Possible Application of Microwave Coagulation Therapy for Recanalising Tumor-occluded Self-expandable Metallic Stents

Abstract: There is no consensus regarding optimal management of tumor ingrowth through self-expandable metallic stents in the biliary system. We investigated the possibility that microwave therapy could be used to treat stent occlusion. We evaluated the thermal properties of a muscle equivalent phantom subjected to microwave energy. The temperature of the phantom was continuously monitored using the probe sensor of a fiberoptic thermometer embedded into the phantom model at different distances from a microwave electrode with and without a stent in place. The temperature of the phantom increased incrementally as the power increased from 30 to 50 watts at distances 2 and 5 mm from the electrode (p<0.01). With the goal of achieving adequate local heating without excessive distant heating, the most effective power was 40 watts. There was a significantly lower rise in temperature with stent in place than that without stent at 2 and 5 mm from the electrode at 40 watts. The temperature increase when the tip of the electrode was kept in contact with the stent was significantly smaller than when the conductor tip was kept apart from the stent (p<0.05). Using this method, the microwave energy did not induce destruction of the stent filament. In a muscle equivalent phantom model, the temperature changes induced by microwave energy were consistent with possible safe and effective application of this modality to recanalization of occluded metallic stents. (Dig Endosc 1999; 11: 158–164)     

A case of obstructive sleep apnoea with anterior cervical osteophytes

Summary  Osteophytes of the cervical spine are usually seen in elderly adults. When prominent, they have been blamed for dysphagia, cough, dysphonia and dyspnoea. This paper reports on an obstructive sleep apnoea (OSA) patient with cervical spinal osteophytes, one cause of airway obstruction. A 75-year-old male complained of pronounced snoring. The diagnosis was mild OSA, apnoea hypopnoea index was 9·4. Patient reported no restrictions in neck movements, experiences of neck pain or neck trauma. Previously, patient underwent a tonsillectomy due to discomfort in the pharyngeal region. A lateral cephalometric image was taken to observe airway before oral appliance therapy. The image revealed the presence of large osteophytes or sclerotic enthesopathy, lying on anterior surfaces from the fourth to seventh cervical vertebrae. A computed tomography (CT) image revealed the relationship of airway position to the spine. In the reconstructed three-dimensional (3D) image, the airway appeared displaced to the right of the craniomandiblar bone, with the hyoid bone similarly displaced in a manner to that of the airway. The spine also appeared displaced to the left side ofcraniomandiblar bone. Additionally, the 3D image revealed calcification of the stylohyoideum ligament and ligamentum nuchae. This present case highlights the necessity of CT examination for OSA patients. There were several ligament calcifications in the head and neck region. Cervical spine osteophytes, as a component of Forestier's or cervical spine disease, have been associated with dysphagia and dysphonia. It was reported that bilateral vocal cord paralysis was caused by osteophytes compressing the post-cricoid area of larynx.     

Severe autoimmune hemolytic anemia associated with IgM warm auto‐antibodies in primary Sjögren’s syndrome

Primary Sjögren’s syndrome is an autoimmune disorder involving mainly salivary and lachrymal glands. However, many extraglandular symptoms have also been reported. Although leucocytopenia and lymphocytopenia are frequently observed in hematological disorders, autoimmune hemolytic anemia is rarely reported. We experienced a case of primary Sjögren’s syndrome developing severe autoimmune hemolytic anemia. The patient’s red blood cells showed spontaneous agglutination in saline at room temperature, and immunoglobulin M (IgM) was detected on the surface of red blood cells by flow cytometry, indicating that autoimmune hemolytic anemia was caused by warm reactive IgM antibodies. Immediate corticosteroid therapy resulted in a dramatic recovery. We report a first case of severe autoimmune hemolytic anemia caused by warm reactive IgM antibodies in primary Sjögren’s syndrome.     

Papuloerythroderma associated with monoclonal gammopathy of undetermined significance

We describe a 73-year-old Japanese man with papuloerythroderma overlapped with monoclonal gammopathy of undetermined significance (MGUS). Clinically, prominent erythroderma was associated with disseminated pruriginous papules, which were characteristically spared on the axillary and inguinal regions, the cubital and popliteal fossae as well as abdominal and small positional folds. Histopathologically, there was a significant perivascular infiltrate of lymphohistiocytic cells intermingled with eosinophils in the upper dermis. A biochemical profile revealed the presence of immunoglobulin G κ chain type monoclonal protein in the serum but the absence of hematological neoplasms. We diagnosed the patient as papuloerythroderma with MGUS, and treated him with narrow-band ultraviolet B and topical steroid. His skin changes were improved, but the sharp γ-globulin peak remained in the electrophoresis of serum protein. This case suggests an association between papuloerythroderma and MGUS.     

