Mid-term outcome of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid sclerotherapy with mucopexy on patients with grade III hemorrhoids

BACKGROUND

Aluminum potassium sulfate and tannic acid (ALTA) is an effective sclerosing agent for the treatment of internal hemorrhoids. ALTA therapy with rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study investigated the midterm outcomes of AM surgery in patients with hemorrhoids.

METHODS

Patients with grade III hemorrhoids who underwent AM surgery were enrolled in this retrospective analysis of prospectively collected data from a single institution. Cumulative success rates, postoperative symptoms, including pain scores, analgesic requirements, and postoperative complications, and patient satisfaction were assessed.

RESULTS

The median number of ALTA injection procedures was 3 (range 1-4), and the median total injection dose was 19 mL (range 7-32 mL). The median number of mucopexy procedures was 2 (range 1-4). The median postoperative pain score (0 = no pain at all, 10 = worst pain imaginable) at rest or during defecation were ≤2. The total dose of analgesics administered during the first two weeks after surgery was 1 (range 0-25). Six patients (5.3%) showed postoperative complications: five showed Clavien-Dindo (C-D) grade I and one showed C-D grade IIIa complications. Cumulative success rates at one, three, and five years were 96.5%, 85.3%, and 85.3%, respectively. Patient satisfaction scores, which were assessed using a 10-point scale, were ≥9 at each postoperative year.

CONCLUSIONS

AM surgery is an effective non-excisional surgery with satisfactory mid-term results for grade III hemorrhoids, and is associated with lower complication rates, postoperative analgesic requirements, and higher patient satisfaction.

Longitudinal changes in life-space mobility and the factors influencing it among chronic community-dwelling post-stroke patients

PURPOSE

To identify longitudinal changes in life-space mobility and the factors influencing it among chronic, stable post-stroke patients.

MATERIALS AND METHODS

This prospective study included Japanese post-stroke patients who received day-care rehabilitation services and could undergo three life-space mobility assessments (at baseline, 12, and 24 months) for over 2 years, using the Life-Space Assessment (LSA) tool. Physical function, cognitive function, and activities of daily living were assessed by self-selected comfortable gait speed, Mini-Mental State Examination (MMSE), and Functional Independence Measure Motor subscale (FIM motor) scores, respectively, in addition to age, sex, time from onset, stroke type, and comorbidities. A multivariable linear mixed-effects model was used to examine the longitudinal changes in LSA scores and associated factors.

RESULTS

A total of 89 participants were enrolled. At baseline, the median age was 74 years, 33% were women, and median time from onset was 75 months. The LSA scores significantly declined over the two-year period. In the multivariate linear mixed-effects model adjusted for clinical characteristics, comfortable gait speed and age were significantly associated with changes in the LSA score, independent of FIM motor scores and MMSE scores.

CONCLUSIONS

Life-space mobility may persistently decline, and gait function may be a determinant influencing these changes in community-dwelling chronic post-stroke patients.Implications for RehabilitationLimited life-space mobility leads to less frequent participation in social activities and an increased risk of adverse health outcomes such as hospitalization.Changes in life-space mobility should be considered in the rehabilitation care plan for chronic post-stroke patients.Life-space mobility may decline persistently in stable post-stroke patients, even if they have periodically received day-care rehabilitation services.Since gait speed is a predominant factor affecting life-space mobility, regular assessment of gait function and appropriate strategies are needed to prevent deterioration of gait speed in chronic post-stroke patients.

Untreated Squamous Cell Lung Carcinoma May Contribute to the Occurrence of Hemophagocytic Syndrome

A 44-year-old man presented at our hospital to be evaluated for persistent fever and dyspnea. A chest computed tomography (CT) scan showed diffuse ground glass shadows and a left hilar tumor shadow. Upon further examination, he was found to have leukopenia, thrombocytopenia, and elevated lactate dehydrogenase and ferritin levels. He was diagnosed with both squamous cell lung carcinoma by a transbronchial lung biopsy and hemophagocytic syndrome by a bone marrow biopsy. After receiving treatment with dexamethasone and etoposide, the blood test abnormalities and performance status improved. Chemotherapy for lung cancer was initiated. He had a partial response after first-line chemotherapy and thereafter underwent left upper sleeve lobectomy.

Drug-induced Hypersensitivity Syndrome by EGFR-TKI in a Patient with Lung Cancer

An 83-years-old woman diagnosed with advanced Epidermal growth factor receptor (EGFR)-mutant lung adenocarcinoma was administered afatinib as a first-line treatment. On Day 17, the patient presented with grade 3 diarrhea and a blood test analysis showed an increased inflammatory response. Afatinib treatment was discontinued on the same day. On Day 26, the patient displayed blepharedema and multiple irregular erythema covering her entire body. Drug-induced hypersensitivity syndrome (DIHS) was suspected, and the systemic administration of 30 mg/day prednisolone was administered. The symptoms subsided thereafter. A blood test analysis 3 weeks after onset revealed a reactivation of Human herpesvirus 6 (HHV-6) and a diagnosis of DIHS due to afatinib therapy was confirmed.

Successful treatment with nivolumab in a patient with lung adenocarcinoma complicated by pulmonary aspergilloma

Immune checkpoint inhibitors (ICIs) are the key drugs used in patients with non‐small cell lung cancer (NSCLC). However, anti‐PD‐1 therapy might worsen chronic infection by reactivating the immune response to infectious diseases. Here, we describe a case of successful treatment with nivolumab in a patient with NSCLC complicated by pulmonary aspergilloma, which was safely treated by surgical resection before administration of nivolumab. In conclusion, to safely treat patients with locally limited chronic pulmonary aspergillosis (CPA), surgical resection should be considered before ICI therapy.

