potentially malignant, surgical excision was performed as first-line therapy. In the surgical management of LAMN, preventing intraoperative rupture is essential to avoid pseudomyxoma peritonei. To achieve this, a magnified laparoscopic surgery may be useful. Although no definitive guidelines describing the indications of lymph node dissection or the appropriate extent of resection exist, laparoscopic ileocecal resection may be used to manage cases of LAMN.

Foreign body granulomas mimic peritoneal dissemination caused by incarcerated femoral hernia perforation: A case report.

BACKGROUND: Foreign body granuloma (FBG) is a well-known type of granulomatous formation, and intraabdominal FBG (IFBG) is primarily caused by surgical residues. Multifocal IFBGs caused by gastrointestinal perforation is an extremely rare and interesting clinicopathological condition that resembles peritoneal dissemination. Here, we present a case of IFBGs mimicking peritoneal dissemination caused by bowel perforation and describe the value of intraoperative pathological examinations for rapid IFBG diagnosis. CASE SUMMARY: An 86-year-old woman with an incarcerated femoral hernia was admitted to the hospital and underwent operation. During the operation, the incarcerated ileum was perforated during repair due to hemorrhage necrosis, and a small volume of enteric fluid leaked from the perforation. The incarcerated ileum was resected, and the femoral hernia was repaired without mesh. Four months later, a second operation was performed for an umbilical incisional hernia. During the second operation, multiple small, white nodules were observed throughout the abdominal cavity, resembling peritoneal dissemination. The results of peritoneal washing cytology in Douglas' pouch and the examination of frozen nodule sections were compatible with IFBG diagnosis, and incisional hernia repair was performed. CONCLUSION: IFBGs can mimic malignancy. Intraoperative pathological examinations and operation history are valuable for the rapid diagnosis to avoid excessive treatments.

A new species of nine-spined stickleback, Pungitius modestus (Gasterosteiformes, Gasterosteidae), from northern Honshu, Japan.

A new species of nine-spined stickleback, Pungitius modestus, is described based on the holotype and 17 paratypes (38.751.7 mm standard length) collected from the inland area of Yamagata Prefecture, northern Honshu, Japan. The new species is distinguished from the other species of Pungitius by the following combination of characters: 3032 small unconnected lateral plates; dorsal-fin rays VIIIX (usually IX)+911; anal-fin rays 710 (usually 8); pectoral-fin rays 10; a short spiny dorsal fin base (26.5%29.8% SL); the first spiny dorsal fin spine behind the pectoral-fin base; a long pre-anal fin (59.9%67.4% SL); the anal-fin spine below the 1st3rd dorsal-fin rays; a short pelvic-fin spine (6.3%9.1% SL); a short anal-fin spine (4.1%6.0% SL); a long caudal peduncle (14.3%19.7% SL); no body markings; membranes of the dorsal-fin spines dark brown with black pigments; the entire male body, and soft dorsal and anal fins, becoming black in the breeding season; the anteroventral process of the ectocoracoid present; and the dorsal extension of the ascending process of the pelvis level with the dorsal-most actinost.

Rapid fluorescence imaging of human hepatocellular carcinoma using the ß-galactosidase-activatable fluorescence probe SPiDER-ßGal.

Fluorescence imaging of tumours facilitates rapid intraoperative diagnosis. Thus far, a promising activatable fluorescence probe for hepatocellular carcinoma (HCC) has not been developed. Herein, the utility of the fluorescence imaging of HCC using a ß-galactosidase (ß-Gal)-activatable fluorescence probe SPiDER-ßGal was examined. ß-Gal activity was measured in cryopreserved tissues from 68 patients. Live cell imaging of HCC cell lines and imaging of tumour-bearing model mice were performed using SPiDER-ßGal. Furthermore, fluorescence imaging was performed in 27 freshly resected human HCC specimens. In cryopreserved samples, ß-Gal activity was significantly higher in tumour tissues than in non-tumour tissues. Fluorescence was observed in HCC cell lines. In mouse models, tumours displayed stronger fluorescence than normal liver tissue. In freshly resected specimens, fluorescence intensity in the tumour was significantly higher than that in non-tumour liver specimens as early as 2 min after spraying. Receiver operating characteristic curves were generated to determine the diagnostic value of SPiDER-ßGal 10 min after its spraying; an area under the curve of 0.864, sensitivity of 85.2%, and specificity of 74.1% were observed for SPiDER-ßGal. SPiDER-ßGal is useful for the rapid fluorescence imaging of HCC. Fluorescence imaging guided by SPiDER-ßGal would help surgeons detect tumours rapidly and achieve complete liver resection.

