Acceptable definition of peripheral early lung cancer

This study was conducted to evaluate the outcome of 88 patients who underwent surgical resection for peripheral non-small cell lung cancers less than 20 mm in diameter. Twenty-one cases with lesions smaller than 10 mm had no lymph node metastasis, intrapulmonary metastasis, pleural dissemination, or distant metastasis. The 5-year survival rate of them was 100%. However, 67 patients with tumors larger than 10 mm showed lymph node metastasis in 14 cases, intrapulmonary metastasis in 3, pleural dissemination in 2 and distant metastasis in 1. And the 5-year survival rates of patients with tumor dimensions of < or = 15 mm and < or = 20 mm were 77.9% and 74.4%, respectively. In addition, patients having adenocarcinoma categorized A and B by Noguchi's classification had no lymph node metastasis, intrapulmonary metastasis, pleural dissemination, or distant metastasis, and showed 100% of 5-year survival rate. To be defined as early cancers in terms of curability, it is thought that the 5-year survival rate of the patients with them is over 95%. Therefore, these results suggest that tumors smaller than 10 mm or adenocarcinoma less than 20 mm in diameter diagnosed as Noguchi's A and B are considered as peripheral early lung cancers.     

Can localization studies be used to direct focused parathyroid operations?

BACKGROUND: There is considerable controversy today concerning the most appropriate surgical approach for patients with primary hyperparathyroidism. The conventional surgical operation involves a bilateral neck exploration through a collar incision with identification of all parathyroid tissue and removal of abnormal parathyroid glands while the patient is under general anesthesia. The success rate of this operation is about 95% or greater in the hands of an experienced endocrine surgeon. Preoperative localization techniques are generally considered to be unnecessary before initial parathyroid operations. The purpose of this investigation was (1) to evaluate the individual and combined accuracy of ultrasonography and technetium 99m sestamibi scans in localizing abnormal parathyroid glands and (2) to determine whether such scans could be used to direct a focused operation. METHODS: We retrospectively studied 338 patients with sporadic primary hyperparathyroidism who had preoperative neck localization studies, ultrasonography and/or technetium 99m sestamibi scans, and parathyroid exploration (238 patients or, reexploration, 60 patients) from January 1996 to April 2000 at the University of California San Francisco/Mount Zion Medical Center. The preoperative localization studies were recorded as true-positive, false-positive, and false-negative and compared with the surgical and pathologic findings and with the outcome of the operation. RESULTS: All of the abnormal parathyroid glands were correctly identified by ultrasonography in 184 of 303 patients (60.7%) and by technetium 99m sestamibi scanning in 183 of 237 patients (77.2%). The sensitivities of ultrasonography and sestamibi were 65% and 80%, respectively. Among the 202 patients who received both ultrasonography and sestamibi scans, a parathyroid tumor was identified at the same site in 105 (52%) of them. When both techniques identified a parathyroid tumor at the same site, the tests were correct in 101 of 105 patients and the sensitivity increased to 96%. CONCLUSIONS: When both the ultrasonography and sestamibi scans identified the same, solitary parathyroid tumor in patients with sporadic primary hyperparathyroidism, this was the only abnormal parathyroid gland in 96% of the patients. A focused parathyroidectomy could therefore be performed in such patients with an acceptable ( approximately 95%) success rate.     

Pre-emptive renal transplantation in children

BACKGROUND: Renal transplantation is a definitive therapeutic modality in end-stage renal disease (ESRD). Most ESRD patients in Japan experience dialysis prior to renal transplantation. The present study was undertaken to examine the usefulness of pre-emptive renal transplantation (PET). METHODS: Between 1987 and 1998, 255 renal transplantations were carried out by the authors. Among those consecutive cases, 10 were cases of PET. In nine pediatric cases, demographics, graft and patient survival, height growth and benefits from successful transplantation were studied and compared with age-matched dialyzed transplantation controls. RESULTS: All transplantation was living-related. There was a disparity of causes of ESRD between the two groups. In PET, acquired renal deterioration due to a congenital lower urinary tract disorder was the major cause. Graft and patient prognosis was favorable in both groups. Growth retardation in PET patients under 15 years of age was significantly less apparent at the time of transplantation and after 3 years compared to the control. The benefits from transplantation were different in the two groups. Most PET patients felt an improvement of their physical condition; however, all of the control patients felt that the major boon was the freedom from the restriction of the daily diet and time for dialysis. CONCLUSION: In pediatric renal transplantation, short-term preceding dialysis does not have a detrimental effect, but PET could benefit ESRD patients by maintaining their quality of life. Moreover, PET minimizes the production of renal dwarfism in prepubertal children. Thus, PET should be taken into consideration in the choice of renal replacement therapy.     

