1

Chest Radiography Screening Assessment Manual
Introduction
Plain chest radiography (CR) is an essential tool for health screening that requires low-dose exposure.
Moreover, it is affordable and is convenient to perform. It facilitates the simultaneous visualization of thewhole thoracic region, thereby immediately identifying the status of the lungs, mediastinum, and thorax andobtaining partial information of the neck and abdomen. CR reduces the number of deaths from lung cancer
if it is performed accurately.1-5
There have been great progress in chest radiography since 2002 after the previous guideline waspublished6: prevailing digital imaging, such as CR, followed by filmless radiology at a later time.7 In 2008,
a questionnaire research performed on 514 member institutions of the Japan Society of Ningen Dock,
where 267 institutions submitted the responses, indicated that digital imaging and filmless radiology were
performed in 77.2% and 53.6% of institutions, respectively. Further use of such tools is expected at present.
In relation to such result, low-dose computed tomography (CT) lung scan for the screening of cancer iscarried out nationwide.8,9 Chest radiography screening and low-dose CT both rely on advances in digitaltechnology. The prevalence of digital imaging in plain radiography has resulted in improved image quality
and uniformization. In digital imaging, radiographic images are generated on films or displays with theirdensity and automatic adjustment of contrast, resulting in good image quality without being significantly
affected by radiograph conditions, which is contrary to the film-screen system. That is, low-quality
radiographs that were considered as “a white rabbit in a snowy mountain” or “a crow in the dark” arealmost obsolete. Although that is gladsome as a result of scientific advancement, on the other hand,radiographs indicating lowered lung field density (increasing blackness) that reflects pulmonary
hyperinflation in typical chronic pulmonary emphysema rarely emerges now.
Although we are in an era in which uniform images can be easily obtained with good generality, an imaging
condition that do no not overlook nodules is still important. Imaging with an exposure voltage ofapproximately 130 kVp in combination with a high-voltage Lysholm grid is advantageous as it can easily
recognize shadows overlapping with bone/mediastinal shadows with lowered contrast. Radiographconditions should be adjusted with a high voltage if possible. In filmless radiology, the use of a3-megapixel display that matches the pixel number of the chest radiographic image is preferred. Positioning
during radiography is also important, which include opening and closing the scapulae, which has asignificant impact on the accuracy of interpretation.
Based on the TNM classification for lung cancer, T1 is defined as a mass ≤3 cm in size.10 When thiscategory is divided in two and compared with each other (T1a [≤2 cm] and T1b [2<, ≤3 cm]), the T1agroup with smaller masses has better prognosis, with 10-year survival rates of 90.3% and 81.5%,
respectively.11 According to previous reports, the lung lesions detected in low-dose CT scan for thescreening of lung cancer measured 1–2 cm,12-15 which is associated with the best prognosis. By contrast, themean size of the masses detected on plain radiography measured 3–4 cm, which include those overlappingwith the mediastinum or other shadows. Nodal shadows in the lung field can be recognized with a tumor
diameter of about 1 cm on radiographs obtained in good conditions. Thus, we should also work to achieve ahigh goal of diagnosing lung cancers as early as possible from plain radiography.

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To achieve this goal, physicians with specialized knowledge must double check the radiographic images
with correct positioning, in addition to ensuring that such images are of high quality, and they must confirm
and describe changes, such as an increase or decrease in shadows via image comparisons if previous
images are available. An accuracy management system supported by such technical and systematic
improvement must be established.

Review of FY2002 Guideline
This manual aimed to revise the previous “Guidelines for Assessment of Health Screening Results and Post
Hoc Instruction”6 published in FY2002.

Terms of the sites (Table 1-1)
“Diaphragmatic area of the lung” is added as pleural plaques were observed in the diaphragmatic area ofthe lung. Because the images were obtained while the individual was in posteroanterior and lateralpositions during health screenings and the findings in the “lateral view” may be described, the term “lateralview” is added to the terms of sites, and a schema of the lateral view is used as reference for interpretation.
“V. Extrapulmonary findings” is moved to the right field and indicated as “9. Extrapulmonary findings.”
Although there was a dispute of whether to omit the “apical area” and integrate it into the “upper lung field”
in light of the description mode of CT scan findings, we concluded that the “apical area” would be left onchest radiography because tuberculosis often occurs in this site and it has a historical significance.