Matrix metalloprotease-14 is a target enzyme for detecting peritoneal metastasis in gastric cancer.

BACKGROUND: Accurate diagnosis of peritoneal metastasis in gastric cancer (GC) is important to determine the appropriate treatment. This study aimed to examine whether matrix metalloprotease-14 (MMP-14) was a candidate enzyme in fluorescence imaging for the diagnosis of peritoneal metastasis in GC. METHODS: GC and normal peritoneal (NP) tissues from 96 and 20 patients, respectively were evaluated for MMP-14 expression. Live cell imaging of GC cell lines (NUGC4, MKN45, MKN74, HGC-27, and Kato-III) was performed using the MMP-14-activatable fluorescence probe; BODIPY-MMP. Furthermore, the overall survival (OS) was calculated in all patients (n = 96). RESULTS: MMP-14 expression was significantly higher in GC tissues (median: 3.57 ng/mg protein; range:0.64-24.4 ng/mg protein) than in NP tissues (median: 1.34 ng/mg protein; median: 0.53-3.09 ng/mg protein) (P < 0.01). Receiver operating characteristic curves showed that the area under the curve, sensitivity, and specificity were 0.907, 84.4%, and 90.0%, respectively. In live cell imaging using the BODIPY-MMP, fluorescence was observed in five GC cell lines. In the analysis of OS, the high expression of the MMP-14 group had a significantly poorer OS rate than the low expression of the MMP-14 group (P = 0.02). In the multivariate analyses, MMP-14 expression was an independent risk factor for OS (hazard ratio: 2.33; 95 % confidence interval: 1.05-5.45; P = 0.04). CONCLUSION: MMP-14 is a promising enzyme in intraoperative fluorescence imaging for peritoneal metastasis in GC, especially in patients with poor prognosis.

ß-Galactosidase is a target enzyme for detecting peritoneal metastasis of gastric cancer.

Diagnosis of peritoneal metastasis in gastric cancer (GC) is essential for determining appropriate therapeutic strategies and avoiding non-essential laparotomy or gastrectomy. Recently, a variety of activatable fluorescence probes that can detect enzyme activities have been developed for cancer imaging. The aim of this study was to identify the key enzyme involved in peritoneal metastasis in GC. The enzymatic activity of gamma-glutamyl transpeptidase, dipeptidyl peptidase IV, and ß-galactosidase (ß-Gal) was assessed in lysates prepared from preserved human GC (n = 89) and normal peritoneal (NP; n = 20) samples. ß-Gal activity was significantly higher in the human GC samples than in NP samples, whereas no differences were observed in the activities of the other enzymes. Therefore, we used SPiDER-ßGal, a fluorescent probe that can be activated by ß-Gal, for imaging GC cell lines, peritoneal metastasis in a mouse model, and fresh human resected GC samples (n = 13). All cell lines showed fluorescence after applying SPiDER-ßGal, and metastatic nodules in the mice gradually developed high fluorescence that could be visualized with SPiDER-ßGal. The human GC samples showed significantly higher fluorescence than NP samples. ß-Gal is a useful target enzyme for fluorescence imaging of peritoneal metastasis in GC.

[A Case of Laparoscopic Resection for Rectal Cancer with Persistent Descending Mesocolon].

A 66-year-old man presenting with melena was diagnosed with rectosigmoid cancer and underwent laparoscopic high anterior resection. Intraoperative findings showed that the descending colon did not adhere to the retroperitoneum and was largely displaced inward, and the descending and sigmoid colon extensively and strongly adhered to the small intestinal mesentery, as predicted prior to surgery. The patient was diagnosed with persistent descending mesocolon(PDM). The first sigmoid artery diverged from the left colonic artery; however, ligation of supplying arteries under laparoscopy was perceived as a risk for marginal artery injury due to the shortening of the mesentery by PDM. Therefore, the sigmoid artery and inferior mesenteric vein were ligated directly from the umbilical wound. No postoperative complications were observed, and the patient was discharged 9 days after the surgery. Although PDM has not been defined, it has been reported that preoperative prediction is possible depending on the positional relationship between the descending colon and the left kidney. In this case, we performed the surgery after taking into consideration the anatomical features assessed preoperatively, leading to a safe operation.