Analysis of the circumstances of death of 56 children suffering from cancer: Proposal for the development of terminal medicine in Japan

In Japan terminal medicine for children dying from cancer has not yet been developed nor has a support system for home terminal care and bereaved families been established. We have analyzed our own experiences in these areas and researched the possibilities of establishing support systems. In the 16 years from 1978 to 1993, 56 children with cancer have been treated and have died at Hamamatsu University Hospital. We analyzed the circumstances of their deaths. We interviewed 25 sets of parents about their acceptance of their child's death. Three children (5%) died unexpectedly during treatment, 27 children (48%) died from the side-effects of intensive treatment, and 26 children (47%) died during terminal care. More children with leukemia and lymphoma died from side-effects than children with solid tumors (P < 0.05). Six out of the 25 families had not yet accepted the loss of their child due to regrets associated with the missed opportunity for terminal care. From our experiences with the five children who received terminal care at home, we recognize the need for a support system run by the hospital and conclude the time is ripe for initiating home-based terminal care in Japan.     

An Inflammatory Polyp of the Sigmoid Colon Observed in a Case with a Ruptured Ovarian Dermoid Cyst

We present here a rare case, an ovarian dermoid cyst with fistulaformation into the sigmoid colon, which forms an inflammatorypolyp of the sigmoid colon. A 58-year-old woman was admitted because of occasional analbleeding. Several examination disclosed the elevation of erythrocytesedimentation rate, a positive test of stool specimen for occultblood, a polyp of the sigmoid colon in barium enema. Laparotomyshowed that a dermoid cyst of the left ovary had ruptured intothe sigmoid. The etiology of the rupture was "idiopathic." Thefistulous communication between the cyst and the sigmoid colonwas thought to have developed the inflammatory polyp over aperiod of about two years.     

Usefulness of contrast-enhanced ultrasound for the diagnosis of recurrent renal cell carcinoma in contralateral kidney

We studied contrast-enhanced ultrasound (CEU) for recurrence of renal cell carcinoma (RCC) at the contralateral kidney during postoperative follow up of localized renal cell carcinoma. CEU successfully detected all recurring cases, despite the fact that 5/6 cases were observed using conventional ultrasound; the remaining one case was not detected using conventional ultrasound. CEU using Levovisto successfully revealed renal tumors as RCC. Lesions were diagnosed as cystic renal tumors by Bosniac classification, and pathological findings demonstrated RCC, in accordance with the prior tumor.     

Blood concentrations of polymorphonuclear leucocyte elastase and interleukin-6 are indicators for the occurrence of multiple organ failures at the early stage of acute pancreatitis

We studied potential indicators of severe acute pancreatitis by measuring the blood concentrations of various cytokines, polymorphonuclear leucocyte elastase (PMN-E), acute phase reactants, pancreatic amylase (P-AMY), pancreatic elastase-1 (E-1) and white blood cell (WBC) counts in patients with acute pancreatitis. In addition, the presence of multiple organ damage was assessed. Subjects consisted of 22 patients with acute pancreatitis including severe (n= 11), moderate (n= 4) and mild (n= 7) cases. A significant positive correlation was observed between the number of organs damaged and the peak concentrations of interleukin (IL)-6, PMN-E, C-reactive protein (CRP) and pancreatic secretory trypsin inhibitor (PSTI). Among these markers, blood concentrations of PMN-E and IL-6 rapidly increased and peaked at the early phase of acute pancreatitis whereas CRP and PSTI did not. The elevation of PMN-E and IL-6 was greater the more severe the symptoms. However, no significant correlation was observed between the number of organs damaged and the maximum serum concentrations of P-AMY and E-1, or the WBC count, which have been considered to be markers of pancreatitis. These results suggest that PMN-E and IL-6 concentrations are useful indicators of severity and prognosis and their determination facilitates the selection of appropriate treatment in the early stages of disease to prevent the aggressive progression of acute pancreatitis.