Rethinking the Utility of the Audio-Only Encounter: A Case of Herpes Zoster Co-Infection in Asymptomatic SARS-CoV-2.

Background: Telemedicine with video communication has become commonly applied during and after the COVID-19 pandemic. While audio-only encounters are not allowed in Japan after August 2023. The Centers for Medicaid and Medicare Services (CMS) in the United States revised the telehealth policy to make the video visit standard. We present here a case with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and diagnosed her with the Herpes zoster at audio-only encounters followed by an in-person clinic visit. Case Presentation: A 31-year-old woman called our hospital for a complaint of right chest discomfort and a tingling sensation. The SARS-CoV-2 infection was confirmed on her with the polymerase chain reaction (PCR) test 4 days before the symptom onset. A telephone encounter was made for her since the video communication failed to be prepared. The attending physician made a diagnosis of herpes zoster based on her verbal explanation of symptoms and localized skin lesions. An anti-viral medication with amenamevir was given. The photos of skin lesions were sent 3 days after the audio visit, which was consistent with herpes zoster. The patient visited our outpatient clinic and was confirmed for herpes zoster serologically with positive antibodies of both varicella-zoster IgM and IgG. Conclusions: The audio-only visit could help diagnose herpes zoster if the follow-up examinations are performed adequately. Audio-only encounters preserve the flexibility of telemedicine when video communication cannot be prepared promptly.

Asymptomatic gastric anisakiasis detected in gastric cancer screening: A case report.

Anisakiasis is a parasitic disease caused by Anisakis simplex and has become an emerging zoonosis as preferences for eating raw or undercooked seafood have become more common. Few case reports of asymptomatic anisakiasis have been published to date. A 79-year-old asymptomatic man underwent esophagogastroduodenoscopy (EGD) for gastric cancer screening. The gastroenterologist diagnosed superficial gastritis without any malignant lesions but found an Anisakis larva while reviewing EGD images. The physician performed a second EGD and removed the larva. The patient reported that he ate the flatfish sashimi for dinner on the day before the first EGD. This case indicates the existence of asymptomatic gastric anisakiasis, indicating that anisakiasis incidence may have previously been underestimated.

[A Case of Rectal Colon Cancer with Paraneoplastic Cerebellar Degeneration].

A case complicated with colorectal and prostate cancers in paraneoplastic(subacute)cerebellar degeneration(PCD)is extremely rare. We report a retrospective case of rectal carcinoma with paraneoplastic cerebellar degeneration. A 79-year-old man with Parkinson's disease was unable to walk because of paralysis. Brain MRI showed cerebellar atrophy. He was admitted to our hospital for anal bleeding and was diagnosed with colon cancer. An associated diagnosis of PCD was made. After resection, his paralysis and dysarthria were resolved to the extent of beingable to walk and speak fluently. Brain MP-RAGE showed no findings suggestive of metastasis or atrophy. He was treated surgically, which resulted in a transient improvement in PCD symptoms. Per blood testing, cytokines IL-6 and IL-10 were lower postoperatively. Immunosuppressive levels of myeloid- derived suppressor cells(MDSCs)were lower compared with the preoperative values. Thus, innate immunocompetence and resolution of paralysis followed the surgical intervention.

[A Case of Recurrent Colon Cancer with Peritoneal Dissemination Treated with Aflibercept Showing Partial Response for One Year].

We report a case of recurrent colon cancer that achieved partial response with chemotherapy of combined 5-fluorouracil (5-FU), irinotecan, Leucovorin(FOLFIRI), and aflibercept. A 65-year-old man was diagnosed with colon cancer with lymph node metastasis. He underwent surgery, but after 1 year, he had a recurrence of peritoneal dissemination, nodal enlargement, and liver metastases. He received chemotherapy(mFOLFOX plus bevacizumab), but suffered progressive disease. Thereafter, FOLFIRI plus aflibercept was administered, and CT revealed a decrease in peritoneal dissemination after 2 cycles of chemotherapy. After 23 cycles, a PET-CT showed no evidence of the disease. We also examined 9 recent cases treated with aflibercept in terms of Grade 3 and 4 adverse effects, leukopenia, neutropenia, thrombocytopenia, hypertension, and sweating. Placentalderived growth factor(PIGF)has been reported to stimulate macrophages and induce production of IL-6, and thus it promotes inflammation and growth of extant cancer. Among the responses to chemotherapy based on the RECIST criteria, a partial response was significantly higher in patients with a low neutrophil-to-lymphocyte ratio(NLR)(p≤0.05)compared to those with high NLR. As regards the relationship between NLR and OS in patients treated with FOLFIRI plus aflibercept, OS was significantly worse in patients with high NLR than those with low NLR(p≤0.05). NLR may be a useful marker in conjunction with aflibercept treatment.

