Case of tuberculous epididymitis caused by intravesical BCG therapy

Intravesical Bacillus Calmette-Guerin (BCG) therapy is commonly used against superficial urothelial carcinoma, especially carcinoma in situ (CIS). We report a case of tuberculous epididymitis that occurred during a course of intravesical BCG therapy. A 76-year-old man had received intravesical BCG therapy for multiple superficial bladder cancer and CIS in prostatic urethra after transurethral resection of bladder tumor (TUR-Bt). He recognized hard nodules in the left scrotum after 4 times intravesical BCG therapy. Skin fistula in scrotum occurred 5 months later. We performed left orchiectomy with scrotum skin resection. Histological diagnosis was tuberculous epididymitis. Postoperatively, he was administered chemotherapy consisting of isoniazid, refampin and ethambutol.     

Differential regulation of lubricin/superficial zone protein by transforming growth factor beta/bone morphogenetic protein superfamily members in articular chondrocytes and synoviocytes

OBJECTIVE: To investigate the role of transforming growth factor beta (TGFbeta)/bone morphogenetic protein (BMP) superfamily members on accumulation of superficial zone protein (SZP) in articular chondrocytes and synoviocytes. METHODS: Chondrocytes and synoviocytes were isolated from articular cartilage and synovium from calf stifle joints and cultured as monolayers in serum-free chemically defined medium. Articular chondrocytes were isolated from 3 distinct zones of the cartilage: superficial, middle, and deep. Accumulation of SZP in the culture medium in response to various members of the TGFbeta/BMP superfamily was demonstrated by immunoblotting and quantified by enzyme-linked immunosorbent assay. RESULTS: TGFbeta stimulated SZP accumulation in both superficial zone chondrocytes and synoviocytes. The 3 isoforms of TGFbeta elicited a similar dose response. Inhibition of TGFbeta receptor type I kinase by the specific inhibitor SB431542 abolished the TGFbeta-stimulated accumulation of SZP. BMPs up-regulated SZP accumulation in the superficial zone; however, the magnitude of the effects was not as great as was observed with TGFbeta. There was an additive action between TGFbeta and BMP on SZP accumulation. The response of synoviocytes to BMP was stronger than that of superficial zone chondrocytes. Activin up-regulated SZP accumulation in synoviocytes, but not in chondrocytes. CONCLUSION: TGFbeta is a critical regulator of SZP accumulation in both superficial zone articular chondrocytes and synoviocytes. TGFbeta and BMP have an additive effect. Synoviocytes are more sensitive to BMP family members and activins than are superficial zone articular chondrocytes. Thus, regulation of SZP accumulation by TGFbeta /BMP superfamily members is regulated differently in articular chondrocytes and synoviocytes.     

Diagnosis of rectal varices via color Doppler ultrasonography

OBJECTIVES: There has been no report on the hemodynamic evaluation of rectal varices by percutaneous color Doppler ultrasonography. Here, we report the usefulness of color Doppler ultrasonography for this purpose. METHODS: Color Doppler ultrasonography was performed in 44 patients: 31 patients with portal hypertension, 7 with liver cirrhosis (LC) without portal hypertension, and 6 non-LC patients. We examined color flow images and measured velocity of blood flow in rectal varices using fast-Fourier transform (FFT) analysis. Next, we performed colonoscopy on these 44 patients as follow-up to confirm findings by color Doppler. Endoscopic findings of rectal varices were evaluated according to the grading system outlined in "The General Rules for Recording Endoscopic Findings of Esophageal Varices" prepared by the Japanese Research Committee on Portal Hypertension. RESULTS: Rectal varices were shown by Doppler color flow images in 27 of the 31 patients (87.1%) with portal hypertension. Blood flow velocity in those 27 rectal varices ranged from 2.0 to 11.6 cm/s (mean 6.5 +/- 2.4 cm/s). Rectal varices were observed in all 27 of these cases by colonoscopy. On the other hand, rectal varices were not observed by colonoscopy in the 7 LC patients without portal hypertension and the 6 non-LC patients not shown to have rectal variceal blood flow via color Doppler ultrasonography. Sensitivity, specificity, and accuracy were 27/27 (100%), 17/17 (100%), 44/44 (100%), respectively, for detection of rectal varices with color Doppler ultrasonography. Next, we compared velocities of rectal varices obtained by color Doppler ultrasonography with colonoscopic findings. Mean velocity (7.1 +/- 2.3 cm/s) in Cb variceal cases (N = 20) was significantly higher than that (4.9 +/- 1.7 cm/s) in the Cw rectal variceal cases (N = 7) (P < 0.05). Mean velocity (8.5 +/- 2.0 cm/s) in the RC-positive cases (N = 9) was significantly higher than that (5.4 +/- 1.8 cm/s) in RC-negative cases (N = 18) (P < 0.01). Mean velocity (9.8 +/- 1.6 cm/s) in rectal bleeding cases (N = 3) was significantly higher than that (6.1 +/- 2.1 cm/s) in patients without bleeding (N = 24) (P < 0.05). Seven days after endoscopic injection sclerotherapy (EIS) treatment, color Doppler ultrasonography showed an extreme decrease in blood flow in all three rectal varices in comparison with values before EIS. CONCLUSIONS: Color Doppler ultrasonography can be considered a very useful noninvasive tool for diagnosis of rectal varices.     

