Recurrent Squamous Cell Carcinoma of the Breast with Undifferentiated Features: Report of a Case

Squamous cell carcinoma of the breast is a rare type of cancer, the origin of which is still uncertain. We report a case of squamous cell carcinoma of the breast with a recurrent tumor that showed undifferentiated features. The patient was a 55-year-old woman who originally presented with a left breast mass in the upper outer quadrant. Echography showed a 46 × 29 × 23-mm mass with cavity formation, and aspiration cytology confirmed a diagnosis of squamous cell carcinoma. A modified radical mastectomy with level III lymph node dissection was performed. Pathologically, the tumor was composed of squamous cell carcinoma and noninvasive ductal carcinoma. A recurrent tumor showing undifferentiated features was detected in the left forechest 3 months after the operation, and tumorectomy with partial resection of the major and minor pectoralis muscles was performed. Despite intensive therapy including chemotherapy (CEF: cyclophosphamide, epirubicin, 5-fluorouracil) and irradiation (50 Gy), the patient died from pulmonary and skin metastases 20 months after her initial operation. The squamous cell carcinoma of the breast in this patient grew rapidly and her prognosis was poor. Immunohistochemical findings indicated the possibility that the squamous cell carcinoma developed from noninvasive ductal carcinoma of the comedo type, and that the undifferentiated cells from the site of recurrence developed from dedifferentiation of the squamous cell carcinoma. Received: August 10, 2001 / Accepted: March 5, 2002     

Endobronchial Lipoma Accompanied with Primary Lung Cancer: Report of a Case

A 72-year-old man was found to have an endobronchial lipoma accompanied with primary lung cancer. A left lower lobectomy with a mediastinal lymph node dissection and a sleeve resection of the lingual bronchus with telescoping bronchial anastomosis were done. The pathological staging was T1N2M0, stage IIIA. A histological examination showed well-differentiated squamous cell carcinoma in segment 10, in addition to the presence of mature adipose tissue which was diagnosed to be a benign endobronchial lipoma originating from the lingual bronchus. The postoperative course was uneventful and the patient was discharged 13 days after the operation. However, he had a recurrence in the subcarinal lymph node, and died 8 months after surgery. Received: March 2, 2001 / Accepted: November 20, 2001     

Recovery of postural stability following conscious sedation with midazolam in the elderly

Purpose. To investigate the differences in recovery of postural stability, after obtaining similar intravenous sedation levels with midazolam, in elderly and younger patients undergoing dental surgery. Methods. We studied 15 elderly patients (>65 years) and 15 younger patients (<55 years) after intravenous sedation. Midazolam was carefully titrated over 4–5 min until slow response to verbal commands, ptosis of the eyelid, or slight slurring of speech was obtained. Parameters were postural balance tests and an addition test, as a psychomotor function test. Results. The dose of midazolam in the elderly group (0.045 ± 0.012 mg·kg⁻¹) was 62% of that in the younger group (0.074 ± 0.026 mg·kg⁻¹). In evaluation of the percentile rank of a balance test with a visual feedback system, which contained a dynamic balance element, recovery at 60 min in the elderly group was significantly slower than that in the younger group. However, the recovery times for the balance test and the addition test, at which the significantly changed values were restored to the baseline values, were 120 min and 90 min, respectively, in both groups. Conclusion. In the recovery from sedation, elderly patients had more difficulty in acquiring postural adjustment during movement than in maintaining a standing posture. If the dose is carefully administered, however, even elderly patients might be able to return home 2 h after midazolam administration, as could the younger patients. Received: November 6, 2001 / Accepted: April 22, 2002     

Anesthetic experience of endoscopic umbilical cord ligation in a case of twin pregnancy with acardia

We had an opportunity to engage in anesthetic management for umbilical cord ligation under endoscopy in a case of twin pregnancy with acardia. The patient was a 24-year-old woman. At the time of surgery, she was at 18 weeks and 2 days of pregnancy. Anesthesia was induced with diazepam 10 mg, fentanyl 150 micrograms, and vecuronium 8 mg, and it was maintained with oxygen (1 l.min-1), air (3 l.min-1) and isoflurane 0.8 to 1.2%. To prevent uterine contraction, ritodrine administration was started before surgery and continued throughout the anesthesia. Throughout the surgery, the fetuses remained immobile, with no sign of uterine contractions. However, an arterial blood sample obtained after anesthetic induction showed mild lactic acidosis, suggesting its relation to ritodrine administration. Anesthetic management for fetal surgery is unique in that it is a non-obstetrical surgical procedure performed on a pregnant patient. Particular attention must be directed to specific aspects, such as the anesthetic effect on the fetus, uterine relaxation during peri-operative period, and prevention of spontaneous abortion or premature labor after surgery. The use of tocolytic agents and fetal monitoring remain for further investigation.     

