Proximal metatarsal osteotomy for hallux valgus: comparison of outcome for moderate and severe deformities

BACKGROUND: We compared the results of a distal soft-tissue procedure with a proximal crescentic osteotomy of the first metatarsal for moderate and severe hallux valgus. MATERIALS AND METHODS: The series consisted of 54 feet treated with this procedure. The average followup was 30 months. Fifty-four feet were divided into two groups including Group M (moderate) (24 feet, preoperative hallux valgus angle of 40 degrees or less and preoperative intermetatarsal angle of less than 18 degrees) and Group S (severe) (30 feet, preoperative hallux valgus angle of greater than 40 degrees or preoperative intermetatarsal angle of 18 degrees or greater). RESULTS: The difference between Group M and S was not significant with regard to the age of patients, duration of followup, or postoperative pain and function scores on the American Orthopaedic Foot and Ankle Society scale. However, postoperative alignment score in Group M was significantly greater than that in Group S (p = 0.038). Postoperative hallux valgus and intermetatarsal angles in Group S were significantly greater than those in Group M, respectively (p = 0.025, p = 0.001). The prevalence of recurrent hallux valgus (hallux valgus angle of 20 degrees or greater) in Group S was significantly higher than that in Group M (p = 0.013). CONCLUSION: This procedure is an effective method for relieving pain and improving function regardless of the severity of hallux valgus. However, the correction of moderate hallux valgus is likely to be better than that of severe hallux valgus.     

Sentinel Node Concept in Clinically N0 Laryngeal and Hypopharyngeal Cancer

Background  Sentinel nodes (SNs) are the lymph nodes that directly receive lymphatic flow from a primary cancer lesion. The SN concept implies that lymphatic metastasis initially occurs at SNs. SN navigation surgery can be introduced for cancers in which the SN concept is established. In SN navigation surgery, lymph node dissection beyond SNs can be omitted if SNs are metastasis free. Although the SN concept has been investigated frequently for oral and oropharyngeal cancer, it has so far been investigated less for laryngeal and hypopharyngeal cancer. In this study, we investigated whether the SN concept is applicable for laryngeal and hypopharyngeal cancer. Methods  Twenty patients with T2–T4 and clinically N0 laryngeal and hypopharyngeal cancer were recruited. ^99mTc-phytate was injected into several sites surrounding the tumor on the day before surgery. Lymphoscintigrams were acquired from at least two different viewpoints. SNs were surveyed intraoperatively, and neck dissections including at least levels II, III, and IV were performed. Results  SNs had occult metastases in five cases. In the remaining 15 cases, neither SNs nor other lymph nodes contained metastases, consistent with the SN concept. There was one false-negative case showing delayed nodal metastasis 2 years after initial surgery. The overall accuracy of the SN concept was 95%. Conclusion  Our study shows that SN biopsy is a reliable strategy to determine correct lymph node status in N0 laryngeal and hypopharyngeal cancer. SN detection was valuable in evaluating the need for neck dissection, whether ipsilaterally or bilaterally. Presented at the 2004 Annual Meeting of the American Academy of Otolaryngology, New York.     

Laparoscopic intragastric surgery under carbon dioxide pneumostomach

BACKGROUND: Laparoscopic intragastric surgery (LIGS) requires a "pneumostomach," which is created by air insufflation via gastroscopy. If the procedure is done without duodenal clamping, migrated air from the stomach causes excessive, prolonged bowel distention, which may lead to drawbacks during and after the operation. Carbon dioxide (CO(2)), with its faster absorption than air, can attenuate bowel distention when used to establish the pneumostomach. The aims of this study were to evaluate feasibility, safety, and effectiveness of the CO(2) pneumostomach in LIGS. METHODS: We have performed 15 LIGSs under the CO(2) pneumostomach (January 1997 to August 2004). The stomach was insufflated with CO(2) through an automatic surgical insufflator up to 8 mm Hg of intraluminal pressure. Neither a duodenal clamp nor an occlusion was employed prior to insufflation. Cardiopulmonary parameters were prospectively registered and retrospectively analyzed. The degree and extent of bowel distention was assessed by a concluding laparoscopy, and the amount of intestinal gas was evaluated by a postoperative plain abdominal radiograph. RESULTS: LIGS was completed in all 15 cases, with a mean intragastric insufflation time of 100 minutes. The CO(2) pneumostomach provided good, constant surgical exposure with sufficient working space. No adverse impact of intragastric CO(2) insufflation was observed on the cardiopulmonary function. Even without duodenal clamping, the insufflated small bowel loops already shrank at the time of the concluding laparoscopy. Fair residual gas was documented radiologically in 2 cases, whereas it was only faint in the remaining 13 cases. No patients showed abdominal pain or bloating postoperatively. CONCLUSIONS: The CO(2) pneumostomach is a feasible, safe alternative and is potentially effective for LIGS by eliminating the need for prior duodenal clamping and by minimizing bowel distention.     

Lupus nephritis with podocytic infolding and intramembranous microstructures

We describe a 24-year-old woman with a distinctive glomerular lesion. She presented with nephrotic syndrome and the diagnosis of systemic lupus erythematosus was made on the basis of laboratory and clinical findings. Renal biopsy showed a bubbling appearance of the glomerular capillary wall indicating lupus nephritis class V. On an electron microscopy, the glomerular basement membrane (GBM) was irregularly thickened and contained abundant vesicular and microtubular bodies. In addition, there were many epithelial foot processes infolding into the GBM. A few small deposits were observed beneath the foot processes and around the vesicular and microtubular bodies. Although the clinicopathological significance of podocytic infolding has not been fully elucidated, it may be a novel morphological entity in the glomerulonephritides.     

