A case of metachronous oligo-hepatic and peritoneal metastases of pancreatic cancer with a favorable outcome after conversion surgery combined with perioperative sequential chemotherapy

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive malignancies, and the prognosis for its recurrence after surgery is very poor. Here, we report a case of metachronous oligo-hepatic and peritoneal metastases in a patient who survived without recurrence for 3 years after conversion surgery combined with perioperative sequential chemotherapy using gemcitabine plus nab-paclitaxel (GnP) and modified FOLFIRINOX (mFOLFIRINOX). The patient was a 70-year-old man with pancreatic ductal carcinoma, classified as cT3N0M0, cStage IIA, who underwent a distal pancreatosplenectomy. At 1 year and 4 months later, two liver metastases and one peritoneal metastasis were detected. A systemic 9-month course of chemotherapy was administered with GnP and mFOLFIRINOX as the first- and second-line chemotherapeutic agents, respectively. The two liver metastases were judged as showing a partial response, but one dissemination was considered stable disease. After receiving informed consent from the patient, we performed resection of the disseminated tumor and lateral segmentectomy of the liver. Adjuvant chemotherapy using mFOLFIRINOX and GnP was administered for 10 months. The patient has now been alive for 5 years and 6 months after the initial pancreatosplenectomy, and 3 years and 3 months after the conversion surgery, without subsequent tumor recurrence. Thus, a multidisciplinary treatment approach including surgery and perioperative sequential chemotherapy using GnP and mFOLFIRINOX may be beneficial for treating metachronous oligo-hepatic and peritoneal metastases, depending on the patient's condition.

Efficacy of prophylactic high-flow nasal cannula therapy for postoperative pulmonary complications after pediatric cardiac surgery: a prospective single-arm study

PURPOSE

This study investigated the incidence of postoperative pulmonary complications (PPC) when high-flow nasal cannula therapy (HFNC) is used prophylactically after pediatric cardiac surgery, and evaluated its efficacy.

METHODS

This was a single-arm prospective interventional study that was conducted in a tertiary teaching hospital with eight beds in the pediatric cardiac ICU after approval by the Ethics Committee. One-hundred children under the age of 48 months who were scheduled for cardiac surgery for congenital heart disease were recruited. HFNC was used for 24 h after extubation at a 2 L/kg/min flow rate. The primary outcome was the incidence of PPC within 48 h after extubation. PPC was defined as atelectasis and acute respiratory failure meeting certain criteria. We considered prophylactic HFNC as effective if the prevalence of PPC was < 10%, based on previous reports of reintubation rates of 6%-9% after pediatric cardiac surgery.

RESULTS

A total of 91 patients were finally included in the analysis. The incidence of PPC within 48 h after extubation was 18.7%, whereas atelectasis was observed in 13.2%, and acute respiratory failure in 8.8%. Reintubation rate within 48 h after extubation was 0%.

CONCLUSIONS

We found the incidence of PPC with prophylactic HFNC after planned extubation after pediatric cardiac surgery. However, the incidence was > 10%; therefore, we could not demonstrate its efficacy in this single-arm study. Further studies are needed to investigate whether the HFNC could be adapted as first-line oxygen therapy after pediatric cardiac surgery.

The Diagnostic Capacity of Pre-treatment 18F-FDG PET/CT for Predicting the Extranodular Spread of Lymph Node Metastases in Patients with Oral Squamous Cell Carcinoma

The aim of this study was to evaluate the ability of pretreatment 90-min 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) to predict the extranodular spread of lymph node metastases in oral squamous cell carcinoma. We retrospectively reviewed the cases of 56 patients who underwent pretreatment 18F-FDG PET/CT and surgery with neck dissection. Maximum standardized uptake value, metabolic tumor volume, and total lesion glycolysis were measured for the 56 primary sites and maximum standardized uptake value was measured for 115 lymph node levels. Extranodular spread was present at 9 lymph node levels in 7 patients. Significant differences were found in metabolic tumor volume and total lesion glycolysis of the primary site, and in lymph node maximum standardized uptake value, between patients with and without extranodular spread (p<0.05). Combining primary site total lesion glycolysis and lymph node maximum standardized uptake volume at their respective optimal cutoffs, the sensitivity, specificity, and accuracy for predicting extranodular spread were 89%, 92%, and 92%, respectively. Pretreatment 18F-FDG PET/CT is useful for predicting extranodular spread in patients with oral squamous cell carcinoma. The combined use of primary site total lesion glycolysis and lymph node maximum standardized uptake value showed greater predictive value than either predictor singly.

