Calcium channel blocker attenuated opioid withdrawal syndrome.

Case: A 61-year-old woman was diagnosed with deep cervical abscess and enlarged mediastinal abscess. These required a protracted period of mechanical ventilation and neck and thoracic drainage surgery with daily wound lavage, necessitating the administration of large amounts of fentanyl and dexmedetomidine. After extubation, fentanyl was discontinued but dexmedetomidine was continued, and she developed hypertension, tachycardia, tachypnea, and hyperthermia within several hours; therefore, she was diagnosed with opioid withdrawal syndrome. Her symptoms failed to improve with either an increased dexmedetomidine dose or a diltiazem infusion for symptomatic management. Ultimately, 20 mg nifedipine was given through a nasogastric tube, which led to a resolution of withdrawal symptoms. Outcome: This is the first case of calcium channel blockers attenuating opioid withdrawal syndrome symptoms in a human. Conclusion: Calcium channel blockers might be alternative therapy to refractory opioid withdrawal syndrome. Case accumulation in the future is expected.

Clincopathological analysis of olfactory neuroblastoma.

Olfactory neuroblastoma (ONB) is a relatively uncommon neoplasm, and its clinicopathological presentation remains unclear. In this study, we investigated the correlation of the clinicopathological presentation with the prognosis of ONB. Twelve ONBs histologically diagnosed during the past 12 years at our university were examined. The tumors were classified in accordance with Kadish clinical staging and Hyams' histological grading. For immunohistochemical analysis, the antibodies of CXCL12, CXCR4, AE1/AE3, CAM5.2, Ber-EP4, Bcl-2, and MIB-1 were used. The patients ranged in age from 19 to 82 years old, and there were five males and seven females. Eight cases had intracranial tumor progression, which equals the advanced Kadish stage (stage C). According to histological grading, five low-grade (grades 1 and 2) and seven high-grade (grades 3 and 4) cases were included. Regarding the prognosis of ONB, a relationship was demonstrated with Hyams' grading, without Kadish staging. The MIB-1 labeling indices of Hyams' high-grade group were increased significantly compared to those of the low-grade group, and the expression level of Bcl-2 was strongly correlated with Hyams' grading. Neither of the chemokines CXCL12 and CXCR4 played a critical role as a prognostic factor, nor did any of the epithelial markers, AE1/AE3, CAM5.2, and Ber-EP4.

[A clinical study on cervical tuberculous lymphadenitis: the position of a low invasive needle aspiration procedure for the diagnosis of cervical tuberculous lymphadenitis].

OBJECTIVE: The diagnosis of cervical tuberculous lymphadenitis has been performed by histological examination using excisional biopsy specimens. However a non-invasive diagnostic procedure alternative to invasive excisional biopsy has been required and fine needle aspiration cytology as well the polymerase chain reaction (PCR) technique have become useful modalities. The aim of this study was to clarify the effectiveness of needle aspiration as a less invasive and more rapid diagnostic procedure than excisional biopsy. MATERIAL AND METHODS: Twenty-one excisinal biopsy specimens and 20 needle aspiration specimens were collected from 29 patients who were diagnosed as having cervical tuberculous lymphadenitis. The detection of mycobacterium tuberculosis with a smear microscopy was performed in 20 specimens, with the culture method in 20 and with the PCR test in 14 specimens. The histopathological positive rates, the detection ratio of mycobacterium, the rupture rate of the local skin lesion and the period necessary for diagnosis were compared between the two percutaneous approaches. RESULTS: The diagnosis of tuberculous lymphadenitis was successful in all cases either by cytological examination in 8 of 21 (40%) or with the histological approach in the other 21 cases. The detection ratios of smear, culture and PCR were 20%, 40% and 64%, respectively. The rupture rate of the local skin after the excisional biopsy was higher than that of the needle aspiration procedure (p = 0.05). The period for diagnosis was significantly longer than that of the needle aspiration procedure (p < 0.001). CONCLUSION: As a less invasive method of diagnosis of cervical tuberculous lymphadenitis, cytology as well as the detection of mycobacterium using an aspiration procedure is highly recommended.

