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This article describes our stereoselective and site-selective chemical methods for exploiting cationic heterocycles as electron-withdrawing groups (EWGs). We envisioned that the phosphoramide N-H proton of a pyridyl phosphoramide 3 would be activated by the cationic pyridinium moiety that is formed upon protonation. The resulting imide-like N-H proton and the acidic pyridinium proton of the pyridinium phosphoramide 3⋅HX cooperate together, making 3⋅HX a highly acidic dual Brønsted acid. The catalytic ability of 3⋅HX was demonstrated in the development of the first asymmetric Diels-Alder reaction between 1-amide dienes and maleimides. Focusing on the activation of N-bromosuccinimide (NBS) because of its structural similarity to maleimides, the enantioselective bromolactonization of trisubstituted olefinic acids was accomplished utilizing pyridyl phosphoramide 3f as a Brønsted base catalyst bearing an acidic N-H proton. Lastly, our strategy for the site-selective acylation of polyol compounds is described. In our system, a pyridine aldoxime ester 10, used as a mild acylating reagent, was activated by a catalytic amount of Lewis acid via the inductive effect of the cationic pyridinium moiety. The resulting metal complex preferentially attracted the alcohol with a Lewis basic site, thereby facilitating selective acylation via a template effect. This metal-template-driven strategy allowed for the site-selective acylation of diverse α-hydroxyamides, including unprotected N-glycolyl aminosugars.

A 66-year-old woman was diagnosed with advanced cecal cancer with metastases to her right ovary, peritoneum, and liver. Ileocecal resection and right salpingo-oophorectomy were performed as cytoreduction surgery before systemic chemotherapy. The colon cancer metastasized to her left ovary during chemotherapy and grew rapidly until it ruptured spontaneously, although the other metastases sites continued to respond to treatment. Emergent left salpingo-oophorectomy was performed. Pathological findings confirmed ovarian metastasis from colon cancer. Ovarian metastases are less responsive to systemic chemotherapy compared to extra-ovarian metastasis and the rapid growth sometimes occurs as a related symptom. Bilateral salpingo-oophorectomy might be recommended in cytoreduction surgery even if the ovarian metastasis is unilateral.

A 70-year-old woman who have achieved complete remission (CR) of acute promyelocytic leukemia (APL) with all-trans retinoic acid and chemotherapy presented with abnormal sensation in the right lateral thigh and the bilateral legs. In addition, neurological examination revealed weakness of the left shoulder abduction, the right hand, and the bilateral lower limbs. Atypical promyelocytes were detected in the cerebrospinal fluid, in spite of normal finding in the peripheral blood smear. Magnetic resonance imaging showed gadolinium-enhanced multiple intradural/extramedullary lesions in the whole spine. Nerve conduction studies of the right limbs revealed sensorimotor conduction abnormalities, conspicuously in the posterior tibial and sural nerves. As a result, she was diagnosed as having intrathecal relapse of APL, associated with multiple mononeuropathy. The neurological symptoms were completely disappeared by intrathecal chemotherapy and whole-spine radiotherapy, suggesting that the neuropathy was possibly caused by meningeal infiltration affecting multiple spinal nerve roots. Since extramedullary or intrathecal relapse is extremely rare in APL compared with other types of leukemia, precise neurological evaluations and suitable treatment should be performed immediately, when APL patients with CR manifest some neurological symptoms.

A male in his eighties underwent abdominoperineal resection under the diagnosis of adenocarcinoma associated with anal fistula (P0, H0, n (-), A1, stage II, ly0, v0). Ten years after the surgery, a painful lymph node swelling was noticed in the left inguinal region. Biopsy specimen showed adenocarcinoma consisting of severe dysplastic cells. Radiotherapy was performed in the pelvic region at a total dose of 50 Gy (2 Gy/day). After the radiotherapy, left inguinal and pelvic lymph nodes markedly shrank and became painless. After one month, the chemotherapy with UFT (UFT 300 mg/day) was started. One year thereafter, para-aortic lymph nodes were found to be enlarged, but a good quality of life was obtained without elevation of tumor markers.

We report a patient with a case of advanced rectal cancer with unresectable liver metastasis, who received the combination of systemic chemotherapy of 5-FU/l-LV and external radiation therapy. He was alive for 21 months. He had been able to maintain a good quality of life without any complaints of the primary rectal tumor.

