Acromegaly presenting with myelopathy due to ossification of posterior longitudinal ligament: a case report.

BACKGROUND: Acromegaly is a rare disease caused by high serum levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1), often originating from a pituitary adenoma. Spinal and peripheral joint abnormalities are caused by these hormonal hypersecretions. In particular, the response to GH is involved in the onset of ossification of the spinal ligament in vitro, especially ossification of the posterior longitudinal ligament (OPLL). However, because acromegaly and OPLL are rare diseases, we seldom encounter them in combination. To the best of our knowledge in the English-language literature, this is the first reported case of acromegaly presenting with thoracic myelopathy due to OPLL. CASE PRESENTATION: A 47-year-old woman presented with lower extremity weakness and paresthesia, gait disorder, and bladder disorder without any trauma. The patient's most remarkable symptom was paraplegia, and we diagnosed myelopathy due to cervical and thoracic OPLL. Furthermore, we suspected acromegaly because of the characteristic facial features, and we found a pituitary adenoma by contrast-enhanced MRI. Cervical and thoracic decompression, posterior fixation, and pituitary adenoma resection were performed. CONCLUSION: We report a case of acromegaly that was detected after the diagnosis of OPLL. The main challenge in acromegaly is delayed in diagnosis. Even in this case, the facial features characteristic of acromegaly had appeared at least 9 years ago. Early diagnosis and treatment of acromegaly improve prognosis and reduce exposure to GH and IGF-1 through early intervention and seem to suppress the progression of ligament ossification. Orthopedic surgeons and neurosurgeons need to keep in mind that acromegaly is associated with bone/joint lesions and ossification of the spinal ligament and should aim to diagnose acromegaly early.

Evaluation of antimicrobial prophylaxis against postoperative infection after spine surgery: Limit of the first generation cephem.

In our department, first-generation cephem (CEZ) are generally administered for 2 days as antimicrobial prophylaxis (AMP) for spinal surgery. However, the incidence of surgical site infection (SSI) has recently increased, particularly cases involving coagulase-negative Staphylococci (CNS) as an etiologic agent. The objective was to elucidate the problems with the current AMP and the risk factors of SSI through a retrospective investigation of affected cases. The subjects were patients who underwent spine surgery at our department between August 2007 and June 2013. The subjects were divided into those who developed SSI (S group) and who did not develop SSI (non-SSI (N) group), patients who developed CNS infection in the S group was subdivided as C group, and the risk factors were investigated. The significance of each factor was analyzed using cross tabulation, and multivariate logistic regression analyses were performed with 22 of the investigation factors as explanatory variables. The incidence of SSI was 2.55%, and the etiologic agent was CNS in 17 patients. Upon comparison between the S and N groups, the presence of 3 or more underlying diseases and blood loss were extracted as significant risk factors. Upon comparison between the C and N groups, emergency surgery and intra- and postoperative steroid administration were extracted as significant risk factors, in addition to the presence of 3 or more underlying diseases and blood loss. The effect of the current AMP using first generation cephem is limited, and reconsideration of the protocol may be necessary.

Decontamination of the Activation Product Based on a Legal Revision of the Cyclotron Vault Room on the Non-self-shield Compact Medical Cyclotron.

The non-self-shield compact medical cyclotron and the cyclotron vault room were in operation for 27 years. They have now been decommissioned. We efficiently implemented a technique to identify an activation product in the cyclotron vault room. Firstly, the distribution of radioactive concentrations in the concrete of the cyclotron vault room was estimated by calculation from the record of the cyclotron operation. Secondly, the comparison of calculated results with an actual measurement was performed using a NaI scintillation survey meter and a high-purity germanium detector. The calculated values were overestimated as compared to the values measured using the NaI scintillation survey meter and the high-purity germanium detector. However, it could limit the decontamination area. By simulating the activation range, we were able to minimize the concrete core sampling. Finally, the appropriate range of radioactivated area in the cyclotron vault room was decontaminated based on the results of the calculation. After decontamination, the radioactive concentration was below the detection limit value in all areas inside the cyclotron vault room. By these procedures, the decommissioning process of the cyclotron vault room was more efficiently performed.

Alcoholic severe acute pancreatitis with positive culture of pancreatic juice treated by nasopancreatic drainage.

