Transhiatal esophagectomy for carcinoma of the esophagus--our ten years experience

During the past 10 years, at University Surgical Clinic Rijeka, 107 patients underwent operation for carcinoma of the esophagus and cardia. Transhiatal esophagectomy was performed in 29 patients; in 28 of them an esophagogastrostomy was performed, and in one patient a pharingogastrostomy. Of the 29 patients, there were 24 men (82.8 %) and 5 women (17.2 %), with an average age of 60.7 years. Histologically, 26 lesions (89.7 %) were squamous cell carcinomas, and 3 (10.3 %) were adenocarcinomas. According to the prognostic stage as defined by the UICC, 15 patients (51.7 %) were stage II A, and 14 (48.3 %) stage III. The lesion was located in the cervical esophagus in two, the thoracic esophagus in thirteen and the lower esophagus in fourteen patients. Six patients died, for a hospital mortality rate of 20.7 %; the most common cause of death was respiratory failure. Pulmonary complications occurred in 14 patients (48.3 %). Anastomotic leak with all clinical manifestations occurred in one patient, while in two patients the radiological diagnosis of anastomotic leakage was made without clinical manifestations. Five patients (17.2 %) developed anastomotic stenosis, which was satisfactory treated by endoscopic dilatation. Mean survival after surgery was 21 months. One-year survival was 65.5 %, two and three-year survival was 37.9 and 17.2 % respectively. Younger patients and patients with lower stage of disease survived significantly longer (p < 0.05).     

A resected case under thoracoscopic surgery of bilateral pulmonary metastases of renal cell carcinoma ten years after radical nephrectomy]

A 68-year-old male had received a left nephrectomy for renal cell carcinoma of the clear cell type in October, 1987. He had been given Interferon alpha (IFN alpha) for one year since then. He was referred to our hospital for bilateral abnormal shadows on the chest roentgenogram in December, 1997. He underwent a video-assisted thoracoscopic biopsy of bilateral lung in January, 1998, 11 years after his nephrectomy. The resected specimens contained a coin lesions measuring approximately 2 cm in diameter, and the lesions were microscopically diagnosed as a renal cell carcinoma of the clear cell type metastatic to the lung. The patient is doing well with no signs of re-recurrence five months after the resection of the metastatic lesion.     

Pharmacotherapies for renal cell carcinoma in Japan

The standard treatment for advanced renal cell carcinoma has changed dramatically in the past decade, from cytokine therapy to targeted therapy. Since sorafenib was approved in April 2008, four tyrosine kinase inhibitors and two mammalian target of rapamycin inhibitors have become available in Japan. Most Japanese renal cell carcinoma patients are treated by urologists who are involved in not only kidney surgeries, but also targeted therapy using tyrosine kinase inhibitors, as well as mammalian target of rapamycin inhibitors. Optimal treatment methods are selected from theoretically‐based global recommendations, such as the National Comprehensive Cancer Network and European Society for Medical Oncology guidelines; however, real‐world clinical practice might be different from that in non‐Asian countries. This might be because of different practical conditions; for example, different adverse events and efficacy profiles, different healthcare system, and so on. In the present review, we examine current pharmacotherapy for renal cell carcinoma from evidence‐based global data, and compare the reality of Japanese clinical practice to explore the importance of individualized patient therapy.     

Incidence of adrenal metastasis from renal carcinoma]

We analysed the cases of renal carcinoma undergoing operation or autopsy from 1970 to 1978 in respect of their metastasizing to the adrenals. Of the 31 cases undergoing autopsy 10 adrenal metastases were found mostly as a result of a widespread metastasis. Of the operated 74 patients 37 underwent nephrectomy alone and 37 nephrectomy together with prophylactic adrenalectomy. The histologic evaluation of the 37 removed adrenals revealed metastases only in 4 cases. Only one of them proved to be a single metastasis, the other occurring together with other metastatic lesions. The value of the adrenalectomy will be discussed.     

Incidental renal cell carcinoma]

We reviewed the cases of incidental renal cell carcinoma that had been treated at the Kitasato University Hospital between July, 1971 and December, 1989. Forty one of the 170 (24.1%) cases were found without any direct signs of renal cell carcinoma. The patients were between 30 and 78 years old (mean 55.0 years) and consisted of 29 males and 12 females. Fifteen cases were detected at the general health check-up and the remaining 26 during the postoperative follow-up for other malignant tumors or other diseases. Twenty three cases were identified by ultrasonography followed by computed tomography (CT) and excretory pyelography in 4 cases each. Especially, the number of patients incidentally found by ultrasonography had increased in the recent 8 years. Urinalysis did not show any microhematuria in 31 of the 37 cases (83.7%), and no tumor mass could be detected by excretory pyelography in 3 cases. We believe that ultrasonography may be valuable as a screening modality for early detection of renal cell carcinoma and should be used as a screening method at the routine health check-up.     

