Method for efficient storage and transportation of sputum specimens for molecular testing of tuberculosis.

SETTING: The polymerase chain reaction (PCR) is a highly sensitive method for the detection of Mycobacterium tuberculosis and is available in most countries, though to a lesser extent in rural areas. OBJECTIVE: To amplify M. tuberculosis DNA sequences of sputum spotted on FTA cards and compare them with the results of microscopic examination among culture-positive samples. DESIGN: A total of 102 sputum specimens of TB patients in treatment were spotted on FTA cards and stored at room temperature until DNA analysis. We assessed the IS6110 region of M. tuberculosis. The efficacy of the PCR assay for the direct detection of M. tuberculosis was evaluated and compared with the results of cultures (Middlebrook 7H9 broth) and smears of fresh sputum specimens. RESULTS: We were able to detect 10 fg/microl of mycobacterial DNA even after 6 months in storage. The PCR sensitivity and specificity using the FTA card system were 82% and 96%, while microscopic examination showed 41% and 95%, respectively. CONCLUSION: The FTA card system for the storage of bacterial DNA from sputum samples should be considered for the molecular diagnosis of tuberculosis. Samples can easily be obtained from geographically isolated populations and shipped by mail for accurate molecular diagnosis.

Low antibody response against tuberculous glycolipid (TBGL) in elderly gastrectomised tuberculosis patients.

To evaluate differences in anti-tuberculous glycolipid (TBGL) antibody titers in patients who developed tuberculosis (TB) with and without gastrectomy, 11 gastrectomised patients who developed TB after surgery (GS-TB), 19 TB patients without any other complications (TB), 12 gastrectomised patients who did not develop TB after surgery (GS) and 27 healthy subjects (H) with normal findings on chest X-ray were evaluated, although there were no differences in the clinical findings at admission between the TB and GS-TB groups. The assay used here allowed us to find low anti-TBGL antibody titers in GS-TB patients.

[Transverse sinus thrombosis in a patient with colon and rectal double cancers: a case report].

We report a case of transverse sinus thrombosis accompanied by colon and rectal double cancers. A 48-year-old male transferred to our department from the division of surgery due to deterioration manifested by headache after colectomy and low anterior resection of the rectum. There was bilateral papilledema and right upper homonymous hemianopsia. On admission all the laboratory data were within normal range. CT showed a left temporal mass lesion of heterogeneous density, which was suspected as being intratumorous hematoma in a metastasis. MRI revealed a left transverse sinus thrombosis. The left transverse and sigmoid sinuses were not opacified, but angiography showed that the occipital and marginal sinuses seemed to be markedly developed. Evacuation of the subcortical hematoma was carried out. Histologically, it was a mixed hematoma in acute and chronic stages without any carcinoma component or vascular malformation. Postoperative course was uneventful, and the patient was returned to the division of surgery in order to follow up the cancer 2 weeks after operation. Angiography 4 months after operation showed almost no recanalization in the left transverse sinus. Further, development of the collateral flow and the double occipital sinus was opacified. Because the coagulation system is often activated by the presence of cancer, it is important to distinguish intracerebral hemorrhage due to sinus thrombosis from intratumorous hemorrhage within a metastatic tumor.

[A case of hemangioma of the heart].

A-74-year old woman who had suffered from anterior chest pain and palpitation was admitted to our hospital. The chest X-ray photograph showed that the heart was enlarged mildly. We found that the tumor lay in the mediastinum by the echocardiograph and was enhanced at the aortic phase of the radioisotope angiography. In order to obtain the histological specimen, she underwent exploratory thoracotomy. The tumor was diagnosed as a cavernous hemangioma. She has been asymptomatic over 1-year period. The RI angiography seemed to be useful to diagnose the hemangioma of the heart.

[Radiofrequency ablation for metastatic lung tumor].

