Alpha galactosidase A activity in Parkinson's disease.

Glucocerebrosidase (GCase, deficient in Gaucher disease) enzymatic activity measured in dried blood spots of Parkinson's Disease (PD) cases is within healthy range but reduced compared to controls. It is not known whether activities of additional lysosomal enzymes are reduced in dried blood spots in PD. To test whether reduction in lysosomal enzymatic activity in PD is specific to GCase, we measured GCase, acid sphingomyelinase (deficient in Niemann-Pick disease types A and B), alpha galactosidase A (deficient in Fabry), acid alpha-glucosidase (deficient in Pompe) and galactosylceramidase (deficient in Krabbe) enzymatic activities in dried blood spots of PD patients (n = 648) and controls (n = 317) recruited from Columbia University. Full sequencing of glucocerebrosidase (GBA) and the LRRK2 G2019S mutation was performed. Enzymatic activities were compared between PD cases and controls using t-test and regression models adjusted for age, gender, and GBA and LRRK2 G2019S mutation status. Alpha galactosidase A activity was lower in PD cases compared to controls both when only non-carriers were included (excluding all GBA and LRRK2 G2019S carriers and PD cases with age-at-onset below 40) [2.85 µmol/l/h versus 3.12 µmol/l/h, p = 0.018; after controlling for batch effect, p = 0.006 (468 PD cases and 296 controls)], and when including the entire cohort (2.89 µmol/l/h versus 3.10 µmol/l/h, p = 0.040; after controlling for batch effect, p = 0.011). Because the alpha galactosidase A gene is X-linked, we stratified the analyses by sex. Among women who were non-carriers of GBA and LRRK2 G2019S mutations (PD, n = 155; control, n = 194), alpha galactosidase A activity was lower in PD compared to controls (2.77 µmol/l/h versus 3.10 µmol/l/h, p = 0.044; after controlling for a batch effect, p = 0.001). The enzymatic activity of acid sphingomyelinase, acid alpha-glucosidase and galactosylceramidase was not significantly different between PD and controls. In non-carriers, most lysosomal enzyme activities were correlated, with the strongest association in GCase, acid alpha-glucosidase, and alpha galactosidase A (Pearson correlation coefficient between 0.382 and 0.532). In a regression model with all five enzymes among non-carriers (adjusted for sex and age), higher alpha galactosidase A activity was associated with lower odds of PD status (OR = 0.54; 95% CI:0.31-0.95; p = 0.032). When LRRK2 G2019S PD carriers (n = 37) were compared to non-carriers with PD, carriers had higher GCase, acid sphingomyelinase and alpha galactosidase A activity. We conclude that alpha galactosidase A may have a potential independent role in PD, in addition to GCase.

Clinical evaluation of eye movements in spinocerebellar ataxias: a prospective multicenter study.

BACKGROUND: Ocular motor abnormalities reflect the varied neuropathology of spinocerebellar ataxias (SCAs) and may serve to clinically distinguish the different SCAs. We analyzed the various eye movement abnormalities detected prospectively at the baseline visit during a large multicenter natural history study of SCAs 1, 2, 3, and 6. METHODS: The data were prospectively collected from 12 centers in the United States in patients with SCAs 1, 2, 3, and 6, as part of the Clinical Research Consortium for Spinocerebellar Ataxias (NIH-CRC-SCA). Patient characteristics, ataxia rating scales, the Unified Huntington Disease Rating Scale functional examination, and clinical staging were used. Eye movement abnormalities including nystagmus, disorders of saccades and pursuit, and ophthalmoparesis were recorded, and factors influencing their occurrence were examined. RESULTS: A total of 301 patients participated in this study, including 52 patients with SCA 1, 64 with SCA 2, 117 with SCA 3, and 68 with SCA 6. Although no specific ocular motor abnormality was pathognomonic to any SCA, significant differences were noted in their occurrence among different disorders. SCA 6 was characterized by frequent occurrence of nystagmus and abnormal pursuit and rarity of slow saccades and ophthalmoparesis and SCA 2 by the frequent occurrence of slow saccades and infrequent nystagmus and dysmetric saccades. SCA 1 and SCA 3 subjects had a more even distribution of eye movement abnormalities. CONCLUSIONS: Prospective data from a large cohort of patients with SCAs 1, 2, 3, and 6 provide statistical validation that the SCAs exhibit distinct eye movement abnormalities that are useful in identifying the genotypes. Many of the abnormalities correlate with greater disease severity measures.