Adult height of three renal transplant patients after growth hormone therapy

Three girls with normal growth hormone secretion had received renal transplantation when aged 2 to 6 years. They had had severely retarded growth (SD for height score was −7.4 to −3.7) at the time of transplantation. After renal transplantation, steroid was withdrawn and they were treated with recombinant human growth hormone; they subsequently reached adult heights of 145 to 156 cm. The SD for adult height score was −2.6 to −0.3. The adult height in two patients was over their target height, calculated using the mean of the parents’ height. This report shows the efficacy of steroid withdrawal and recombinant human growth hormone therapy in achieving adult height in these three girls after renal transplantation.     

Predictive factors for the effect of the α1-D/A adrenoceptor antagonist naftopidil on subjective and objective criteria in patients with neurogenic lower urinary tract dysfunction

Study Type – Therapy (RCT)
Level of Evidence 1b What's known on the subject? and What does the study add? α‐blockers may have little effect in the facilitation of storage and emptying in patients with neurogenic lower urinary tract dysfunction (NLUTD). Naftopidil is a novel α‐blocker, which is selective for the α1‐D/A adrenoceptor. This study showed the first objective evidence for the effect of naftopidil in treatment of NLUTD patients by pressure‐flow study.

OBJECTIVES

? To assess the effect of α1‐D/A adrenoceptor antagonist naftopidil on patients with neurogenic lower urinary tract dysfunction (NLUTD) and voiding difficulty. ? To explore the effectiveness of naftopidil in these patients by using urodynamic variables, including pressure flow study (PFS), and to find good and simple parameters (International Prostate Symptom Score (IPSS), Post‐void residual urine (PVR), and uroflowmetry (UFM) parameters) as substitution of PFS for predicting the effect of naftopidil.

PATIENTS AND METHODS

? The main inclusion and exclusion criteria were, IPSS ≥8, voiding symptoms with IPSS ≥5, IPSS‐quality of life (QOL) ≥2, PVR ≥50 mL, and without prostatic enlargement ≥20 mL. ? After initial assessment, patients were stepwisely administered for 12 weeks with the following: placebo for 2 weeks, naftopidil 25 mg/day for 2 weeks, naftopidil 50 mg/day for 2 weeks, and naftopidil 75 mg/day for 6 weeks. At the end of both placebo and 6 weeks’ naftopidil 75 mg/day, their IPSS, UFM, PVR, and PFS were assessed. ? A total of 82 Japanese patients (men 40, women 42) with lower urinary tract symptoms complicated by NLUTD, with a mean age of 63.9 years, were included from private or institutional clinics. ? The lesions were spinal cord 42, and peripheral nervous system 40. The spinal cord lesions were all lumbar spine (injury or lumbar canal stenosis).

RESULTS

? In all patients, pressure at maximum urinary flow rate (P_detQ_max) in PFS significantly decreased (P < 0.05), and maximum urinary flow rate in UFM significantly increased (P < 0.01). Analysis of data for men and for women also showed a significant decrease in PVR, %PVR, and total IPSS score. ? The degree of improvement of voided volume, PVR (%), and IPSS in patients with PVR <300 mL was significantly greater than those in patients with PVR ≥300 mL. ? The degree of improvement of P_detQ_max in PFS, and IPSS in patients with bladder contractility was significantly greater than that in patients without bladder contractility.

CONCLUSIONS

? α1‐D/A adrenoceptor antagonist naftopidil has a significant effect on both symptoms and urodynamic variables of patients of both genders with NLUTD in Japan. ? PVR <300 mL and bladder contractility are predictive factors for the efficacy of naftopidil on patients with NLUTD.     