BACKGROUND: Severe acute pancreatitis (SAP) is a serious disease associated with alcoholism and has a high mortality rate. Effective treatments have not been established. METHODS: A 58-year-old man was admitted due to alcoholic SAP. Endoscopic retrograde cholangiopancreatography revealed pancreatic calculi at the pancreas head and a stricture in the pancreatic duct from the pancreas head to the body. Endoscopically, nasopancreatic drainage (NPD) was placed through the minor papilla to the pancreas tail beyond the stricture. RESULTS: Pancreatic juice culture was positive for Streptococcus and Enterobacter. The day after NPD, upper abdominal pain was relieved. After changing NPD to a pancreatic stent, the patient was discharged on day 21 post-NPD. CONCLUSION: Alcoholic SAP may reflect aggravation of chronic pancreatitis. The possibility of acute bacterial inflammation should be considered in all cases of chronic alcoholic pancreatitis who present with severe features of inflammation, even in the early stages of an attack. Treatment of this subset of cases by drainage could be of great importance and NPD may be the preferred method.

Sigmoid Colon Perforation in Diffuse Large B-Cell Lymphoma Due to Tacrolimus-Induced Immunodeficiency: A Case Report.

The sigmoid colon is an uncommon site for the origin of primary malignant lymphomas in the GI tract. Additionally, immunosuppressive agents, widely used in treating autoimmune diseases, have been associated with the induction of malignancies, including lymphoproliferative disorders. In this report, we present a rare case of GI perforation suggesting a link between immunosuppressive therapy, particularly tacrolimus treatment, and diffuse large B-cell lymphoma (DLBCL). A 75-year-old female patient presented with abdominal pain to our ER. She had a medical history of polymyositis and interstitial pneumonia, treated with the immunosuppressant tacrolimus. An abdominal CT scan revealed free gas in the abdominal cavity, leading to a diagnosis of GI perforation. The patient exhibited generalized peritonitis and underwent emergency surgery the same day. During surgery, a perforation in the sigmoid colon was identified, and a Hartmann procedure was performed. Postoperative pathology showed CD20+, CD30+, CD5-, CD10-, BCL6+, MUM1+, and MIB-1 LI of 50-60%. The diagnosis of DLBCL was confirmed, classified as EBV-positive diffuse large B-cell lymphoma, not otherwise specified (NOS), in the sigmoid colon, with positive EBER-ISH, LMP-1, and EBNA2 findings. Given her history of immunosuppressant use, she was categorized as having other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD), according to the WHO Classification of 2017. This case highlights the importance for clinicians to consider the risk of oncogenesis associated with the prolonged use of immunosuppressive agents.

A Case of Acute Colonic Pseudo-Obstruction and Anastomotic Leakage After Sigmoidectomy for Sigmoid Volvulus.

Acute colonic pseudo-obstruction (ACPO) is characterized by significant colonic distension without a mechanical obstruction. We present a case of an 83-year-old male who developed ACPO following laparoscopic surgery for sigmoid volvulus. This report details the patient's postoperative journey, highlighting the diagnostic and management challenges encountered. Despite various medical interventions, the patient's condition necessitated further surgical attention due to complications. This case underscores the importance of early diagnosis and aggressive management in ACPO to prevent life-threatening consequences and improve patient outcomes.

A Rare Case of Completely Calcified Lumber Juxta-facet Cyst: A Case Report.

Introduction: Juxta-facet cysts (JFCs) are extradural lesions. Calcification of cyst walls is often reported, although completely calcified facet cysts are extremely rare. Case Presentation: A 65-year-old man presented with a 1-year history of the right lower extremity weakness and pain, and chronic low back pain. Imaging showed hypointensity on T1- and T2-weighted magnetic resonance images which can be very well appreciated on a completely calcified computed tomography mass arising from the right L3/4 facet joint. The patient underwent a total cyst removal with a facetectomy of the right L3/4 facet, and L3 to L4 posterior fusion. Conclusion: We presented a case of a completely calcified JFC in a patient with back pain and radiculopathy who underwent cystectomy and spinal fusion. JFCs should be considered in the differential diagnosis of calcified extradural lesions.

Incidence of synchronous and metachronous pancreatic carcinoma in 168 patients with branch duct intraductal papillary mucinous neoplasm.