Efficacy of 5-aminolevulinic acid-mediated photodynamic therapy in a mouse model of esophageal cancer.

5-Aminolevulinic acid-mediated photodynamic therapy (ALA-PDT) is a minimally invasive therapeutic modality used in the management of various cancers, but to a lesser extent for esophageal cancer (EC). The current study investigated the antitumor effects of ALA-PDT. Human EC cells were treated with ALA, after which ALA-induced fluorescence was examined under a fluorescence microscope. The cytotoxic effects of ALA-PDT were assessed using three types of LEDs (blue, green and red) in vitro and in vivo. Subcutaneous tumor model mice was constructed with KYSE150 cells. ALA-PDT was performed once a week for 4 weeks and tumor weights were measured. A popliteal lymph node (PLN) metastasis murine model was generated using KYSE150 cells. KYSE150 cells were inoculated into the left footpad of nude mice. ALA-PDT was performed on the footpad once a week for 4 weeks. PLNs were then removed 3 weeks after the last treatment. The lymph nodes were evaluated by hematoxylin and eosin staining. Red fluorescence of protoporphyrin IX (PpIX) was observed in all EC cell lines. ALA-PDT using LEDs exerted significant antitumor effects in vitro and in vivo. The antitumor effects of ALA-PDT with blue LED were the strongest, followed by green and red LEDs. The number of metastasized PLNs was significantly smaller in the ALA-PDT group (0%) than in the control group (37.5%). The present results indicated that ALA-PDT is effective for EC.

Oncological Safety of Ultrasonically Activated Surgical Devices During Gastric Cancer Surgery.

BACKGROUND/AIM: Ultrasonically activated surgical devices (USADs) have become indispensable instruments for gastrointestinal surgery. In this study, we investigated the oncological safety of the use of USADs. MATERIALS AND METHODS: We harvested and cultivated the splashes and mist scattered from an USAD when cutting MKN45-derived cancer nodules. Seven days later, we observed viable cancer cells and the total number of cells was counted. The histopathology of the nodules cut by the USAD was also examined. RESULTS: The existence of viable cancer cells was confirmed by ex vivo cell culture. The number of viable cancer cells was reduced by slow grasping of the USAD. The surface of cancerous tissue cut by the USAD was partially heat-denatured, however, there were some parts in which cancerous tissue was exposed on the surface. CONCLUSION: Surgeons should recognize the possibility that cancer cells may be scattered by USAD use.

5-ALA-assistant automated detection of lymph node metastasis in gastric cancer patients.

BACKGROUND: 5-aminolevulinic acid (5-ALA) has been utilized for cancer diagnosis as a fluorescence probe. We have reported the feasibility of 5-ALA-induced protoporphyrin IX (PpIX) fluorescence for detecting lymph node (LN) metastasis in gastrointestinal malignancies. However, a major barrier to the fluorescence diagnosis has been that the evaluation has been highly dependent on the observers. In this study, we examined the validity of a developed device for automated detection without subjectivity. METHODS: Gastric cancer patients who received oral administration of 5-ALA (20 mg/kg) prior to surgery were enrolled. For a total of 323 LNs obtained from 64 patients, the diagnostic results of the device were compared to those of conventional histopathological examination based on hematoxylin-and-eosin-stained slides. The accuracy with the device was compared to that of stereoscopic detection with conventional fluorescence microscopy for 211 LNs from 42 patients. We used two types of image processing that we previously developed to eliminate autofluorescence of background tissues: differential and ratio methods. RESULTS: For detection of metastasis in 323 LNs, the areas under the receiver operating characteristic curves with the differential method and ratio method were 0.921 and 0.909, respectively. The sensitivity, specificity, and accuracy with the differential method were 78.0%, 96.8%, and 94.4%; while those with the ratio method were 78.0%, 96.1%, and 93.8%, respectively. In 211 LN analysis, the diagnostic accuracy with the device was comparable to that of stereoscopic examination. CONCLUSION: Our device for automated detection of LN metastasis using 5-ALA can be a useful tool for intraoperative diagnosis.

Deep-UV excitation fluorescence microscopy for detection of lymph node metastasis using deep neural network.