Three Cases of Serous Oligocystic Adenomas of the Pancreas; Evaluation of Cyst Wall Thickness for Preoperative Differentiation from Mucinous Cystic Neoplasms

Background

Serous oligocystic adenoma (SOA), a rare pancreatic neoplasm, is generally a benign lesion without the necessity of surgery. Preoperatively, it is difficult to discriminate SOA from mucinous cystic neoplasm (MCN), which essentially needs surgical treatment. The purpose of this study was to evaluate the cyst wall thickness of SOAs and MCNs for preoperative differential diagnosis.

Methods

We experienced three cases of SOAs with typical histopathological features. The cyst wall thickness of the SOAs was evaluated in the area protruding out of the pancreas and was compared with that of 13 MCNs histopathologically. The same evaluation and comparison were conducted on preoperative computed tomography (CT) images retrospectively.

Results

The SOAs had a uniformly thin cyst wall measuring less than 1 mm. In contrast, the largest area of a cyst wall in MCNs ranged from 2.5 to 10.0 mm. On CT images, all but one of the MCNs showed a detectable cyst wall, while the cyst walls were hardly recognizable in two of the three SOAs.

Conclusions

For preoperative differentiation between SOAs and MCNs, the evaluation of cyst wall thickness may be an important tool and may contribute to the decision of treatment strategy.     

Irinotecan+cisplatin and irradiation are effective for brain metastases of gastric cancer--two case reports

We treated two patients in whom irinotecan (CPT-11)+cisplatin (CDDP) and irradiation showed efficacy against brain metastases of gastric cancer. CPT-11 and CDDP were administered on days 1 and 15 of a 28-day cycle at 60 mg/m(2) and 30 mg/m(2), respectively. The first patient was a 63-year-old man,who complained of headache and weakness. In March 2003, he was diagnosed as having Stage IV gastric cancer with peritoneal dissemination (T3, Nx, P1) and underwent total gastrectomy with D1 dissection. Chemotherapy with S-1 was continued after surgery. Two years and two months later, a metastatic tumor was found in the upper lobe of the right lung. The protocol was changed to S-1+CDDP, but progression of his disease occurred. The weekly paclitaxel (PTX) therapy was tried instead. Seven months later, he developed headache and weakness, and multiple brain metastases were diagnosed by CT scanning. We performed total brain irradiation (30 Gy) and started CPT-11+CDDP therapy, which was continued on a fortnightly basis at 60 mg/m(2) and 30 mg/m(2), respectively. The brain metastases regressed (PR), and this therapy led to a marked improvement in his quality of life. The second patient was a 78-year-old man, who complained of weakness of the lower extremities and dizziness. In November 2003, he was diagnosed as having stage IB gastric cancer (T2 (ss), N0, P0), and underwent total gastrectomy and splenectomy with D2 dissection. One year and four months later, local recurrence at the anastomosis was detected, as well as a metastatic tumor in the right lung. S-1, S-1+CDDP, and weekly PTX therapy were all tried. One year later, the patient was admitted with weakness and dizziness,and brain metastases were detected by CT scanning. We then performed Cyber Knife treatment and administered CPT-11+CDDP. As a result, his brain metastases partially regressed (PR).     