Transanal repair of rectocele: prospective assessment of functional outcome and quality of life

AIM

This study aimed to assess the functional outcome of transanal repair of rectocele using patient symptom scores and quality of life (QOL) instruments.

METHOD

Patients who underwent transanal repair for symptomatic rectocele between February 2012 and August 2017 were included. This study was a retrospective analysis of prospectively collected data. A standard questionnaire including the Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI) and QOL instruments [Patient Assessment of Constipation (PAC)-QOL, Fecal Incontinence QOL Scale, Short-Form 36 Health Survey (SF-36)] was administered before and after the operation. Physiological assessment and proctography were performed before and after the operation.

RESULTS

Thirty patients were included. The median follow-up was 36 (6-72) months. Postoperative proctography showed a reduction in rectocele size [34 mm (14-52 mm) vs 10 mm (0-28 mm), P < 0.0001]. Physiological assessment showed no significant postoperative changes. Constipation was improved in 15/21 patients (71%) at 1 year and 14/20 patients (70%) at the mid-term follow-up. The CSS score reduced at 3 months [12 (8-12) vs 6 (1-12), P < 0.0001] and remained significantly reduced over time until the mid-term follow-up. Faecal incontinence was improved in two-thirds patients at 1 year. Four patients developed new-onset faecal incontinence. All the PAC-QOL scale scores significantly improved over time until 1 year, while two of the eight SF-36 scale scores showed significant postoperative improvement.

CONCLUSION

Transanal repair for rectocele improves constipation and constipation-specific QOL.

The INTERNATIONAL MISSION study: minimally invasive surgery in ovarian neoplasms after neoadjuvant chemotherapy

OBJECTIVES

The aim of this retrospective multicenter study was to investigate the extent, feasibility, and outcomes of minimally invasive surgery at the time of interval debulking surgery in different gynecological cancer centers.

METHODS/MATERIALS

In December 2016, 20 gynecological cancer centers were contacted by e-mail, to participate in the INTERNATIONAL MISSION study. Seven centers confirmed and five were included, with a total of 127 patients diagnosed with advanced epithelial ovarian cancer after neoadjuvant chemotherapy and minimally invasive interval surgery. Only women with a minimum follow-up time of 6 months from interval surgery or any cancer-related event before 6 months were included in the survival analysis. Baseline characteristics, chemotherapy, and operative data were evaluated. Survival analysis was evaluated using the Kaplan-Meier method. RESULTS : All patients had optimal cytoreduction at the time of interval surgery: among them, 122 (96.1%) patients had no residual tumor. Median operative time was 225 min (range 60 - 600) and median estimated blood loss was 100 mL (range 70 - 1320). Median time to discharge was 2 days (1-33) and estimated median time to start chemotherapy was 20 days (range 15 - 60). Six (4.7%) patients experienced intraoperative complications, with one patient experiencing two serious complications (bowel and bladder injury at the same time). There were six (4.7%) patients with postoperative short-term complications: among them, three patients had severe complications. The conversion rate to laparotomy was 3.9 %. Median follow-up time was 37 months (range 7 - 86): 74 of 127 patients recurred (58.3%) and 31 (24.4%) patients died from disease. Median progression-free survival was 23 months and survival at 5 years was 52 % (95% CI: 35 to 67).

CONCLUSIONS

Minimally invasive surgery may be considered for the management of patients with advanced ovarian cancer who have undergone neoadjuvant chemotherapy, when surgery is limited to low-complexity standard cytoreductive procedures.

A prospective observational study to assess PD-L1 expression in small biopsy samples for non-small-cell lung cancer

Background

Programmed cell death-1 (PD-1) immune checkpoint inhibitor antibody has proven to be effective in advanced non-small cell lung cancer (NSCLC) patients positive for programmed cell death-1 ligand-1 (PD-L1). However, there are currently no prospective studies evaluating PD-L1 expression for small biopsy samples.

Methods

To prospectively investigate the reliability of small samples for NSCLC, we included patients who underwent diagnostic biopsy by flexible bronchoscopy, computed tomography (CT) and ultra-sonography (US) guided core-needle to determine the PD-L1 expression status. In pathologically confirmed NSCLC, PD-L1 expression was evaluated using companion diagnostic PD-L1 immunohistochemistry. We evaluated: 1) tumor cell count and sample size, 2) tumor proportion score (TPS): <1, 1–49%, 50%≦, and 3) the concordance rate of TPS by biopsy and surgical samples.

Results

Of the 153 cases of PD-L1 expression, 110 were assessed using endobronchial ultrasonography guided transbronchial biopsy (EBUS-TBB) (thin bronchoscopy 84 cases; normal bronchoscopy 26 cases), 23 were endobronchial ultrasonography guided transbronchial needle aspiration (EBUS-TBNA), and 20 cases of CT or US-guided core-needle biopsy. Tumor cell count and sample size were significantly larger for normal bronchoscopy than thin bronchoscopy or EBUS-TBNA samples. Moreover, tumor cell counts for each subsequent biopsy decreased. In all cases, TPS distribution (undiagnosed, <1%, 1–49, 50%≦) was 2.6, 34.6, 31.4, 31.4%, respectively. TPS positive cases using thin bronchoscope was 55.9%, normal bronchoscope was 73.1% and EBUS-TBNA was 78.3%. In early stage adenocarcinoma, TPS was lower compared with advanced stages. Conversely, in squamous cell carcinoma, the rates of TPS were similar regardless of stage. The concordance rate of TPS by biopsy and surgical materials was 86.7%.