Renal cell carcinoma presenting high serum level of CA19-9 due to hydronephrosis: a case report

A 58-year old female was referred to our hospital due to left renal cyst that was pointed out at her health check-up. Abdominal CT scan showed left hydronephrosis with a 20 x 12 x 11cm tumor. The serum CA19-9 level elevated to 4,400 U/ml. Urinary cytology in the left renal pelvis was negative, therefore we could not diagnose whether the mass was renal cell carcinoma or renal pelvic tumor before surgery. She underwent left radical nephrectomy, and frozen section revealed renal cell carcinoma. Immunohistological stain clarified CA19-9 was limited to epithelium lining the renal pelvis and was not contained in carcinoma cells. After the surgery, the serum CA19-9 decreased to the normal range. Serum CA19-9 is known to be sometimes elevated in patients with urothelial carcinoma, but rarely elevated in those with renal cell carcinoma. We thought that hydronephrosis by tumor occlusion caused CA19-9 elevation in our case.     

Esophageal intubation: Can it be avoided with the airway scope (Pentax-AWS)?

Airway scope (AWS) is a rigid indirect laryngoscope with integrated tube guidance and can improve laryngeal exposure compared to the conventional direct laryngoscope. It is expected that the clear and improved laryngeal view obtained with AWS can eliminate the risk of esophageal intubation. We, however, experienced 3 cases of esophageal intubation out of 600 clinical cases with AWS in 15 month after its market release. Two cases were by novice anesthesiologists with fewer than 10 intubation experiences with AWS. Although they had had more than 100 intubation experiences with Macintosh laryngoscope, they did not have sharp eye for incorrect intubation with AWS. The third case was performed by an experienced laryngoscopist but it was difficult to identify the glottic opening because patient had distracted airway anatomy due to laryngeal tumor. In all cases esophageal intubation was immediately noticed and airway was secured uneventfully. We conclude that intubation under vision with improved laryngeal view is still not sufficient to prevent esophageal intubation.     

High concentrations of landiolol,a β<Subscript>1</Subscript>-adrenoceptor antagonist,stimulate smooth muscle contraction of the rat trachea through the Rho-kinase pathway

Purpose Gradually progressing contraction of airway smooth muscle is suggested to be due to the Rho-kinase signaling pathway. In our preliminary study in rat tracheas, landiolol, a β₁-adrenoceptor antagonist, at high doses caused gradually progressing contraction, and this contraction reached a plateau after 20 min. Therefore, this study was carried out to clarify whether landiolol could stimulate the Rho-kinase pathway or the phosphatidylinositol (PI) response in the rat trachea. Methods Seventy-eight male Wistar rats weighing 250–350 g were used for the experiments. Their tracheas were cut into 3-mm-wide ring segments or 1-mm-wide slices. Measurements of isometric tension and [³H] inositol monophosphate (IP₁) production were conducted, using these tracheal rings or slices. Data values are expressed as means ± SD, and statistical significance (P < 0.05) was determined using analysis of variance (ANOVA). Results Landiolol (700 μM)-induced contraction was completely inhibited by fasudil at 30 μM, while the landiolol-induced contraction was not inhibited by 4-diphenylacetoxy-N-methyl-piperidine methobromide (4-DAMP), ketanserin, or nicardipine. Landiolol did not stimulate IP₁ production. Conclusion These results suggest that high concentrations of landiolol could cause airway smooth muscle contraction through the Rho-kinase pathway, but not through the PI response coupled with muscarinic M₃ receptors, 5-HT receptors or the activation of L-type Ca²⁺ channels.     

Platelet-rich plasma accelerated surgical angio-genesis in vascular-implanted necrotic bone: an experimental study in rabbits

Background Platelets contain many kinds of growth factors with the ability to accelerate angiogenesis. We analyzed whether a single injection of platelet-rich plasma (PRP) would accelerate surgical angiogenesis in necrotic bone implanted with vascular tissue.

Methods We used 24 Japanese White rabbits. PRP was refined from autologous blood by separation twice with centrifugation. A removed iliac bone was frozen in liquid nitrogen to ensure complete cellular necrosis. A narrow hole was made in the bone and the saphenous vascular bundle was passed through the hole. The bone was wrapped after injection of either 1 mL (1) PRP, or (2) saline solution into the hole, and was placed subcu-taneously in the thigh. In both groups, angiogenesis was compared 1 week and 2 weeks after surgery.

Result Angiogenesis was observed along the implanted vascular bundle in both groups. At 1 and 2 weeks after surgery, both the vessel density and the average length of newly formed vessels of the experimental group were significantly greater than in the control group. Both the vessel density and the length were greater after 2 weeks than after 1 week.

Interpretation A single injection of PRP accelerates surgical angiogenesis in vascular-implanted necrotic bone.