Atomic structure of an FeCrMoCBY metallic glass revealed by high energy x-ray diffraction

Amorphous bulk metallic glasses with the composition Fe₄₈Cr₁₅Mo₁₄C₁₅B₆Y₂have been of interest due to their special mechanical and electronic properties, including corrosion resistance, high yield-strength, large elasticity, catalytic performance, and soft ferromagnetism. Here, we apply a reverse Monte Carlo technique to unravel the atomic structure of these glasses. The pair-distribution functions for various atomic pairs are computed based on the high-energy x-ray diffraction data we have taken from an amorphous sample. Monte Carlo cycles are used to move the atomic positions until the model reproduces the experimental pair-distribution function. The resulting fitted model is consistent with ourab initiosimulations of the metallic glass. Our study contributes to the understanding of functional properties of Fe-based bulk metallic glasses driven by disorder effects.

Atomic arrangements in an amorphous CoFeB ribbon extracted via an analysis of radial distribution functions

We discuss the atomic structure of amorphous ferromagnetic FeCoB alloys, which are used widely in spintronics applications. Specifically, we obtain the pair-distribution functions for various atomic pairs based on high-energy x-ray diffraction data taken from an amorphous Co₂₀Fe₆₁B₁₉specimen. We start our reverse Monte Carlo cycles to determine the disordered structure with a two-phase model in which a small amount of cobalt is mixed with Fe₂₃B₆as a second phase. The structure of the alloy is found to be heterogeneous, where the boron atoms drive disorder through the random occupation of the atomic network. Our analysis also indicates the presence of small cobalt clusters that are embedded in the iron matrix and percolating the latter throughout the structure. This morphology can explain the enhanced spin polarization observed in amorphous magnetic materials.

Structural properties of PbTe quantum dots revealed by high-energy x-ray diffraction

High-energy x-ray diffraction (HE-XRD) experiments combined with an analysis based on atomic-pair-distribution functions can be an effective tool for probing low-dimensional materials. Here, we show how such an analysis can be used to gain insight into structural properties of PbTe nanoparticles (NPs). We interpret our HE-XRD data using an orthorhombic Pnma phase of PbTe, which is an orthorhombic distortion of the rocksalt phase. Although local crystal geometry can vary substantially with particle size at scales below 10 nm, and for very small NPs the particle size itself influences x-ray diffraction patterns, our study shows that HE-XRD can provide a unique nano-characterization tool for unraveling structural properties of nanoscale systems.

Experimental observation of density fluctuations in liquid metals associated with liquid-liquid, liquid-gas and metal-nonmetal transitions

We have developed a special technique and succeeded to carry out small-angle x-ray scattering measurements for some liquid metal systems. The purpose is to investigate effects of transitions such as liquid-liquid (LLT), liquid-gas (LGT) and metal-nonmetal (MNMT) transitions on mesoscopic density fluctuations in liquids. In liquid Te systems (Se-Te and Ge-Te mixtures), which show continuous LLT accompanying MNMT, parameters of density fluctuations show maxima almost in the middle of the transition, both in strength and spatial size. This work (and Kajihara et al 2012 Phys. Rev. B86 214202) was the first direct observation that density fluctuations exhibit maximum corresponding to LLT. However in this study, we could not clearly separate the effects of LLT and MNMT on the observed density fluctuations. Thus, we also investigated fluid Hg under high pressure and high temperature conditions, which shows MNMT near a critical point of LGT, to investigate how MNMT affects them. We observed distinct density fluctuations; a strength and a correlation length of them show maxima at around a critical isochore of LGT, and the former is basically consistent with a phase diagram (compressibility) of LGT; they do not show any peaks at MNMT region. Precise analysis revealed that MNMT only affects a shift of another parameter, a short-range correlation length. These results in fluid Hg indicate that the density fluctuations are mainly derived from a critical phenomena of LGT and MNMT does not play any critical role on them. We believe that the latter conclusion also holds true for liquid Te systems; MNMT plays no important role on the density fluctuations in liquid Te systems and LLT is the main origin of them.

p-Methylbenzyl Group: Oxidative Removal and Orthogonal Alcohol Deprotection

We describe the practical removal of p-methylbenzyl (MBn) protections of alcohols by treatment with 2,3-dichloro-5,6-dicyano-p-benzoquinone. When a molecule bears benzyl and MBn groups, the oxidant selectively removes the latter groups. Further, the MBn groups tolerate ceric ammonium nitrate, resulting in chemoselective removal of the p-methoxybenzyl group in the presence of the MBn groups. These orthogonal alcohol deprotections would provide novel synthetic strategies of organic compounds.