Poland syndrome accompanied by internal iliac artery supply disruption sequence: a case report.

BACKGROUND: Poland syndrome is a congenital malformation characterized by ipsilateral hand and chest wall depression, including an absence or hypoplasia of the breast and pectoral muscles. These hypoplastic defects are reportedly caused by a subclavian artery supply disruption sequence. CASE PRESENTATION: A 45-year-old Japanese woman, an out-patient, underwent an emergency examination for intense left lower abdominal pain. Computed tomography images revealed a hydronephrotic left kidney and dilatation of the left ureter. No ureteral calculus or neoplasm was found. In addition, no abnormalities connected to her left abdominal pain were found. Nephritis was diagnosed based on the results of urine analysis, and a course of antibiotics was administered. Computed tomography images also revealed a history of breast reconstruction with a custom-made silicone implant in her right breast. The present case showed symptoms of Poland syndrome, which were absence of the sternal head of the right pectoralis major and asymmetrical malformation of the chest wall due to hypoplasia of the right rib cage. In addition to typical Poland syndrome symptoms, she had hypoplasia of her right kidney, hypoplasia of the right gluteus minimus muscle, right-sided pelvic hypoplasia, spinal curvature to the right, and a cystic mass in her right ovary. CONCLUSIONS: In the present case of Poland syndrome, computed tomography images revealed malformation of the chest wall, absence of the pectoral muscle, and hypoplasia of a left kidney. Unilateral visceral hypoplasia is reported to be caused by a subclavian artery supply disruption sequence that occurs around 7 to 8 weeks of gestation. The present case can be considered a rare atypical phenotype of Poland syndrome with possible subclavian artery supply disruption sequence with internal iliac artery supply disruption.

[Two Cases of Unresectable Advanced Rectal Cancer with a Long-Term Survival for Which Pathological Complete Response Was Achieved through Neoadjuvant Effective Chemotherapy].

We report 2 unusual cases of Stage IV rectal cancer for which pathological complete response was achieved with neoadjuvant chemotherapy(NAC)consisting of a combination of 5-fluorouracil(5-FU), oxaliplatin, Leucovorin(mFOLFOX6)or irinotecan(FOLFIRI), and bevacizumab, without radiotherapy. Case 1: A 65-year-old man was diagnosed as having rectal cancer with an invasive carcinoma of the prostate and lymph node metastasis. He refused to undergo surgery and received NAC instead. After NAC with mFOLFOX6 and FOLFIRI was performed, CT scan and colonoscopy revealed no evidence of disease. The subsequent result was compatible with a complete pathological response. The patient is currently alive 4 years after the first chemotherapy, without evidence of recurrence and adjuvant chemotherapy. Case 2: A 75-year-old man was diagnosed as having rectal cancer with an invasive carcinoma of the bladder and lymph node metastasis. After providing neoadjuvant bevacizumab-containing chemotherapy, low anterior resection of the rectum was performed. Operative findings showed that the tumor was only ulcer and the lymph nodes were not enlarged. The subsequent results indicated that pathological findings revealed no cancer and a complete pathological response. In conclusion, the survival benefits from NAC are still unclear for patients with an initially unresectable rectal cancer. We report 2 rare cases of rectal cancer with long survival and a complete pathological response after neoadjuvant chemotherapy.

[Three Cases of High-Grade Malignant Cancer of Unknown Primary with a Long-Term Survival].