Association between Histological Types and Enhancement of Dynamic CT for Primary Lung Cancer

The aim of this study was to explore enhancement patterns of different types of primary lung cancers on 2-phase dynamic computed tomography (CT). This study included 217 primary lung cancer patients (141 adenocarcinomas [ADs], 48 squamous cell carcinomas [SCCs], 20 small cell lung carcinomas [SCLCs], and 8 others) who were examined using a 2-phase dynamic scan. Regions of interest were identified and mean enhancement values were calculated. After excluding the 20 SCLCs because these lesions had different clinical stages from the other cancer types, the mean attenuation values and subtractions between phases were compared between types of non-small cell lung carcinomas (NSCLCs) using the Kruskal-Wallis test. Late phase attenuation and attenuation of the late minus unenhanced phase (LMU) of SCCs were significantly higher than those of ADs (p<0.05). To differentiate SCC and AD in the late phase, a threshold of 80.21 Hounsfield units (HU) gave 52.9% accuracy. In LMU, a threshold of 52.16 HU gave 59.3% accuracy. Dynamic lung CT has the potential to aid in differentiating among NSCLC types.

P1650Clinical significance of uNGAL, uKIM-1, and uL-FABP in patients with acute pulmonary edema

Introduction

Novel urinary biomarkers such as urinary neutrophil gelatinase-associated lipocalin (u-NGAL),urinary kidney injury molecule-1 (u-KIM-1), and urinary liver-type fatty acid-binding protein (uL-FABP) are proposed to be reliable markers for acute heart failure (AHF). Acute pulmonary edema (APE) is one of the vascular phenotypes of AHF, such as `vascular failure”, often with high blood pressure at admission. We aimed to investigate the differences in the clinical impact and prognostic utility of urinary biomarkers in AHF patients with and without APE.

Methods and results

This prospective observational study included 203 AHF patients (mean age: 77 years, 52% male). uL-FABP, u-NGAL, and u-KIM-1 were measured at admission and before discharge, with correction for urinary creatinine. APE was defined as acute-onset dyspnea and radiographic alveolar edema requiring non-invasive positive pressure ventilation. The primary outcome was a composite of all-cause death and AHF rehospitalization for 1 year. The median uL-FABP levels at admission were higher in APE (n=42) than in non-APE patients (n=161; 10.8 [4.5–23.7] vs. 20.7 [5.9–63.5] μg/gCr, p=0.017), whereas u-KIM-1, u-NGAL, and serum creatinine did not significantly differ between AHF patients with and without APE. The primary outcome did not differ between patients with and without APE. However, among patients with APE, Kaplan–Meier analysis showed that higher uL-FABP (≥median: 20.7 μg/gCr) was associated with adverse events (log-rank: p=0.019). After adjusting for age, sex, serum creatinine, and brain natriuretic peptide, multivariable Cox hazard analysis showed that higher uL-FABP is an independent predictor of adverse events (HR: 4.0 [1.2–18.2], p=0.023).

Conclusion

Unlike u-NGAL and u-KIM-1, uL-FABP was higher in APE patients than in non-APE patients. Further, among patients with APE, higher uL-FABP was predictive for poor prognosis.

Acknowledgement/Funding

None

A rapid caliber change in the inferior vena cava during multiphasic contrast-enhanced computed tomography may signal an acute anaphylactic reaction to nonionic contrast medium

Severe anaphylactic reactions to an intravenous nonionic iodine contrast medium (NICM) are uncommon but can result in permanent morbidity or death if not managed appropriately. An anaphylactic reaction to an NICM typically manifests as clinical symptoms that include an itchy nose, sneezing, and skin redness. To our knowledge, a rapid change in the caliber of the inferior vena cava (IVC) during multiphasic contrast-enhanced computed tomography (CT) has not been reported. Here, we report the computed tomographic findings in three cases of hypovolemic shock caused by an anaphylactic reaction to an NICM. We suspect that a decrease in caliber of the IVC during multiphasic contrast-enhanced CT may be a predictor of an allergic-like reaction to an NICM. Patients in whom physicians and radiographers detect a rapid caliber change in the IVC during multiphasic contrast-enhanced CT should be managed carefully.