BACKGROUND: Radiofrequency ablation (RFA) is a thermal ablation technique which results in coagulative necrosis. Several preliminary studies have evaluated the efficacy of RFA for liver tumor and benign prostate disease, but few studies for lung tumor. We experienced RFA for a metastatic lung tumor and it was effective. CASE: A 61-year-old woman was admitted to our hospital with chest pain. Extended thymothymomectomy with lymph node dissection was performed after diagnosis of thymic carcinoid. After 14 months, multiple small lung nodules, which had been 5-10 mm in diameter, were appeared and resected. However, 23 months after the first operation and 14 months after the second operation, multiple small lung nodules were appeared again and RFA was performed for 1 tumor without any complications. We used RITA 500 PA (RITA Medical Systems, INC.) and quadruple-hook radiofrequency probe with electrodes. Under local anaesthesia and ultrasound guidance, the probe was inserted into the target tumor and the hooks were deployed. The tumor became smaller (35 mm to 25 mm in diameter) in 2 months. CONCLUSION: RFA is an effective and minimally invasive technique to destruct local tumors.

[Spontaneous regression of thymoma; report of a case].

A 44-year-old woman was admitted to our hospital with chest pain. Chest roentgenograms and computed tomography (CT) scan revealed an anterior mediastinal tumor and bilateral pleural effusion. However, CT scan 3 days after magnetic resonance imaging (MRI) revealed regression of the tumor. Extended thymo-thymectomy was performed via median sternotomy. The tumor was in the right lobe of the thymus. Pathologically the tumor was diagnosed as a mixed type non-invasive thymoma, but some parts of the tumor cells were necrotic. This is the 10th case of spontaneous regression of thymoma reported in the Japanese literature.

[Recurrence and pulmonary metastasis of extradural paraganglioma in thoracic vertebral canal: report of a case].

A 70-year-old female was operated on for extradural spinal cord tumor in 1982. Microscopic examination revealed the tumor as paraganglioma. Tumor recurred at paravertebral twice in 1985 and 1989, and they were also resected. In 1995, her chest X-ray film showed round tumor in the right upper field. Exploratory open lung biopsy was performed in 1996, and right upper lobectomy was performed according to for malignant lung tumor because intra-operative microscopic findings showed carcinoid or lung metastasis of paraganglioma. Chest wall tumor at paravertebral was resected at the same time. Postoperative microscopic examination revealed the tumors were same as operated paraganglioma. The 2nd thoracotomy was done in 1999, and two chest wall tumors and a pulmonary nodule in right S8 segment were resected. They were recurrence and pulmonary metastasis of paraganglioma. Now 18 years after initial operation, she is out of hospital in tumor free.

[Surgical treatment of lung cancer over 80 years of age: investigation from post operative complications].

Seventeen patients with lung cancer over 80 years were treated surgically from 1983 through 1993 in our department. Thirteen patients were male and four were female. The histology of the tumor was adenocarcinomas, squamous, large and small cell carcinomas, in 9, 6, 1 and 1 cases, respectively. More than single lobectomy was performed in each patient. Unilateral pulmonary occlusion test was applied in patients whose expected contralateral FEV1.0/BSA was less than 800 ml.m2, or expected residual FEV1.0/BSA was less than 850 ml.m-2. Postoperative cardiovascular complications, such as PAT, PAC, PVC or Af, were seen in 9 patients, respiratory problems, namely, sputa retention, retained secretions or atelectasis, in 7 patients. Blood chemistry and hematology were performed for about three weeks after operations, and found increases in serum transaminases, and leukocytosis. However, there were no operative death. We conclude that some patients over 80 years of age are candidates for surgery after careful cardiopulmonary preoperative evaluation.

[Prediction of postoperative pulmonary hemodynamics for the second lobectomy after the contralateral lobectomy].