Static and dynamic structures of liquid Ba8Ga16Sn30: a melt of the thermoelectric clathrate compounds

X-ray diffraction and inelastic x-ray scattering measurements of liquid Ba₈Ga₁₆Sn₃₀ have been carried out to investigate local structure and atomic dynamics in the liquid. The pair distribution function shows shorter and longer interatomic distances in the first coordination shell. The dynamic structure factor exhibits the inelastic excitations on both sides of the quasielastic central peak. The inelastic excitations disperse with increasing the momentum transfer, suggesting the longitudinal acoustic mode. We found a low energy excitation in addition to the longitudinal acoustic excitation in the dynamic structure factor and it reminds us a strong relationship with a rattling motion of a guest (Ba) atom in the solid state. The temperature dependence of the pair distribution function and the longitudinal acoustic excitation energy is very weak in a range from 600 to 900 °C. The result suggests that Ba and other atoms in the melt are located around minimum positions of the effective pair potential approximated as a harmonic one.

Deep-learning-based, computer-aided classifier developed with a small dataset of clinical images surpasses board-certified dermatologists in skin tumour diagnosis

BACKGROUND

Application of deep-learning technology to skin cancer classification can potentially improve the sensitivity and specificity of skin cancer screening, but the number of training images required for such a system is thought to be extremely large.

OBJECTIVES

To determine whether deep-learning technology could be used to develop an efficient skin cancer classification system with a relatively small dataset of clinical images.

METHODS

A deep convolutional neural network (DCNN) was trained using a dataset of 4867 clinical images obtained from 1842 patients diagnosed with skin tumours at the University of Tsukuba Hospital from 2003 to 2016. The images consisted of 14 diagnoses, including both malignant and benign conditions. Its performance was tested against 13 board-certified dermatologists and nine dermatology trainees.

RESULTS

The overall classification accuracy of the trained DCNN was 76·5%. The DCNN achieved 96·3% sensitivity (correctly classified malignant as malignant) and 89·5% specificity (correctly classified benign as benign). Although the accuracy of malignant or benign classification by the board-certified dermatologists was statistically higher than that of the dermatology trainees (85·3% ± 3·7% and 74·4% ± 6·8%, P < 0·01), the DCNN achieved even greater accuracy, as high as 92·4% ± 2·1% (P < 0·001).

CONCLUSIONS

We have developed an efficient skin tumour classifier using a DCNN trained on a relatively small dataset. The DCNN classified images of skin tumours more accurately than board-certified dermatologists. Collectively, the current system may have capabilities for screening purposes in general medical practice, particularly because it requires only a single clinical image for classification.

Treatment of Acute Myocardial Infarction with Cardiogenic Shock using Left Ventricular Assist Device

We have treated ten cardiogenic shock patients after acute myocardial infarction (AMI) with a left ventricular assist device (LVAD). These patients were later divided into three groups: the first group with ventricular septal perforation, the second with aorto-coronary bypass grafting (ACBG) before LVAD implantation and the third group without ACBG. LVAD maintained the systemic circulation in each group, and cardiac function recovered enough to remove LVAD in 70% of the total patients. Two of three patients in the first group were discharged from hospital. Two weaned cases in the second group died of multiple organ failure and one was discharged, and hemorrhagic necrosis was seen in the bypassed area of the myocardium. One patient of the third group could not be weaned from LVAD because of respiratory failure though his heart function began to recover. Another case in the third group underwent bypass grafting after removal of LVAD. However ACBG surgery should be done very carefully because a patient in shock is occasionally intolerant to major surgery. In all groups, the major cause of death was multiple organ failure which was probably caused by the prolonged low output condition prior to LVAD application. In the light of this experience, it appears that LVAD should be applied before irreversible damage occurs to major organs, including the heart itself. To ensure the timely application of LVAD, some way must be found to introduce systematic application of LVAD into the normal course of AMI treatment.