Terms of findings (Table 2)
The previous items were changed in terms of their categories, terminological issues, frequency of use,overlaps between Findings field and Disease term field, and need for the addition of new items.

1) Items moved to another category
Three items in [Airway lesions], namely, “bulla or cystic shadows,” “enhanced transparency in the lungfield,” and “pulmonary hyperinflation,” were moved to [Intrapulmonary lesions] to improve consistency.

2) Changes in literal items“Isolated nodular shadow” → “Nodular shadow:” to be simpler and more versatile. Used for shadows ≤3
cm in size.
“Round shadow” → “Tumor shadow” to contrast with and supplement nodular shadow“Cavitary shadow” → “Cavity shadow:” simplified term (in Japanese)“Localized infiltrative shadow” → “Infiltrative shadow”“Linear/thick linear shadows” → Divided into “linear shadow” and “thick linear shadow”“Shadow of cured inflammation” → “Scar shadow”“Silhouette sign” → Written in Japanese characters“Dilatation of pulmonary arterial trunk” → “Pulmonary arterial dilatation:” for versatility“Abnormal pulmonary vascular shadow” → “Abnormal pulmonary vascular route:” scimitar syndrome,
pulmonary arteriovenous fistula, pulmonary sequestration, etc.

3“Bulla or cystic shadow” → “Cystic shadow (bulla)”“Round back/scoliosis” → Divided into “scoliosis” and “round back”“Pacemaker device” → “Medical devices”: pacemaker, ICD (Implantable Cardioverter Defibrillators), and
CRT-D (Cardiac Resynchronization Therapy)3) Deleted items“Diffuse reticular shadows”“Enhanced transparency in the lung field” was deleted because it is challenging to recognize on digital
images.
“Tumor shadow in the thoracic wall” was deleted from [Thorax/thoracic wall lesions] because it isextremely rare.

4) Additional items“Reticular shadows,” “decreasing pulmonary vascular shadows,” “pleural plaque,” “esophageal hiatus
hernia,” “spinal compression fracture,” and “stenting” were added. [Hilar diseases] are newly defined andincluded “hilar lymphadenopathy” and “pulmonary arterial dilatation.” “Lymph node calcification” wasadded to [Others].

5) Items moved from Disease term field“Inverted organs” were corrected as “visceral inversion” and moved to the Findings field.
“Post-breast operation” was moved from the Disease term field to [Postoperative change]. It corresponds tototal/partial mastectomy.

Disease terms (Table 3)
Similar to the Findings field, the previous items were changed in terms of their categories, terminologicalissues, frequency of use, overlaps between the Findings field and Disease term field, and need for the
addition of new items.

1) Items moved to the Findings field
As described in 2) E), “inverted organs” were corrected as “visceral inversion” and were moved to theFindings field. “Post-breast operation” and “postoperative change” were moved to the Findings field to[Postoperative changes] for integration.

2) Changes in literal items“Lung benign tumor” → “Benign lung tumor”“Interstitial pneumonia (pulmonary fibrosis)” →“Interstitial pneumonia/pulmonary fibrosis”:

morphologic findings regardless of the cause.
“Pneumoconiosis” → “Pneumoconiosis (e.g., asbestosis and silicosis)”43) Deleted items“Round back/scoliosis,” “funnel chest,” “azygos lobe,” “right aortic arch,” and “dextrocardia” were deleted
because they overlap with the items in the Findings field.
“Cardiac hypertrophy” and “valvular heart diseases” were deleted because they cannot be assessed on chest
radiogram. An enlarged medical finding was described as “enlarged cardinal shadow.”

4) Additional items“Nontuberculous mycobacteriosis” and “pulmonary aspergillosis”: both were added below “pulmonary
tuberculosis.”“Pleural mesothelioma” was added to [Pleural lesion].

5) Items that were considered for addition“Pulmonary edema” described in the International Classification of Diseases, Tenth Revision (ICD-10) is
not indicated as an item, and similar findings will be classified as “cardiac failure.”

