Pacing lead-induced granuloma in the atrium: a foreign body reaction to polyurethane.

We described a case of an 82-year-old male who presented with a granuloma entrapping the polyurethane-coated pacing lead at the site of contact on the atrium. He had been paced for 8 years without symptoms or signs suggestive of an allergic reaction to the pacemaker system and died from thrombosis of the superior mesenteric artery and heart failure. A histological examination of the nodule showed an incidental granuloma with multinucleated giant cells. No granuloma was found in the heart or the lung.

[A case of meningeal carcinomatosis due to gastric cancer treated with intrathecal chemotherapy].

A 71-year-old man was admitted to our hospital in September 2009 because of severe headache due to meningeal carcinomatosis. In July 2007, subtotal gastrectomy was carried out for gastric cancer. Because intraabdominal cytodiagnosis was positive, he received systemic chemotherapy for 2 years. Recurrent signs were not found on chest or abdominal CT just before hospitalization. He was given NSAIDs and corticosteroid, but his symptom did not improve. Subsequent intrathecal chemotherapy with MTX and Ara-C improved clinical symptoms dramatically. He received care at home for 3 months before he passed away due to pleural and peritoneal recurrence. Recently, since the frequency of meningeal carcinomatosis is increasing, combination treatment of intrathecal chemotherapy and systemic chemotherapy should be considered not only for improvement of clinical manifestations, but also for prognostic improvement.

Survival of geriatric patients after percutaneous endoscopic gastrostomy in Japan.

AIM: To examine the long term survival of geriatric patients treated with percutaneous endoscopic gastrostomy (PEG) in Japan. METHODS: We retrospectively included 46 Japanese community and tertiary hospitals to investigate 931 consecutive geriatric patients (≥ 65 years old) with swallowing difficulty and newly performed PEG between Jan 1st 2005 and Dec 31st 2008. We set death as an outcome and explored the associations among patient's characteristics at PEG using log-rank tests and Cox proportional hazard models. RESULTS: Nine hundred and thirty one patients were followed up for a median of 468 d. A total of 502 deaths were observed (mortality 53%). However, 99%, 95%, 88%, 75% and 66% of 931 patients survived more than 7, 30, 60 d, a half year and one year, respectively. In addition, 50% and 25% of the patients survived 753 and 1647 d, respectively. Eight deaths were considered as PEG-related, and were associated with lower serum albumin levels (P = 0.002). On the other hand, among 28 surviving patients (6.5%), PEG was removed. In a multivariate hazard model, older age [hazard ratio (HR), 1.02; 95% confidence interval (CI), 1.00-1.03; P = 0.009], higher C-reactive protein (HR, 1.04; 95% CI: 1.01-1.07; P = 0.005), and higher blood urea nitrogen (HR, 1.01; 95% CI: 1.00-1.02; P = 0.003) were significant poor prognostic factors, whereas higher albumin (HR, 0.67; 95% CI: 0.52-0.85; P = 0.001), female gender (HR, 0.60; 95% CI: 0.48-0.75; P < 0.001) and no previous history of ischemic heart disease (HR, 0.69; 95% CI: 0.54-0.88, P = 0.003) were markedly better prognostic factors. CONCLUSION: These results suggest that more than half of geriatric patients with PEG may survive longer than 2 years. The analysis elucidated prognostic factors.

The sky blue method as a screening test to detect misplacement of percutaneous endoscopic gastrostomy tube at exchange.

BACKGROUND: During tube exchange for percutaneous endoscopic gastrostomy (PEG), a misplaced tube can cause peritonitis and death. Thus, endoscopic or radiologic observation is required at tube exchange to make sure the tube is placed correctly. However, these procedures cost extensive time and money to perform in all patients at the time of tube exchange. Therefore, we developed the "sky blue method" as a screening test to detect misplacement of the PEG tube during tube exchange. METHODS: First, sky blue solution consisting of indigocarmine diluted with saline was injected into the gastric space via the old PEG tube just before the tube exchange. Next, the tube was exchanged using a standard method. Then, we checked whether the sky blue solution could be collected through the new tube or not. Finally, we confirmed correct placement of the tube by endoscopic or radiologic observation for all patients. RESULTS: A total of 961 patients were enrolled. Each tube exchange took 1 to 3 minutes, and there were no adverse effects. Four patients experienced a misplaced tube, all of which were detectable with the sky blue method. Diagnostic parameters of the sky blue method were as follows: sensitivity, 94% (95%CI: 92-95%); specificity, 100% (95%CI: 40-100%); positive predictive value, 100% (95%CI: 100-100%); negative predictive value, 6% (95%CI: 2-16%). CONCLUSION: These results suggest that the number of endoscopic or radiologic observations to confirm correct replacement of the PEG tube may be reduced to one fifteenth using the sky blue method.

[Gemcitabine treatment in patients with stage IV pancreatic cancer and prognostic factors for survival of patients with stage IVb(a retrospective survey at 15 hospitals in Niigata Prefecture)].