Molecular cloning and gene expression of endoplasmic reticulum stress proteins in Japanese monkey, Macaca fuscata

BACKGROUND

Immunoglobulin heavy-chain binding protein (BiP), calreticulin (Crt), and protein disulfide isomerase (PDI), are major resident endoplasmic reticulum (ER) stress proteins which are involved in diverse roles relating to successful folding, assembly, intracellular localization, and degradation of other proteins.

METHODS

In this study, we molecular cloned cDNAs for BiP, Crt, and PDI from Japanese monkey (Macaca fuscata), and analyzed tissue-specific expression of respective genes.

RESULTS AND CONCLUSIONS

The lengths of protein-coding regions of these cDNAs for BiP, Crt and PDI are 1965, 1254, and 1533 bp, respectively. Each protein has a signal peptide and a KDEL motif in N- and C-terminal parts respectively, showing its intracellular localization to be the lumen of the ER. These stress proteins are highly conserved, showing that their similarities among mammals are more than 90% in the level of amino acid. The expression of the genes for stress proteins differed among the monkey tissues examined. BiP and PDI gene expression was predominant in secretory tissues such as liver and kidney, and brain tissues. But Crt gene expressed rather ubiquitously in a variety of tissues.

Correlation of visual hallucinations with occipital rCBF changes by donepezil in DLB

The authors explored the neural substrate of visual hallucinations in dementia with Lewy bodies (DLB) by investigating changes in regional cerebral blood flow (rCBF) and psychiatric symptoms, before and after cholinesterase inhibitor treatment. Twenty subjects with DLB were treated with donepezil for a 12-week period. Hallucinations attenuated while receiving therapy, whereas occipital rCBF focally increased, suggesting that functional visual association cortex deficits may cause visual hallucinations in patients with DLB.

Dementia associated mental and behavioural disturbances in elderly people in the community: findings from the first Nakayama study

OBJECTIVE

To determine the prevalence of mental and behavioural disturbances associated with dementia in elderly people living in the Japanese community of Nakayama.

METHODS

A door to door three phase population survey was carried out on all persons aged 65 years and older living at home. The study included a psychiatric interview, neurological and neuropsychological examination, and cranial computed tomography. Participants with dementia were rated on the neuropsychiatric inventory.

RESULTS

Of 1438 inhabitants, 1162 (81.0%) completed the protocol. The prevalence of dementia was 4.8%. Of the 60 participants with dementia (Alzheimer's disease 35%, vascular dementia 47%, and dementia from other causes 17%), 53 (88.3%) had shown one or more mental and behavioural disturbances. Apathy/indifference (56.7%), followed by agitation/aggression (35%), aberrant motor behaviour (31.7%), and irritability (31.7%) were the common symptoms. More productive (positive) symptoms such as delusions and aberrant motor behaviour were found in the Alzheimer group than in the vascular dementia group.

CONCLUSIONS

A wide range of dementia associated mental and behavioural disturbances developed in the majority of community dwelling individuals with dementia. The findings suggest that a screening programme focusing on identifying these symptoms should be included in the physician's diagnostic tools for dementia.

Changes in appetite, food preference, and eating habits in frontotemporal dementia and Alzheimer's disease

BACKGROUND

Despite numerous reports of changes in satiety, food preference, and eating habits in patients with frontotemporal dementia, there have been few systematic studies.

OBJECTIVES

To investigate the frequency of changes in eating behaviours and the sequence of development of eating behaviours in frontotemporal dementia and Alzheimer's disease, using a caregiver questionnaire.

METHODS

Three groups of patients were studied: frontal variant frontotemporal dementia (fv-FTD) (n = 23), semantic dementia (n = 25), and Alzheimer's disease (n = 43). Level of education and dementia severity was similar in the three groups. The questionnaire consisted of 36 questions investigating five domains: swallowing problems, appetite change, food preference, eating habits, and other oral behaviours.