BACKGROUND/AIMS: Although branch duct intraductal papillary mucinous neoplasms of the pancreas (BD-IPMN) are being diagnosed with increasing frequency, the incidence of concomitant pancreatic carcinoma (PC) is not well known. We investigated the incidence and clinical features of synchronous and metachronous PC in patients with BD-IPMN. METHODS: We studied 168 BD-IPMN patients diagnosed by various imaging modalities, including endoscopic retrograde pancreatography, between 1990 and 2008. We reviewed the medical records and clinical features in both patients developing and not developing PC. The diagnosis of PC was histologically verified in all patients. RESULTS: PC was observed in 9 (5.4%) of 168 patients. Five were synchronously detected at the time of BD-IPMN diagnosis, whereas four were metachronously identified during the follow-up period. All PCs occurred in regions separate from the BD-IPMN lesion. All PCs represented histologically invasive ductal adenocarcinomas, whereas the BD-IPMN lesion was diagnosed as adenoma. Patients developing PC were significantly older than patients not developing PC (p = 0.017). The diameters of the BD-IPMN lesions and main pancreatic ducts were significantly smaller in patients developing PC than patients not developing PC (p = 0.013 and p < 0.001, respectively). CONCLUSIONS: It was not infrequent for PC to occur in the pancreas with BD-IPMN. Particular attention should therefore be paid to the development of PC, even in low-risk BD-IPMN, as well as to changes in BD-IPMN.

[A case of pancreatic carcinoma presenting as pancreaticopleural fistula with pancreatic pleural effusion].

A 63-year-old man was admitted with left pleural effusion, and an amylase level of 30994IU/l. A diagnosis of pancreaticopleural fistula was made, based on the findings of magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography (ERP). After the placement of an endoscopic naso-pancreatic drainage tube, the pleural effusion markedly reduced. When ERP was performed for internal drainage, the main pancreatic duct and stricture were biopsied and showed pancreatic ductal adenocarcinoma histologically. CT revealed a mass in the head of the pancreas. He underwent pylorus-preserving pancreaticoduodenectomy. To the best of our knowledge this is the first case of pancreatic carcinoma presenting as pancreaticopleural fistula with pancreatic pleural effusion. Clinicians should pay attention to the possible presence of cancer and pancreaticopleural fistula in patients with pancreatic pleural effusion.

Adult Morquio syndrome requiring occipito-thoracic fusion.

Morquio syndrome is a relatively rare entity that is often associated with atlantoaxial instability from early childhood due to odontoid dysplasia based on a mucopolysaccharoidal disorder. Here, we present the case of a 55-year-old male patient with Morquio syndrome who developed cervical myelopathy, which is an extremely rare condition in the older population. Myelopathy developed gradually with upper-limb paresthesia and clumsiness of both hands. The patient had a characteristic "gargoyle-like" coarse face with a trunk shortening-type short stature. Imaging of the cervical spine demonstrated several problems, including diminutive structures called platyspondyly with small pedicles and fragile bone quality, hypoplasia of the C1 posterior arch that migrated into the spinal canal, and os odontoideum with atlantoaxial instability. With intraoperative navigation guidance, posterior decompression of C1 followed by occipito-cervico-thoracic spinal fusion was successfully performed in this complicated case. Clinical and radiographic outcomes were both excellent and have been maintained for 2 years postoperatively.

[Gemcitabine in combination with S-1 or UFT in patients with advanced pancreatic cancer].

The present retrospective study aimed to evaluate the anti-tumor activity and toxicity of combination chemotherapy with gemcitabine (GEM) and oral S-1 or UFT in patients with advanced or metastatic pancreatic cancer. Ninety-four patients received chemotherapy. Among them, sixty-three were treated with GEM alone, twenty-two with UFT and GEM (UFT/GEM), and nine with S-1 and GEM(S-1/GEM). The median survival time was 8.7 months with GEM, 7.3 months with UFT/GEM, and 23.3 months with S-1/GEM. The overall response rate was 11.1%, 10.0%, and 22.2%, respectively. The 1-year survival rate was 29.5%, 36.4%, and 85.7%, respectively. Although the treatment-related adverse effects were not infrequent in patients treated with S-1/GEM, they were moderate in intensity. The combination chemotherapy with S-1/GEM was well tolerated and yielded a high response rate in patients with pancreatic cancer.

A Case of a Spinal Extradural Arachnoid Cyst.

The patient was a 49-year-old woman with a chief complaint of hip and buttock pain that had persisted for 3 years. She visited our hospital for aggravation of the pain. Percussion tenderness of the spinous process was observed and a T1-low, T2-high cystic lesion was detected on the dorsal side of the dural canal at the 12th thoracic vertebral level on MRI performed by a previous physician. Plane CT showed severe scalloping at the same level. During laminectomy for the 11th and 12th thoracic vertebrae, a cystic lesion of about 60 × 25 mm was noted on the dorsal side of the dural canal, with a communication pathway with the cyst present near the left 12th nerve root bifurcation. This pathway was ligated and the cyst was excised. The histopathological diagnosis was an arachnoid cyst. Pain improved after surgery, and as of 10 months after surgery, the cystic lesion has not recurred. A spinal extradural arachnoid cyst (SEAC) is a relatively rare disease. This case shows that surgical ligation of a communicating tract and cystectomy are necessary and contrast-enhanced CT was useful for the identification of the position of the communication pathway before surgery.