Liquid-like thermal conduction in intercalated layered crystalline solids

As a generic property, all substances transfer heat through microscopic collisions of constituent particles ¹ . A solid conducts heat through both transverse and longitudinal acoustic phonons, but a liquid employs only longitudinal vibrations^2,3. As a result, a solid is usually thermally more conductive than a liquid. In canonical viewpoints, such a difference also serves as the dynamic signature distinguishing a solid from a liquid. Here, we report liquid-like thermal conduction observed in the crystalline AgCrSe₂. The transverse acoustic phonons are completely suppressed by the ultrafast dynamic disorder while the longitudinal acoustic phonons are strongly scattered but survive, and are thus responsible for the intrinsically ultralow thermal conductivity. This scenario is applicable to a wide variety of layered compounds with heavy intercalants in the van der Waals gaps, manifesting a broad implication on suppressing thermal conduction. These microscopic insights might reshape the fundamental understanding on thermal transport properties of matter and open up a general opportunity to optimize performances of thermoelectrics.

Role of Neuron-Glial Interaction Mediated by IL-1β in Ectopic Tooth Pain

Although many reports have demonstrated that ectopic pain develops in the orofacial region following tooth pulp inflammation, which often causes misdiagnosis and inappropriate treatment for patients with pulpitis, the precise mechanism remains unknown. In the present study, we hypothesized that the functional interaction between satellite glial cells and neurons mediated by interleukin 1β (IL-1β) in the trigeminal ganglion (TG) is involved in ectopic orofacial pain associated with tooth pulp inflammation. The digastric muscle electromyogram (D-EMG) activity elicited by capsaicin administration into the maxillary second molar tooth pulp was analyzed to evaluate the noxious reflex and was significantly increased in rats with inflammation of the maxillary first molar (M1) versus rats injected with saline. A significant increase in the expression of connexin43 (Cx43), a gap junction containing protein, was observed in activated satellite glial cells surrounding second molar-innervating neurons in the TG after M1 pulpitis. Daily administration of Gap26, a Cx43 mimetic peptide and inhibitor, in the TG significantly suppressed the enhancement of capsaicin-induced D-EMG activity and the percentage of Fluoro-Gold (FG)-labeled cells encircled by glial fibrillary acid protein-immunoreactive (IR) + Cx43-IR cells after M1 pulp inflammation ( P < 0.01). The percentage of FG-labeled cells encircled by glial fibrillary acid protein-IR + IL-1β-IR cells, IL-1 type I receptor-IR cells labeled with FG, and TRPV1-IR cells labeled with FG significantly increased after M1 pulp inflammation ( P < 0.01). Daily administration of IL-1ra, an IL-1 receptor antagonist, into the TG significantly reduced the enhancement of capsaicin-induced D-EMG activity and the percentage of TRPV1-IR neurons labeled with FG after M1 pulp inflammation ( P < 0.01). The present findings suggest that satellite glial cell is activated in the TG via activated gap junctions composed of Cx43 following tooth pulp inflammation, which leads to the hyperactivation of remote neurons via IL-1β mechanisms and results in ectopic tooth pulp pain in the adjacent tooth.

Total Synthesis of Lagerstannin C: Follow-up of the Khanbabaee’s Synthesis

This report describes the total synthesis of lagerstannin C, a natural ellagitannin that has d-gluconic acid in the molecule. The study presented here is the first synthesis of the gluconic acid containing ellagitannin. The key step in the synthesis is the opening of δ-lactone through transesterification to form the corresponding benzyl ester.

A new approach for estimating the density of liquids

We propose a novel approach with which to estimate the density of liquids. The approach is based on the assumption that the systems would be structurally similar when viewed at around the length scale (inverse wavenumber) of the first peak of the structure factor, unless their thermodynamic states differ significantly. The assumption was implemented via a similarity transformation to the radial distribution function to extract the density from the structure factor of a reference state with a known density. The method was first tested using two model liquids, and could predict the densities within an error of several percent unless the state in question differed significantly from the reference state. The method was then applied to related real liquids, and satisfactory results were obtained for predicted densities. The possibility of applying the method to amorphous materials is discussed.

Liver stiffness measurement using acoustic radiation force impulse elastography in hepatitis C virus-infected patients with a sustained virological response

BACKGROUND

Acoustic radiation force impulse (ARFI) elastography is a non-invasive method for measuring liver stiffness. However, there are no reports evaluating the value of ARFI elastography for liver fibrosis in chronic hepatitis C patients with a sustained virological response (SVR).