Parallel description of disease terms along with the terms of findings
In the health screening phase, it is usually challenging to obtain a definite diagnosis from abnormal findings
detected during screening. Therefore, disease terms are not often used as radiographic findings in the healthscreening phase. However, if a suspected pathological condition requires an immediate thoroughexamination or treatment, such as pulmonary tuberculosis, lung abscess, and lung cancer with “cavitary
shadow” or acute pneumonia with “infiltrative shadow,” diseases terms may be described along withfindings, such as “suspected cavitary shadow/pulmonary tuberculosis” to encourage a client to undergo athorough examination.
Findings/disease terms should be presented in a manner that the clients will understand. However, in suchcases, the use of disease terms will likely cause anxiety. For example, the use of the term “lung cancer”
should be considered prudently. In addition, one should consider selecting a disease term to be presented
that corresponds to the obtained finding, which includes disease terms, such as pulmonary tuberculosis/old
inflammation/lung cancer for a nodular shadow. Thus, the client will not experience extreme anxiety.
Presenting multiple suspected disease terms for one finding should be avoided.
For coordination with blood test data, infiltrative shadow on a radiographic image along with advanced
CRP (C-reactive protein) value is likely to indicate pneumonia. However, whether blood test data can be
immediately obtained while interpreting radiographic images differs according to the system in each
institution, and it is challenging to unify. However, clinical symptoms must be considered, and blood test
data should be assessed if available when making assessments.
Although disease terms could be matched with ICD codes, health screening can only present suspecteddisease terms, and real-time diagnosis cannot be made in many cases.

Assessment categories
Characteristics of the assessment categories

For assessment categories, the status of diagnosis and treatment may differ according to the timing of

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medical checkup even for the same finding with the same disease term particularly in repeaters. In a newpatient or a patient with a newly developed finding, it seems to be relatively easy to unify assessment
categories. Even in a new patient, it is likely that the category may be selected taking into consideration thefindings, clinical symptoms, blood test data, and policy of the institution. For example, if “pneumonia” issuspected, the result could be “D2,” which indicates the need for thorough examination and treatment, “D1,”which requires direct treatment, or “D,” which includes both intentions. Thus, it is unrealistic to define
uniform assessment categories.
For other items, extremely mild “scoliosis” is often encountered in routine clinical practice, and it may bebetter than the abovementioned criterion, which is the condition considered as the finding. The School
Health Act defines the criterion for scoliosis as ≥15º of lateral curvature of the spine, and a criterion ≥20º
may be used in adults. In addition, “enlarged cardiac shadow” is generally diagnosed when the
cardiothoracic ratio of an individual is ≥50%. However, the website of Disability Pension Hot Line showsthat the Recipient Qualification for Disability Pension includes individuals “older than 20 years” and thosewith “CTR ≥60%.” However, the Recipient Qualification is comprehensively assessed based on activities
of daily living and other test results. Findings that include “D2” should be selected based on acomprehensive consideration.
“Diaphragmatic elevation” may be initiated due to the accumulation of visceral fat, and disease category
correlated to lifestyle improvement can be considered.
Introduction of risk factors

In view of how to reflect the disease categories to secondary disease prevention, the risk factor should be
actively introduced to assessment categories. In clients with pulmonary diseases with high incidence ofcomplication due to lung cancer, such as pulmonary cyst (bulla), chronic obstructive pulmonary disease(COPD), interstitial pneumonia, etc., resulting to need for chest CT scan may be useful for the early
detection of lung cancer, which can be detected with low-dose CT scan. The concurrent use of chest CT
scan with information collected via medical interview, such as smoking, medical, occupational, and family
history, is also useful.
In low-dose CT scan for the screening of lung cancer, findings, such as COPD, have a strong impact onpatients; therefore, they are considered more receptive to the recommendation of smoking secession thanrecommendation provided in usual health screening, with the expectation of secondary prevention bysmoking secession.
It would be expected in the future that the introduction of risk factors into the assessment categories would
have a favorable effect on the secondary prevention of lung cancer.
If the number of COPD cases continuously increases, then there will be a problem regarding on how to deal
with the additional steps in the workflow of assessment. However, as the health screening system is usednationwide, the different medical interview data will be ready for use while interpreting chest radiographs
in the future, thereby resolving the current problems.