We report a case of advanced hepatocellular carcinoma (HCC). A 73-year-old man with positive HBV and HCV underwent a partial hepatectomy (S6 and S5) twice and transcatheter arterial (chemo) embolization (TAE) four times, thereafter. During these treatments, HCC became intractable and the patient complained of general fatigue. The liver function was Child's classification A, and serum AFP was 6,737 ng/ml. Abdominal CT scan revealed recurrent lesions in the right hepatic lobe and left adrenal gland. The catheter for hepatic arterial infusion chemotherapy was inserted from the left femoral artery. Arterial chemotherapy with 5-fluorouracil (5-FU 750 mg) and cisplatin (CDDP 10 mg) was performed every two weeks. During 6 courses of this regimen, a significant side effect did not appear. Abdominal CT revealed no change in size, but serum AFP decreased up to 794 ng/ml and the general fatigue subsided. After 2 months, serum AFP began to increase and became 1454 ng/ml. The regimen of arterial chemotherapy was changed to epirubicin (EPI 40 mg every two weeks) and UFT-E (300 mg/day for four weeks), followed by a week off. An appetite loss (grade 2) appeared, but it could be well controlled. Serum AFP decreased again, up to 54 ng/ml. A good QOL was kept for about one year after the initiation of hepatic arterial infusion chemotherapy.

In colorectal cancer, hepatic and pulmonary metastases are the most common and most important prognostic factors. Surgical resection is the first choice of treatment for hepatic and pulmonary metastases if completely resectable. However, only a few patients survived long term after metastatectomy. We present the two cases, in which surgical resection for pulmonary and/or hepatic metastases from colorectal cancer resulted in long-term survival for more than ten years without recurrence.

According to a new system for postgraduate clinical training, 33 medical trainees have been accepted for the past two years at Osaka General Medical Center. Before practicing clinical medicine in each division by a super-rotated table, orientation is scheduled for 5 days to master the basic systems indispensable to the hospital. In this orientation, training in laboratory medicine is performed for 7 hours (3.5 hours for 2 days). Trainees are divided into 4 groups and learn emergency tests of chemistry, hematology and urinalysis, blood transfusion, physiology and microbiology for 60 min each. Laboratory technologists instruct the trainees to gain the basic skills. The main contents are blood gas measuring in chemistry, sample preparation in hematology and urinalysis, taking each other's ECG, ordering blood products for transfusion, serologic study of infectious diseases, and Gram stain in microbiology. Although it is difficult to find time for routine analysis and instructing trainees in the clinical laboratory, it is a suitable opportunity for revision, also for laboratory technologists, and for communication to discuss clinical matters.

The patient, a 40-year-old woman, underwent total gastrectomy and excision of the pancreatic tail, spleen and gallbladder for gastric cancer in September 2000. The lesion was judged to be P1, SE, H0, N2 and Stage IV and the patient was managed on a regular schedule as an outpatient. In September 2004, she passed blood-stained feces and rectal palpation detected a hard nodule at the anterior rectal wall. A fiber optic examination of the sigmoid colon detected an ulcerous lesion with a hemorrhage at the anterior rectal wall. A biopsy revealed the lesion to be Group V poorly differentiated adenocarcinoma. Starting in October 2004, 100 mg/day of TS-1 was administered for 3 weeks; intravenous drip infusion of 100 mg/body of CDDP was conducted in the second week for a period of 24 hours. After 3 courses of this regimen, a fiber optic examination of the colon conducted in February 2005 no longer detected the rectal tumor, leaving only a cicatrix. Upon a CT examination, the para-aortic lymph nodes that had been enlarged were notably reduced in size and an improvement was eminent in the hypertrophic rectal wall. The patient no longer experienced constipation or melena. Her clinical course is being observed while an oral administration of 100 mg/day of TS-1 continues.

In colorectal cancer, liver metastasis is the most common and most important prognostic factor. Although surgical resection is the first choice of treatment for liver metastasis of colorectal cancer, there are many cases we cannot choose the surgical treatment. The chemotherapy is very important in such cases. We examined 18 cases of unresectable liver metastases from colorectal cancer which were adapted a hepatic arterial infusion of 5-FU (HAI) with a weekly high-dose infusion method (WHF) as the first-line treatment, and then systemic chemotherapy of CPT-11 in combination with 5-FU as the second-line treatment. The response rate of this treatment is 72% (13/18) and the 1-, 2-, 3-year survival rates were 100% (16/16), 83% (10/12), and 50% (5/10), respectively. The combination chemotherapy of HAI with systemic chemotherapy using CPT-11 seemed to be an effective treatment method.