We performed a retrospective survey at 15 hospitals in Niigata Prefecture to assess the effectiveness of gemcitabine in patients with stage IV pancreatic cancer and to analyze prognostic factors impacting survival in patients with stage IVb. The subjects were 244 unresectable or metastatic pancreatic cancer patients(IVa 68, IVb 176)who were treated with gemcitabine as first-line therapy. The overall response rate was 6.1% and the median survival time(MST)was 194 days. The MST of stage IVa(312 days)was double that of stage IVb(167 days). Prognostic factors for survival of patients with stage IVb were analyzed(performance status, response rate, liver metastasis, peritonitis carcinomatosa, paraaortic lymph node metastasis)with the Cox proportional hazards model. Performance status, response rate, and liver metastasis were significant factors influencing survival. When we compare an effect of other chemotherapy with GEM, we should treat stage IVa and stage IVb separately, and subdivision is necessary for stage IVb.

[A case of intractable chronic abdominal pain caused by hepatomegaly associated with primary amyloidosis, successfully treated with celiac plexus block].

A 51-year-old female previously diagnosed as primary amyloidosis suffered from recurrent abdominal pain. The result of thorough examination indicated that the main cause of the pain was severe hepatomegaly. Continuous venous administration of narcotics and other alternative therapies did not provide symptomatic relief, and thus the patient was treated with celiac plexus block, which resulted in effective pain control and improved ADL level. Though the procedure of celiac plexus block is simple and celiac plexus block is applicable without causing severe complication, it is not widely used. From this case, it is considered that celiac plexus block is one of the most effective means to relieve intractable pain associated with both benign malady and abdominal malignant tumor.

[A case of recurrent esophageal cancer with lung metastases successfully treated with docetaxel-combination chemotherapy].

We report a case of a 67-year-old woman diagnosed with advanced esophageal cancer. She was treated with chemo-radiotherapy (5-FU/CDDP therapy and irradiation) initially, and primary lesion was well controlled. Two and a half years after first treatment, a chest CT showed multiple lung metastasis, which were confirmed by thoraco-laparoscopy. We chose docetaxel/CDDP combination chemotherapy, because of severe side effects due to the first treatment. After 3 courses, lung metastatic lesions were reduced. The following courses combining docetaxel-nedaplatin were done as ambulatory treatment. These regimens could be one choice for recurrent esophageal cancer, especially FP therapy-resistant or intolerant cases.

Pancreatic T-cell lymphoma with high level of soluble interleukin-2 receptor.

An 82-year-old man was admitted to hospital with symptoms of abdominal fullness and loss of appetite. Abdominal computed tomography (CT) scan and ultrasonography showed enlargement of the whole pancreas with para-aortic lymphadenopathy. Endoscopic retrograde pancreatography (ERP) showed diffuse narrowing of the main pancreatic duct (MPD), and brushing cytology from the MPD was non-neoplastic. Differential diagnosis between lymphoma and other exocrine and endocrine pancreatic malignancies was needed, and the level of serum soluble interleukin-2 receptor (17 751 U/ml) was revealed to be significantly high, which was strongly suggestive of pancreatic lymphoma. Chemotherapy was refused by the patient's family and the patient succumbed after 2 months of conservative follow-up. Autopsy revealed diffuse, mixed cell-type, non-Hodgkin's lymphoma of T-cell subtype.

Advanced gastric glandular-endocrine cell carcinoma with 1-year survival after gastrectomy.

Primary gastric endocrine cell carcinoma (ECC) is extremely rare. In general, when it is advanced, gastric ECC causes extensive ulceration (type 2) and invades or metastasizes to other organs, frequently to the liver and sometimes to the lungs or bones, and carries a poor prognosis. We herein report a 67-year-old man with advanced gastric ECC of extensive-polypoid shape (type 1) but without distant metastasis, who underwent total gastrectomy and treatment with oral tegafur-uracil (UFT), and showed no sign of recurrence 1 year later.

Risk factors for nodal micrometastasis of submucosal gastric carcinoma: assessment of indications for endoscopic treatment.

BACKGROUND: Despite the widespread use of endoscopic mucosal resection (EMR) for intramucosal gastric carcinoma, there is no standardized therapy for those patients in whom the carcinoma is found, after EMR, to have invaded the submucosa.Our aim in this study was to examine the relationship between the clinicopathological features of submucosal invasive carcinomas and their incidence of nodal micrometastasis, as detected by anti-human cytokeratin immunohistochemistry, in order to assess the curative potential of submucosal carcinoma by EMR.METHODS: Fifty surgically resected submucosal gastric carcinomas which would have satisfied the absolute indications for EMR, except for the criterion of submucosal invasion, were examined. The extent of submucosal invasion was determined by measuring its vertical and horizontal spread. Immunohistochemical analysis was performed with anti-human cytokeratin antibody (CAM5.2).RESULTS: Three of 50 cases (6.0%) were positive for nodal metastasis by routine H&E examination. Nodal micrometastases were detected in 11 of 47 cases (23.4%). Statistical analysis revealed that both the depth and the width of carcinoma in the submucosa were significantly larger in cases with than in those without micrometastasis ( P = 0.019 and P = 0.006, respectively). The group with lymphatic invasion showed more frequent micrometastasis than the group without ( P = 0.014). There were no micrometastases in submucosal carcinomas whose submucosal invasion was less than 200 &mgr;m vertically and less than 320 &mgr;m horizontally.CONCLUSIONS: The present study indicates that differentiated gastric adenocarcinoma with minimal submucosal invasion (less than 200 &mgr;m vertically and less than 320 &mgr;m horizontally) and not accompanied by peptic ulcer or other risk factors, such as lymphatic invasion, can be considered as having high curative potential by EMR alone, without the necessity for further radical surgery.