Sonic hedgehog derived from human pancreatic cancer cells augments angiogenic function of endothelial progenitor cells.

Hedgehog signaling is important in the pathogenesis of pancreatic cancer. Several recent observations suggest the involvement of sonic hedgehog (SHH) in postnatal neovascularization. We identified a novel role for SHH in tumor-associated angiogenesis in pancreatic cancer. Immunohistochemical analysis revealed that patched homolog 1 (PTCH1), both a receptor for and transcriptional target of hedgehog signaling, was expressed in a small fraction of endothelial cells within pancreatic cancer, but not in normal pancreatic tissue. When endothelial progenitor cells (EPC) isolated from human peripheral blood were cultured with supernatant from SHH-transfected 293 cells or pancreatic cancer cells, mRNA levels of vascular endothelial growth factor (VEGF), stromal cell-derived factor-1 and angiopoietin-1 were significantly increased, whereas no such induction was observed in human umbilical vein endothelial cell (HUVEC) and human dermal microvascular endothelial cell (HMVEC). HUVEC tube formation was stimulated when cocultured with EPC, and preconditioning EPC with supernatant from KP-1 N pancreatic cancer cells highly expressing SHH significantly enhanced the effect. The effect was partially attenuated by specific inhibition of SHH with cyclopamine or a neutralizing antibody. These findings suggest that tumor-derived SHH can induce angiogenesis, and this is mediated by its effects on EPC specifically. Targeting SHH would be a novel therapeutic approach that can inhibit not only proliferation of cancer cells but also EPC-mediated angiogenesis.

[Milk-of-calcium in a pseudocyst of the pancreas].

A 59-year-old woman with a history of abdominal injury was admitted to our hospital for abdominal discomfort. CT revealed a cyst showing a fluid-calcium level in the pancreatic body. EUS-FNA was performed to aspirate the fluid in a cyst. Aspirated was milky-white odorless material. Chemical analysis showed high amylase level in the fluid. Spectroscopic analysis revealed that the fluid mainly consists of calcium phosphate. To the best of our knowledge, this is the first case of milk-of-calcium in a pancreatic pseudocyst with an analysis of cystic fluid obtained by EUS-FNA.

Use of intrawound vancomycin powder against postoperative infection after spine surgery.

Local application of vancomycin has recently become widely used in spine surgery. However, local application is not included in the indication and has not been approved by the US Food and Drug Administration (FDA). Thus, we searched for reports with "intra wound-vancomycin" and "SSI" as keywords in the MEDLINE database, and investigated the efficacy, problems with use, and future prospects based on these reports. Intrawound vancomycin was described as effective in most of the reports, but was found to have no effect or to aggravate the condition in some reports. A toxic effect on osteoblasts due to a high local concentration was described in some reports, whereas local application was found to be safe in other studies. The amount of vancomycin used and the administration method varied among the reports. Overall, the results suggest that intrawound vancomycin is clinically effective, but this has yet to be established in a randomized controlled trial. There is a need to identify cases that should be selected for this treatment and to investigate the dose and optimum concentration of vancomycin for clinical use.

A high-throughput sequence analysis of Japanese patients revealed 11 candidate genes associated with type 1 autoimmune pancreatitis susceptibility.

The pathogenesis of autoimmune pancreatitis is unknown. In the present study we used high-throughput sequencing with next generation sequencing to identify the candidate genes associated with AIP. A total of 27 type 1 AIP patients and 30 healthy blood donors were recruited, and DNA samples were isolated from their mononuclear cells. A high-throughput sequencer with an original custom panel of 1031 genes was used to detect the genetic variants in each sample. Polymorphisms of CACNA1S (c.4642C>T), rs41554316, rs2231119, rs1042131, rs2838171, P2RX3 (c.195delG), rs75639061, SMAD7 (c.624delC) and TOP1 (c.2007delG), were identified as candidate genetic variants in patients with type 1 AIP. P2RX3 and TOP1 were significantly associated with AIP, even after adjusting bay means of Bonferroni's correction. In addition, we also identified eight candidate genetic variants that were associated with the relapse of type 1 AIP, namely: rs1143146, rs1050716, HLA-C (c.759_763delCCCCCinsTCCCG), rs1050451, rs4154112, rs1049069, CACNA1C (c.5996delC) and CXCR3 (c.630_631delGC). Finally polymorphisms of rs1050716 and rs111493987 were identified as candidate genetic variants associated with extra-pancreatic lesions in patients with type 1 AIP. These candidates might be used as markers of AIP susceptibility and could contribute to the pathogenesis of type 1 AIP.