Conclusion

Utilizing smaller samples for evaluation, the frequency of TPS was comparable to past clinical trials using larger samples. The differences in TPS were influenced by diagnostic tools, cancer histologic types and staging. The concordance of TPS between EBUS-TBB samples and surgical materials was high.

Trial registration

This study was performed at the Department of Respiratory Medicine at St. Marianna University School of Medicine Hospital, with ethics approval (#3590) and registered as a clinical trial (UMIN000027030).

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5773-3) contains supplementary material, which is available to authorized users.

Laparoscopic ventral rectopexy in patients with fecal incontinence associated with rectoanal intussusception: prospective evaluation of clinical, physiological and morphological changes

BACKGROUND

Physiological changes after laparoscopic ventral rectopexy (LVR) in patients with rectoanal intussusception (RAI) remain unclear. This study was undertaken to evaluate physiological and morphological changes after LVR for RAI, and to study clinical outcomes following LVR with special reference to fecal incontinence (FI).

METHODS

The study was conducted on patients who had LVR for RAI between February 2012 and December 2016 at our institution Patients with RAI and FI were included in the study. Patients with RAI and obstructed defecation and those with RAI and neurologic FI were not included. The patients had anorectal manometry preoperatively, and 3, 6, and 12 months postoperatively. Defecography was performed before and 6 months after the procedure. FI was evaluated using the Fecal Incontinence Severity Index (FISI).

RESULTS

There were 34 patients (median age 77 years (range 60-93) years). Thirty-two patients (94%) were female and the median number of vaginal deliveries was 2 (range 0-5). Neither maximum resting pressure nor maximum squeeze pressure increased postoperatively. There was an overall increase in both defecatory desire volume (median preoperative 75 ml vs. 90 ml at 12 months; p = 0.002) and maximum tolerated volume (median preoperative 145 ml vs.175 ml at 12 months; p = 0.002). Postoperatively, RAI was eliminated in all patients but one, although 13 had residual rectorectal intussusception found at defecography. There was an overall reduction in both rectocele size (median preop 29 mm vs. postop 10 mm; p = 0.008) and pelvic floor descent (median preop 26 mm vs. postop 20 mm; p = 0.005). Twelve months after surgery, a reduction of at least 50% was observed in the FISI score for 31 incontinent patients (91%).

CONCLUSIONS

LVR for RAI produced adequate improvement of FI, and successful anatomical correction of RAI was confirmed by postoperative proctography. Postoperative increase in the rectal volume may have a positive effect on continence.

Altered expression of glutamate transporter-1 and water channel protein aquaporin-4 in human temporal cortex with Alzheimer's disease

AIMS

Glutamate neurotoxicity plays an important role in the pathogenesis of various neurodegenerative disorders. Many studies have demonstrated that glutamate transporter-1 (GLT-1), the dominant astrocytic glutamate transporter, is significantly reduced in the cerebral cortex of patients with Alzheimer's disease (AD), suggesting that glutamate-mediated excitotoxicity might contribute to the pathogenesis of AD. In a previous study, we have demonstrated marked alterations in the expression of the astrocytic water channel protein aquaporin-4 (AQP4) in relation to amyloid β deposition in human AD brains. As a functional complex, GLT-1 and AQP4 in astrocytes may play a neuroprotective role in the progression of AD pathology. However, few studies have examined the correlation between the expression of GLT-1 and that of AQP4 in human AD brain.

METHODS

Here, using immunohistochemistry with antibodies against GLT-1 and AQP4, we studied the expression levels and distribution patterns of GLT-1 in areas showing various patterns of AQP4 expression in autopsied temporal lobes from eight patients with AD and five controls without neurological disorders.

RESULTS

GLT-1 staining in the control group was present throughout the neocortex as uniform neuropil staining with co-localized AQP4. The AD group showed a significant reduction in GLT-1 expression, whereas cortical AQP4 immunoreactivity was more intense in the AD group than in the control group. There were two different patterns of GLT-1 and AQP4 expression in the AD group: (i) uneven GLT-1 expression in the neuropil where diffuse but intense AQP4 expression was evident, and (ii) senile plaque-like co-expression of GLT-1 and AQP4.

CONCLUSIONS

These findings suggest disruption of glutamate/water homoeostasis in the AD brain.

Successful use of linezolid for refractory Mycobacterium abcessus infection: A case report

A 51-year-old male patient was receiving treatment for Mycobacterium abscessus infection for approximately 10 years. However, as his condition gradually progressed to type II respiratory insufficiency, he was referred to our hospital, which was near his home. Computed tomography on his first visit revealed an abscess in the right lower lobe. Because respiratory insufficiency was evident, he was admitted the same day. We began treatment with meropenem, amikacin, and clarithromycin, but his symptoms did not improve. In accordance with the 2007 American Thoracic Society/Infectious Diseases Society of America statement, we administered linezolid, which resulted in gradual improvement in his physical status and imaging findings.

A novel technique of introducing the mesh at the distal dissection while performing laparoscopic ventral rectopexy

AIM

Laparoscopic ventral rectopexy (LVR) is considered an effective treatment for rectal prolapse and/or rectoanal intussusception. After the dissection of the rectovaginal septum down to the pelvic floor, a strip of mesh is introduced and should be secured as distally as possible. We have developed a novel technique of introducing the mesh at the distal dissection.

