[Surgical approaches for superior sulcus tumor].

Surgical approach is one of the most crucial aspects in the treatment of superior sulcus tumor (SST). Posterior approach as described by Paulson and coworkers is appropriate for the resection of SST invading posterior part of the 1st rib and the vertebrae, whereas anterior approaches as described by Masaoka, Dartevelle, Grunenwald, or Rusca are suitable for resection of SST involving subclavian vessels. We present 2 cases of SST who underwent complete resection through the posterior approach and a modified hemi-clamshell approach, respectively. We also discuss the surgical approaches for SST with referring to literatures.

Standardization of laboratory data and establishment of reference intervals in the Fukuoka Prefecture: a Japanese perspective.

Standardization of 22 clinical chemistry analytes and five serum protein constituents has been performed in the Fukuoka Prefecture, which has a population of approximately five million. The standardization project was established to determine reference intervals for these analytes by educating physicians, medical technologists and staff of medical institutions, and by daily or monthly monitoring the use of common control samples through e-mail. Standardization extended to 97% of the institutions in the prefecture. Results for 14 of the 22 clinical chemistry analytes have become highly reliable and differences between institutions decreased. Standardization of other analytes is now in progress. Regional collaboration based on international guidelines led to a significant improvement in interlaboratory comparability. Areas where further improvements are needed have been identified.

Screening for gastroenterological malignancies in new and maintenance dialysis patients.

To screen for gastroenterological malignancies in dialysis patients, we used the fecal occult blood test, examined the upper and lower gastrointestinal tract, and used abdominal ultrasonography in 178 patients starting dialysis (171 on hemodialysis and 7 on continuous ambulatory peritoneal dialysis (CAPD)) and 34 patients on maintenance dialysis (27 on hemodialysis and 7 on CAPD). Screening disclosed ten cancers (one esophageal cancer, three gastric cancers, four colorectal cancers, and two hepatocellular carcinomas) in 9 of the patients starting dialysis. Six cancers (one esophageal, three gastric, one colorectal, and one renal) were detected in 5 of the patients on maintenance dialysis. Since an increased incidence of malignancy has been reported in dialysis patients, gastroenterological screening appears to be worthwhile.

Statistical analysis of malignant tumors detected as the cause of vocal cord paralysis.

It is well known that vocal cord paralysis is sometimes the only sign of an otherwise symptom-free malignant tumor. We report 69 cases of vocal cord paralysis caused by malignant tumor experienced at our clinic over the past 18 years. They consisted of 28 cases of thyroid cancer, 21 lung cancer, 14 esophageal cancer, 3 mediastinal tumors and 3 tumors of miscellaneous origin: 41 cases were male and 28 female. In the 65 patients with unilateral paralysis, the left side was affected in 45 and the right in 20. The remaining 4 patients had bilateral paralysis. There was a marked sex difference in the origin of malignant tumors; the incidence of lung cancer was higher in males with paralysis on the left side, while that of thyroid cancer was higher in females. Ultrasonography (US) of the neck, chest X-ray, CT scan of the chest and contrast esophagography should be performed for the detection of malignant tumors in cases with left paralysis, while US of the neck and chest X-ray appear to be sufficient in cases of right paralysis.

[A case of spontaneous rupture of the ascending aorta].

We report a rare case of spontaneous rupture of the ascending aorta without any evidence of aneurysm formation or aortic dissection. A woman aged 64 was admitted to our cardiac care unit as an emergency patient with severe chest pain. Her face was pale and systolic blood pressure was 70 mmHg in spite of intravenous administration of dopamine (10 micrograms/kg/min). She had a history of hypertension for two years under good medical control. No trace of the chest trauma was noted before her admission. Physical examination revealed neck vein engorgement and distant heart sounds. Chest X-ray film showed enlargement of the cardiac silhouette. ECG showed no evidence of acute coronary syndrome. Pericardial effusion with a floating hematoma-like mass was detected by 2-dimensional echocardiogram. Pericardiocentesis revealed bloody pericardial fluid (Ht: 26%). Aortagraphy was performed resulting in a clinical diagnosis of acute aortic dissection, but there were no signs of a false lumen, aneurysm formation or extravasation of the contrast medium. Although continuous pericardial drainage was performed, she suddenly lost consciousness, collapsed and died. A longitudinal intimal laceration 5 cm long was observed in the ascending aorta. Pathological examination revealed cystic medial necrosis and irregularity of the elastic fibers in the media. No atheromatous plaque was noted in the intima. Spontaneous rupture of the aorta is a life-threatening condition that requires urgent surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Head and neck carcinomas in patients under the age of forty years.