AIM

To investigate the diagnostic performance of ARFI elastography for the assessment of liver fibrosis in hepatitis C virus (HCV) infected patients with an SVR.

METHODS

In this prospective study, we enrolled 336 patients: 121 HCV patients with an SVR (44.6% women) and 215 patients with HCV (47.9% women). ARFI elastography measurements of all patients were performed on the same day of liver biopsy.

RESULTS

The diagnostic accuracies, expressed as areas under the receiver operating characteristic curves for ARFI elastography, in HCV patients with an SVR and those in patients with HCV were 0.818 and 0.875 for the diagnosis of significant fibrosis (≥F2), 0.909 and 0.888 for the diagnosis of severe fibrosis (≥F3), and 0.981 and 0.890 for the diagnosis of liver cirrhosis (F4), respectively. The optimum cut-off values for ARFI elastography were 1.26 m/s for ≥F2, 1.31 m/s for ≥F3 and 1.49 m/s for F4 in HCV patients with an SVR. The liver stiffness values were lower in patients with SVR compared with those in patients with HCV at the same stage of fibrosis. The liver stiffness values were affected by the necroinflammatory activity and the time after SVR.

CONCLUSION

Acoustic radiation force impulse elastography is an acceptable method for predicting the severity of fibrosis in patients with hepatitis C virus and a sustained viral response.

Intermediate-range chemical ordering of cations in molten RbCl-AgCl

A first sharp diffraction peak (FSDP) is observed in the X-ray total structure factor of a molten mixture of RbCl-AgCl, while both pure melts of RbCl and AgCl do not exhibit FSDP individually. Molecular dynamics simulations were performed to investigate the origin of the FSDP with the polarizable ion model (PIM). Coexistence of covalent Ag-Cl and ionic Rb-Cl bonds leads the system to evolve intermediate range ordering, which is simulated by introducing the induced polarization in different ways between Ag-Cl with fully polarizable treatment based on Vashishta-Raman potential and Rb-Cl with suppression over-polarization in the nearest neighbor contribution based on Born-Meyer potential. The partial structure factors for both the Ag-Ag and Rb-Rb correlations, SAgAg(Q) and SRbRb(Q), show a positive contribution to the FSDP, while SAgRb(Q) for the Ag-Rb correlation exhibits a negative contribution, indicating that Ag and Rb ions are distributed in an alternating manner within the intermediate-range length scale. The origin of the intermediate-range chemical ordering of cations can be ascribed to the preferred direction of the dipole moments of anions in the PIM.

Prognostic value of systemic inflammation-based markers in advanced pancreatic cancer

BACKGROUND

The prognostic significance of various systemic inflammation-based markers has been explored in different cancers. These markers can be used to assist with decision-making in oncology clinics.

AIM

The aim of this study was to investigate the prognostic significance of three systemic inflammation-based factors: neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and modified Glasgow Prognostic Score (mGPS) in patients with advanced pancreatic cancer.

METHODS

Data were collected retrospectively for advanced pancreatic cancer patients treated between 1 January 2008 and 31 December 2012 at the Royal Perth Hospital. The ratios were dichotomised as <5 versus ≥5 for NLR and <200 versus ≥200 for PLR. Modified Glasgow Prognostic Scores were scored as: mGPS '0' = both C-reactive protein (CRP) and albumin normal, mGPS '1' = elevated CRP < 10 mg/L and mGPS '2' = both elevated CRP > 10 mg/L and albumin < 35 g/L. Univariate and multivariate analyses were carried out.

RESULTS

Data were evaluable for 124 patients. Median survivals based on the three inflammation-based prognostic markers evaluated were: NLR <5 versus ≥5 = 8.5 months versus 2.6 months respectively (P = 0.0007; hazard ratio (HR) 1.81), PLR <200 versus ≥200 = 9.1 months versus 4 months respectively (P = 0.007; HR 1.64) and mGPS score 1, 2, 3 = 8.3 months, 9.6 months and 1.8 months respectively (P = 0.0004). Besides Eastern Cooperative Oncology Group performance status, NLR, PLR and mGPS were significant independent prognostic markers both on univariate as well as multivariate analysis.