Subthalamic nucleus deep brain stimulation for Parkinson's disease: evidence for effectiveness and limitations from 12 years' experience.

OBJECTIVE: To present the result and experience of subthalamic nucleus deep brain stimulation for Parkinson's disease. DESIGN: Case series. SETTING: Prince of Wales Hospital, Hong Kong. PATIENTS: A cohort of patients with Parkinson's disease received subthalamic nucleus deep brain stimulation from September 1998 to January 2010. Patient assessment data before and after the operation were collected prospectively. RESULTS: Forty-one patients (21 male and 20 female) with Parkinson's disease underwent bilateral subthalamic nucleus deep brain stimulation and were followed up for a median interval of 12 months. For the whole group, the mean improvements of Unified Parkinson's Disease Rating Scale (UPDRS) parts II and III were 32.5% and 31.5%, respectively (P<0.001). Throughout the years, a multidisciplinary team was gradually built. The deep brain stimulation protocol evolved and was substantiated by updated patient selection criteria and outcome assessment, integrated imaging and neurophysiological targeting, refinement of surgical technique as well as the accumulation of experience in deep brain stimulation programming. Most of the structural improvement occurred before mid-2005. Patients receiving the operation before June 2005 (19 cases) and after (22 cases) were compared; the improvements in UPDRS part III were 13.2% and 55.2%, respectively (P<0.001). There were three operative complications (one lead migration, one cerebral haematoma, and one infection) in the group operated on before 2005. There was no operative mortality. CONCLUSIONS: The functional state of Parkinson's disease patients with motor disabilities refractory to best medical treatment improved significantly after subthalamic nucleus deep brain stimulation. A dedicated multidisciplinary team building, refined protocol for patient selection and assessment, improvement of targeting methods, meticulous surgical technique, and experience in programming are the key factors contributing to the improved outcome.

Intensity-modulated radiation therapy for T4 nasopharyngeal carcinoma. Treatment results and locoregional recurrence.

PURPOSE: The purpose of this work was to examine outcomes in patients with T4 nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiation therapy (IMRT). METHODS AND MATERIALS: Between 2007 and 2010, 154 patients with nonmetastatic T4 NPC were treated with IMRT to a total dose of 70 Gy in 33-35 fractions. In addition, 97% of patients received concurrent platinum-based chemotherapy. The median follow-up time was 52.8 months. RESULTS: The rates of 5-year actuarial locoregional control, distant metastasis-free survival, progression free-survival, and overall survival (OS) were 81.2, 72.2, 61.9, and 78.1%, respectively. A total of 27 patients had locoregional recurrence: 85.2% in-field failures, 11.1% marginal failures, and 3.7% out-of-field failures. Fourteen patients with locoregional recurrence received aggressive treatments, including nasopharyngectomy, neck dissection, or re-irradiation, and the 5-year OS rate tended to be better (61.9%) compared to those receiving conservative treatment (32.0%, p=0.051). In patients treated with 1 course of radiotherapy, grade ≥3 toxicities of ototoxicity, neck fibrosis, xerostomia, epistaxis, and radiographic temporal lobe necrosis occurred in 18.2, 9.8, 6.3, 2.1, and 5.6% of patients, respectively. Increased ototoxicity, osteonecrosis, severe nasal bleeding, and temporal necrosis were observed in patients treated by re-irradiation. CONCLUSION: IMRT offers good locoregional control in patients with T4 NPC. For patients with locoregional recurrence after definitive radiotherapy, aggressive local treatment may be considered for a better outcome.

Medulloblastoma in adults. Treatment outcome, relapse patterns, and prognostic factors.