Incidence and early prognosis of aneurysmal subarachnoid hemorrhage in Kumamoto Prefecture, Japan

OBJECTIVE: We analyzed the community incidence and early prognosis of first-ever aneurysmal subarachnoid hemorrhages (SAHs) to obtain the same prognostic information used by physicians and families in a defined geographic area in Japan. METHODS: During the 5-year period from January 1, 1996, to December 31, 2000, 2115 patients were registered in the Data Bank for Cerebral Aneurysms of Kumamoto Prefecture, a defined area in Japan with a population of 1.86 million. Registration was based on a comprehensive referral system for SAH patients; computed tomographic scans were available for all patients, including those who were moribund or dead on arrival. We compared the treatment outcomes at 3 months after the first-ever SAH in surgically and conservatively treated patients. RESULTS: The age-adjusted annual incidence of SAH for men, women, and both sexes was 15.9, 26.6, and 21.6 per 100,000 person-years, respectively. In men, the incidence reached a plateau after age 40 years. In women, conversely, it rose after age 40 and peaked in the 9th decade of life. Of the 1634 surgically treated patients, 1153 (70.6%) had a favorable outcome; this was true for only 27 of 477 (5.7%) conservatively treated patients. Four patients were lost to follow-up. The clinical outcome did not differ between patients treated by open surgery and those treated endovascularly. Approximately 30% of our patients were older than 70 years at the time they experienced their first SAH. CONCLUSION: The incidence of SAH obtained in this study was similar to earlier Japanese reports and Finnish studies. The importance of managing elderly patients with cerebral aneurysms will continue to increase.     

Clinical experience of autologous blood transfusion in patients undergoing nephrectomy with renal cell carcinoma]

We studied the possibility of performing radical nephrectomy with only predeposit autologous blood transfusion in the treatment of patients with renal cell carcinoma. A total of 15 patients who ranged in age from 32 to 69 years and had a hemoglobin concentration of over 12 g/dl on admission underwent radical nephrectomy with preoperative autologous blood donation. Five patients did not need transfusions. Seven patients were transfused only autologous blood. The other 3 required some homologous blood in addition to their own banked blood. In our series, patients were able to donate 600 ml of blood during the last week before surgery and their hemoglobin concentration did not decrease by over 2 g/dl except in the case of two patients with advanced disease. Therefore, it was concluded that an adequate autologous blood volume for nephrectomy was 600 ml and that 80% of renal cell carcinoma surgery could be performed without homologous blood transfusion. For patients requiring resection of renal cell carcinoma, autologous transfusion is recommended as safe and convenient.     

Papillary renal cell carcinoma six years after renal cystectomy.

A papillary renal cell carcinoma developed in this patient in the same position that six years previously had undergone unroofing of a benign cyst. The discussion includes a brief review of the relationship between renal cyst and carcinoma.     

Prevalence of renal cell carcinoma: A nation-wide survey in Japan, 2002

OBJECTIVE: To investigate the incidence of renal cell carcinoma, classified by sex, age group and region in Japan, following a 5-year interval after a previous survey performed in 1997. METHODS: The survey was conducted between the beginning of January 2002 and the end of December 2002. A total of 1288 institutions in all 47 prefectures throughout Japan were requested to register cases. RESULTS: There were 7405 persons with renal cell carcinoma, consisting of 5063 males and 2342 females. Crude incidence rates were 8.2 and 3.6 per 100 000 population for men and women, respectively. Incidence rates in the Hokkaido region were highest followed by the Shikoku region. CONCLUSIONS: Despite incidence of renal cell carcinoma increasing to 7405 from the 6358 persons in 1997, statistical data reported by the Ministry of Health, Labor and Welfare indicate that rising age-adjusted death rate for this tumor reached a ceiling in the past decade. Early detection may have contributed to this current trend; however, further epidemiological research is required to fully elucidate this.     

Incidence, predictors and associated outcomes of renal cell carcinoma in long-term dialysis patients

We carried out an analysis of the United States Renal Data System to determine the incidence, risk factors and prognosis of renal cell carcinoma (RCC) in a national population of patients receiving incident long-term dialysis. In Cox regression, male gender, older age, end-stage renal disease caused by obstruction, tuberous sclerosis, focal segmental glomerulosclerosis, as well as acquired renal cysts, were independently associated with RCC. Most cases of RCC in incident long-term dialysis patients occurred in patients without acquired renal cysts. A diagnosis of RCC was associated with increased risk of subsequent mortality overall and in all high-risk groups.     