A 44 year-old woman presented with epigastralgia in March 2004 was diagnosed as having type II gastric cancer by gastrofiberscope, and histological diagnosis of biopsy specimens was group V (tub2, por1). Since multiple liver metastases were observed in subsegments 2, 3, and 5 by abdominal ultrasonography, systemic chemotherapy was first conducted for tumor down sizing. The patient was treated by three cycles of the one month regimen (CDDP 70 mg/m2, day 8, for 24hrs, and TS-1 80 mg/m2, day 1-14; 2 week cessation of the drugs). CT scan taken on May 16, 2005 revealed that the tumor diameters in subsegments 2, 3, and 5 were 1 cm, 3 cm, and 1.5 cm, respectively. On September 14, liver tumors were markedly shrunk. Tumor in subsegment 2 became undetectable, and the diameters in those in subsegments 3 and 5 were 1.5 cm, and 0.5 cm, respectively. On September 28, a distal gastrectomy associated with S3 partial hepatectomy and microwave coagulation therapy for S5 tumor was performed without any macroscopic residual lesions. The prognosis of liver metastasis of gastric cancer is generally poor, and there is no comprehensive therapy. The marked clinical response in this patient suggests that this combination therapy with CDDP and TS-1 might be a promising preoperative chemothepapy for unresectable gastric cancer.

To evaluate the clinical effectiveness of metallic stent in the palliation of malignant bile duct obstruction in aged patients, 30 patients over 65 years of age with malignant biliary obstruction were investigated retrospectively. Overall survival duration after the stent placement was 13-1,275 (mean: 278, median: 169) days. The period of tube-free on the outpatient basis after stent insertion was 0-1,162 (mean: 192, median: 121) days. The estimated cost savings by eliminating hospitalization was greater than the stent cost. Four patients survived over 18 months despite their advanced clinical stages. It seems difficult to develop guidelines for the indication of stent placement in the treatment of malignant bile duct obstruction for aged patients.

A 56-year-old man is presented with diarrhea, which he had experienced since February 2004. He was diagnosed as having advanced pancreatic cancer by enhanced abdominal CT scan in May 2004. He was diagnosed with unresectable pancreatic cancer, and treated with a combination of radiation (3 Gy/day) and injections of gemcitabine (GEM) 1,200 mg/week (800 mg/m2, BSA 1.6). Abdominal CT scan revealed a minor response (tumor diameter 5.7 x 4.8 --> 5.2 x 4.4). Accordingly, the improvement of performance status and reduction in serum levels of arcinoembryonic/carbohydrate antigen 19-9 (CA19-9) were observed. In July 2004, chemotherapy and radiotherapy were switched to GEM+UFT (UFT 360 mg/day, a total of 4,320 mg, GEM 1,200 mg according to the body mass, a total of 2,400 mg). The patient's performance state was stable for 6 months but serum levels of CA19-9 increased from March 2005, and he complained of diarrhea and back-pain. Therefore, the combination chemotherapy with GEM and cisplatin (CDDP) was started in April 2005, but there was no clinical effect. GEM and TS-1 are currently being administered. Pancreatic cancer is one of the worst prognoses of any malignant disease. Although the prognosis of unresectable pancreatic cancer is very poor, we presented a case where performance status and survival benefits were obtained by undergoing chemoradiation with GEM and combination chemotherapy with UFT and GEM.

A 44-year-old male was admitted in a state of semicoma, tonic convulsion and elevated body temperature nine days after sustaining head injury. He had severe nuchal rigidity. Computed tomography revealed dilation of ventricles and swelling of the brain parenchyma. We performed cerebrospinal fluid (CSF) drainage of both lateral ventricles immediately. The fluid drained from both ventricles was just like pus. We diagnosed the patient's condition as posttraumatic ventriculitis and meningitis. We performed intraventricular lavage (IL) which was our ventricular irrigating technique. IL was repeated until the 7th day postoperatively. The CSF data improved immediately. Continuous spinal drainage (CSD) also was used for CSF drainage from the 7th day postoperatively. The patient recovered without the need for CSF shunt. Some authors have reported the usefulness of continuous intraventricular irrigation (CIVI) for treatment of severe ventriculitis. However, their patients required CSF shunt surgeries. Such shunts are likely to become infected more frequently than routine shunting. Our IL was able to drain pus and inflammatory products in the ventricles before the formation of septations in the ventricles. We emphasize that IL in combination with CSD is able to bring about good results for patients with severe ventriculitis.