BACKGROUND AND PURPOSE: In this study, the clinical outcome and prognostic factors of adult medulloblastoma patients receiving multimodal treatment were investigated. PATIENTS AND METHODS: The clinical manifestations, treatment variables, and outcome of adult patients with medulloblastoma at our institution between 1983 and 2009 were retrospectively reviewed. RESULTS: A total of 20 adult patients were included (median age 22 years). Craniospinal irradiation (CSI) was given postoperatively. The craniospinal axis received a median of 30 Gy (range 23.4-39.6 Gy) in fractions of 1.6-2 Gy/day, and the tumor was boosted to a total median dose of 50 Gy (range 50-55.25 Gy). The 3-year disease-free survival (DFS) and overall survival (OS) rates for all patients were 45% and 50%, respectively. In univariate analysis, Karnofsky Performance Scale (KPS) > 70, neurologic symptoms duration > 30 days, lateral tumor location, standard risk patients, no hydrocephalus, radiotherapy (RT) treatment field (CSI + brain boost), and CSI dose ≥ 30 Gy were associated with better DFS. Standard-risk patients, RT treatment field (CSI + brain boost), and CSI dose ≥ 30 Gy were also significantly associated with better OS. CONCLUSION: The combined modality treatment results in a favorable outcome for adult medulloblastoma patients. Further investigation of the prognostic factors, radiation-related factors, and systemic chemotherapy is needed.

Imprint cytology improves accuracy of computed tomography-guided percutaneous transthoracic needle biopsy.

The aim of the present study was to investigate whether imprint cytology can improve the diagnostic accuracy of computed tomography-guided transthoracic core biopsy. Between October 1997 and June 2004, thoracic lesions in 622 patients underwent biopsy using 19-gauge coaxial guiding needles and 20-gauge biopsy needles under computed tomography guidance. Touch imprint cytology and histopathology were performed for all biopsy specimens. Of these lesions, 431 (74.1%) were diagnosed as malignant, 151 (25.9%) as benign and 40 (6%) as nondiagnostic. Imprint cytology plus histology shows an improved diagnostic accuracy of 96.4% compared with that of imprint cytology alone (92.3%) or histopathology alone (93.0%). Procedure-related complications requiring further treatment occurred in eight (1.4%) patients. In conclusion, imprint cytology combined with histopathology can improve the diagnostic accuracy of computed tomography-guided transthoracic needle biopsy.

Vascular endothelial growth factor 189 mRNA isoform expression specifically correlates with tumor angiogenesis, patient survival, and postoperative relapse in non-small-cell lung cancer.

PURPOSE: The purpose of this study was to evaluate the correlation between the expression of four different vascular endothelial growth factor (VEGF) mRNA isoforms (VEGF121, VEGF165, VEGF 189, and VEGF206) and the clinicopathologic characteristics, tumor angiogenesis, and outcome of patients with non-small-cell lung cancer. PATIENTS AND METHODS: We examined the expression of four different VEGF mRNA isoforms in 57 non-small-cell lung cancers using reverse transcriptase polymerase chain reaction and the tumor angiogenesis using immunohistochemical staining. RESULTS: All 57 lung cancer samples expressed the VEGF121, VEGF165, and VEGF189 mRNA isoforms, and three expressed the VEGF206 mRNA isoform. A high tumoral VEGF189 mRNA isoform expression ratio was associated with a high intratumoral microvessel count (P = .013), short survival (< 24 months; P = .001), and early postoperative relapse (< 12 months; P = .001). Survival and postoperative relapse time were significantly shorter in patients with a high compared with a low tumor VEGF189 mRNA isoform expression ratio (P = .0001 and P = .0086, respectively, log-rank test). In contrast, the VEGF165 and VEGF 206 mRNA isoform expression ratios showed no statistical correlation with tumor angiogenesis, postoperative relapse time, or survival. A high VEGF121 mRNA isoform expression ratio was associated with short survival (< 24 months) and early relapse (< 12 months). Multivariate analysis showed that VEGF 189 mRNA isoform expression, microvessel count, and nodal status were the most important independent prognostic factors for patient survival and postoperation recurrence. CONCLUSION: The VEGF189 mRNA isoform expression ratio shows a greater correlation with tumor angiogenesis, postoperative relapse time, and survival than do the expression ratios for the VEGF121, VEGF165, and VEGF206 mRNA isoforms and can be used as a prognostic indicator for patients with non-small-cell lung cancers.