METHOD

A nylon thread with straight needle was passed through the posterior wall of vagina at the distal extent of the dissection, which was caught in the abdominal cavity and fixed at the end of the mesh extracorporeally. The mesh was then introduced, pulled toward the pelvic floor and settled at the pierced site by the perineal operator.

RESULTS

Sixty-eight female patients underwent LVR using this technique. There were no intra-operative and postoperative mesh-related complications. The mean distance from the vaginal ostium to the point of passing a nylon thread through the posterior wall of the vagina was 2 cm. Postoperative proctography showed the anatomical correction in 47 of the 48 patients who were examined.

CONCLUSION

The surgeon can confirm that the mesh is introduced and secured at the distal dissection by using this technique while performing LVR.

Quality of life after laparoscopic ventral rectopexy

AIM

This study evaluated continence, constipation and quality of life (QOL) before and after laparoscopic ventral rectopexy (LVR) METHOD: Between February 2012 and July 2014, patients who underwent LVR for external rectal prolapse (ERP) and/or rectoanal intussusception (RAI) were prospectively included. A standard questionnaire including the Fecal Incontinence Severity Index (FISI), the Constipation Scoring System (CSS) and QOL instruments (Short-Form 36 Health Survey, Fecal Incontinence QOL scale, Patient Assessment of Constipation-QOL) were administered before and after operation. Psychiatric patients and those with dementia were excluded from the study. Defaecography was performed 6 months postoperatively.

RESULTS

Fifty-nine patients were included in the study period and 44 (19 with ERP, 25 with RAI) completed the follow-up questionnaire and were reviewed after a median of 26 (range 12-42) months. There was no recurrent ERP. Postoperative defaecography showed new-onset RAI in 6 and persistent RAI in 1. One year after surgery, incontinence was improved in 30/39 patients (77%) and constipation in 19/32 (59%). The FISI scores reduced between preoperative status and 1 year after surgery [32 (13-61) vs 11 (0-33), P < 0.0001]. The CSS scores also reduced [preoperative 12 (5-18) vs 1 year 5 (1-12), P < 0.0001]. Compared with the preoperative scores, almost all of the scale scores on the three kinds of QOL instruments significantly improved over time. The presence of new-onset or persistent RAI did not have an adverse effect on the improvement of QOL.

CONCLUSION

LVR improves both generic and symptom-specific QOL with good functional results.

Anterior intussusception descent during defecation is correlated with the severity of fecal incontinence in patients with rectoanal intussusception

BACKGROUND

Rectoanal intussusception (RAI) is a common finding on evacuation proctography in patients with defecation disorders. However, it remains unclear whether intussusception morphology affects the severity of fecal incontinence (FI). The aim of this study was to examine the effect of morphology during defecation on the severity of FI in patients with RAI.

METHODS

We included 80 patients with FI who were diagnosed as having RAI on evacuation proctography. Various morphological parameters were measured, and the level of RAI was divided by the extent of descent onto (level I) or into (level II) the anal sphincter. FI symptoms were documented using the FI Severity Index (FISI).

RESULTS

Twenty-eight patients had level I and 52 had level II RAI. The mean (range) FISI score was 24.0 (8-47). FISI scores tended to be significantly higher in level II than in level I [26.3 (10-47) vs. 21.8 (8-42); p = 0.05]. The mean anterior intussusception descent was significantly greater in level II than in level I [24.2 (9.2-39.5) vs. 17.7 (7.8-39.4) mm; p < 0.0001]. Regression analysis showed that anterior intussusception descent was predictive of increased FISI scores.

CONCLUSIONS

The severity of FI may be affected by anterior intussusception descent in patients with RAI.

New-onset rectoanal intussusception may not result in symptomatic improvement after laparoscopic ventral rectopexy for external rectal prolapse

BACKGROUND

This study was designed to assess defecatory function in patients who underwent laparoscopic ventral rectopexy (LVR) for external rectal prolapse (ERP).

METHODS

Thirty-one patients who underwent evacuation proctography 6 months postoperatively were assessed. Preoperative proctography had been performed in 21 patients of these patients. Defecatory function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI).

RESULTS

The findings of postoperative proctography revealed no full-thickness ERP in any patient, although in 10 patients the ERP was replaced by rectoanal intussusception (RAI). Of the 31 patients, 30 presented with fecal incontinence preoperatively. Ten of 30 had new-onset RAI. Six months postoperatively, a reduction of at least 50 % in the FISI score of the patients with new-onset RAI tended to be significantly smaller than in the patients without RAI (6/10 vs. 18/20, p = 0.141). Seventeen patients presented with obstructed defecation preoperatively. Seven of them had new-onset RAI. Six months postoperatively, a reduction of at least 50 % in their CSS score in the patients with new-onset RAI was significantly smaller than in patients without RAI (0/7 vs. 8/10, p = 0.002).

CONCLUSIONS

Evacuation proctography showed new-onset RAI in some patients with ERP who underwent LVR, which was associated with a lack of symptomatic improvement.

Patterns of care in patients with cervical cancer 2012: results of a survey among German radiotherapy departments and out-patient health care centers

BACKGROUND

Platinum-based primary or adjuvant chemoradiation is the treatment of choice for patients with cervical cancer. However, despite national guidelines and international recommendations, many aspects in diagnosis, therapy, and follow-up of patients with cervical cancer are not based on valid data.

