Quantitative assessment of technical proficiency in performing needle-knife precut papillotomy

Background  Although needle-knife precut papillotomy (NKPP) is considered a useful alternative for achieving selective biliary cannulation, controversy remains regarding the technical proficiency needed to perform the procedure and its safety. This study evaluated whether procedural experience with NKPP predicted either successful cannulation or the development of complications. Methods  This study retrospectively investigated 104 patients, out of 589 consecutive patients with native papillary, who underwent NKPP performed by a single endoscopist between October 2002 and July 2006. To demonstrate changes in NKPP, the 104 patients were divided chronologically into two groups according to periods: period A (October 2002 to September 2004) and period B (October 2004 to July 2006). Results  Of the 104 consecutive patients who underwent NKPP, 41 (41/267, 15%) were treated in period A and 63 (63/322, 20%) in period B. There was no significant difference in the overall success rate between periods A (90%) and B (98%) (p = 0.08). However, the initial success rate was higher in period B (95%) than in period A (80%) (p < 0.05). The complication rates were not significantly different between the two groups (10% vs 16%; p = 0.56). Although all complications involved pancreatitis, severe pancreatitis was not observed. Conclusion  Whereas the initial success rate for NKPP can increase with procedural experience, the complication rate does not seem to decrease. Furthermore, the need for NKPP does not appear to decrease with increasing endoscopic retrograde cholangiopancreatography (ERCP) experience.     

President’s Address

In breast cancer surgery, there has been a major shift toward less invasive local treatment: from extended or radical mastectomy to modified radical mastectomy, from modified radical mastectomy to breast conserving therapy, and from routine axillary lymph node dissection to sentinel lymph node biopsy. Many breast surgeons have experienced an evolutionary progression of surgical management of breast cancer. However, there is an increasing demand for minimally invasive and non-surgical treatment methods for patients with small breast cancer. Radiofrequency (RF) ablation is the most promising among non-surgical ablation techniques in the treatment of breast cancer, although it is still in the investigative stage. Nevertheless, surgery still plays an integral role in the treatment of breast cancer, because local therapy is important for enhancing survival in the presence of systemic therapy. In clinical practice, surgical oncologists must individualize treatments, selecting a surgical or non-surgical procedure that provides the best local control, does not compromise the chances of cure, and achieves the best cosmetic results.     

Frontal assessment battery and brain perfusion image in Parkinson's disease

The objective was to compare brain perfusion image using 3-dimensional stereotactic surface projection analysis of N-isopropyl-p-123I iodoamphetamine single photon emission computed tomography between Parkinson's disease patients with a high frontal assessment battery score and those with a low frontal assessment battery score. Thirty nondemented patients with Parkinson's disease were studied. Patients were divided into 2 groups: a high-scoring group whose frontal assessment battery score was 12 or more and a low-scoring group whose frontal assessment battery score was 11 or less. The high-scoring group included 21 patients, and the low-scoring group included 9 patients. They underwent N-isopropyl-p-123I iodoamphetamine single photon emission computed tomography, and we analyzed the data by the 3-dimensional stereotactic surface projection method. Results showed that left inferior parietal lobule and left supramarginal gyrus perfusion of the low-scoring group were significantly decreased compared with the high-scoring group. It is concluded that patients with Parkinson's disease may have frontal lobe dysfunction, but the decreased frontal assessment battery score may be caused not by progressed frontal lobe dysfunction but by parietal lobe dysfunction added to their preexisting frontal lobe impairment.     

Expression of p21waf-1/cip-1 Is Significantly Induced in the Livers of LEC Rats with Chronic Liver Injury

It is reported that hepatocytes isolated from LEC rats with chronic liver injury show reduced growth activity in primary culture. To elucidate the molecular basis of this phenomenon, we examined expression of p21^waf-1/cip-1 and p27, cyclin-dependent kinase inhibitors, by northern blot analysis. The expression of p21^waf-1/cip-1 in the LEC rat liver was 3-fold higher than that of age-matched SD rat liver, while there was no significant difference in p27 expression level. Western blot analysis also revealed a significant increase in p2l^waf-1/cip-1 in the nuclear matrix fraction of the LEC rat liver. Immunohisto-chemically, p21^waf-1/cip-1 was detected in the nuclei of normal LEC rat hepatocytes, but not in those of hepatocellular carcinoma cells, suggesting selective growth of neoplastic hepatocytes.     

Clinical and pathologic factors predicting axillary lymph node involvement in breast cancer

The diagnosis of axillary disease remains a challenge in the management of breast cancer and is a subject of controversy. In 1998, the Japanese Breast Cancer Society conducted a study assessing axillary lymph node involvement in breast cancer. The study included (a) clinical assessment by pre-operative imaging modalities, (b) histologic assessment for peritumoral lymphatic invasion, (c) biologic assessment by gelatinolytic activity using film in situ zymography, and (d) sentinel lymph node (SLN) biopsy. Clinical assessments by CT, PET, and US as well as biologic assessment were limited in their ability to detect axillary lymph node disease, although these imaging techniques may be useful to exclude node-positive patients from the need for SLN biopsy. Histologic assessment for peritumoral lymphatic invasion was useful, particularly for detecting false-negative cases by SLN biopsy. Nevertheless, the utility of SLN biopsy in assessing axillary nodal status was confirmed. Axillary lymph node dissection (ALND) can be avoided in patients with a small tumor and a negative SLN. However, further studies will be required to investigate the value of SLN biopsy for predicting regional control and survival before it can replace routine ALND as the optimal staging procedure for operable breast cancer.     

Efficacy of controlled-release oxycodone for dyspnea in cancer patients--three case series

Dyspnea is a common symptom in patients with advanced cancer. Systemic morphine administration has been reported as an effective pharmacological treatment to control dyspnea. However, there have been few reports on similar effects of alternative opioids except for morphine. To evaluate the effect of controlled-release oxycodone on the relief of dyspnea, we investigated three cases with opioid substitution from subcutaneous morphine to oral oxycodone. In all cases, both opioids provided equivalent effects for the palliation of cancer dyspnea with no significant adverse effects. Future studies in the appropriate clinical designs will be needed to confirm our findings.     

Current Controversies Concerning Sentinel Lymph Node Biopsy for Breast Cancer

BACKGROUND AND METHODS: The objectives of this article are to review existing controversies regarding sentinel lymph node (SLN) biopsy and to identify potential areas of consensus in order to eliminate routine axillary lymph node dissection (ALND). RESULTS: A combination of peritumoral injection with radioisotopes and subdermal or subareolar injection with blue dye may result in enhanced success rates of SLN identification. Preoperative lymphoscintigraphy is most useful for detecting an internal mammary SLN, but the practicability of internal mammary SLN biopsy is still in the investigative stage. Intraoperative diagnosis of SLN is useful because patients with SLN metastases may be treated immediately with ALND, but it is unreasonable to expect that either examination of frozen sections or imprint cytology will detect every metastatic disease. SLN micrometastases may be of prognostic importance and these can be identified with H and E staining on permanent sections of 200 micro m intervals. While ALND is preferable for patients even with a small tumor (T1) and SLN micrometastases, radiation therapy is an acceptable alternative. SLN biopsy may be indicated for patients with DCIS detected as a palpable mass or those with large calcification areas in the breast. The accuracy of SLN biopsy after neoadjuvant chemotherapy is considered to be unproven. CONCLUSION: Since SLN biopsy has been adopted by surgeons around the world, consistency of technique and case selection has attained great significance.