Hepatocellular carcinoma with peritoneal dissemination which was regressed during vitamin K2 and vitamin E administration

A 65-year-old man with positive anti-hepatitis C antibody and chronic renal failure was diagnosed as having a ruptured hepatocellular carcinoma (HCC) based on computed tomography (CT). The patient underwent transcatheter arterial embolization (TAE) for the HCC. After one more session of TAE, the patient underwent surgery. But HCC seeding peritoneally was pointed out. Vitamin K2 and vitamin E were administered as a conservative treatment. Six months after starting vitamins K2 and E, the primary tumor did not increase in size and intraperitoneal dissemination disappeared on CT with a significant decrease of alpha-fetoprotein. Even though this is only one case, combination therapy of vitamin K2 and E may induce growth suppression of HCC.     

Osler-Weber-Rendu disease with esophageal varices and hepatic nodular change

A 72-year-old male visited our hospital for further evaluation of esophageal varices. Telangiectasias were present in the stomach. He had recurrent epistaxis, which was also confirmed in his family's medical history. We diagnosed this case as Osler-Weber-Rendu disease. He had concomitant with hepatic nodular change. Abdominal angiography showed arterio-portal (A-P) shunts, superior mesenteric artery (SMA)-superior mesenteric vein (SMV) shunt, extension of SMV, and dilated and meandering portal vein. Esophageal varices were treated by endoscopic variceral ligation (EVL) and argon plasma coagulation (APC) therapy for prophylaxis of bleeding.     

Hyperplastic nodular hepatic lesions following end-to-side portacaval shunting in childhood

We describe a 48-year-old man with nodular intrahepatic lesions accompanied by communication between the inferior vena cava and portal systems as well as absence of intrahepatic portal veins. After infection with malaria in childhood, end-to-side portacaval shunting had been performed to treat upper gastrointestinal bleeding at the age of 15 years. A biopsy specimen obtained under ultrasonographic guidance showed hyperplastic nodules suggestive of focal nodular hyperplasia. The estradiol concentration in the blood was elevated (55 pg/ml). This case suggests that portacaval shunting may be associated with hyperplastic liver nodules through hyperestrogenemia and abnormal hepatic hemodynamics.     

Therapy with Bortezomib plus Dexamethasone Induces Osteoblast Activation in Responsive Patients with Multiple Myeloma

Bortezomib is a novel proteasome inhibitor that has shown marked antitumor effects in patients with multiple myeloma (MM). We evaluated the feasibility and efficacy of bortezomib plus dexamethasone (BD) therapy and assessed bone metabolism in relapsed or refractory MM. Fourteen patients received 1.3 mg/m2 bortezomib on days 1, 4, 8, and 11 along with 20 mg/dose of dexamethasone on days 1, 2, 4, 5, 8, 9, 11, and 12 in a 21-day cycle. After 1 to 3 cycles of BD therapy, 9 patients (64%) achieved an objective response (5 very good partial responses and 4 partial responses). Notably, a rapid increase in the serum concentration of alkaline phosphatase (ALP) was observed in 6 of the treatment-responsive patients. Moreover, serum levels of bone-formation markers (bone-specific ALP and osteocalcin) significantly increased in 5 and 2 responsive patients, respectively. Radiographic examination showed improvement in bone lesions, suggesting that BD therapy induces osteoblast activation in responders. Adverse events included thrombocytopenia of grades 1 to 3, peripheral neuropathy of grades 1 to 2, and grade 3 ileus and were transient and manageable. Although severe lung injury has been reported among Japanese patients treated with bortezomib, no pulmonary complications were observed during BD therapy. Our results suggest that BD therapy is a safe and promising therapeutic approach for Japanese patients with MM.     