Conclusion
Based on the abovementioned discussions, the manual has been revised with amendments in the sites of

6findings, terms of findings, disease terms, and assessment categories.
1. Sites of findings
The basic structure was not changed with the addition of “lateral side” and “diaphragmatic area of the lung”
in the table. A schema of the lateral view has been prepared as a reference for interpretation.
2. Terms of findings/disease terms
Based on the board discussion, some terms have been revised/added, and deletion has been proposed. Some
categories have been revised/moved, which include cystic shadow, and some terms have been moved fromthe Disease term field to the Findings field.
3. Assessment categories
For assessment categories, the status of diagnosis and treatment may differ according to the timing of
medical checkup even for the same finding with the same disease term particularly in repeaters. Even in a
new client or a client with a newly developed finding, it is likely that the category may be selectedconsidering the findings, clinical symptoms, blood test data, policy of the institution, etc.; thus, it seems
unrealistic to narrow down to a specific assessment category.
4. Introduction of risk factors to assessment categories
Although positive opinions were presented in the board discussion, for the introduction, whether the healthscreening systems facilitate the identification of requirements, such as smoking habits, medical history,
occupational history, family history, etc. on the site during interpretation of radiograms is quite important.
Considering the future status, health screening systems with such features can be used nationwide.
As a reference, the literature included in “pulmonary complications” in the Diagnosis and Treatment
Guideline for COPD version 4 2013 that was edited by the Japanese Respiratory Society and listed at theend of the current document.

References 1
1) Okamoto N, Suzuki T, Hasegawa H, et al: Evaluation of a clinic-based screening programme for lungcancer with a case-control design in Kanagawa, Japan. Lung Cancer 1999; 23: 77-85.
2) Sagawa M, Tsubono Y, Saito Y, et al: A case-control study for evaluating the efficacy of mass screening
program for lung cancer in Miyagi Prefecture, Japan．Cancer 2001; 92: 588-594.
3) Tsukada H, Kurita Y, Yokoyama A, et al: An evaluation of screening for lung cancer in Niigata Prefecture
Japan: A population-based case-control study. Br J Cancer 2001; 85: 1326-1331.
4) Nishii K, Ueoka H, Kiura K, et al: A case-control study of lung cancer screening in Okayama Prefecture,
Japan．Lung Cancer 2001; 34:325-332.
5) Nakayama T, Baba T, Suzuki T, et al: An evaluation of chest X-ray screening for lung cancer in Gumma
Prefecture, Japan: a population-based case-control study. Eur J Cancer 2002; 38:1380-1387.
6) 2002 Guidelines for health check-up instruction
http://www.ningen-dock.jp/wp/common/data/other/release/N_Gaido2004.11.pdf [2013.09.30]
7) Hirotaka Takizawa: Fact-finding report on chest CT screening at members of the Japan Society of Ningen
Dock. Ningen Dock 2009;24:657-664.

78) Hirotaka Takizawa, Hitoshi Sasamori, Masayuki Hatakeyama, Yuichiro Maruyama, Fact-finding reporton chest CT screening at members of the Japan Society of Ningen Dock. Ningen Dock 2011; 25:
778-787.
9) The National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, Black WC, Clapp
JD et al.:Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. N Engl J
Med 2011;365:395-409.
10) Clinical and pathological lung cancer handling protocol．Japan Lang Cancer Society，Seventh edition.
201011) Suzuki M, Yoshida S, Tamura H, et al: Applicability of the revised International Association for the
Study of Lung Cancer staging system to operable non-small-cell lung cancers. Eur J Cardio-thorac Surg
2009; 36:1031-1036.
12) Sone S, Li F, Yang Z, et al: Results of three-year mass screening programme for lung cancer using
mobile low-dose spiral computed tomography scanner. Br J Cancer 2001; 84:25-32.
13) Sobue T, Moriyama N, Kaneko M et al: Low-dose heIical computed tomography: Anti-Lung Cancer
Association Project. J Clin Oncol 2002; 20:911-920.
14) Nawa T, Nakagawa T, Kusano S et al: Lung cancer screening using low-dose spira CT: results ofbaseline and 1-year follow-up studies. Chest 2002; 122:15-20.
15) Henschke CI, Naidich DP, Yankelevitz DF et al: Early lung cancer action project: initial findings fromrepeated screening. Cancer 2001; 92:153-159.