Relationship between clinicopathological factors and fluorine-18-fluorodeoxyglucose uptake in patients with papillary thyroid cancer.

OBJECTIVE: To examine the relationship between clinicopathological factors and fluorine-18-fluorodeoxyglucose (F-FDG) uptake in patients with papillary thyroid cancer (PTC). MATERIALS AND METHODS: Fifty-four patients were included in this study.F-FDG positron emission tomography was performed before surgery. Immunohistochemistry of glucose transporter (GLUT) was performed using postoperative histopathological specimens. We investigated the relationship between maximum standardized uptake value (SUVmax) and GLUT-1, GLUT-3, and GLUT-4 expression/SUVmax and prognostic risk factors {tumor size, age, sex, extrathyroidal extension, and lymph node metastasis [ly (+)]}. RESULTS: GLUT-3 and GLUT-4 expressions significantly correlated with SUVmax (GLUT-3: r=0.38, P=0.008; GLUT-4: r=0.46, P=0.001), but GLUT-1 did not (r=0.21, P=0.147). The tumor size correlated with SUVmax (r=0.5, P<0.001), but GLUT-1, GLUT-3, and GLUT-4 did not (GLUT-1: r=0.006, P=0.681; GLUT-3: r=0.05, P=0.705; GLUT-4: r=-0.17, P=0.217). Both SUVmax and GLUT-4 expressions were statistically significant with ly (+) (SUVmax: P=0.012; GLUT-4: P=0.018), but GLUT-1 and GLUT-3 expressions were not (GLUT-1: P=0.165; GLUT-3: P=0.499). There was no significant difference between other clinicopathological factors and SUVmax or any GLUT expressions. CONCLUSION: F-FDG uptake in PTC may be determined by GLUT-3 and GLUT-4 expressions and may be related to tumor size and lymph node metastasis of PTC. F-FDG uptake may reflect tumor progression of PTC.

Histiocytic sarcoma of the parotid gland region.

Histiocytic sarcoma (HS) is a malignant neoplasm showing the morphological and immunophenotypic features of mature histiocytes. Reported herein is a case of HS of the parotid gland region. A 53-year-old woman noticed a swelling of the right preauricular area. Preoperative fine needle aspiration cytology showed an admixture of pleomorphic atypical cells and mature lymphocytes. She underwent total parotidectomy. Grossly, the tumor was located at the parotid gland to subcutaneous tissue, and showed infiltrative growth with massive necrosis and hemorrhage. Microscopically, the tumor was composed of marked pleomorphic cells with eosinophilic cytoplasm. Bizarre multinuclear giant cells were scattered and intermingled. Tumor cells were positive for CD68 (KP-1 and PG-M1), CD163, S-100 protein, CD1a, CD4 and CD31, but negative for CD3, CD20, CD21, CD79a, DEC205 and langerin, immunohistochemically. Monoclonal proliferation of B cells was not confirmed on polymerase chain reaction for IgH. The patient had recurrent lesions in the pelvis and stomach 5 months after parotidectomy and died of the disease 10 months after the operation.

Nuclear ß-catenin expression in basal cell adenomas of salivary gland.