Renal cell carcinoma with malignant pleural mesothelioma after asbestos exposure: a case report

A 66-year-old man visited complaining of cough and sore throat. He had been exposed to asbestos 43 years ago. Chest X-ray revealed left pleural effusion and abnormal shadow in the right lung field. Chest computed tomography (CT) showed multiple enhanced nodules in the right pleural cavity. Abdominal CT showed a 3-cm enhanced tumor in the lower pole of the left kidney. Left radical nephrectomy was performed. Pathological diagnosis was renal cell carcinoma. Postoperatively pleural biopsy was performed by using thoracoscopy. White plaque was seen at the costal pleura and surface of lung. Pathological diagnosis was malignant pleural mesothelioma based on using mesothelium-associated antibodies: calretinin (+), CK5/6 (+), D2-40 (+), HBME-1 (+), TTF-1 (-), MOC31 (-), CEA (-). Combination therapy (extrapleural pneumonectomy, chemotherapy, and radiotherapy) was initiated. Malignant mesothelioma is a devastating neoplasm with a strong etiological relationship with asbestos exposure. The incidence is rising in industrialized countries, with the peak expected in the year 2020. However, renal cell carcinoma with malignant pleural mesothelioma is very rare and this is the 2nd case in the Japanese literature.     

Ureteral avulsion: a rare complication of ureteroscopy

A case of ureteral avulsion as a complication of ureteroscopy is presented. A 55-year-old woman was admitted to the hospital with the complaint of hematuria. The intravenous pyelography revealed a calculus measuring 16 x 12 mm located in the left upper ureter. Transurethral ureterolithotripsy was performed with 8 F rigid ureteroscopy. A safety guide wire was inserted and left ureteral olifice was dilated to 9 F. The ureteroscopy was smoothly introduced just under the stone. The stone was fragmentated with a pneumatic lithotripter. A part of the stone was pushed back to the renal pelvis, so the ureteroscope was passed to that stone and fragmentation was done as much as possible. The ureteroscopy was gently pulled out to the bladder, but the distal ureter was torn at the ureteral orifice and could be seen at the urethral orifice. Pelvis, upper ureter and middle ureter were intact, so open intervention for repair was not performed. A 6Fr double pigtail stent was placed over the safety guidewire. Cystscopy indicated a part of the distal ureter was protruded from the ureteral orifice. Eight weeks later, the protruded part of ureter was necrotic and calcified for ischemia. Transurethral resection of necrotic ureter was performed. Histologically, resected ureter changed necrotic tissue for ischema. Postoperatively intravenous pyelography did not reveal left hydronephrosis and cystoscopy indicated that the left ureteral orifice was almost normally repaired.     

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.     

Long-term prognosis of incidental renal cell carcinoma--clinical analysis of renal cell carcinoma detected by our health checkup

PURPOSE: We retrospectively evaluated the characteristics and long-term prognosis of incidentally detected renal cell carcinoma by health checkup. MATERIALS AND METHODS: From January 1987 to December 2005, 556 patients were treated for renal cell carcinoma in our department. Among them, 56 patients were detected by abdominal ultrasonography in health checkup of our health care center. We reevaluated the pathological stage according to 2002 TNM classification and tumor type of renal cell carcinoma according to 2004 World Health Organization histological classification. Survival analysis was determined by Kaplan-Meier's method and log-rank test. RESULTS: Of the patients, 50 were male and 6 were female. The age of the patients ranged 37 to 68 years old at diagnosis (median 54 years). The tumors were located in the right kidney in 22 patients and in the left kidney in 34. Pathologically T1a tumors were found in 40 patients (71%), T1b in 13 (23%), T2 in 2 (4%) and T3b in 1 patients (2%). One case of T3b had N2 and M1 disease. The followup time after the operation ranged 3 to 215 months (median 121 months). Seven patients died of renal cell carcinoma. One of the 7 patients in T1a disease died at 64 months, 4 in T1b at 47, 91, 119, 163 months, 1 in T2 at 39 months and 1 in T3b at 13 months, postoperatively. The cause specific 10-year survival rate was 97% for T1a disease and 57% for T1b (p < 0.01), respectively. CONCLUSION: Most of renal cell carcinomas were T1a disease, which were detected incidentally by health checkup. The cause specific survival rate was significantly higher for T1a disease than for T1b. Our data suggested that early detection was important for good prognosis. The abdominal ultrasonography was only method for detection in routine health checkup and should be broadly implemented.