Spontaneous remission of primary diffuse large B-cell gastric lymphoma.

Spontaneous and complete disappearance of diffuse large B-cell lymphoma (DLBL) of the stomach is extremely rare. Although regression of gastric DLBL after eradication of Helicobacter pylori has recently been reported, we present two consecutive cases of stage I DLBL of the stomach which disappeared after only nonspecific therapy, including histamine 2-receptor antagonist (H2RA); both cases were documented histologically and endoscopically. Both patients were positive for H. pylori, and later received H. pylori eradication therapy. The disease has not recurred after 11 and 6 months, respectively. Our cases suggest that the option of combination therapy with H2RA either with or followed by H. pylori eradication is appropriate for consideration as an initial approach in standard therapy for stage I diffuse large B-cell gastric lymphoma.

[Phase I study of concurrent radiotherapy with TS-1 and vitamin A (TAR Therapy) for head and neck cancer].

The triple combination of 5-fluorouracil (5-FU), vitamin A and radiation (FAR therapy) has been effectively used to treat head and neck cancer. The biological anti-tumor effect of 5-FU depends on the activity of its metabolizing enzyme, dihydropyrimidine dehydrogenase (DPD). TS-1 is a novel oral DPD inhibitory fluoropyrimidine (DIF). To improve the anti-tumor effect of FAR therapy, we have applied TS-1 in place of 5-FU injection in the combination of Vitamin A and radiation (TAR therapy). In this study, we have examined the appropriate duration of TS-1 medication and the clinical efficacy and safety of TAR therapy. TS-1 was administered orally at a dose of 65 mg/m2 twice a day. Vitamin A (Retinol Palmitate: 50,000 U/day) was administered intra-musculary on each day of radiation. Radiation was given (1.5-2 Gy/day: 5 days/week) for 30-40 Gy. The levels were divided according to the length of TS-1 application as follows: level 1, 2 weeks; level 2, 3 weeks; level 4, 4 weeks. Grade 4 toxicity of anorexia was observed in one case of level 3. We decided that level 2 (3 weeks of TS-1 administration) was the appropriate length of TS-1 application. TAR therapy is a useful concurrent chemo-radiotherapy which might improve the response rate and QOL of patients with HNSCC.

Treatment of Renal Cell Carcinoma with 2-Stage Total en bloc Spondylectomy after Marked Response to Molecular Target Drugs.

Metastatic renal cell carcinoma of the bone occurs at a high rate, and the prognosis is poor. In general, total en bloc spondylectomy is considered when there is only one vertebral metastasis and the primary disease is treated. However, palliative surgery is selected when the primary disease is not being treated or metastasis occurs to an important organ. We encountered a patient in whom lung and vertebra metastases were already present at the time of the first examination at our department and the prognosis was considered poor. However, molecular targeted therapy was markedly effective and enabled 2-stage total en bloc spondylectomy. As of one year after total en bloc spondylectomy, the condition has improved to cane gait, and surgery for lung metastasis is planned. Molecular target drugs might markedly change the current therapeutic strategy for renal cell carcinoma.

Unruptured cystic artery pseudoaneurysm accompanied by Mirizzi syndrome: a report of a case.

Pseudoaneurysm of the cystic artery is a rare complication of cholecystitis. 34 cases have been reported from 1976 to 2012, searched on MEDLINE and most of the cases have presented with gastrointestinal bleeding. We report the third case of an unruptured pseudoaneurysm of the cystic artery associated with calculous cholecystitis. An 85-year-old female presented to the emergency unit with epigastric pain and jaundice. Laboratory data and contrast-enhanced computed tomography (CT) revealed calculous cholecystitis and Mirizzi syndrome accompanied by a pseudoaneurysm in the gallbladder. Color Doppler ultrasonography (US) clearly demonstrated the pulsatile pseudoaneurysm. After biliary drainage and antimicrobial therapy, selective hepatic angiography with the aim of providing transcatheter arterial embolization was performed but the pseudoaneurysm had already thrombosed spontaneously. Open cholecystectomy was successfully carried out. Histological specimens demonstrated the pseudoaneurysm with organized thrombus in the epithelial wall of the gallbladder thickened with severe fibrosis. It is suggested that cholecystitis with unusual symptoms such as gastrointestinal bleeding requires immediate enhanced CT and US with Doppler imaging in order not to overlook a rare but life-threatening pseudoaneurysm.