BACKGROUND: Nuclear localization of ß-catenin is known in a wide variety of human neoplasms; however, there are few reports in basal cell adenoma of the salivary gland. Our objective was to confirm the nuclear localization of ß-catenin in basal cell adenoma and to examine whether nuclear ß-catenin expression could be a useful marker in the diagnosis of basal cell adenoma. METHODS: To evaluate the nuclear localization of ß-catenin in basal cell adenomas, immunohistochemistry (IHC) and mutation analysis of CTNNB1 were performed in 22 and 21 cases, respectively. Mutation analysis of CTNNB1 in exon 3 was performed by DNA direct sequencing. In a comparative study, IHC for ß-catenin was also performed in 157 other salivary gland tumors. RESULTS: Nuclear ß-catenin expression was examined in 22 basal cell adenomas; scores were 2+ in 18 cases (81.8%), 1+ in three cases (13.6%), and 0 in one case (4.5%). Expression was localized in the basaloid myoepithelial cells. CTNNB1 mutation analysis was performed in 21 basal cell adenomas; mutations, including I35T and T41P, were detected in 11/21 (52%) cases. In comparison with other salivary gland tumors, one of three basal cell adenocarcinomas showed nuclear ß-catenin expression, whereas there was no nuclear ß-catenin expression in 154 other salivary gland tumors. CONCLUSIONS: We demonstrated nuclear ß-catenin expression and activation of the CTNNB1 gene in basal cell adenoma. Although nuclear ß-catenin expression may be unable to distinguish basal cell adenoma from basal cell adenocarcinoma, it should be a helpful marker in the diagnosis of basal cell adenoma.

Cytological features of cystadenocarcinoma in cyst fluid of the parotid gland: Diagnostic pitfalls and literature review.

Cystadenocarcinoma is a rare malignant tumor, with an estimated incidence of 2% of malignant salivary gland tumors. Cytological diagnosis of cystadenocarcinoma is important for differential diagnosis between benign lesions and malignant tumors with cystic growth. We report a case of cystadenocarcinoma causing difficulty in cytological diagnosis. A 23-year-old man presented with an asymptomatic mass in the left parotid gland that had been present for 2 years. The mass was elastic hard, measuring 30 x 35 mm in diameter. Preoperative fine-needle aspiration cytology (FNAC) showed a small number of tumor cell clusters in the cystic fluid. The cluster was arranged in a ball-like structure and was cohesive with overlapping. Tumor cells had a small vacuolated, soap-bubble appearance in the cytoplasm. The papillary-cystic variant of acinic cell carcinoma (ACC-PCV) was suggested from these findings on FNAC. Histologically, the tumor was not encapsulated, but formed large cystic spaces against a background of fibrous connective tissue. The tumor cells in the cystic dilated duct showed papillary structures, which were continuous with the lining cuboidal cells. There was neither a definite double-layered arrangement in cystic ducts and solid islands nor histological findings characteristic of the papillary-cystic or follicular pattern of ACC-PCV. As tumor cells with a small vacuolated, soap-bubble appearance of the cytoplasm are common findings of both cystadenocarcinoma and ACC-PCV, they are of little use for differentiation; however, they are so characteristic that the majority of benign salivary gland lesions with cystic structures can be excluded, if enough attention is paid.

Comparison of preoperative fine-needle aspiration cytology diagnosis and histopathological diagnosis of salivary gland tumors.

We investigated 115 patients with salivary gland epithelial tumors who had undergone preoperative fine needle aspiration cytology (FNAC) of salivary glands and had been diagnosed by postoperative histopathological examination. We compared the findings of preoperative FNAC with their histopathological types in salivary gland tumors, and discuss the results and problems. The diagnostic accuracy, sensitivity, and specificity of preoperative FNAC of salivary glands were 98.2%, 88.2%, and 100%, respectively. The percentage of inadequate specimens was 6.1%. The rates of agreement in the diagnosis of pleomorphic adenoma, Warthin tumor, and basal cell adenoma were 96%, 92.9%, and 55.5%, respectively. The rate of agreement of histopathological types in the malignant tumors was 30%. We realized again not only that the diagnostic accuracy of preoperative FNAC for salivary gland tumors was high, but also that it was a safe, easy-to-perform, clinically very useful diagnostic procedure. However, this study exposed several problems which are the inadequate sampling rate and the difficulty in diagnosing malignant tumors. We have been making efforts to take appropriate specimens by writing comments on the cytological report indicating a re-examination, or by the presence of the clinical laboratory technician at the FNAC procedure. We consider it necessary to adequately re-aspirate the solid portion after cyst fluid aspiration, or to re-perform FNAC at a later date, and to improve the diagnostic accuracy by further experience with more patients.