We presented 7 cases who were performed the second lobectomy for the second lung cancer after the first successful lobectomy on the contralateral lung (3 cases for right upper lobectomy + left lower lobectomy and 4 cases for right upper lobectomy + left lower lobectomy). In 6 patients, the predicted postoperative FEV1 estimated by multiplying the preoperative FEV1 by the fraction of perfusion to the contralateral lung was less than 800 ml/m2BSA, which is our first cut-off for identifying lung resection candidates. Unilateral pulmonary arterial occlusion test (UPAO) revealed that total pulmonary vascular resistance (TPVRI) in 3 of those 6 patients was lower than 700 dyne.sec.cm-5/m2BSA, our second cut-off for lung resection. More precise postlobectomy pulmonary hemodynamics in another 3 of those 6 patients were then estimated by adapting selective pulmonary occlusion test (SPAO). Since TPVRI during SPAO was lower than the cut-off value, it was suggested that second lobectomy would be feasible with low incidence of post operative cardiopulmonary complication. There was no serious complications in all 7 cases during their postoperative course. We believe that more precise prediction of postoperative pulmonary hemodynamics by adapting UPAO and SPAO could be one of the tools to minimumize postoperative cardiopulmonary complications in those patients needed second lobectomy for the second lung cancer after the first successful lobectomy on the contralateral lung even though their impaired lung fung function.

[A case of lung cancer combined with ocular myopathy and idiopathic thrombocytopenic purpura which was presumed to be caused by heart catheterization].

A 61-year-old patient was admitted to our hospital because of a chest abnormal shadow. He was suffered from ocular myopathy for more than 4 years. A lab data on the admission showed only a slight thrombocytopenia. After the unilateral pulmonary arterial occlusion test for the preoperative evaluation of thoracotomy, the hemorrhagic tendency was appeared. A detailed examination proved idiopathic thrombocytopenic purpura which was presumed to be caused by the heart catheterization. We employed high-dose intravenous gamma-globulin infusion and concentrated platelet transfusion for 5 days for preventing hemorrhagic complications during the thoracotomy. The partial resection was undergone for the left upper lobe tumor, which was proved as large cell carcinoma. The postoperative hemorrhage was well controlled. We conclude that the high-dose intravenous gamma-globulin infusion and/or concentrated platelets transfusion should be positively employed for the patients with even slight thrombocytopenic purpura.

[Features of home care for patients with advanced breast cancer].

We examined the features of home care for patients with noncurable breast cancer. The patients were 21 women with advanced breast cancer who entered the home care program between April 1987 and May 2001. The first feature was that their young age: six of them were in their forties, five were in their fifties, and the mean age was 57.4 years old. The second feature was that the period home care was provided was long. The mean duration of home care from the beginning to their death was 143 days. This was because the period of sickness and the period until the breast cancer's relapsing were both long. The mean period until the relapse was 2.3 years, and the mean period of sickness was 4.1 years. The third feature was the great variety of symptoms. It is this cause that there are a lot of metastasis organs. The fourth feature was that no special treatment, such as infusion therapy, was really necessary to alleviate the symptoms. Pain control was important because there were a lot of patients whose main complaint was pain. However, pain could be controlled with morphine. In conclusion, if it is excluded not to have the nursing power because the age is generally young, home care can be comparatively offered to the person who has an advanced breast cancer for a long term.

[Intra-arterial infusion chemotherapy for locally advanced breast cancer using implantable reservoir connected with catheter inserted in recurrent radial artery].

Intra-arterial infusion chemotherapy through a catheter incubated at the recurrent radial artery and connected to an implantable reservoir was performed in eight patients with supraclavicular lymph node metastasis including four locally advanced recurrent breast cancers and two inflammatory breast cancer. Clinical response in breast cancer patients was 1 CR, 3 PR, 1 NC, and 1 PD. There was no complication related with catheter insertion. Therefore from the aspect of quality of life, this system was considered useful for treatment of advanced breast cancer, especially locally advanced recurrent breast cancer.

[Home care for terminally ill cancer patients in 1997].