MTX-HOPE (methotrexate, hydrocortisone, vincristine, sobuzoxane, and etoposide) as a low-dose salvage chemotherapy for recurrent or refractory non-Hodgkin's lymphoma

We conducted a clinical study of MTX-HOPE (day 1, methotrexate 20 mg per os (po); day 2, hydrocortisone 100 mg intravenous (iv), vincristine 1 mg iv; day 3,4 sobuzoxane 400 mg po; etoposide 25 mg po, repeating every 2 or 3 weeks) in 14 relapsed or refractory patients with non-Hodgkin's lymphoma. Ten responders were obtained 5 CR and 5 PR), and heavily treated patients were included in the responders. The median duration of over all survival which was estimated with Kaplan-Meier curve was 11.1 months (range, 2-18+ months), and the median duration of response was 6.9 months (range, 0.8+ -16.4+ months).Out of the 14 patients,eleven were treated with this regimen in an outpatient setting. Grade 4 neutropenia and thrombocytopenia were observed in 4 and 2 patients,and grade 3 GPT-elevation and stomatitis in two and one, respectively. This newly developed MTX-HOPE therapy may be a promising treatment option for such patients as are intolerable for high-dose chemotherapies with PBSC rescue or wish for outpatient therapy.     

Validity of recommended minimum dose of prior morphine to initiate transdermal fentanyl patch in prescribing information - multicenter survey of on prescriptions by palliative care specialists in Japan

For initiating the minimum-size (0.25 microg/hour) transdermal fentanyl patch (TDF), 45 mg a day of oral morphine is the recommended minimum dose (RMD) in Japan according to the prescribing information. However, little is known about the validity of the RMD, and we can presume there are many cases where clinicians are inclined to initiate the minimum-size TDF at the early stage contrary to the RMD due to the high morbidity rate of digestive system cancer in Japan. In order to verify the validity of the RMD, we collected 71 retrospective cases where the minimum-size TDF was initiated against the restriction of RMD. The prior morphine (or equivalent doses of other opioids) was prescribed by palliative care specialists at 5 facilities which belong to Symptom Control Research Group (SCORE-G). Then, the side effects and pain control from the 1st to the 4th day were analyzed. The mean age of subjects was 68, and the main reason for initiating TDF therapy was gastrointestinal symptoms (63.4%). The frequency of side effects such as somnolence, nausea, vomiting and constipation did not show a significant correlation with the prior opioid dose.However,severe dyspnea and respiration depression were documented in two patients, and the above rate was three times higher than the nationwide result of the same side effects (0.9 8%). According to the Numeric Rating Scale (from 0: no pain to 10: the worst pain), the pain intensity decreased from 6.6 on the 1st day to 2.8 on the 2nd day, 3.3 on the 3rd day, and 2.9 (p < 0.001) on the 4th day. We conclude that, although introducing the minimum-size TDF against the RMD served to decrease the pain intensity,it raised the side effects on the respiratory system even when prescribed by palliative care specialists. Therefore,the RMD regulation is valid for general practitioners from a medical safety standpoint.     

Three-weekly docetaxel with prednisone is feasible for Japanese patients with hormone-refractory prostate cancer: a retrospective comparative study with weekly docetaxel alone

BACKGROUND: We previously reported that weekly treatment with docetaxel alone is useful for and well tolerated by patients with hormone-refractory prostate cancer (HRPC). Here, we compare it with the regimen of docetaxel once every 3 weeks (q3w) plus daily prednisone (PSL) based on a TAX 327 trial in order to clarify the efficacy and toxicity of docetaxel regimens in Japan. METHODS: Thirty-two patients with HRPC were treated with docetaxel weekly (regimen 1) or docetaxel q3w plus PSL daily (regimen 2) at Tsukuba University Hospital and the changes in serum prostate-specific antigen (PSA), tumor size and survival were evaluated. The dose of docetaxel in regimen 1 was based on our previous report and that of regimen 2 was modified from a TAX 327 trial. RESULTS: A >50% decrease in PSA was observed in 53% of the patients with a median time to progression of 3.5 months and 69% with 8.5 months with regimens 1 and 2, respectively. Patients who received regimen 2 had a significantly better survival rate than those who received regimen 1. Myelosuppression and neuropathy were statistically more frequent in regimen 2 than in regimen 1. CONCLUSION: A regimen of docetaxel q3w with PSL daily was associated with a high rate of PSA reduction and prolongation of patient survival. Although docetaxel has not been approved in Japan yet, this treatment is considered feasible for Japanese patients with HRPC.