Right lung cancer with right aortic arch

An abnormal shadow was detected on chest X-ray mass screening in an asymptomatic 63-year-old man. The further examinations revealed the shadow to be primary lung cancer (Rt. S6. adenocarcinoma, cT2N0M0, c-stage IB) with right aortic arch. We used 3 dimentional-computed tomography (3D-CT) to assess an anatomical feature of vessels in detail. The right lower lobectomy and the dissection of medi astinal lymph nodes was performed. We confirmed no abnormal anatomy of pulmonary artery and vein at surgery, and it was possible to perform right lower lobectomy with the common procedure. Since lymph node was found by intraopetrative pathological examination, since no metastasis from interlobar to subcarinal lymph node was found, we did not perform dissection of upper mediastinal dissection, which was equivalent to ND2a lymph nodes dissection of the left lung cancer in General Rule for Clinical and Pathological Record of Lung Cancer. The patient with right aortic arch is known to have variant anatomy of other intrathoracic vessels occasionally. 3D-CT was quite useful in assessing anatomical feature, and enabled us to perform safe operation.     

Idiopathic retroperitoneal fibrosis diagnosed by CT-guided needle biopsy: a case report

A 72-year-old man was admitted to another hospital because of general fatigue and dyspnea secondary to renal insufficiency. Abdominal computed tomography (CT) and magnetic resonance imaging showed left atrophic kidney, right hydronephrosis, and an intra-pelvic mass of soft-tissue density located anterior to the sacrum, involving the right ureter at the level between the 5th lumber vertebra and the sacrum. He was referred to our hospital after percutaneous nephrostomy was constructed into right kidney. CT-guided needle biopsy revealed the idiopathic retroperitoneal fibrosis, leading us to give him steroid therapy. Three weeks later, radiographic findings showed a remarkable reduction of the mass and the improvement of the right ureteral stricture.     

Lymphoepithelial Cyst of the Pancreas: Report of a Case

A lymphoepithelial cyst (LEC) is an extremely rare benign lesion of the pancreas. During a medical check-up, a 77-year-old man without any symptoms was found to have a cyst in the body of the pancreas. His serum carbohydrate antigen 19-9 level was slightly elevated. Computed tomography showed a multilocular, low-attenuating cyst on the superior surface of the pancreatic body. Thus, we performed distal pancreatectomy with splenectomy. Histological examination revealed that the cyst wall was lined with squamous epithelium and surrounded by abundant mature lymphoid tissue. Keratinous substances were present in the cyst. An LEC of the pancreas is associated with a good prognosis and, although unusual, it should be considered in the differential diagnosis of pancreatic cystic lesions. Minimal resection of the cyst should be performed whenever possible, and extensive surgery avoided. For patients with a high surgical risk, fine-needle aspiration biopsy may be considered.     

Evaluation of peripheral facial nerve palsy with R 2 wave latency in blink reflex]

Electrically elicited blink reflexes were investigated in 60 patients with peripheral facial nerve palsy. The purpose of this study was to evaluate the utility of analysis of R 2 wave in blink reflex as a prognostic indicator for the patients with facial palsy. The patients treated by stellate ganglion block were classified into three groups: Group I scored more than 90 points (full score is 100 points) within 2 weeks, Group II scored more than 90 points over 2 weeks, and Group III scored less than 90 points. The examinations were performed at the first visit, and 2, 4, 6 weeks after the onset of facial palsy. Latencies of ipsilateral and contralateral R 2 wave were measured by electrical stimulation on both side. There were significant differences of R 2 latency between ipsilateral and contralateral side in each of the three groups at the first visit. In Group II, contralateral R 2 latency obtained by stimulation of the paralytic side was prolonged significantly. In Group III, the ipsilateral R 2 wave was not observed. The results of this study indicate that measurement of the R 2 latency of blink reflex is useful in judging the severity of the peripheral facial nerve palsy. The R 2 latencies obtained by stimulation of ipsilateral and contralateral side should be used as one of the parameters for evaluation of the prognosis of patients with peripheral facial nerve palsy.     