Nephron sparing surgery for renal cell carcinoma with normal contralateral kidney: 25 years of experience

PURPOSE: We report the long-term results of our consecutive series of 504 patients who underwent NSS for cancer suspicious, solid renal tumors in the presence of a normal opposite kidney at our institution since 1979. MATERIALS AND METHODS: A total of 715 patients underwent NSS since 1969, including 504 for an elective indication, that is with a normal opposite kidney. Of these patients 381 (75.6%) had RCC, 123 (24.4%) had cancer suspicious benign lesions, including 53 (10.5%) with oncocytoma, 33 (6.5%) with angiomyo(lipo)ma, 23 (4.6%) with a complicated cyst and 13 (2.8%) with other benign lesions. Of the 381 patients with RCC 283 (74.3%) had clear cell, 68 (17.8%) had papillary and 30 (7.9%) had chromophobic RCC. Mean tumor diameter was 3.0 cm (range 0.5 to 11.0). Mean followup was 6.77 years (range 0.2 to 24.1). The oncological outcome was studied, including pathological features associated with tumor progression. RESULTS: Estimated cancer specific survival rates at 5 and 10 years were 98.5% and 96.7%, respectively. Estimated survival rates free of distant metastasis at 5 and 10 years were 97.5% and 95.1%, respectively. Nine patients with localized RCC experienced local recurrence after NSS. Estimated survival rates free of local recurrence at 5 and 10 years were 98.3% and 95.7%, respectively. CONCLUSIONS: The long-term results of our series support the concept of organ sparing surgery for RCC in the presence of a normal opposite kidney with excellent long-term survival and a low tumor recurrence rate.     

Incidence of Urogenital Cancers in Gunma Prefecture, Japan: A 10-Year Summary

Background : Although the incidence of urogenital cancers in Japan is lower than that of other cancers, it is increasing steadily. Thus, an epidemiologic study was necessary to determine the measures that would decrease the mortality rate associated with these cancers.
Methods : The subjects were 4759 patients with urogenital cancer who were living in Gunma Prefecture and who were newly diagnosed between 1985 and 1994. The data were analyzed by year and by patients' ages. The incidence rates of each disease were expressed as the number of cases per 100,000/year, and age-adjusted rates were adjusted to the world population.
Results : The number of males and females afflicted by urogenital cancers increased over the 10-year period. The increase in age-adjusted incidence rates was sharpest for prostate, renal cell, and testicular cancers among males, and for renal cell, renal pelvic and ureter cancers among females. When age-specific rates were plotted against age on double logarithmic scales, the cancers were classified as type 1 (linear), type 2 (linear until a certain age, then flattening out or decreasing), or type 3 (irregular) based on the slope of the line. The magnitude of increase in the age-specific incidence rates of type 1 cancers with age was on the order of the 12th power for prostate cancer and the 5th power for bladder cancer. When the 10 years were divided into 2 periods (earlier and later), the age-specific incidence rates of prostate and renal cell cancers increased in all age groups, whereas the age-specific incidence rates of cancers that increased less sharply remained stable or even declined in some age groups.
Conclusion : These epidemiologic data should be useful in reducing the mortality rates associated with these cancers.     

Incidence and outcome of osteoporotic fractures in 2004 in Sado City,Niigata Prefecture,Japan

Osteoporotic fracture in elderly populations is increasing worldwide, but there are few data on the incidence and outcome of osteoporotic fractures, including upper extremity and vertebral fracture, during a certain period in a defined geographic area. The purpose of this study was to determine the incidence of osteoporotic fractures in a particular area: Sado City, Niigata Prefecture, Japan. From January to December 2004, osteoporotic fractures of the vertebra, hip, distal radius, and proximal humerus in Sado City were recorded. The incidence, age, gender, type of fracture (for hip fracture), right or left side (for distal radius, proximal humerus, and hip fracture), place of injury, cause of injury, outcome, hospitalization period, and patient status regarding taking of drugs for osteoporosis treatment were checked for each fracture. The incidence was calculated based on the whole population of Sado City. The incidence per 100,000 population was 232.8, 121.4, 108.6, and 37.1 for fractures of the vertebra, hip, distal radius, and proximal humerus, respectively. The total incidence of these four kinds of fracture was 499.9 per 100,000 persons per year. The average age at the time of injury was 81.4, 77.7, 75.7, and 60.2 years old for fractures of the hip, vertebra, proximal humerus, and distal radius, respectively. As the average age increased, the percentage of fractures that occurred indoors also increased; that is, a higher percentage of hip fractures occurred indoors, followed by fractures of the vertebra, proximal humerus, and distal radius. Most patients were not taking anti-osteoporosis drugs before fractures of the hip or vertebra. We determined the incidence of major osteoporotic fractures in 1 year in a defined geographic area. Our data showed that 81% of hip fracture patients also had a vertebral fracture and that the average age at the time of injury was higher for hip fractures than for vertebral fractures. Therefore, these results suggest that vertebral fracture leads to hip fracture, indicating that early fracture prevention and continuous prevention strategies through positive treatment are of importance in osteoporotic elderly people.     