METHODS

To evaluate the current patterns of care for patients with cervical cancer in Germany, a questionnaire with 25 items was sent to 281 radiooncologic departments and out-patient health care centers.

RESULTS

The response rate was 51%. While 87% of institutions treat 0-25 patients/year, 12 % treat between 26 and 50 and only 1% treat more than 50 patients/year. In 2011, the stage distribution of 1,706 treated cervical cancers were IB1, IB2, IIA, IIB, IIIA/IIIB, and IV in 11, 12, 11, 22, 28, and 16%, respectively. CT (90%) and MRI (86%) are mainly used as staging procedures in contrast to PET-CT with 14%. Interestingly, 27% of institutions advocate surgical staging prior to chemoradiation. In the majority of departments 3D-based (70%) and intensity-modulated radiotherapy (76%) are used for percutaneous radiation, less frequently volumetric arc techniques (26%). Nearly all colleagues (99.3%) apply conventional fractioning of 1.8-2 Gy for external-beam radiotherapy, in 19% combined with a simultaneous integrated boost. Cisplatinum mono is used as a radiosensitizer with 40 mg/m(2) weekly by 90% of radiooncologists. For boost application in the primary treatment, HDR (high-dose rate) brachytherapy is the dominant technique (84%). In patients after radical hysterectomy pT1B1/1B2, node negative and resection in sound margins adjuvant chemoradiation is applied due to the occurrence of 1-4 other risk factors in 16-97%. There is a broad spectrum of recommended primary treatment strategies in stages IIB and IVA.

CONCLUSION

Results of the survey underline the leading role but also differences in the use of chemoradiation in the treatment of cervical cancer patients in Germany.

Randomized clinical trial of the influence of mechanical bowel preparation on faecal microflora in patients undergoing colonic cancer resection

BACKGROUND

This study investigated the influence of mechanical bowel preparation (MBP) on faecal microflora, using rRNA-targeted reverse transcription-quantitative polymerase chain reaction in patients undergoing colonic cancer resection.

METHODS

Forty-two patients undergoing elective colonic surgery were randomized into MBP or no-MBP groups (21 in each group). The main outcome was the bacterial microflora and faecal organic acid content of faecal material obtained at operation.

RESULTS

Clinical characteristics were similar in the two groups. Bowel content in the resected specimens did not differ significantly. The count of bacterial microflora, such as Bifidobacterium and total Lactobacillus, in both intraoperative faecal material and first material after surgery was significantly lower in the MBP group than the no-MBP group (P < 0·050). Levels of faecal organic acids, such as acetic acid, propionic acid and butyric acid, in intraoperative faecal material were significantly lower, and levels of lactic acid were significantly higher, in the MBP group than in the no-MBP group (P < 0·050). The succinic acid level was significantly higher after surgery than before operation in the MBP group (P = 0·008).

CONCLUSION

Preoperative MBP caused an imbalance in the bowel microflora, suggesting that it offers no advantages in terms of enterobacterial microflora for patients undergoing colonic cancer resection.

REGISTRATION NUMBER

UMIN000003153 (http://www.umin.ac.jp/ctr/index.htm).

Associations of various gene polymorphisms with toxicity in colorectal cancer patients receiving oral uracil and tegafur plus leucovorin: a prospective study

BACKGROUND

To assess the predictive value of polymorphism in nine genes, primarily thymidylate synthase (TS) and orotate phosphoribosyltransferase (OPRT), which relates to 5-fluorouracil (5-FU) metabolism, for toxicity in patients treated with oral uracil/tegafur (UFT) plus leucovorin (LV).

PATIENTS AND METHODS

We treated 99 patients with stage II or III colorectal carcinoma with oral UFT + LV. Germline DNA from patients was genotyped for 5-FU and folate metabolism-relating genes. CYP2A6, tegafur-activating enzyme, and uridine diphosphate-glucuronosyltransferase 1A1 genetic variation were also assessed. Toxicity was graded by the National Cancer Institute Common Toxicity Criteria, version 2.0.

RESULTS

The multivariate logistic regression revealed that OPRT 638G>C polymorphism was associated with grade 3 diarrhea [odds ratio (OR) 19.84 for patients with the C/C homozygous type compared with patients with wild type, P = 0.014] and polymorphisms of UGT1A1 were associated with hyperbilirubinemia (OR 38.76 for homozygotes and double heterozygotes of *6 or *28 compared with wild type, P = 0.0008). No relationships were observed between TS polymorphisms and any toxicity.

CONCLUSIONS

OPRT polymorphism predicts toxicity, especially grade 3 or greater diarrhea to oral UFT + LV adjuvant chemotherapy, whereas TS does not, in our study cohort. UGT1A1 polymorphism seems to be a risk factor for hyperbilirubinemia due to UFT+LV.

Phase I study of S-1 combined with irinotecan (CPT-11) in patients with advanced colorectal cancer

PURPOSE

To determine the maximum tolerated dose, recommended dose and dose-limiting toxicities of irinotecan plus S-1 in advanced colorectal cancer.

PATIENTS AND METHODS

S-1 was administered orally at 80 mg/m2/day for 21 consecutive days followed by a 2-week rest. CPT-11 was given intravenously on days 1 and 15 of each course, at an initial dose of 60 mg/m2/day, stepping up to 80, 100, 120 or 140 mg/m2/day. Courses were repeated every 5 weeks, unless disease progression or severe toxicities were observed.