The original hole-in-one guide for atlantoaxial transarticular screw fixation

Atlantoaxial fusion by transarticular screw fixation provides firm fixation, and good results have been reported. However, there are also problems, such as injury of the vertebral artery at the time of screw insertion. For accurate facet fusion, we developed a new hole-in-one guide for screw fixation and obtained good results with its use. In 60 adult subjects, we measured the antero-posterior and transverse axes and determined the center of the atlantoaxial surface and the insertion point of the screw in three dimensions on computed tomography scans. Based on these values, we measured the optimum screw insertion angle on sagittal and coronal planes, and the distance between the center and the posterior margin of the joint surface; our new hole-in-one guide was produced with these data. When the guide tip is determined to be located at the center posterior margin of the axial joint surface, and the guidewire insertion point is determined to be located at the center of the axial inferior facet immediately above the C2/3 joint, the guidewire is passed through the axial pedicle and the center of the atlantoaxial joint. Since April 1997, we have used this hole-in-one guide technique in eight patients with atlantoaxial instability. The screws passed the pars interarticularis and the center of the atlantoaxial joint in all patients with safety and accuracy. No complications associated with this technique occurred. Received: December 24, 1999 / Accepted: August 25, 2000     

Intrahepatic cholangiojejunostomy for unresectable malignant biliary tumors with obstructive jaundice

We reviewed our experience with intrahepatic cholangiojejunostomy as a palliative therapy for patients with unresectable malignant diseases involving the ductal confluence or the common hepatic duct. Fifteen patients with malignant biliary obstruction were treated by cholangiojejunostomy at our hospital. Two patients had intrahepatic cholangiocarcinoma, 7 had gallbladder carcinoma, 5 had bile duct carcionoma, and 1 had pancreatic carcinoma. Segment III cholangiojejunostomies were performed in 14 patients and segment V cholangiojejunostomy in 1. Contraindications for surgical resection were locoregional invasion of tumors involving the proper and/or common hepatic artery and portal vein in 15 patients and the presence of hepatic metastases in 6 patients. Liver metastases were detected in 5 of the 7 patients with gallbladder carcinoma. Postoperative complications occurred in 2 patients (13%), but there was no leakage of the cholangioenteric anastomosis in our series. There was no operative mortality after cholangiojejunostomy. Of the 9 patients who survived for more than 6 months after surgery, 7 showed a significant improvement in performance status (PS) (82 ± 10%) 3 months after the surgery compared with the preoperative PS (70 ± 7%). Four of the 9 patients had recurrent cholangitis as a late complication, but 4 were completely free from jaundice. Median survival after cholangioenteric bypass was 9 months (range, 2–25 months). With respect to tumor location, the median survival time was 4 months (range, 2–25 months) in patients with gallbladder carcinoma and 15.5 months (range, 12–22 months) in those with bile duct carcinoma. While the median survival period after surgery was only 3 months (range, 2 to 8 months) in the 5 patients with hepatic metastases from gallbladder carcinoma, 2 patients without liver metastasis survived for 9 and 25 months after segment III cholangioenteric bypass. In conclusion, cholangiojejunostomy can provide useful palliation for malignant biliary obstruction when combined with careful patient selection. Received: September 5, 2000 / Accepted: November 8, 2000     

Successful rescue and maintenance of long-term remission of anti-HLA antibody-mediated acute allograft rejection by rituximab-containing therapy: case report

Abstract:  A 38-yr-old man with chronic renal failure received a second kidney transplantation from a cadaveric donor. Complement-dependent cytotoxicity cross-match (CDC) was negative against T cells, but positive with the B-cell warm test. Human leukocyte antigen (HLA)-typing showed a one haplo-identical match. The blood type was compatible. He was treated with tacrolimus, mycophenolate mofetil (MMF), methylpredonisolone (MP), and basiliximab as immunosuppressive therapy. A clinical episode graft biopsy and Flow-PRA on post-operative day (POD) 19 showed anti-HLA antibody-mediated acute rejection (AHR). The patient was treated with plasmapheresis (PP). Renal biopsy performed on POD 65 because of re-rise of serum creatinine level showed worsening of renal injury. The patient was treated with rituximab (100 mg/body) with PP and MP pulse therapy, followed by tacrolimus and MMF. Graft function thereafter improved. A renal allograft biopsy specimen on POD 300 and Flow-PRA showed the remission of AHR within one-yr after transplantation.     

