Treatment of hypopharyngeal carcinomas--an institutional analysis of the results of FAR radiochemotherapy, radical resection, and free jejunum flap reconstruction and the indication of neck dissection

The treatment results of 65 patients with hypopharyngeal carcinomas treated at our institute between 1995 and 2000 were analyzed. In general, concurrent radiochemotherapy (RCT), consisting of intravenous 5-FU injection, intra-muscular vitamin A injection, and radiation (FAR therapy) was used as an initial treatment for advanced hypopharyngeal carcinomas and early hypopharyngeal carcinomas. Tumor responses were evaluated at the time of radiation doses of 30Gy. Patients who showed a complete response (CR) subsequently received curative radiation doses of 60 to 70Gy. Patients who did not show a CR underwent radical surgery consisting of pharyngo-laryngo-cervical esophagectomy, neck dissection for positive cervical nodes and/or the primary tumor sides, and reconstruction using a free jejunum flap. The disease-specific 5-year survival rates were 92%, 55%, 35% and 49% for stage I/II, III, IV and all cases, respectively. Eight out of 9 patients with stage I/II disease who showed a CR after receiving 30Gy of RCT survived with an intact larynx after definitive RCT. All the patients with stage II/III disease who underwent radical surgery after receiving 30Gy of RCT did not have a recurrence, whereas the 5-year survival rate of patients with stage IV disease who underwent RCT and radical surgery was 45%. Seventeen out of 19 patients with clinically negative cervical nodes on the opposite side of their primary tumors showed no nodal metastasis after RCT without neck dissection. This result suggests that elective neck dissection after RCT is not necessary. To improve the treatment results for hypopharyngeal carcinomas, early detection of this disease is prerequisite. In addition, the clinical diagnosis of highly malignant cases and new molecular-targeted therapies based on an analysis of distant metastasis mechanisms should be developed to overcome the poor prognosis of advanced hypopharyngeal carcinomas.     

Laminin gamma2 chain expression in squamous cell carcinomas of the tongue and its clinical relevance

Laminin gamma2 chain (LNgamma2) expression and its clinical relevance were examined in squamous cell carcinomas of the tongue. When tumor cells were attached to each other and showed expansive growth, LNgamma2 was expressed only in the peripheral cells of the tumor nests (peripheral expression). In contrast, when tumor cells showed infiltrative growth diminishing cell-cell adhesion, LNgamma2 expression was diffusely observed in almost all of the cells (diffuse expression). Patients with caricinoma cells of the primary lesions showing peripheral LNgamma2 expression were classified as the peripheral expression type, whereas patients with carcinoma cells showing diffuse LNgamma2 expression at least in part of the invasive fronts were classified as the diffuse expression type. Among 30 patients with tongue carcinomas of more than stage II, 19 patients were the peripheral expression type and 11 patients were the diffuse expression type. The 3-year disease-specific survival rates for the peripheral type and diffuse type were 64% and 34%, respectively. LNgamma2 may play an important role in growth and invasion of tongue carcinomas. In particular, it seems likely that the diffuse LNgamma2 expression in carcinoma cells has a significant relevance to the malignant characteristics of infiltrative carcinoma cells. In addition, LNgamma2 expression may be a useful prognostic factor for the patients with carcinomas of the tongue.     

Postpartum hypercalcemia in a patient with previous thyroid carcinoma: a report of 2 cases

We report postpartum hypercalcemia in 2 patients with previous thyroid carcinoma who had undergone total thyroidectomy and total parathyroidectomy and required vitamin D and calcium therapy to control hypoparathyroidism. Postpartum, they required less vitamin D and calcium for satisfactory control. While lactating, they maintained normal serum calcium without supplementary vitamin D or calcium. Transient remission of hypoparathyroidism symptoms has been observed during lactation. Some studies have shown that parathyroid-related protein (PTHrP) is produced by breast tissue, having an endocrine-like effect. We discuss the mechanism of postpartum hypercalcemia.     