RESULTS

A total of 20 patients were entered in this study. The maximum tolerated dose of CPT-11 was considered to be 100 mg/m2, because 2 of 3 patients developed dose-limiting toxicities, such as anorexia, fatigue and diarrhea. Therefore, the recommended dose of CPT-11 was set at 80 mg/m2. Tumor responses were seen in 8 of 14 patients with measurable lesions.

CONCLUSION

A combination of S-1 with CPT-11 is safe and can be recommended for further phase II studies in patients with advanced colorectal cancer.

A full digital, high definition video system (1080i) for laryngoscopy and stroboscopy

Objective:

This study aimed to estimate the effectiveness of a full digital, high definition video system for laryngeal observations.

Methods:

A newly available, full digital, high definition video camera and high definition video monitor were used. With an endoscopic adaptor and rigid telescope, laryngoscopy and stroboscopy were performed on patients with various kinds of laryngeal lesions.

Results:

All laryngeal lesions were observed and recorded by the full digital, high definition video camera without incident. The image quality for laryngoscopy and stroboscopy was far superior to that of a conventional video system, including video-endoscopy. Even tiny structures or lesions could clearly be visualised on the monitor. The still image obtained from the full digital, high definition video camera was 1920 × 1080 pixels and was comparable to that obtained from a still camera.

Conclusions:

Full digital, high definition video cameras are now commonplace products and can easily be applied to patients with laryngeal disorders. They provide superior laryngeal images, compared with conventional video systems. Furthermore, high definition video systems are cheaper than proprietary medical video systems. We consider our system to represent an accessible technique of gaining superior laryngeal observation in otolaryngological clinics.

Head torsion technique for detailed observation of larynx and hypopharynx

We introduce here an easy but effective method for detailed observation of the larynx and hypopharynx. During the endoscopic observation, the patient's head is turned to one side. Anatomical structures on the same side of the endolarynx, such as the laryngeal ventricle and inferior surface of the vocal fold, are easily observed. In addition, observation of the opposite side of the hypopharynx also becomes easier. Such head turning is also useful in patients with an oblique larynx, in whom the epiglottis obstructs insertion of the endoscope. This is a simple but very effective technique for laryngeal and hypopharyngeal observation.

Intracranial cerebrospinal fluid measurement studies in suspected idiopathic normal pressure hydrocephalus, secondary normal pressure hydrocephalus, and brain atrophy

OBJECTIVE

To investigate intracranial cerebrospinal fluid (CSF) distribution in patients with a clinical diagnosis of idiopathic normal pressure hydrocephalus (INPH).

METHODS

24 patients with a clinical diagnosis of INPH were studied. Control groups comprised 17 patients with secondary normal pressure hydrocephalus (SNPH), 21 patients with brain atrophy, and 18 healthy volunteers. Ventricular volume (VV) and intracranial CSF volume (ICV) were measured using a magnetic resonance based method and the VV/ICV ratio was calculated.

RESULTS

The SNPH group showed a marked increase in the VV/ICV ratio compared with the healthy volunteers (37.8% v 15.6%, p < 0.0001). The brain atrophy group showed a significant increase in ICV compared with the healthy volunteers (284.4 ml v 194.7 ml, p =0.0002). The INPH group showed an increase in ICV (281.2 ml, p = 0.0002) and an increase in the VV/ICV ratio (38.0%, p < 0.0001). Fifteen of 24 INPH patients underwent shunting; 11 improved and four did not.

CONCLUSIONS

The results suggest that INPH patients have brain atrophy in addition to hydrocephalic features. This may help to explain the difficulties encountered in the diagnosis and the unpredictable response rate to shunt surgery in INPH patients.

Nervous branch passing through an accessory canal in the sphenozygomatic suture: the temporal branch of the zygomatic nerve

A nervous branch which passes through a small canal in the sphenozygomatic suture is sometimes observed during dissection. To examine the origin, course and distribution of this nervous branch, 42 head halves of 21 Japanese cadavers (11 males, 10 females) and 142 head halves of 71 human dry skulls were used. The branch was observed in seven sides (16.7%); it originated from the communication between the lacrimal nerve and the zygomaticotemporal branch of the zygomatic nerve or from the trunk of the zygomatic nerve. In two head halves (4.8%), the branch pierced the anterior part of the temporalis muscle during its course to the skin of the anterior part of the temple. The small canal in the suture was observed in 31 head halves (21.8%) of the dry skulls. Although this nervous branch is inconstantly observed, it should be called the temporal branch of the zygomatic nerve according to the constant positional relationship to the sphenoid and zygomatic bones. According to its origin, course and distribution, this nervous branch may be considered to be influential in zygomatic and retro-orbital pain due to entrapment and tension from the temporalis muscle and/or the narrow bony canal. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer LINK server located at http://dx.doi.org/10.1007/s00276-002-0027-4.

Histological findings after placement of a self-expanding stent in rectal carcinoma with complete obstruction--case report

Patients with acute obstruction due to colorectal carcinomas frequently require emergency surgery. However, such emergency procedures are associated with various complications, a high mortality rate and a poor prognosis. If the obstruction could be immediately relieved, the patient could later undergo an elective operation with a much better prognosis. Recently, expanding metallic stents have been used to treat obstruction due to colorectal carcinoma. In the case reported here, we initially inserted a colonoscopic retrograde bowel drainage tube per anus to achieve decompression. We then placed a self-expanding metallic stent, since we anticipated a prolonged preoperative period due to high fever, congestive heart failure, cerebral infarction, and persistent high blood sugar concentrations. The patient had no complications for 57 days after placement of the stent, and eventually underwent an elective operation. Histologically, the side of the cancerous lesion compressed by the stent was thin and consisted solely of a serosal layer. Implantation of a metallic stent is safe for the treatment of acute malignant obstruction. Stent placement is indicated not only as a palliative treatment for inoperable or recurrent cases, but also as a preoperative procedure before elective surgical resection.