Blood eosinophilia as a marker of favorable outcome after allogeneic stem cell transplantation

Eosinophilia is observed in a variety of disorders including acute and chronic graft-versus-host disease (GVHD). The clinical records of 237 patients who underwent allogeneic stem cell transplantation (allo-SCT) were retrospectively reviewed. Eosinophilia, defined as a relative eosinophil count>4% within the first 100 days, was observed in 135 patients (57%). The incidence of grades II-IV acute GVHD was significantly higher in patients without eosinophilia than in those with eosinophilia (68% vs. 43%; P<0.001). The incidence of chronic GVHD was significantly higher in patients without eosinophilia than in those with eosinophilia (73% vs. 56%; P=0.011). Relapse rate was similar between patients with and without eosinophilia (33% vs. 27%; P=0.438). The probability of nonrelapse mortality was 10% in patients with eosinophilia, which was significantly lower than that in patients without eosinophilia (31%; P<0.001), and the overall survival (OS) at 3 years was 67% in patients with eosinophilia, which was significantly higher than that in patients without eosinophilia (51%; P=0.003). Multivariate analysis identified older age, high-risk disease, acute GVHD, sex disparity between patient and donor, and the absence of eosinophilia as significant factors for reduced OS. These data lead us to conclude that eosinophilia after allo-SCT may serve as a favorable prognostic marker.     

Significance of Ductal Margin Status in Patients Undergoing Surgical Resection for Extrahepatic Cholangiocarcinoma

OBJECTIVES: The objective of this study was to determine whether carcinoma in situ at the bile duct margin is prognostically different from residual invasive carcinoma in patients with extrahepatic cholangiocarcinoma. Although there are many reports that the ductal margin status at bile duct resection stumps is a prognostic indicator in patients with extrahepatic cholangiocarcinoma, some patients who undergo resection with microscopic tumor involvement of the bile duct margin survive longer than expected. METHODS: A retrospective clinicopathological analysis of 128 patients who had undergone surgical resection for extrahepatic cholangiocarcinoma was conducted. The status of the bile duct resection margin was classified as negative in 105 patients (82.0%), positive for carcinoma in situ in 12 patients (9.4%), and positive for invasive carcinoma in 11 patients (8.6%). RESULTS: Ductal margin status was an independent prognostic indicator by both univariate (p = 0.0022) and multivariate (p = 0.0105) analyses, along with lymph node metastasis. There was no significant difference between patients with a negative ductal margin and those with a positive ductal margin with carcinoma in situ (p = 0.5247). The 5-year survival rate of patients with a positive ductal margin with carcinoma in situ (22.2%) was significantly better (p = 0.0241) than with invasive carcinoma (0%). There was a significant relationship between local recurrence and ductal margin status (p = 0.0401). CONCLUSIONS: Among patients undergoing surgical resection for extrahepatic cholangiocarcinoma, invasive carcinoma at the ductal resection margins appears to have a significant relation to local recurrence and also a significant negative impact on survival, whereas residual carcinoma in situ does not. Discrimination whether carcinoma in situ or invasive carcinoma is present is important in clinical setting in which the resection margin at the ductal stump is positive.     

Preoperative parameters, including percent of positive biopsy cores, in predicting pathological findings after radical prostatectomy

OBJECTIVES: We investigated whether preoperative parameters predict pathological stage at radical prostatectomy for patients with clinically localized prostatic cancer. MATERIALS AND METHODS: We studied a total of 160 men with clinically localized prostatic cancer (less than or equal to clinical T2) who underwent radical rertropubic prostatectomy at Wakayama Medical University. Clinical Ts patients are not included in this study. Preoperative parameters include patient age, Body Mass Index, preoperative serum PSA value, biopsy Gleason score, clinical stage, the percent of positive biopsy cores (%PosBx) and the percent of positive biopsy cores on the dominant side (%DomPosBx). Univariate and multivariate analysis were performed to examine the prognostic significance of these preoperative parameters. Significant independent factors were combined to create a table to predict pathologically organ confined disease. RESULTS: Univariate analysis showed preoperative serum PSA value (p< 0.001), biopsy Gleason score (p =0.001), clinical stage (p = 0.026), %PosBx (p= 0.002) and %DomPosBx (p=0.003) were significantly related to the pathological stage. On multivariate analysis, serum PSA value (p< 0.01), biopsy Gleason score (p<0.05) and %DomPosBx (p<0.05) were significant independent predictors of pathological stage. CONCLUSION: We provide two model combinations using preoperative clinical factors, one is a combination of serum PSA and biopsy Gleason score and the other is a combination of serum PSA and %DomPosBx, which define a new preoperative model for predicting pathological organ confined prostatic cancer. These combinations are useful and provide important information for urologists to determine the appropriate treatment strategy for clinically localized prostatic cancer.