Primary choriocarcinoma of the urinary bladder

A 72-year-old woman with asymptomatic macrohematuria was referred to our hospital. Cystoscopy revealed a 7 cm sessile tumor on the left lateral wall of the bladder. Subsequently an intravenous pyelography revealed left hydronephrosis. We performed transurethral biopsy and resection of the bladder tumor under the diagnosis of ordinary malignant bladder tumor. Histopathologically, the lesion was shown to be an undiffentiated urothelial carcinoma, G3, > or = pT2, containing syncytiotrophoblastic giant cells. The level of serum human chorionic gonadotropin-beta (hCG-beta) level was slightly elevated (0.3 ng/ml; normal value: < 0.1). Because a further examination revealed an invasion into the surrounding fat tissue of the bladder and left ureter, a total cystohysterectomy with an ileal conduit were performed. The final histopathological classification was choriocarcinoma of the urinary bladder, pT3a, pN1, pMx. An adjuvant combination chemotherapy was carried out using methotrexate, vinblastine, adriamycin and cisplatin (MVAC). After two courses of chemotherapy, the serum hCG-beta levels returned to normal. Eleven months postoperatively, however, there was evidence of multiple lung metastases. The patient died 12 months after the surgery as a result of complications caused by widespread metastases.     

Three cases of small cell carcinoma of the urinary bladder: a case report

We report three cases of small cell carcinoma of the urinary bladder. Case 1: A 69-year-old man showed microscopic hematuria during follow up of prostate cancer of stage D2. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage of pT2N0M0. Complete remission was achieved by three courses of chemotherapy consisting of irinotecan and carboplatin. The patient was died by prostate cancer 16 months after the chemotherapy. Case 2: An 83-year-old woman presented with macroscopic hematuria. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage of pT2N0M0 and partial cystectomy was performed. The patient has been alive without any evidence of tumor recurrence at 6 months after surgery. Case 3: An 84-year-old man presented with macroscopic hematuria. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage ofcT3bN0M1 with multiple liver metastases. Complete remission was achieved by three courses of chemotherapy consisting of etoposide and carboplatin.     

Soy-derived isoflavones inhibit the growth of adult T-cell leukemia cells in vitro and in vivo

Adult T-cell leukemia occurs in human T-lymphotropic virus type I-infected individuals and is endemic to the south-western area of Kyushu in Japan. In this communication, we examined the effect of soy isoflavones on the growth of adult T-cell leukemia cells in vitro and in vivo . In the in vitro study, daidzein and genistein but not glycitein significantly inhibited the proliferation of ED-40515 and Hut102 cells in a dose-dependent manner. Among the isoflavones studied, genistein had the highest growth-inhibitory effect; however, genistein did not exert an apparent growth-inhibitory effect on Jurkat and Molt-4 cells, which were non-adult T-cell leukemia cells. Genistein prevented the G₁/S or G₂/M transition at 3 and 10 or 30 µM, respectively. Genistein upregulated p21 protein expression together with p53 accumulation. In addition, treatment with 30 µM genistein strongly induced phosphorylation of checkpoint kinase (CHK) 2 and p53 at serines 15, 20 and 37. Caffeine, an inhibitor of ataxia-telangiectasia mutated protein kinase, alleviated the genistein-induced p53 and CHK2 phosphorylation, suggesting the involvement of DNA damage at 30 µM. However, marked phosphorylation of CHK2 and p53 could not be detected at 3 and 10 µM genistein. These data indicate that genistein has biphasic growth-inhibitory properties. The in vivo studies demonstrated that soy-derived isoflavones significantly inhibit ED-40515 cell growth and infiltration into various organs in non-obese diabetic severe combined-immunodeficiency common γ-chain knockout mice. Taken together, it is evident that soy isoflavones might serve as a promising compound for the treatment of adult T-cell leukemia. ( Cancer Sci 2007; 98: 1740–1746)     

Surgical interventions for focal progression of advanced gastrointestinal stromal tumors during imatinib therapy

Background Although imatinib has shown high activity in the majority of patients with advanced gastrointestinal stromal tumors (GIST), it has become clear that secondary resistance appears during chronic therapy. The aim of this study was to retrospectively analyze the safety and prognostic effects of surgical interventions for focal progression during imatinib treatment. Methods Between January 2002 and May 2005, 16 patients who had focal lesions of secondary-resistant GIST to imatinib treatment (male/female, 12 : 4; median age, 62 years) underwent surgical interventions such as resection, radiofrequency ablation, and their combination. Results Postoperative complications, including liver abscess, bile leak, wound infection, and ileus were mostly mild, and the patients recovered with conservative therapy. There was no hospital death. The median time to progression (TTP) of all patients was 5.5 months, and only one patient died of the disease; the others are alive after a median follow up of 12.4 months. Patients with complete resections of resistant lesions (n = 7) showed significantly better median TTP than those with incomplete resections (n = 9; P = 0.014). The impact of curability on focal lesions with secondary resistance was mainly significant in patients with tumors of stomach origin (P = 0.013), and a smaller number (P = 0.014) and smaller size (P = 0.018) of resistant lesions. Overall survival was 100% at 1 year and 75% at 2 years. Conclusion Our study indicates that surgical interventions in patients with GIST resistant to imatinib therapy are efficacious when complete resections are performed, when the lesions are of gastric origin, when the number of lesions is lower, and when the lesions are a smaller size.