CONCLUSIONS

Our findings suggest that the NLR, PLR and mGPS derived from routine blood tests can be used as clinically meaningful biomarkers to stratify advanced pancreatic cancer patients into different prognostic groups.

Reassessment of selectivity index in nephrotic syndrome with special reference to the clinical significance of a small-molecular IgG fraction in the urine

The selective index O and the transR IgG have been valuable in clinical use, but they do not appear to always correctly reflect the GBM sieving effect on plasma protein and thus do not correctly predict the response to steroids. We applied a new technique to 22 nephrotic patients with the following results. (a) Fragments of IgG molecules (M-IgG, MW 5-10 X 10(4); S-IgG, MW 1-5 X 10(4)) were present in the urine in addition to normal IgG (L-IgG). These fragments were immunologically identical with the intact IgG molecule and therefore, could falsely portray GMB permeability. (b) The data strongly suggest that the S-IgG fragment found in the nephrotic urine is the IgG-Fc fragment present in increased amounts in such urine. (c) IgG L/S shows a positive correlation with O and transR IgG and can be used as a new and better selectivity index of GBM permeability. This, in turn, may provide a more accurate means of predicting the response to steroid therapy. For example, in the cases we analyzed, the transR IgG and O were incorrect in 31.9% and 22.7%, respectively, whereas with our new method they were incorrect in only 13.6%.

Olanzapine and Betamethasone Are Effective for the Treatment of Nausea and Vomiting due to Metastatic Brain Tumors of Rectal Cancer

Brain lesions originating from metastasis of colorectal cancer represent 3–5% of all brain metastases and are relatively rare. Of all distant metastases of colorectal cancer, those to the liver are detected in 22–29% of cases, while those to the lungs are detected in 8–18% of cases. In contrast, brain metastasis is quite rare, with a reported incidence ranging from 0.4 to 1.8%. Treatments for metastatic brain tumors include surgery, radiotherapy, chemotherapy and supportive care with steroids, etc. Untreated patients exhibit a median survival of only approximately 1 month. The choice of treatment for brain metastasis depends on the number of lesions, the patient's general condition, nerve findings and presence of other metastatic lesions. We herein report the case of a 78-year-old male who presented with brain metastases originating from rectal carcinoma. He suffered from nausea, vomiting, anorexia and vertigo during body movement. He received antiemetics, glycerol and whole brain radiation therapy; however, these treatments proved ineffective. Olanzapine therapy was started at a dose of 1.25 mg every night. The persistent nausea disappeared the next day, and the frequency of vomiting subsequently decreased. The patient was able to consume solid food. Olanzapine is an antipsychotic that has recently been used as palliative therapy for refractory nausea and vomiting in patients receiving chemotherapy. We consider that olanzapine was helpful as a means of supportive care for the treatment of nausea and vomiting due to brain metastasis.

Structural disorder in lithium lanthanum titanate: the basis of superionic conduction

High-energy x-ray and neutron diffraction measurements on polycrystalline La(2/3-x)Li(3x)TiO(3) (0.075 < x < 0.165) were performed. The total scattering structure factors were analysed by the reverse Monte Carlo (RMC) modelling technique, resulting in three-dimensional particle configurations. These configurations were then used for revealing the distributions of La and Li ions and to understand the relationship between these distributions and ionic conduction. An alternating arrangement of La-rich and La-poor layers along the c-axis was found in the x = 0.075 composition. Intriguingly, this arrangement has gradually disappeared in samples with higher Li concentration. Furthermore, RMC models exhibit disordered distributions of Li ions, situated mainly on the La-rich layer, and there is a significant probability of Li ions occupying the interstitial sites (T site) between the O-3 triangle plane of the TiO(6) octahedron and an La ion or its vacancy site. It was also found on the basis of the RMC models that the bond valence sum (BVS) for Li ions behaves differently on La-rich and La-poor layers at low Li concentration compositions, but they are similar at high Li concentration compositions. This is consistent with the behaviour of the alternating arrangement of La-rich and La-poor layers. It is also suggested that the Li ions around the bottleneck at (1/2, 0, 0) (bottom layer) can jump to an adjacent bottleneck at (0, 1/2, 0) through the T site and not only Li ions in the La-poor layers but also Li ions in the La-rich layers contribute to the bottleneck-bottleneck Li conduction.