RESULTS

The frequencies of symptoms in all five domains, except swallowing problems, were higher in fv-FTD than in Alzheimer's disease, and changes in food preference and eating habits were greater in semantic dementia than in Alzheimer's disease. In semantic dementia, the developmental pattern was very clear: a change in food preference developed initially, followed by appetite increase and altered eating habits, other oral behaviours, and finally swallowing problems. In fv-FTD, the first symptom was altered eating habits or appetite increase. In Alzheimer's disease, the pattern was not clear although swallowing problems developed in relatively early stages.

CONCLUSIONS

Change in eating behaviour was significantly more common in both of the frontotemporal dementia groups than in Alzheimer's disease. It is likely that the changing in eating behaviours reflects the involvement of a common network in both variants of frontotemporal dementia-namely, the ventral (orbitobasal) frontal lobe, temporal pole, and amygdala.

Yersinia pseudotuberculosis infection in breeding monkeys: detection and analysis of strain diversity by PCR

In the last three decades, several monkeys reared in outdoor/indoor-outdoor breeding colonies and cages of the Primate Research Institute, Kyoto University, died of yersiniosis caused by Yersinia pseudotuberculosis, necessitating introduction of a method to detect the bacteria rapidly and thus allow preventive measures to be undertaken. A rapid nested polymerase chain reaction (PCR) method for identification of Y. pseudotuberculosis in fecal samples and a random amplified polymorphic DNA (RAPD)-PCR approach for distinguishing between bacterial strains were therefore developed. Yersinia pseudotuberculosis isolates from monkey specimens were found to be classifiable into several types. To determine the source of infection, hundreds of fecal samples of wild rats, pigeons, and sparrows were collected from around the breeding colonies and cages, and subjected to PCR analyses. Yersinia pseudotuberculosis was detected in 1.7% of the fecal samples of wild rats. The DNA fingerprints of the bacteria revealed by RAPD-PCR were the same as that of one strain isolated from macaques, suggesting the wild rat to be a possible source of infection.

Frontotemporal lobar degeneration: a study in Japan

Frontotemporal lobar degeneration is the most common form of cortical dementia occurring in the presenium after Alzheimer's disease. We analyzed two types of frontotemporal dementia (FTD) and semantic dementia (SD) selected from a consecutive series of outpatients based on neuropsychological symptoms, psychiatric symptoms and abnormal behavior. In our series of 134 patients with primary degenerative dementia, there were 16 cases of FTD and 6 cases of SD. Patients with subgroups of FTD and patients with SD were distinguishable only by the presence of aphasia in the latter group. They were not distinguishable from one another by other neuropsychological examinations, behavioral abnormalities or psychiatric symptoms assessed with the Neuropsychiatric Inventory.

Fractal analysis of cerebral blood flow distribution in Alzheimer's disease

This study describes a method for quantifying cerebral blood flow (CBF) distribution in Alzheimer's disease (AD) from SPECT images obtained with (99m)Tc-hexamethylpropyleneamine oxime (HMPAO) by 3-dimensional fractal analysis (3D-FA).

METHODS

HMPAO SPECT was performed on 68 patients with probable AD and 14 healthy control subjects. We delineated the CBF images using 4 cutoff levels (35%, 40%, 45%, and 50% of the maximal voxel radioactivity) and measured the total number of voxels in the areas surrounded by the contours obtained with each cutoff level. We calculated fractal dimensions from the relationship between the total number of voxels and the cutoff levels transformed into natural logarithms.

RESULTS

The fractal dimensions (mean +/- SD) for patients with probable AD and healthy subjects were 0.74 +/- 0.33 and 0.52 +/- 0.09, respectively. A significant difference in the fractal dimension was found between groups (P = 0.001). Statistically significant correlations were obtained between the fractal dimension and the Mini-Mental State Examination score (r = -0.598; P < 0.0001) and between the fractal dimension and the AD Assessment Scale (r = 0.670; P < 0.0001). The fractal dimensions for subjects with clinical dementia rates (CDRs) of 0, 1, 2, and 3 were 0.52 +/- 0.09, 0.63 +/- 0.21, 0.77 +/- 0.23 (P < 0.05 vs. the group with a CDR of 1), and 1.43 +/- 0.49 (P < 0.0001 vs. the group with a CDR of 2), respectively.