References 2Japanese Respiratory Society: "Guidelines for COPD (chronic obstructive pulmonary disease)diagnosis and treatment In Fourth Edition 2013 "I-H-2. lung cancerl) Chatila WM, Thomashow BM, Minai OA, et al: Comorbidities in chronic obstructive pulmonary disease.
Proc Am Thorac Soc 2008; 5: 549-55.
2) Sin DD．Anthonisen NR．Soriano JB et al: Mortality in COPD: Role of comorbidities. Eur RespirJ 2006;
28: 1245-1257.
3) Hackshaw AK, Law MR, Wald NJ: The accumulated evidence on lung cancer and environmental
tobacco smoke. BMJ 1997; 315: 980-988.
4) de Torres JP, Bastarrika G, Wisnivesky JP, et al: Assessing the relationship between lung cancer risk andemphysema detected on low-dose CT of the chest．Chest 2007; 132: 1932-1938.
5) Wilson DO, Weissfeld JL, Balkan A, et al: Association of radiographic emphysema and airflow
obstruction with lung cancer. Am J Respir Crit Care Med 2008; 178: 738-744.
6) Zulueta JJ, Wisnivesky JP, Henschke CI, et al: Emphysema scores predict death from COPD and lungcancer. Chest 2012; 141: 1216-1223.
7) Wasswa-Kintu S, Gan WQ, Man SF, et al: Relationship between reduced forced expiratory volume inone second and the risk of lung cancer. A systematic review and meta-analysis. Thorax 2005; 60:
570-575.

88) El-Zein RA, Young RP, Hopkins RJ, et al: Genetic predisposition to chronic obstructive pulmonary
disease and/or lung cancer: important considerations when evaluating risk. Cancer Prev Res（Phila）2012;
5:522-527.
9) Adcock IM, Caramori G, Barnes PJ: Chronic obstructive pulmonary disease and lung cancer: newmolecular insights. Respiration 2011; 81: 265-84.
10）de Torres JP, Marin JM, Casanova C, et al: Lung cancer in patients with chronic obstructive pulmonary
disease--incidence and predicting factors. Am J Respir Crit Care Med 2011; 184: 913-919.
I-H-2. Pulmonary fibrosis associated with emphysema
1) Cottin V, Nunes H, Brillet PY, et al: Combined pulmonary fibrosis and emphysema: a distinct
underrecognised entity. Eur RespirJ 2005; 26: 586-593.
2) Washko GR, Hunninghake GM, Fernandez IE, et al: Lung volumes and emphysema in smokers withinterstitial lung abnormalities. N Engl J Med 2011; 364: 897-906.
3) Kawabata Y, Hoshi E, Murai K, et al: Smoking-related changes in the background lung of specimens
resected for lung cancer: a semiquantitative study with correlation to postoperative course.
Histopathology 2008; 53:707-714.
4) Katzenstein AL, Mukhopadhyay S, Zanardi C, et al: Clinically occult interstitial fibrosis in smokers:
Classification and significance of a surprlsingly common finding ln lobectomy specimens. Hum Patho1
2010; 41: 316-322.

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Table 1 Description of the results
Table 1-1 Site of the findings
I Right

1. Apical area

II Left

2. Upper lung field

III Bilateral

3. Middle lung field

IV Lateral (newly added)

4. Lower lung field
5. Whole lung field
6. Hilar area
7. Mediastinal area
8. Diaphragmatic area of the lung (new)
9. Extrapulmonary area

Table 1-2 Definition of the assessment category
A

NormalB

Mild abnormality

C

Need for follow-up (specify the retest period)

D

Need for medical care

D1

Need for treatment

D2

Need for a thorough examination

E

Under treatment

Table 1-3 Description of interpretation/assessment
Site of findings

Findings

Diagnosis/suspected diseasea. Suspectedb. Definite
a. Suspectedb. Definite
a. Suspectedb. Definite