Electronystagmographic findings in patients with cerebral degenerative disease

Cerebral degenerative diseases produce a variety of abnormal neuro-otological findings on electronystamography (ENG). To assess their diagnostic value and determine which manifestations are helpful in making a diagnosis, ENG findings from 72 cases of confirmed cerebral degenerative disease were analyzed. We observed a high incidence of saccadic pursuit and upward ocular dysmetria, which is likely to be useful in diagnosing cerebral degenerative disease. In contrast, moderate incidences of horizontal ocular dysmetria, gaze-evoked and rebound nystagmus, vertical positioning nystagmus and impaired visual suppression appeared to reflect the degree of dysfunction, while optokinetic nystagmus appeared to reflect both the presence of disease and its severity. Cases of spinocerebellar ataxia 6 and spinocerebellar ataxia 3 tended to produce horizontal and vertical gaze-evoked nystagmus, whereas progressive supranuclear palsy produced a higher incidence of upward gaze-evoked nystagmus, and positioning nystagmus at the sagittal plane appeared frequently in cases of non-hereditary spinocerebellar degeneration.

Intracranial cerebrospinal fluid distribution and its postoperative changes in normal pressure hydrocephalus

BACKGROUND

This study was conducted to investigate the usefulness of intracranial cerebrospinal fluid (CSF) volume measurement using MR-based methods in the management of patients with normal pressure hydrocephalus (NPH).

METHODS

The study group comprised 19 patients with NPH who showed a favorable outcome after ventricular shunting, 15 normal volunteers (NV), and 15 patients with cerebrovascular disease (CVD). A 3D-fast asymmetric spin echo MR imaging sequence and the region-growing method were used to extract the CSF space from MR images. Ventricular volume (VV) and intracranial CSF volume (ICV) were measured and the VV/ICV ratio was calculated in each case. In NPH patients, the CSF volume was measured again after shunting.

FINDINGS

The mean VV and VV/ICV ratio in the NPH group (91.1 mL and 45.2%, respectively) were significantly (p < 0.01) higher than those in the NV group (26.5 mL and 13.7%) and in the CVD group (44.5 mL and 17.8%). On the other hand, mean ICV values were not significantly different among the three groups. The VV was markedly decreased postoperatively (mean -40.7%), whereas the ICV was unchanged, resulting in a marked reduction in the VV/ICV ratio (mean -39.3%).

INTERPRETATION

These results suggest that patients with NPH have a unique intracranial CSF distribution, with an enlarged VV and a slightly increased ICV, resulting in a high VV/ICV ratio. Shunting led to dramatic improvement in our patients. It is likely that CSF measurement can provide valuable information in the management of patients with NPH.

Cross-sectional shapes of the internal auditory canal in patients with acoustic neuromas

Cross-sectional images of the internal auditory canal (IAC) were investigated in 23 patients with acoustic neuroma in order to clarify the widening of the IAC. The area of the IAC and the ratio of areas (neuroma side:normal side) were calculated. The shape of the IAC was fitted by an ellipse to obtain the length of the axes and the direction of the long axis. The area of the IAC was 34.2+/-12.2 mm2 in the neuroma side and 18.1+/-4.8 mm2 in the normal side. The neuroma side was larger than the normal side in all patients, and the mean ratio of areas was 1.9. However, the degrees of cochlear and vestibular damage did not correlate with the ratio of areas. The mean ratio of axes of the approximated ellipse was 1.17+/-0.09 in the neuroma side and 1.14+/-0.10 in the normal side; however, no significant difference was seen between the ratio of axes. The directions of the long axes were not always consistent with the positions of the originating nerves of the tumour. Referring to hypothetical models of enlargement of the IAC, our data suggest that the widening of the IAC in the acoustic neuroma was expansive. The data also indicated that symptoms of the acoustic neuroma were caused not only by compression of the nerves but also by other mechanisms, such as vascular insufficiency to the inner ear.

Three-dimensional image for the middle fossa approach and its anatomical considerations

OBJECTIVE

To investigate the usefulness and significance of three-dimensional images in the middle cranial fossa approach.

STUDY DESIGN

Retrospective study.

METHOD

Three-dimensional images of 12 patients with acoustic neuromas were made for surgical guidance. An image showing an ideal surgical view was prepared, which showed no overlap between the labyrinthine bone and internal auditory canal (IAC) with a slight gap between them. The IAC was located and opened referring to this image.

RESULTS

Directions of the images in the ideal surgical view were anterior from lateral position in all cases. Viewing toward the vestibule, angle from lateral plane was 24 degrees +/- 12 degrees (mean +/- standard deviation). In 11 of 12 patients, the IAC was safely opened; in one patient the IAC could not be opened because of bleeding. Overall hearing preservation rate was 82%.

CONCLUSION

Our method facilitated not only in the identification of the IAC but also in avoiding inner ear damage. Our data indicated that the center of craniotomy should be made anterior to the external auditory canal and surgery should be viewed from an anterolateral position for a safe procedure.