Primary testicular plasmacytoma with hydrocele of the testis

A case of primary testicular plasmacytoma complicated with hydrocele of the testis is reported. An 86-year-old man presented with hydrocele of the right testis. High inguinal orchiectomy was performed as the preoperative aspiration cytology of the hydrocele fluid showed atypical cells. Immunohistochemical study of the right testis revealed testicular plasmacytoma positive for IgG. He remained well 9 months after the orchiectomy. This is the second reported case where the preoperative diagnosis of testicular plasmacytoma was made based on the hydrocele fluid cytology.     

A case of paroxysmal nocturnal hemoglobinuria combined with focal segmental glomerular sclerosis

A 81-year-old woman was admitted to our hospital because of edema and massive proteinuria on September 26, 1995. On admission, the palpebral conjuctiva were slightly anemic, and edema of the eyelids and legs was observed. Laboratory findings were as follows, urine protein(3+), occult blood(3+), WBC 2,600/microliter, Hgb 10.0 g/dl, reticulocytes 20@1000, TP 5.0 g/dl, Alb 2.7 g/dl, T-Cho 376 mg/dl, TG 194 mg/dl, LDH 763 U/l, haptoglobin < 93 mg/dl, Ham's test(+), sugar water test(+), and indirect coombs (+). The erythrocytes of this patient showed a negative population consisting of double negative erythrocytes evaluated by flow cytometric two-color analysis using monoclonal antibodies specific to CD55 and CD59. From these findings, the diagnosis of paroxysmal nocturnal hemoglobinuria(PNH) was made. The patient showed nephrotic syndrome and a renal biopsy was performed. The histological findings of renal biopsy showed focal and segmental sclerosis and adhesion of glomerular tufts. Interstitial fibrosis with atrophic tubules and lymphocyte infiltration were also observed. There was no specific staining of immunoglobulins and complement by immunofluorescence. The diagnosis of focal segmental glomerular sclerosis(FSGS) was made. There have been only three case reports of glomerular disease in patients with PNH, such as purpura nephritis, IgA nephropathy and membranous nephropathy. The complication of FSGS and PNH is every rare and there has been no report of FSGS in a case with PNH. The onset of PNH resulted from the loss of CD55 and CD59, which was critical in the onset of FSGS in the present case.     

Right ventricular dynamic cardiomyoplasty for the univentricular heart with pulmonary hypertension

OBJECTIVES: We conducted an acute experimental study to test the feasibility of dynamic cardiomyoplasty in a setting of modified Fontan procedure for univentricular heart with pulmonary hypertension to obtain a possible proxy for high-risk Fontan candidates. METHODS: After electrical preconditioning of the left latissimuss dorsi for 6 weeks in 8 dogs, the right ventricular cavity was totally obliterated with concomittent closure of the tricuspid valve and right pulmonary artery. Modified Fontan circulation was established with the aortic homograft anastomosed between the right atrium and pulmonary trunk, incorporated with a pericardial pouch as a compression chamber (neoright ventricle) fixed onto the epicardial surface of the ventricle. After cardiopulmonary bypass termination, a latissimus dorsi was applied to wrap the pericardial pouch and ventricle clockwise and stimulated with a trained-pulse (25 Hz) at 1:1 synchronization ratio with cardiac beats. RESULTS: Profound right heart failure was noted during Fontan circulation in increased pulmonary vascular resistance (11 +/- 3.2 Wood units), whereas graft pacing showed significant augmentation of systolic pulmonary pressure by 54 +/- 12%, the mean pulmonary flow by 68 +/- 23%, and aortic pressure by 23 +/- 5% at a physiological range of central venous pressure (13.2 +/- 0.7 mmHg). Right heart function curve analysis confirmed marked augmentation of right heart performance, restoring almost normal pulmonary circulation. These functional benefits were sustained up to 4 hours in 4 animals until experiments were terminated. CONCLUSIONS: Dynamic cardiomyoplasty in a modified Fontan procedure is a viable surgical option for univentricular heart, not a Fontan candidate.     

Significance of monitoring Bio-Intact PTH (1-84) during parathyroidectomy for secondary hyperparathyroidism