CONCLUSION

Quantification of CBF distribution on SPECT images in AD was possible using 3D-FA. The fractal dimension was well correlated with the cognitive impairment, as assessed in neuropsychologic tests. 3D-FA may be a useful method for objectively evaluating the progression of AD.

Increased prevalence of vascular dementia in Japan: a community-based epidemiological study

BACKGROUND AND OBJECTIVE

It has been suggested that there is a major difference in the ratio of AD to vascular dementia (VaD) between Japan and Western countries. To determine the type-specific prevalence of dementia in community-dwelling elderly from the Japanese community of Nakayama, all patients with dementing illness underwent a CT scan.

METHODS

A door-to-door three-phase population survey was carried out on all persons aged 65 years and older residing at home on the prevalence day (January 1, 1997). The ascertainment of cases was made between January 1997 and March 1998. The study included a psychiatric interview; physical, neurologic, and neuropsychologic examinations; comprehensive laboratory tests; and cranial CT. A public health nurse also interviewed a person close to each subject. Dementia was defined according to the Diagnostic and Statistical Manual of Mental Disorders, third edition-revised, criteria, AD according to the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association, and VaD according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition, combined with information from the patient's neurologic history and CT scanning.

RESULTS

Of 1438 inhabitants, 1162 (81.0%) completed the protocol. The prevalence of dementia was 4.8%. Of the 60 subjects with dementia, 35% had AD, 47% had VaD, and 17% had dementia resulting from other causes.

CONCLUSIONS

The prevalence of dementia was similar to previous reports, but, contrary to results of virtually all studies conducted in developed countries and those recently conducted in Japan, almost half of the cases in the present study appeared to have VaD with neuroradiologic confirmation.

Relationship between blood flow kinetics and severity of Alzheimer's disease: assessment of severity using a questionnaire-type examination, Alzheimer's disease assessment scale, cognitive sub-scale (ADAS(cog))

We assessed hemokinetics associated with changes in Alzheimer's disease (AD) severity in 90 AD patients by researching the relationship between AD Assessment Scale, cognitive sub-scale (ADAS(cog)) scores and regional cerebral blood flow (rCBF). In the present study, we employed the questionnaire-type ADAS(cog) examination to accurately assess the severity of AD. Between five groups classified on the basis of ADAS(cog) score, significant differences were observed in parietal, lateral temporal and superior frontal rCBF. In addition, in parietal and lateral temporal regions, significant correlations were also observed between ADAS(cog) score and rCBF. In superior frontal rCBF, significant differences were noted only between group 5 (> or =40 ADAS(cog) points) and each of the other groups; there was no significant correlation between rCBF and ADAS(cog) score. Thus, we propose the following mechanism for blood flow kinetics associated with changed severity: In an early stage of AD, blood flow in the medial temporal cortex is impaired, and gradually involves the temporoparietal regions. While the medial temporal impairment of blood flow reaches a plateau, temporoparietal blood flow continues to be impaired well into a severe stage, at which point blood flow impairment in the frontal region is initiated.

Alteration of rCBF in Alzheimer's disease patients with delusions of theft

We investigated the neural substrate of the delusion of theft in patients with Alzheimer's disease (AD). Nine AD patients with only one type of delusion (delusions of theft) and nine age, cognitive function-matched AD patients without any type of delusions were selected from 334 consecutive outpatients of Ehime University Hospital. All subjects underwent (99m)Tc-HMPAO SPECT scanning, and SPECT images were analyzed by Statistical Parametric Mapping (SPM). AD patients with delusions of theft showed significant hypoperfusion in the right medial posterior parietal region compared to patients without delusions. Our data suggest that attention impairment or lack of awareness of illness caused by right parietal dysfunction might play a role in producing the delusion of theft.

Utility of (99m)Tc-HM-PAO SPECT hippocampal image to diagnose early stages of Alzheimer's disease using semiquantitative analysis

OBJECTIVE

Examination of the utility of (99m)Tc-hexamethylpropylene amine oxide ((99m)Tc-HM-PAO) SPECT hippocampal image to diagnose early stages of Alzheimer's disease (AD) using semiquantitative analysis.

SUBJECTS

10 early-stage AD patients and 8 normal sex-matched elderly controls.