Mutations in Kir2.1 Cause the Developmental and Episodic Electrical Phenotypes of Andersen's Syndrome

Andersen's syndrome is characterized by periodic paralysis, cardiac arrhythmias, and dysmorphic features. We have mapped an Andersen's locus to chromosome 17q23 near the inward rectifying potassium channel gene KCNJ2. A missense mutation in KCNJ2 (encoding D71V) was identified in the linked family. Eight additional mutations were identified in unrelated patients. Expression of two of these mutations in Xenopus oocytes revealed loss of function and a dominant negative effect in Kir2.1 current as assayed by voltage-clamp. We conclude that mutations in Kir2.1 cause Andersen's syndrome. These findings suggest that Kir2.1 plays an important role in developmental signaling in addition to its previously recognized function in controlling cell excitability in skeletal muscle and heart.

Nerve origin of the acoustic neuroma

Two hundred and seventy-one Japanese patients who underwent surgical removal of neuroma from the cerebello-pontine angle using the translabyrinthine approach were retrospectively reviewed in order to investigate the nerve origin on an anatomical basis. In 269 out of the 271 cases, the origin of the neuromas was identified. Among these cases, 84.8 per cent of tumours originated from the inferior vestibular nerve (IVN), followed by the superior vestibular nerve (SVN) (8.9 per cent). Of the 5.6 per cent of tumours arising from the vestibular nerve, however, it could not be determined whether they originated from the SVN or IVN. Two cases of neuromas originating from the facial nerve were seen (0.7 per cent). No neuroma arose from the cochlear nerve. Currently, the diagnosis of acoustic neuromas is best made with Gd-enhanced magnetic resonance imaging (MRI). However, our data indicate that the development of a functional test of the individual IVN can be useful for screening most cases of acoustic neuroma and in facilitating their early diagnosis.

Synergistic effect of CGS16949A and 5-fluorouracil on a human breast cancer cell line

The effects of the aromatase inhibitor, CGS16949A, and the fluoropyrimidine, 5-fluorouracil (5-FU), on cell cycle distribution and growth were studied using FACS analysis and MTT assay in the human breast cancer cell line, SK-BR-3. CGS16949A induced an increase in the G0-G1 fraction on SK-BR-3 cells, and the growth inhibition rate of the combination of both (65.7 +/- 3.0%) was significantly higher than 10 nM CGS16949A (37.9 +/- 6.9%) or 100 microg/ml 5-FU (45.6 +/- 4.5%); p < 0.01). Administering 5-FU after preincubation with CGS16949A significantly increased the combined cytotoxic efficacy, suggesting that clinical therapy using this combined therapy may be more efficient.

Genetic changes in colorectal carcinoma tumors with liver metastases analyzed by comparative genomic hybridization and DNA ploidy

BACKGROUND

Liver metastases are found in 10% of primary colorectal malignancies, and they affects the prognosis of patients with colorectal carcinoma. The authors investigated DNA copy number aberrations by using comparative genomic hybridization (CGH) and DNA ploidy alterations by using flow cytometry (FCM) in patients with primary colorectal carcinoma (primary tumors). To determine whether there are characteristic DNA copy number alterations that contribute to liver metastasis, cytogenetic aberrations were examined by CGH and FCM.

METHODS

The authors analyzed 35 primary tumors, including 16 primary tumors with liver metastasis, by using CGH and FCM.

RESULTS

Increases in DNA copy numbers were detected in 6q (5 of 16 tumors), 7q (6 of 16 tumors), 8q (7 of 16 tumors), 9p (5 of 16 tumors), 13q (8 of 16 tumors), 20p (9 of 16 tumors), and 20q (15 of 16 tumors) in primary tumors with liver metastases. Decreases in DNA copy numbers were found in 17p (5 of 16 tumors), 18p (6 of 19 tumors), 18q (8 of 16 tumors), and 22q (5 of 16 tumors). In contrast, primary tumors without liver metastasis showed gains in chromosome arms 8q (2 of 19 tumors), 13q (2 of 19 tumors), 20p (6 of 19 tumors), and 20q (5 of 19 tumors); however, they showed no gains in 6q or 7q and showed losses in chromosome arms 17p (2 of 19 tumors), 18p (4 of 19 tumors), 18q (6 of 19 tumors), and 22q (5 of 19 tumors). There was a significant difference in the frequency of DNA copy number gains and losses in 6q (P < 0.05), 7q (P < 0.01), 8q (P < 0.05), 13q (P < 0.05), and 20q (P < 0.01), respectively, between primary tumors with and without liver metastases. The differences in the DNA index were not significant between the two groups of primary tumors.

CONCLUSIONS

In liver metastases of primary tumors from patients with colorectal carcinoma, a correlation between DNA copy number aberrations and gains of chromosome arms 6q, 7q, 8q, 13q, and 20q is suggested.

Breast carcinomas with immunocytochemical detection of aromatase in fine-needle aspirates: report of three cases

Three postmenopausal women with breast carcinoma underwent the fine-needle aspiration (FNA) preoperatively, and these specimens were stained by the antiaromatase antibody. We evaluated the identification of the aromatase immunoreactivity in breast carcinoma specimens obtained from both FNA and surgery. FNA specimens showed positive intracellular immunoreactivity of aromatase in these cases. The presence for aromatase in FNA specimens was identified with that in the surgical specimens. To our knowledge, the present cases are the first to report the aromatase staining of FNA specimens. The immunoreactivity of aromatase in FNA specimen may be useful to estimate the effectiveness of new aromatase inhibitors in patients with breast carcinoma. HUM PATHOL 32:348-351.