A case of cutaneous myoepithelial carcinoma

BACKGROUND: Cutaneous myoepithelioma, both benign and malignant, is a rare neoplasm composed of neoplastic myoepithelial cells showing diverse histopathological features, and criteria for discriminating benign or malignant have not been fully clarified. PATIENT: We present a case of cutaneous myoepithelial carcinoma in a 62-year-old woman presenting a solid mass in the right back. RESULTS: Resected tumor was located in the whole dermis and subcutis. Histopathologically, two different growth patterns were noted: a small-nested or trabecular pattern in the superficial part and a large nodular pattern with extensive central necrosis in the deep part. Tumor cells were all epithelioid, although plasmacytoid and glycogen-rich clear cells were also observed within the large nodules of the deep part. Immunohistochemically, the cells were positive for both epithelial and myogenic markers, suggesting myoepithelial origin. Lymphatic invasion and lymph node metastasis were evident despite inconspicuous atypia and low mitotic rate. CONCLUSION: The final diagnosis was cutaneous myoepithelial carcinoma. At present, it seems to be difficult to predict the behavior of myoepithelioma of the skin and soft tissue, although atypia and high mitotic rate are reported to be associated with local recurrence and metastasis.     

"Dismembered spiral flap pyeloplasty" for uretero-pelvic junction obstruction]

We report a new operative technique for plastic correction of uretero-pelvic junction (UPJ) obstruction: dismembered spiral flap pyeloplasty. It is similar to the method described by Culp & DeWeerd in that a flap is made spirally but different in that UPJ is detached. Relatively a long and wide spiral (oblique) flap, the apex of which directs cranioventrally or craniodorsally, is made using the dilated pelvis. The apex of the flap is reflected downward and anastomosed to the split ureteral end. Because the flap is made obliquely, one side of the flap base is approximated to the opposite pelvic margin; this helps to make gradual funnelling of pelvio-ureteric transition. The method seems to be fit for cases with considerably long stenosis of UPJ and with the UPJ locating relatively close to the medial margin of the renal parenchyma. Seven of 26 pyeloplasties were done by this method in our institute, and all the 7 cases had satisfactory results.     

A case of pulmonary thromboembolism due to circulating lupus anticoagulant

A 22-year-old man was admitted because of hemosputum and progressive dyspnea with 3 attacks of chest pain and dyspnea over the previous 4 months. Chest roentgenography showed pulmonary infarction of the left lower lobe, and the diagnosis was confirmed by pulmonary perfusion and inhalation scintigraphy and pulmonary arteriography. Thrombolytic therapy was performed, but no significant effect could be obtained and anticoagulant therapy was performed continuously. No deep-vein thrombosis could be seen. He was considered to have autoimmune hemolytic anemia with lupus anticoagulant on the basis of auto-antibody data. Lupus anticoagulant is an antibody to phospholipid, and it is suggested that a decrease in the production of prostanoid in the endothelium causes thrombosis. In this case, as the patient showed a low level of 6-keto-PGF1 alpha in the blood, it is suggested that one of the etiological factors of pulmonary thromboembolism is a disorder of prostacyclin production in the endothelium, causing thrombosis by lupus anticoagulant.     

Establishment of tumor cell lines from a patient with head and neck cancer and their different sensitivities to anti-cancer agents

The authors established five cell lines from a human head and neck tumor. The five cell lines (HC-2, HC-3, HC-4, HC-7, and HC-9) exhibited different sensitivities to Adriamycin, cisplatin, bleomycin, 5-fluorouracil, vincristine, and daunomycin. The D50 was 200 ng/ml Adriamycin (doxorubicin) for HC-7 and 45 ng/ml for HC-2. At the inception of long-term culture (11 months) in the absence of any drug, the sensitivity to Adriamycin of HC-7-5 (subcloned from HC-7) was 3.4 times greater than that of HC-2-6 (subcloned from HC-2); by 11 months, it decreased to 1.6 times that of HC-2-6. The cytocidal action of Adriamycin on HC-2-6 and HC-7-5 was potentiated when Adriamycin was combined with verapamil or cepharanthine. Cepharanthine also potentiated daunomycin and vincristine (VCR) against HC-2-6 and HC-7-5 cells, and it almost completely overcame drug-resistance to daunomycin and vincristine in HC-7-5/VCR, a multidrug-resistant variant isolated after long exposure to vincristine of HC-7-5 cells in culture. The cellular accumulation of [3H]-daunomycin by HC-7-5 cells was about 70% that of HC-2-6 cells. By Northern blot analysis, using a multidrug-resistance gene (mdr-1) probe, neither HC-2-6 nor HC-7-5 expressed the mdr-1 gene, but HC-7-5/VCR or other multidrug-resistant variants showed active expression of the mdr-1 gene. Differential sensitivities among the five cell lines to 5-fluorouracil, cisplatinum, and bleomycin appear to be mediated through other mechanism beside the mdr-1 gene.