SETTING

Outpatient division of the Ehime University Hospital.

METHOD

We performed (99m)Tc-HM-PAO SPECT perfusion imaging in each subject. A semiquantitative method of assessing regional variation was used. The regions of interest for temporal regions were set at images parallel to the long axis of the hippocampal formation which were reconstructed at 30 degrees negative to the orbitomeatal line and those for other regions were set on ordinary transaxial images.

RESULTS

The regional cerebral blood flow ratio of the bilateral medial temporal lobe at the hippocampal image was significantly lower in the AD subjects than in the normally aged controls without any other differences in ordinary transaxial images.

CONCLUSION

This study suggests that (99m)Tc-HM-PAO SPECT hippocampal images might be a helpful tool for the diagnosis of very-early-stage AD.

Interrater reliability of the Physical Self-Maintenance Scale and the Instrumental Activities of Daily Living Scale in a variety of health professional representatives

This study was performed to assess interrater reliability of the Japanese version of the Physical Self-Maintenance Scale (PSMS) and the Instrumental Activities of Daily Living Scale (IADL), which are simple and efficient assessment instruments of functional abilities in elderly patients. The subjects were 25 consecutive patients with Alzheimer's disease who were outpatients of the Department of Neuropsychiatry in Ehime University School of Medicine and their principal caregivers. One neuropsychiatrist administered the PSMS and IADL, and all sessions were videotaped. Then one clinical psychologist, one public health nurse and one neurologist, and one occupational therapist from another institution, viewed the videotape and performed reassessments. All interrater reliabilities between the neuropsychiatrist and the neurologist, the public health nurse, the clinical psychologist and the occupational therapist were extremely good. Interrater reliability between the public health nurse and the clinical psychologist, between the clinical psychologist and the neurologist and between the public health nurse and the neurologist was also extremely good. The PSMS and IADL showed good interrater reliability between personnel from different disciplines. They are likely to be useful tests for everyday medical consultations and for field research.

Validity of the Short-Memory Questionnaire in vascular dementia

PURPOSE

To determine whether the Short-Memory Questionnaire (SMQ) being administered by caregivers to patients with Alzheimer's disease (AD) is also valid when given to patients with vascular dementia (VaD).

METHODS

Subjects were 58 patients with VaD, 26 patients with cerebrovascular disorders free of cognitive deficit (CVD) and 62 healthy controls. All subjects received the Mini-Mental State Examination (MMSE), and their primary caregivers (or family members with same household) received the SMQ.

RESULTS

In the VaD patients, the SMQ score was highly correlated with the MMSE score. When 39/40 was defined as a cutoff point based on the results of previous study, the SMQ properly classified 55 of the 58 VaD patients and 61 of the 62 controls, but only about half of the 26 CVD patients, as cases.

CONCLUSION

The SMQ, a simple quantitative rating test for memory disturbance, is useful for the assessment and screening of VaD patients as well as AD patients, although careful attention should be paid to the assessment of CVD patients.

Bilateral giant intracavernous carotid artery aneurysms mimicking a cavernous sinus neoplasm--case report

An 84-year-old female presented with bilateral giant intracavernous carotid artery aneurysms manifesting as right total ophthalmoplegia and trigeminal nerve paresis. Computed tomography and magnetic resonance imaging showed the two aneurysms as one fused mass, so the initial diagnosis was a parasellar tumor occupying the bilateral cavernous sinuses. The correct diagnosis required cerebral angiography. Considering her age, no surgical or interventional treatment was given. Eight months later, her right eye movement partially recovered and she had no further symptoms. There was no definite causative factors other than aging in this case.

Acute cerebellar edema following intra-arterial tissue plasminogen activator thrombolysis for basilar artery occlusion--case report

A 61-year-old male developed acute cerebellar swelling after thrombolytic therapy for basilar artery occlusion. He was treated with intra-arterial tissue plasminogen activator 12 hours following symptomatic onset, and did well in the immediate post-treatment period but deteriorated the next day. Computed tomography demonstrated acute cerebellar edema and hydrocephalus. Suboccipital external decompression and ventricular drainage were performed. He survived and 1 year later he could perform daily activities at home. Computed tomography and angiography are essential to monitor the post-treatment course following thrombolysis of vertebrobasilar occlusive disease.