From 1973 to 1988, 1,104 patients with head and neck carcinomas (excluding thyroid carcinoma) were admitted to the Yokohama City University Hospital, and among them, 48 (4.3%) were under the age of 40 years. We made a retrospective survey of these young patients. There were 36 males and 12 females. An increasing ratio of male to female was seen with increasing age. The primary site was most frequently the nasopharynx (29 cases), followed by the maxillary sinus (9 cases), and the tongue (4 cases). Squamous cell carcinoma in these young patients characteristically showed a low grade of differentiation.

[Clinical studies of malignant tumors in the nasal cavity].

Nineteen cases with malignant tumors in the nasal cavities have been treated at the department of otolaryngology, Yokoharma City University, during the 10 years from 1978 to 1987. 1. Cases were 8 males and 11 females, and their ages ranged from 27 to 84 years (Mean age: 64.6). 2. In the histological classification, 9 cases were the epithelial malignant tumors (squamous cell carcinoma 5; adenoid cystic carcinoma 2; transitional cell carcinoma 1; malignant pleomorphic adenoma 1), 9 cases were non-epithelial malignant tumors (malignant melanoma 6; malignant lymphoma 2; olfactory neuroblastoma 1), and one case was unclassified malignant tumor. 3. Cases with epithelial malignant tumors showed better prognosis after treatment of surgical and radiation therapy. But those of non-epithelial malignant tumor were worse. 4. A very rare case with malignant pleomorphic adenoma, originated at the lateral nasal wall was reported and its clinical features and treatment were discussed. This tumor has not been reported up to the present in Japan.

[A statistical study of clinical cases of malignant tumors first manifested by vocal cord paralysis].

One of the most important problems in dealing with vocal cord paralysis is to clarify the cause of paralysis. In those case where the definite cause is unknown, it is possible that an occult type of malignant tumors exists along the course of the vagus or recurrent laryngeal nerves. For the past 16 years, 62 out of 560 cases with vocal cord paralysis were diagnosed to have malignant tumors first manifested by paralysis of vocal cord. They consisted of 25 cases of thyroid carcinoma, 18 lung carcinoma, 13 esophageal carcinoma, 3 mediastinal tumors and 3 tumors of miscellaneous origin. Among these, 36 were male and 26 were female and the mean age was 63 years old. In 40 cases, paralysis was found on the left side, in 18 on the right and bilaterally in the remaining 4. There was a marked sexual difference in the origin of malignant tumors, i.e. the incidence of lung carcinoma was higher in male with paralysis on the left side, while that of thyroid carcinoma was higher in female. In some cases with thyroid carcinoma, vocal cord paralysis was noted more than a year before the detection of the tumor. Ultrasonography of the neck, chest x-ray, CT scan of the chest, fluoroscopy of the pharyngo-esophagus should be performed for the detection of malignant tumors in cases with left vocal cord paralysis, while ultrasonography of the neck and chest x-ray should be sufficient in right paralysis, although additional fluoroscopy of the pharyngo-esophagus seemed preferable in male.

[A case report of aortitis syndrome with massive aortic regurgitation (AR), and ostial stenosis of the right coronary artery].

A 55-year-old female with massive aortic regurgitation and ostial stenosis of the right coronary artery due to aortitis syndrome was reported. The patient was admitted to the hospital with anterior chest pain and dyspnea on exertion. Retrograde aortogram showed massive aortic regurgitation and selective coronary angiogram revealed ostial stenosis of the right coronary artery. She was treated with aorto-coronary bypass (A-C bypass) and aortic valve replacement (AVR) with St. Jude Medical prosthetic valve. At operation, ostial stenosis of the right coronary artery due to aortitis syndrome was confirmed. Aortic valve replacement with a prosthetic valve and saphenous vein grafting to the distal right coronary artery were performed. Steroid therapy was started immediately after the operation. She recovered well and no complications was recognized after the operation.

[A case report of successful surgical treatment of fungal endocarditis].

A successfully treated case of fungal endocarditis for native aortic and mitral valves was reported. A 56-year-old male was admitted with high fever, dyspnea on exertion and oliguria. Infective endocarditis, urinary tract infection and acute renal failure were most suspected by findings of physical examination and urinalysis, but repeated blood cultures were sterile. In the course of treatment for urinary tract infection, high fever and leucocytosis recurred and then blood cultures were positive for Candida parapsilosis. Despite intensive antifungal therapy, blood cultures were consistently positive for Candida parapsilosis. Echocardiogram showed vegetation on the aortic and mitral valve. Aortic and mitral valve replacements with prosthetic heart valves were carried out on April, 1986. Cultures of the vegetation on the mitral valve revealed Candida parapsilosis. Intensive administration of antifungal drug was done postoperatively. Postoperative course was uneventful and he was discharged in excellent condition on the 84th postoperative day. During follow-up period of 1 year, the patient has been doing very well and there were no sign of recurrence of fungal infections.