We report 3unusual cases of cancer of unknown primary(CUP)with a long-term survival after chemotherapy. A 56-yearold man was diagnosed as having CUP with invasion of an enlarged carcinoma 20 cm in size to the pancreas and peritoneal dissemination. He received chemotherapy with paclitaxel, carboplatin, and gemcitabine. After the chemotherapy, CT scan and PET-CT revealed no evidence of disease, so tumor resection was performed. The subsequent pathological findings revealed no cancer and a complete pathological response. The patient is currently alive 4 years after the first surgery, without evidence of recurrence and adjuvant chemotherapy. A 60-year-old man was diagnosed as having CUP with an undifferentiated carcinoma and lymph node metastasis. He received chemotherapy with paclitaxel, carboplatin, and gemcitabine. However, unanticipated adverse events(finger ulcer)occurred. Thus, the chemotherapy was changed to paclitaxel, carboplatin, and etoposide. The patient is currently alive 4.2 years after the first chemotherapy, without evidence of recurrence. A 59-year-old man was diagnosed as having CUP with neuroendocrine carcinoma(NEC)and lymph node metastasis. He received chemotherapy with irinotecan and cisplatin. The lymph node metastases disappeared, but bone metastasis was found. The chemotherapy was changed to paclitaxel, carboplatin, and etoposide. The patient is currently alive 3.5 years after the first chemotherapy, without evidence of recurrence. We report 3rare cases of high-grade malignant CUP with complete pathological response, partial response, stable disease, and long-term survival after chemotherapy.

Determination of the optimal acquisition protocol of breath-hold PET/CT for the diagnosis of thoracic lesions.

OBJECTIVE: The aim of this study was to determine the optimal acquisition scan protocol for deep inspiration breath-hold (BH) fluoro-2-deoxy-D-glucose positron emission tomography (PET) for the examination of thoracic lesions. METHODS: We studied 32 thoracic lesions in 21 patients. Whole-body PET/computed tomography (CT) scanning with free breathing (FB) was performed for 3 min per bed position, followed by a BH-CT and five BH-PET for 20 s each. Summed BH images with total acquisition times of 40, 60, 80 and 100 s were generated (BH × 2, BH × 3, BH × 4 and BH × 5, respectively). The displacements between PET and CT images, the lesion volume of the PET image, the maximum standardized uptake value (SUVmax) and the quality of the PET image were assessed in relation to the clinical characteristics of each patient and the summation of the BH-PET images. RESULTS: BH-PET decreased the tumor volume significantly (FB: 7.23 ± 9.70 cm³, BH × 5: 4.71 ± 5.14 cm³, P<0.01) and increased the SUVmax (FB: 6.27 ± 5.41, BH × 5: 7.53 ± 6.28, P<0.01). The displacement between the PET and CT images was improved significantly in the BH scans (FB: 0.77 ± 0.53 cm, BH × 5: 0.36 ± 0.24 cm, P<0.01). In addition, aging and lung function of patients influenced the reproducibility of BH-PET. The summed BH-PET images, obtained by summation of three or more BH-PET images (total acquisition time of 60 s or more), achieved good image quality. CONCLUSION: BH-PET/CT improved the misregistration between PET and CT images and increased the SUVmax of thoracic lesions. The recommended number of BH-PET images for summation with 20 s of acquisition time is three or more.

Phantom study on three-dimensional target volume delineation by PET/CT-based auto-contouring.

OBJECTIVE: The aim of this study was to determine an appropriate threshold value for delineation of the target volume in PET/CT and to investigate whether we could delineate a target volume by phantom studies. METHODS: A phantom consisted of six spheres (phi 10-37 mm) filled with 18F solution. Data acquisition was performed PET/CT in non-motion and motion status with high 18F solution and in non-motion status with low 18F solution. In non-motion phantom experiments, we determined two types of threshold value, an absolute SUV (T(SUV)) and a percentage of the maximum SUV (T%). Delineation using threshold values was applied for all spheres and for selected large spheres (a diameter of 22 mm or larger). In motion phantom experiments, data acquisition was performed in a static mode (sPET) and a gated mode (gPET). CT scanning was performed with helical CT (HCT) and 4-dimensional CT (4DCT). RESULTS: The appropriate threshold values were aT% = 27% and aT(SUV) = 2.4 for all spheres, and sT% = 30% and sT(SUV) = 4.3 for selected spheres. For all spheres in sPET/HCT in motion, the delineated volumes were 84%-129% by the aT% and 34%-127% by the aT(SUV). In gPET/4DCT in motion, the delineated volumes were 94-103% by the aT% and 51-131% by the aT(SUV). For low radioactivity spheres, the delineated volumes were all underestimated. CONCLUSION: A threshold value of T% = 27% was proposed for auto-contouring of lung tumors. Our results also suggested that the respiratory gated data acquisition should be performed in both PET and CT for target volume delineation.