In 1997, home care was provided for thirty-seven terminally ill cancer patients, fifteen patients with gastric cancer, nine patients with colorectal cancer, four patients with breast cancer, and nine patients with other miscellaneous cancer. The shortest period of home care was three days, the longest was six hundred seventeen days, and the average was one hundred eight days. Medical treatment at home consisted of dosage of morphine for 30 patients, parenteral nutrition for 30 patients, dosage of steroids for 29 patients, infusion of haloperidol for 8 patients, continuous draining of ascites for 6 patients, and continuous draining of intestinal fluid through nasogastric tube for 3 patients. As of May 31, 1998, 3 patients were alive but 34 patients had died, 31 of them at home. The characteristic trends in this year were reinforcement of the home care system in our hospital, prolongation of mean at-home days, inhalation of nebulized morphine for management of dyspnea, restriction of indication of home infusion therapy and active cooperation with public health center and welfare office.

[Ten years experience of home parenteral nutrition or hydration in advanced cancer patients].

From April 1987 to May 1997, ninety-six advanced cancer patients including ninety-one among 159 home care patients and five outpatients were administered parenteral nutrition or hydration. Eventually, 67 patients died at home. We concluded through our experience that advanced cancer patients who were unable to eat or drink might live at home with the support of parenteral nutrition or hydration. But four conditions are needed for satisfactory home care of these patients. First, patients understanding their disease condition therefore together with their family hope for home care. Second, the home care support team is organized in an institution. Third, the home care support team is on call for emergencies. Fourth, the home care support team can not only manage home parenteral nutrition but also provide palliative care, including pain control.

[Medical support system to enable advanced cancer patients to die at home].

Among 207 advanced cancer patients that received home care during the period from April, 1987 to December, 1998, 144 died in their own house, and 129 people were confirmed dead by a doctor of this department. Eighty (62%) of these 129 people died outside the hospital working hours. Moreover, 47 people (36%) died on a day the hospital was closed. The time difference between the actual death time and the doctor's death confirmation time was less than 60 minutes for 88 people, over 60 minutes for 41 people, over 120 minutes for 17 people, and over 180 minutes for seven people. The doctor in charge performed the death confirmation for 107 people (83%). Forty-seven people had received a visit by the doctor or nurse on the day of death, and 57 people had received a visit on the day before death. The existence of the medical support system of 24 hour correspondence and various guidance for the family on the method of making urgent reports when near death, how to spend the last hours, and the postmortem procedures were especially important in making home death possible.

[Home anti-cancer therapy with a venous port].

Home anti-cancer chemotherapy and palliation in the terminal stage were performed for patients with advanced cancer of the digestive system, using a venous port implanted beneath the skin via the subclavian vein. Patients under 75 years of age (5 with esophageal, 61 gastric, 59 colorectal, 5 cholangio, 5 pancreatic, 1 hepatic and 1 ileal cancer) were treated. With two portable balloon pumps, continuous intravenous infusion of 5-FU (300 or 400 mg/body/day) combined low-dose injection of cisplatin (5 mg/body/day) was continued for 10 days, and repeated 3 times for 6 weeks. The response rate was 17.9% in 78 patients according to valuation of the tumor mass. In 119 patients also undergoing a tumor marker evaluation, an effect was seen in 26.1%. No severe side effects such as renal dysfunction or bone marrow suppression were seen, and no special infusion was needed. Therefore, such treatment can be continued for a long time. Use of a venous port should make easy the switchover to HPN and the amelioration of the symptoms of the terminal stage, such as pain, and helps patients cope with the worry. Therefore, the present technique is useful in a series of cancer treatments including surgery, chemotherapy and the amelioration of symptoms.

[Trial of home anti-cancer chemotherapy with infusion of 5-FU and low-dose cisplatin].

