A study of sternocleidomastoid muscular atrophy after modified neck dissection.

To elucidate the conditions of atrophy in the sternocleidomastoid muscle (SCM) after modified neck dissection (MND), we tried to scrutinize the atrophic regions in the SCM and determine the cause of atrophy, by electromyography in 40 patients with SCM atrophy following MND. We also examined the detailed anatomy of the SCM in 40 cadavers. Atrophy was observed in the caudal portion in the SCM in 90% of the patients. Electromyographic examination revealed neurogenic atrophy in 24 patients, ischemic atrophy in 11, and a mixing of both types in 5. The SCM was found to be innervated by the spinal accessory nerve (SAN) and the SCM branch of the cervical nerve. The main artery feeding the cranial half of the SCM was a branch of the occipital artery (Oc) or the external carotid artery (Ex), and the auxiliary artery was a branch of the posterior auricular artery (Ap). The main artery feeding the caudal half of the SCM was a branch of the superior thyroidal artery (St), and the auxiliary artery was a branch of the subclavian artery (Sc). Postoperative SCM atrophy is attributed to damage of the feeding artery in the SCM caudal portion and local damage in the nerve fibers running through the SCM. To prevent this type of atrophy, it is important to carefully handle this muscle itself and protect the nerve fibers running through it, as well as to conserve the SCM branches of the St and Sc.

Prediction of bone mass in renal hyperparathyroidism by newly developed bone metabolic markers: evaluation of serum levels of carboxy-terminal pyridinoline cross-linked telopeptide of type I collagen and carboxy-terminal propeptide of type I procollagen.

Serum levels of the carboxy-terminal pyridinoline cross-linked telopeptide of type I collagen (ICTP) and the carboxy-terminal propeptide of type I procollagen (PICP) were measured in 95 patients with renal hyperparathyroidism who had undergone a total parathyroidectomy and autotransplantation of a small portion of the resected gland. The results were compared with the serum levels of other bone metabolic markers and bone mineral densities in the distal radius (R-BMD) and lumbar vertebrae (L-BMD), which were measured by dual energy x-ray absorptiometry and converted to the percentage of the mean value of sex- and age-matched healthy controls. The preoperative mean values of ICTP and PICP were 142.4 ng/ml and 187.8 ng/ml, respectively. Although the serum levels of PICP levels exceeded the normal range in 42.1% of the patients, those of ICTP exceeded it in all of them. The serum levels of ICTP correlated positively not only with those of tartrate-resistant acid phosphatase (TRACP), total alkaline phosphatase (ALP), and osteocalcin but also negatively with the values of %R-BMD and %L-BMD and seemed to manifest specifically the disturbance of bone metabolism. On the other hand, the serum levels of PICP correlated with those of ALP and TRACP but not with values of %BMDs. After surgery, the serum levels of ICTP decreased gradually, but those of PICP increased immediately up to peak values at 7 days and then decreased gradually after 14 days, reaching the normal range at 3 months. These changes in the bone metabolic markers seemed to reflect the change in bone metabolism that was converting from bone resorption to bone formation. The percent change in the PICP/ICTP ratio at 7 days correlated significantly with the percent change in R-BMD at 12 months, and it was suggested that postoperative bone gain might be predicted using a combination of postoperative changes in PICP and ICTP.

[Detection and localization of enlarged parathyroid glands in patients with hyperparathyroidism using 99mTc-methoxyisobutylisonitrile (MIBI): a study of subtraction scintigraphy with 99mTc-pertechnetate].