[Changing modality of the treatment in upper urinary tract calculi. Percutaneous nephrolithotripsy and transurethro-ureteral lithotripsy].

From March, 1984 to April, 1985, 70 cases of upper urinary tract calculi (73 renal units) were treated by percutaneous nephrolithotripsy or transurethro-ureteral lithotripsy, mainly utilizing ultrasonic lithotrite. While in the early period of treatment, two stage procedure of creation of nephrostomy tract and percutaneous nephrolithotripsy was performed for renal and upper or middle part of the ureteral calculi, one stage procedure, nephrostomy tract formation followed by ultrasonic nephrolithotripsy is commonly used in recent cases. During this period, conventional stone surgery was seen in 6 cases of pyelolithotomy and 2 of ureterolithotomy, while 52 cases of stone surgery were performed during the earlier period (from January, 1983 to February, 1984). Renal and upper or middle part of ureteral calculi were successfully removed in 49 out of 58 cases (84.5%). Most of the patients required 1 or 2 trials of percutaneous nephrolithotripsy. Middle or lower part of ureteral calculi were removed in transurethro-ureteral approach in 11 of the 12 cases. Hematuria and fever were most common complications after treatment and 3 patients required blood transfusion after 3 or 4 sessions of nephrolithotripsy. Percutaneous nephrolithotripsy and transurethro-ureteral lithotripsy are now widely used for treatment of upper urinary tract calculi, replacing the conventional surgical treatment. Moreover, very recently, extracorporeal shock wave lithotripsy is available in Japan. To the patients with renal calculi indicative of this treatment, both percutaneous nephrolithotripsy and extracorporeal shock wave lithotripsy are introduced and either way of treatment can be chosen by the patient himself.

[Sequential combination chemotherapy consisting of vincristine, peplomycin, methotrexate, cis-diamminedichloroplatinum (II), cytosine arabinoside and 5-fluorouracil, for advanced urothelial cancer].

Two VPM-CisCF chemotherapy regimens (vincristine (VCR), peplomycin (PEP), methotrexate (MTX), cis-diamminedichloroplatinum (II) (CDDP), cytosine arabinoside (Ara-C) and 5-fluorouracil (5-FU), established using human bladder cancer xenografts in nude mice were applied for advanced urothelial cancer. VPM-CisCF (I) consisted of 0.4 mg/m2 VCR on days 1 and 4, 2 mg/m2 PEP on days 1-7, 2 mg/m2 MTX on days 2, 3, 5 and 6, 20 mg/m2 CDDP on days 8, 20 mg/m2 Ara-C on days 8 and 13, and 150 mg/m2 5-FU on days 10-12. VPM-CisCF (II) consisted of 0.6 mg/m2 VCR on days 1 and 3, 3 mg/m2 PEP on days 1-4, 3 mg/m2 MTX on days 2 and 3, 35 mg/m2 CDDP on day 4, 20 mg/m2 Ara-C on days 4 and 7, and 200 mg/m2 5-FU on days 5 and 6. These doses were adjusted for each case: the above mentioned dose x [(80/(40 + Age))2 + (Karnofsky's performance status/100)2]. VPM-CisCF (I) was administered to 6 patients (bladder cancer and transitional cell carcinoma), intra-arterially in two cases. One patient showed a complete response and survived for 7 months, three partial response (PR) surviving for 13, 8 and 37 (arterial-infused case) months, one showed minor response (MR) surviving for 4 months, and one had no change (NC) surviving for 5 months. VPM-CisCF (II) was administered to 11 patients (1 ureteral cancer, 1 renal pelvic cancer, 9 bladder cancer, and 10 transitional cell carcinoma except a case of mixed type of transitional cell carcinoma and squamous cell carcinoma). Four of the patients who had PR survived for 9, 8, 8 and 7 (alive) months, two who had MR survived for 8 and 4 months, three who had NC survived for 6, 4 and 4 months, and who two had progressive disease survived for 8 and 6 months. The major toxicities were myelosuppression and gastrointestinal symptoms, especially nausea and vomiting, but the treatment was well-tolerated.

[Renal cell carcinoma, primary lesion which was not easily identified: report of two cases].

We report two cases of renal cell carcinoma, primary lesions of which were not diagnosed at an early stage. The first case was a 58-year-old woman, who had nephrectomy due to staghorn calculus of left kidney. Fifteen months later, she died of metastatic cancer whose origin was unknown until the left kidney was re-examined. It was sarcomatoid renal cell carcinoma. The second case was 43-year-old woman, who had amputation of right index finger due to metastatic tumor. Renal cell carcinoma was highly suspected, but no tumor could be found in her kidneys although various urological examinations were performed. Two years later, abdominal CT scan showed a space-occupying lesion (SOL) of left kidney. She had left nephrectomy, and the origin was finally identified.