BACKGROUND: The Bio-Intact PTH (1-84) assay has recently been developed to specifically measure the intact PTH (1-84) molecule, and in this study we used it to investigate sequential changes in serum Bio-Intact PTH (1-84) levels during parathyroidectomy for secondary HPT. MATERIAL AND METHODS: The subjects of this study were 70 patients (41 women, 29 men) who underwent parathyroidectomy between April 2002 and March 2005. Ethylene diamine tetraacetic acid serum samples were drawn via a peripheral venous catheter after induction of anesthesia (basal), and at 5, 10, and 30 min after diseased glands excision. Serum active PTH (1-84) was measured by the Bio-Intact PTH (1-84) assay, which is a two-site chemiluminometric assay. RESULTS: When 4 or more diseased parathyroid glands were removed, the basal of Bio-Intact PTH (1-84) level in patients without persistent HPT (52 cases) was 539 +/- 355 pg/mL. The level of the Bio-Intact PTH (1-84) at 30 min after sufficient parathyroidectomy had decreased to less than 45 pg/mL, whereas the Bio-Intact PTH (1-84) level in patients with persistent HPT at 30 min was greater than 45 pg/mL (3 cases). After removal of three or fewer diseased parathyroid glands (15 cases), the Bio-Intact PTH (1-84) at 30 min in patients without persistent HPT (13 cases) was less than 45 pg/mL. The 2 patients whose the Bio-Intact PTH (1-84) at 30 min was greater than 45 pg/mL underwent reoperation, and residual enlarged parathyroid gland in the neck was removed. CONCLUSIONS: The Bio-Intact PTH (1-84) level at 30 min after parathyroidectomy seems to be useful for judging whether the parathyroidectomy is complete irrespective of the number of glands removed from patients with secondary HPT. When only three diseased parathyroid glands are removed, the surgeon can decide whether to continue or stop neck exploration according to the level of Bio-Intact PTH (1-84) at 30 min.     

Complicated anesthetic management for esophageal atresia repair in a baby with total anomalous pulmonary venous connection diagnosed after esophageal surgery

A male newborn infant born at 38 weeks of gestation and weighing 2,660 g, was diagnosed as esophageal atresia. Although there was mild cyanosis at birth, his initial ultrasonographic examination performed by neonatologist showed normal anatomy of the heart. He underwent a surgical repair of esophageal atresia under general anesthesia. Anesthesia was induced with fentanyl and pancuronium, and maintained with sevoflurane and 60% oxygen. Frequent desaturation occurred during the procedure, requiring manual hyperventilation with 100% oxygen. Since blood pressure during the operation was unstable, volume loading with albumin was attempted. Further echocardiography was performed by pediatric cardiologist after going back to NICU. This revealed total anomalous pulmonary venous connection (TAPVC). He underwent cardiac surgery for repair of TAPVC on the next day. Although TAPVC was not preoperatively diagnosed regardless of results of echocardiogram, cyanosis and unstable blood pressure should be considered as signs of potential cardiac disease. Fluid restriction, higher hemoglobin, lower inspired oxygen and slightly higher carbon dioxide rather than albumin administration and hyperventilation should have been attempted during the esophageal repair.     

Informed consent for colorectal cancer surgery

There are two issues in informed consent for colorectal cancer surgery. One is the actual surgical technique. Recently intersphincteric resection (ISR) has been performed to avoid permanent colostomy, although it is not standard procedure. Regarding QOL score, Patients with colostomies do not necessarily have lower quality of life scores than patients who undergo sphincter-preserving surgery because of frequent bowel movements. Lateral lymphadenectomy for lower rectal cancer was standard procedure; however, its indications became limited due to urinary and sexual dysfunction. Preoperative radiotherapy is considered instead of lateral lymphadenectomy, as in the Western concept of the local recurrence of rectal cancer. Now laparoscopic surgery is accepted for stage I colon cancer according to the guidelines of the Japan Society for Cancer of the Colon and Rectum. The other issue is postoperative complications like anastomotic leakage, intestinal obstruction, etc. Frequent bowel movements and urinary and sexual dysfunction should also be explained before rectal cancer surgery.     

A Rare Case of Granular Cell Tumor of the Anal Region: Diagnostic Difficulty to Masses in the Anal Area

Granular cell tumor may be located anywhere in the body; however, the gastrointestinal tract is infrequently involved and anal granular cell tumors are extremely rare. We report herein a rare case of granular cell tumor in the anal region. In the current case, a 66-year-old Japanese woman was found to have a polypoid lesion in the anus with hemorrhoids. The mass detected as an anal polypoid lesion with ulceration was resected and diagnosed as granular cell tumor by histologic examination. Granular cell tumor of the anal region is rare, and benign perianal polypoid lesions are relatively uncommon clinical findings. They might present diagnostic challenges to surgeons and pathologists. Awareness of the differential diagnosis of granular cell tumor and careful microscopic examination might allow proper management and diagnosis.Key words: Granular cell tumor, Anal, Polypoid massGranular cell tumor is a relatively rare neoplasm that is firmly identified as a neural lesion due to its close association with nerves and its immunohistochemical characteristics.¹⁻⁵ Granular cell tumors may be located anywhere in the body; however, the gastrointestinal tract is infrequently involved and anal granular cell tumors are extremely rare.³⁻⁸ We report herein a rare case of granular cell tumor in the anal region. The concern with anal tumor is differential diagnosis, since benign mesenchymal anal tumors are relatively rare.^7,8 Thus, an anal polypoid lesion might present diagnostic challenges to surgeons and pathologists.