Purulent pericarditis in childhood: ten years of experience

Background/Purpose: Purulent pericarditis is a rapidly fatal disease if left untreated. This article describes our experience with diagnosis and management of 18 patients seen over a 10-year period. Methods: Eighteen children with purulent pericarditis were treated in our clinics between 1990 and 2000. Ten patients were boys and 8 were girls, and the mean age of all patients was 4 years (range, 8 months to 12 years). Results: Most common findings were fever and cardiac tamponade. Staphylococcus aureus was the most common causative agent, and the most common predisposing factor was respiratory tract infection. Chest radiography and echocardiography were the most important methods for diagnosis, and pericardiosynthesis was diagnostic in purulent pericarditis. The treatment methods performed in our patients were subxiphoidal pericardial tube (10 patients), pericardiectomy after subxiphoidal pericardial tube (2 patients), pericardiectomy (3 patients), and pericardiocentesis-intrapericardial thrombolytic treatment (3 patients). Only one patient (5.5%) died who was critically ill at the time of admission. Conclusions: Subxiphoidal tube drainage and pericardiectomy were performed with good results in these cases. Intrapericardial streptokinase and pericardial aspiration method also was thought to be beneficial. J Pediatr Surg 37:1404-1408.     

A survey on incidental renal cell carcinoma in Japan.

A survey of renal cell carcinoma detected incidentally (incidental renal cancer) in 116 collaborating institutions was conducted nationwide in Japan between 1980 and 1988. The analysis of 1,428 cases demonstrated a dramatic increase in the frequency of incidental renal cancer from 20 cases in 1980 to 338 cases in 1988. Detection occurred at routine health examinations in 32.8% of the cases and during examinations for unrelated diseases in the remainder. The chief method of detection was ultrasonography (68.2%), followed by computerized tomography (21.8%) and excretory urography (6.4%). Tumor extension was within the renal capsule in 76.5% of the cases and the mean tumor diameter was 5.4 cm. The 5-year survival rate was 76.5% but it was better in cases detected by ultrasonography compared with other methods. These results were compatible with previous reports and suggest that incidental renal cancer detection may improve the prognosis of renal cancer as a whole.     

Decennial trends in hip fractures over 20 years in Yamagata Prefecture,Japan

BackgroundHip fracture is among the most common injuries in elderly people. We aimed to investigate the decennial trends in hip fractures in patients ≥65 years of age.MethodsA questionnaire was distributed to all hospitals with a Department of Orthopaedic Surgery in Yamagata Prefecture to collect data on hip fractures occurring in 1996, 2006 and 2016.ResultsThe response rate was 100%. The total numbers of hip fractures in 1996, 2006 and 2016 were 665, 1169 and 1,728, respectively (crude incidence: 258, 373 and 494 per 100,000 person-year, respectively). Injuries frequently occurred in the early morning and daytime morning in 1996. In contrast, they frequently occurred in activity times (e.g., morning and afternoon) in 2006 and 2016. Among the patients, 80–90% were injured by simple falls, and 70–80% were injured indoors. The incidence of trochanteric fractures was approximately 1.8–1.9 times greater than incidence of neck fractures in all years. Especially, trochanteric fractures in females of ≥90 years of age markedly increased. The rate of surgical treatment was the same in 1996 and 2006, but was lower in 2016. In 1996, the percentage of independent walkers at discharge and 1 year later was almost the same. In 2006 and 2016, the rate of independent walkers was low at discharge, but increased 1 year later. The rate of discharge to home decreased gradually. The combined percentage of patients discharged to home and to rehabilitation institutions in 2006 and the percentage of patients who entered the regional referral clinical pathway in 2016 were both approximately 70%, with no marked changes observed.ConclusionsHip fractures, especially trochanteric fractures in super-aged females, increased. Discharge to home decreased, and the use of the regional referral clinical pathway was widespread. Ambulation ability was reduced at discharge, but improved after 1 year.