In this study we investigated the detectability of abnormal parathyroid gland(s) by 99mTc-methoxyisobutylisonitrile (MIBI) scintigraphy in patients with hyperparathyroidism. The subjects were 6 patients with primary hyperparathyroidism (PHP) with a single adenoma and 13 patients with renal hyperparathyroidism (RHP) on chronic maintenance hemodialysis. The imaging data of 99mTc-pertechnetate were subtracted from those of 99mTc-MIBI (MIBI-Tc), and number and location of the positive images on scintigrams were compared with those obtained by conventional scintigraphy using 201Tl-Cl and 99mTc-pertechnetate (Tl-Tc). All of the patients underwent surgery, and the number and location of the abnormal parathyroid glands were confirmed. The number of resected parathyroid glands were 6 in PHP and 52 in RHP. The detectability of MIBI-Tc was 83.3% in PHP and 51.9% in RHP, while that of Tl-Tc was 100% and 44.2%, respectively. Although no statistically significant difference in the detectability was found between MIBI-Tc and Tl-Tc, the number of false positives with MIBI-Tc was less than that with Tl-Tc. The detectability of MIBI-Tc depended on the size of the parathyroid gland. The maximal diameter and weight of the smallest parathyroid gland detected were 15 mm and 290 mg in PHP, and 9 mm and 50 mg in RHP. The existence of the thyroid gland did not reduce the detectability of MIBI-Tc. In conclusion, MIBI-Tc was clinically very useful for the detection of abnormal parathyroid glands in patients with hyperparathyroidism.

Evaluation of bone loss and the serum markers of bone metabolism in patients with hyperparathyroidism.

Bone loss and the serum markers of bone metabolism were studied in 22 patients with primary hyperparathyroidism and 108 patients with renal hyperparathyroidism. The parameters of bone loss were bone mineral density in the distal radius and lumbar vertebrae, measured by dual energy X-ray absorptiometry, and bone mass index (sigma GS/D) and the metacarpal index, in the second metacarpal bone, measured by the digital image processing method. Alkaline phosphatase (AIP), intact osteocalcin (OC), and the carboxyterminal propeptide of type I procollagen (PICP) were measured as serum markers of bone formation, while tartrate-resistant acid phosphatase (TRACP) and the carboxyterminal pyridinoline cross-linked telopeptide of type I collagen (ICTP) were measured as serum markers of bone resorption. Bone loss and elevated markers of bone metabolism were observed both in patients with skeletal symptoms and in those without. Furthermore, the decrease in the cortical bone mass was more predominant than that of the trabecular bone. As markers of bone formation, AIP and OC seemed to be more sensitive than PICP, and as markers of bone resorption, ICTP appeared to be more sensitive than TRACP. Thus, a close correlation was observed between bone loss and the markers of bone formation and resorption.

Familial non-multiple endocrine neoplasia medullary thyroid carcinoma: report of a case confirming a new clinical entity in Japan.

Most hereditary medullary thyroid carcinomas (MTC) occur in association with multiple endocrine neoplasia (MEN) type 2 syndromes. Since Farndon et al. reported two kindreds, that is collections of relatives, with familial non-MEN MTC in 1986, only five kindreds with this disorder have been reported in the English literature. In this paper, we describe a rare Japanese kindred with familial non-MEN MTC, confirming the existence of this distinct clinical entity in Japan. A 42-year-old woman underwent a left hemithyroidectomy with modified neck dissection (MND) under a diagnosis of sporadic MTC at 28 years of age. She developed lymph node metastasis in the right neck region 7 years after the initial surgery, and underwent MND and right hemithyroidectomy. Although no findings of MTC were histologically confirmed in the resected right thyroid lobe, C-cell hyperplasia was observed. Hereditary MTC was strongly suspected, but we could not confirm specific manifestations associated with MEN type 2 in any family members. However, 7 years later, a paternal aunt and cousin were diagnosed with MTC. Other family members were evaluated by ultrasonography and calcium-pentagastrin provocation testing, and three additional patients with MTC across two generations were found. None of these patients had any extrathyroidal manifestations associated with MEN type 2, and the entity of familial non-MEN MTC was confirmed.

HLA antigens in arterial occlusive diseases in Japan.

Using a NIH standard lymphocytotoxicity test, a possible Japanese specific HLA antigen, HLA-BJW 22.2 was identified in 17 out of 48 patients with thromboangiitis obliterans (35.4 per cent), in 5 out of 15 patients with Takayasu's arteritis (33.3 per cent) and in 11 out of 113 normal controls (9.7 per cent). On the other hand, HLA-CWl was found in 4 out of 47 patients with arteriosclerosis obliterans (8.5 per cent) and in 41 out of 113 normal controls (36.3 per cent).