We tried home anti-cancer chemotherapy for patients with advanced or recurrent cancer of the digestive system, using two disposable balloon pumps connected to an implantable drug delivery system via central venous line. There were 33 patients under 75 years old, including 20 cases of gastric cancer, 9 cases of colorectal cancer, 2 cases of cholangiocarcinoma and 2 cases of esophageal cancer enrolled in this study. The protocol was combined chemotherapy with continuous intravenous infusion of 5-FU (300 mg/body/day) and low-dose intravenous injection of cisplatin (5 mg/body/day) in 10-day courses for two weeks, and it was repeated 3 times for 6 weeks. Because of side effects such as nausea, vomiting and bone marrow suppression, treatment was discontinued in 12 cases with peritoneal cancer infiltration. In two of 10 with estimable disease, the reduction of the metastatic lymph node was observed, but no effect was shown in the colorectal metastatic liver tumor. Thanks to the portability of the pump with this method, the patient need not undergo hospitalization. Moreover, there is no renal dysfunction or other major side effects, quality of life is not compromised and a return to family and social life is possible. Thus, if the patient cannot take the oral nutrition, it is easy to start home hyper-alimentation.

[How to palliate the symptoms of terminally ill patients at home].

We reported the kind of symptoms and how they could be palliated in terminally ill patients at home based on our experience of about 9 years. Cancer pain, which was the most frequent symptom, appeared in 67 among 126 patients receiving home care, and it could be effectively controlled with morphine; no patient returned to the hospital because of aggravation of pain. Very few patients stayed in the hospital and never returned home due to uncontrollable pain. Home parenteral infusion was done for 63 patients who were unable to eat or drink because of peritonitis carcinomatosa or cancer cachexia. High fever in the tumor mass was controlled by glucocorticoid hormone, and ascites was drained continuously when the patients suffered from abdominal distension. From analysis of the cases in which home care was interrupted or those in which patients were unable to transfer to home care, symptoms that were difficult to palliate at home were nausea caused by bowel obstruction, acute symptoms (bleeding, disturbance of consciousness, and so on), and dyspnea. But if the patients and family are eager for home care and an adequate medical support system is in place, home care may be possible despite these symptoms.

[Home anti-cancer chemotherapy with continuous infusion of 5-FU combined with low-dose cisplatin injection via implantable venous port with portable balloon pump].

Home anti-cancer chemotherapy was performed for patients with advanced cancer of the digestive plantable venous port placed beneath the skin via the subclavian vein. 128 patients under 75 years old (enrolled: 6 patients with esophageal, 65 with gastric, 44 with colorectal, 5 with cholangio, 5 with pancreatic, one with hepatic and one with ileal cancer) were treated. Continuous intravenous infusion of 5-FU (300-400 mg/body/day) combined with low-dose injection of cisplatin (5 mg/body/day) was continued for 10 days, and repeated 3 times for 6 weeks. The response rate was 23.6% in 72 patients with valuation of tumor mass. In 83 patients for whom a tumor marker evaluation was also performed, an effect was seen in 30.1%. No severe side effects such as renal dysfunction were observed, and no special infusions were needed. Therefore, a quality of life was maintained in which bathing was possible and patients were released from the hospital. Hyperalimentation through the venous port, and palliation during the terminal stage, is easily accomplished. It is useful method for surgery, chemotherapy and palliative therapy in the treatment of cancer.

[A patient with multiple pulmonary metastases from colonic cancer who survived for 5 years by effectual administration of 5'-DFUR].

The patient was a 69-year-old woman who had been diagnosed with a bowel obstruction due to colonic cancer, with simultaneous multiple pulmonary metastases. The primary lesion was resected and 5'-DFUR was administered for 2 years at an out-patient clinic. During those 2 years, there was no change in CEA value and the pulmonary lesions were fading on the roentogenograms. It then became doubtful whether the pulmonary shadows were real metastases or not, and 5'-DFUR administration was discontinued. After stopping the medication, her CEA value rose and the tumor shadows increased in intensity. 5'-DFUR was therefore re-administrated and her CEA value declined. Afterwards, a re-elevation in CEA value was seen, and low-dose FP therapy was added on an out-patient basis. Anti-cancer chemotherapy of 5'-DFUR (oral) and low-dose FP (i.v.) was contributed to her 5-year survival.