Deep-UV (DUV) excitation fluorescence microscopy has potential to provide rapid diagnosis with simple technique comparing to conventional histopathology based on hematoxylin and eosin (H&E) staining. We established a fluorescent staining protocol for DUV excitation fluorescence imaging that has enabled clear discrimination of nucleoplasm, nucleolus, and cytoplasm. Fluorescence images of metastasis-positive/-negative lymph nodes of gastric cancer patients were used for patch-based training with a deep neural network (DNN) based on Inception-v3 architecture. The performance on small patches of the fluorescence images was comparable with that of H&E images. Gradient-weighted class activation mapping analysis revealed the areas where the trained model identified metastatic lesions in the images containing cancer cells. We extended the method to large-size image analysis enabling accurate detection of metastatic lesions. We discuss usefulness of DUV excitation fluorescence imaging with the aid of DNN analysis, which is promising for assisting pathologists in assessment of lymph node metastasis.

Terbium ion as RNA tag for slide-free pathology with deep-ultraviolet excitation fluorescence.

Deep-ultraviolet excitation fluorescence microscopy has enabled molecular imaging having an optical sectioning capability with a wide-field configuration and its usefulness for slide-free pathology has been shown in recent years. Here, we report usefulness of terbium ions as RNA-specific labeling probes for slide-free pathology with deep-ultraviolet excitation fluorescence. On excitation in the wavelength range of 250-300 nm, terbium ions emitted fluorescence after entering cells. Bright fluorescence was observed at nucleoli and cytoplasm while fluorescence became weak after RNA decomposition by ribonuclease prior to staining. It was also found that the fluorescence intensity at nucleoplasm increased with temperature during staining and that this temperature-dependent behavior resembled temperature-dependent hypochromicity of DNA due to melting. These findings indicated that terbium ions stained single-stranded nucleic acid more efficiently than double-stranded nucleic acid. We further combined terbium ions and DNA-specific dyes for dual-color imaging. In the obtained image, nucleolus, nucleoplasm, and cytoplasm were distinguished. We demonstrated the usefulness of dual-color imaging for rapid diagnosis of surgical specimen by showing optical sectioning of unsliced tissues. The present findings can enhance deep-ultraviolet excitation fluorescence microscopy and consequently expand the potential of fluorescence microscopy in life sciences.

[A Case of Locally Advanced Rectal Cancer with Abscess and Rectovesical Fistula Curatively Resected Following Preoperative Chemotherapy].

A 63-year-old man with bloody stools, anal incompetence, and feeling of fatigue was diagnosed as having a RAS mutanttype rectal cancer with abscess and rectovesical fistula. Computed tomography revealed that the tumor had invaded the seminal vesicle, prostate, and bladder and formed an abscess. In addition, his general condition was poor. Thus, we evaluated the lesion as unresectable. His nutritional status improved, and the infection was controlled after colostomy. Then, we performed chemotherapy with 5-fluorouracil, Leucovorin, and oxaliplatin(FOLFOX)plus bevacizumab. However, after a single course of chemotherapy, the systemic inflammatory reaction was prolonged. Despite treatment of the infection with antibiotics, it was not fully controlled, making it difficult to continue chemotherapy. A new lesion did not appear, but the primary tumor increased in size. Thus, we performed pelvic exenteration. Pathological examination revealed that the tumor was a well-differentiated adenocarcinoma invading the sigmoid colon and bladder. We resected it curatively and administered adjuvant chemotherapy postoperatively. No recurrence was observed during 10 months' follow-up.

[Early Gastric Cancer with Many Enlarged Lymph Nodes as Sarcoid Reaction - A Case Report].

The patient was a 57-year-old man. Upper gastrointestinal endoscopy revealed a 0- II c lesion at the anterior wall of the greater curvature in the lower third of the stomach, and the biopsy of this tumor gave the diagnosis of tubular adenocarcinoma. Abdominal contrast-enhanced computed tomography revealed many enlarged regional and non-regional lymph nodes. Because there was no definite evidence of lymph node metastasis, distal gastrectomy with D2 was performed. Histopathological examinations found the sarcoid reaction(SR)in lymph nodes, but could not demonstrate any cancer cells. SR is the epithelioid cell granuloma in lymph nodes found in patients without systemic sarcoidosis but with cancer. Early gastric cancer with SR is rare, with only 22 reported cases in Japan. SR is considered as one of the differential diagnoses when we find many enlarged lymph nodes in patients with early gastric cancer.