[Emergency distal arch replacement for traumatic thoracic aortic dissection with subarachnoid hemorrhage]

A 77-year-old woman was transferred as traumatic thoracic aortic dissection with subarachnoid hemorrhage soon after a traffic accident. Her consciousness was slightly compromised and cardiogenic shock was developed. Serial computed tomography (CT) scans revealed an unchanging subarachnoid hemorrhage and a progressive mediastinal hemorrhage and pericardial effusion due to traumatic type B aortic dissection. An emergency distal arch replacement was performed under cardiopulmonary bypass 4 hours after the injury. She woke up 3 days after the operation without progression of subarachnoid hemorrhage on a cerebral CT scan. She was discharged 36 days after the injury.

[Evaluation of airway obstruction compressed by thoracic great vessels or their branches using multi-slice helical computed tomography]

Airway obstruction due to compression by the thoracic great vessels or their branches sometimes appears in patients with congenital heart disease. However, to make a definitive diagnosis may not be easy, because respiratory symptoms are common and stem from a variety of causes in this cohort. Thus, some invasive evaluation, including angiography, bronchial fiberscopy, and bronchography has usually been required. We employed multi-slice helical computed tomography (MSCT) and 3-dimensional (3D) image reconstruction in 7 cases (median age, 107 days ; range, 21 days to 6 years) who were suspected of complicating external vascular compression as a cause of respiratory symptoms. The CT scan clearly showed detailed anatomy of the thoracic vessels and interrelationship with the airway systems. It also disclosed a culprit artery compressing the trachea or bronchus. Different from other invasive or noninvasive examination modalities, MSCT allows precise evaluation of 2 independent organ systems, such as vascular and respiratory systems. We conclude that MSCT with 3D image reconstruction represents a reliable less-invasive technique for assessment of symptomatic airway obstruction caused by vascular compression.

Anterior capsule opacification: a cell culture model

We cultured the human lens epithelial cells with attaching anterior lens capsule using surgically removed capsular flaps obtained in intraocular lens implantation. The capsular flap was placed with cell side down in a small culture well. In phase contrast microscopy, an anti-meniscus plate was placed on the bathing medium to avoid optical aberration. The human lens epithelial cells showed outgrowth which ceased after 3 to 4 weeks of incubation. The cells under the capsule lost distinctive cell margin. The cells outgrew from the capsular edge both onto the anterior capsular surface and the well bottom. The outgrowth length and Bromodeoxyuridine uptake indicated a low proliferative potency of the human lens epithelial cells.

Evaluation of telomerase activity in non-genital Bowen's disease

We investigated the level of telomerase activity (TA) in 17 specimens of non-genital Bowen's disease (BD) and in 14 specimens of skin without sun exposure (non-exposed skin) using a non-isotopic PCR-based telomeric repeat amplification protocol (TRAP) assay. Expression of human telomerase reverse transcriptase (hTERT; the catalytic subunit of telomerase) was also evaluated by immunochemistry in the non-genital BD tissues. Moderate to high levels of TA were detected in 41.2% of 17 non-genital BD specimens (P = 0.001). In contrast, TA was not evident in non-exposed skin. Recently, nucleolin was reported to be associated with hTERT, so we used this antibody instead of hTERT antibody. Immunohistochemistry showed that nucleolin expression was associated with high TA levels in non-genital BD. Our results also revealed differences of TA levels among non-genital BD specimens. High levels of TA in those specimens were not age related. Five out of 7 specimens (71.4%) with moderate to high TA levels were from sun-exposed sites, while the remaining 10 specimens with low levels of TA were from non-exposed sites. These results suggested that cellular DNA damage caused by ultraviolet irradiation might be associated with an increase of TA in non-genital BD. Among non-genital BD specimens, 4 out of 17 (23.5%) showed high levels of TA (median relative TA value: 79.8%; P = 0.003), which might be associated with immortalization or transformation to invasive squamous cell carcinoma.

[Local recurrence of Castleman disease]

A rare case of recurrent Castleman disease is reported. A 49-year-old man was referred to our division under the suspicion of mediastinal tumor. We performed tumor resection successfully, and the tumor was shown to be Castleman disease by histology. The patient had a past history of this disease, therefore it was suggested that the tumor recurred at the same site 20-years after removal.