Assessment Category

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Table 2 Findings
Findings

Category[Intrapulmonary lesions]
Nodular shadow

D2

Tumor shadow

D2

Cavitary shadow

D2

Infiltrative shadow

D2

Linear shadow

B

Thick linear shadow

C, D2

Scar shadow

B

Calcification shadow

B

Atelectasis

D2

Silhouette sign

D2

Increased markings

B, C

Abnormal vascular route

B, D2

Decreasing pulmonary vascular shadow

B, D2Multiple nodular shadows

D2

Patchy shadow

D2

Granular shadows

D2

Reticular shadows

D2

Multiple annular shadows

D2

Cystic shadow (bulla)C, D2

Pulmonary hyperinflation

D2[Hilar diseases]
Hilar lymphadenopathy

D2

Pulmonary arterial dilatation

C, D2[Airway lesions]
Tracheostenosis

D2

Tracheal deviation

D2

Bronchial wall thickening

C, D2

Bronchiectasis

C, D2[Mediastinal lesions]Mediastinal tumor shadow

D2Mediastinal enlargement

D2Mediastinal lymphadenopathy

D2Mediastinal emphysema

D2Mediastinal calcification

B

Esophageal hiatus hernia

B, C

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[Pleural lesions]
Pleural effusion

D2

Pneumothorax

D2

Pleural tumor shadow

D2

Pleural thickening

B

Pleural adhesion

B

Pleural calcification

B, D2

Pleural plaqueD2[Diaphragmatic lesions]
Diaphragmatic hernia

D2

Diaphragmatic elevation

B

Diaphragmatic tumor shadow

D2[Rib lesions]
Rib tumor shadow

D2

Broken rib shadow

D2

Rib bone sclerosis

B

Rib bone island

B

Rib fracture/post-rib fracture

B

Rib malformation/deformity

B[Thorax/chest wall lesions]
Scoliosis

B

Round backB

Funnel chest

B

Osteoarthritis of the spine

B

Spinal compression fracture

C, D2

Thoracic deformity

B

Clavicle fracture/post-clavicle fracture

B

Abnormal clavicle shadow

C, D2[Cardiac/large vascular lesions]
Enlarged cardiac shadow

C, D2

Aortic dilatation

D2

Aortic arch protrusion

B

Aortic tortuosity

B

Aortic calcification shadow

B[Congenital lesions]
Azygos lobe

B

Right aortic arch

B

Dextrocardia

B13
Visceral inversion

B[Postoperative changes]
Post-thoracoplasty

B

Post-lobectomy/pneumonectmy

B

Post-pneumothorax

B

Post-sternal splitting incision

B

Postoperative change

B

Post-breast operation

B[Others]
Lymph node calcification

B

Foreign body

B, C

Remaining contrast medium

B

Medical devices

B

Stenting

B

Shunt tube

B

No abnormal findings

A

Table 3 Disease term
Disease term

Category[Intrapulmonary lesions]
Pneumonia

D2, D1

Pulmonary suppuration

D2, D1

Pulmonary tuberculosis

D2, D1

Nontuberculous mycobacteriosis

D2, D1

Pulmonary aspergillosis

D2, D1

Pulmonary tumor

D2, D1

Metastatic pulmonary tumor

D2, D1

Benign lung tumor

B

Interstitial pneumonia/pulmonary fibrosis

D2, D1

Pneumoconiosis (e.g., asbestosis and silicosis)

D2, D1

Sarcoidosis

D2, D1

Old pulmonary tuberculosis

C

Old lung lesion

B

Pulmonary emphysema

C, D2

Pulmonary cystic disease

C, D2[Airway lesions]
Chronic bronchitis

D2, D1

Diffuse panbronchiolitis

D2, D1

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Bronchiectasis

D2, D1

Middle lobe syndrome

D2, D1[Mediastinal lesions]Mediastinal tumor

D2Mediastinal emphysema

D2[Pleural lesions]
Pleurisy (pleural effusion)

D2

Pneumothorax

D2

Pleural tumor

D2Prior pleurisyBC

Pleural mesothelioma

D2, D1[Diaphragmatic lesions]
Diaphragmatic eventration

B

Diaphragmatic tumor

D2[Rib lesion]
Rib tumor

D2[Thorax/chest wall lesion]
Chest wall tumor

D2[Cardiovascular lesions]Aortic aneurysm

D2

ArteriosclerosisC

Cardiac failure

D2

Japan Society of Ningen Dock

Chest Radiography Screening Assessment Committee

Chief Commissioner

Hirotaka Takizawa (Kashiwado Memorial Foundation)

Members

Hitoshi Sasamori (Makita General Hospital)
Ikko Hashizume (Hamamatsu Medical Center)
Masayuki Hatakeyama (Nara City Medical Association)

External Evaluation Committee Members
Katsushi Kurosu (Chiba University Hospital)
April, 2014