The effects of inhaled nitric oxide, gabexate mesilate, and retrograde flush in the lung graft from non-heart beating minipig donors.

BACKGROUND: The use of lung grafts from non-heart-beating donors (NHBD) is one way of solving the donor organ shortage problem. In this experiment, we studied the effect of retrograde flush (RF) from the left atrium before harvest, inhaled nitric oxide (NO), and gabexate mesilate (FOY), a protease inhibitor, in the lung grafts from NHBD. METHODS: Forty-eight Lee-Sung, small-ear, miniature pigs (15-20 kg) were divided into 24 pairs (donor and recipient) and four groups. The donor lungs were flushed and harvested 90 min after cardiac arrest. No i.v. heparin was administered until the time before flush and harvest. Left single lung transplantation was undertaken, and the recipients were observed for 18 hr. The grafts warm and cold ischemia times were 90 (controlled) and 183+/-23.4 min. Group 1 (untreated control, UC, n=6) had core perfusion through a Swan-Ganz catheter followed by a single, antegrade flush with modified Euro-Collin's solution containing heparin, urokinase, and PGE1. Group 2 (RF group, n=6) had the same as group 1, except that one additive retrograde flush through the left atrium was administered. Group 3 (NO group, n=6) had the same as group 1, except that 20 parts per million (ppm) inhaled NO was administered for the cadaver donors before the graft harvest, and for the recipients after the grafts reperfusion. Group 4 (FOY group, n=6) had the same as group 1, except that the recipients received FOY i.v. infusion from the beginning of the recipient's operation and continuously throughout the experiments. RESULTS: Compared with the group 1 (control), group 2 (RF) had significantly (P<0.05) lower mean pulmonary artery pressure, pulmonary vascular resistance (PVR), lung wet/dry ratio, histological lung injury score, and higher PaO2/FiO2 and pulmonary dynamic compliance. Group 3 (NO) had significantly lower mean pulmonary arterial pressure, PVR, lung injury score, degree of tissue neutrophils infiltration (histological and myeloperoxidase assay), bronchoalveolar lavage fluid protein content and neutrophils (PMNs) percentage, and higher PaO2/FiO2 and pulmonary dynamic compliance. Group 4 (FOY) had significantly lower PMNs infiltration, lung injury score, wet/dry ratio, bronchoalveolar lavage fluid protein and PMNs percentage, and higher PaO2/FiO2. Group 2 (RF) revealed better gas exchange (PaO2/FiO2) than the control (group 1) at earlier reperfusion periods (1st and 5th hr). On the contrary, group 4 (FOY) had higher PaO2/FiO2 than group 1 only at later period (18th hr). Pathologically, retrograde flush (group 2, RF) inhibited the intravascular thrombi formation more effectively than the NO or FOY treatment. However, the NO or FOY treatment inhibited the neutrophil infiltration more effectively than did the retrograde flush. CONCLUSION: The retrograde flush, inhaled NO and FOY infusion are beneficial to the protection of the NHBD lung grafts at an early reperfusion period, through different mechanisms. The use of these treatments in combination might help us to find a better way to protect the NHBD grafts against the preservation and reperfusion injury.

Ultrasonography of Pancoast tumor.

Eleven patients with Pancoast tumor, who failed to yield diagnostic materials by conventional sputum cytology and fiberoptic bronchoscopy, were studied by real-time linear-array and sector ultrasonography. The sector scanner through the supraclavicular approach adequately visualized the external profile and the internal texture of the lesions in all 11 patients, which is a significant improvement (p less than 0.05) over what can be accomplished with linear-array scanner through the intercostal approach. All patients received percutaneous transthoracic aspiration under ultrasound guidance. Positive cytologic diagnosis was established in ten of the 11 patients (91 percent). Additional biopsies performed in seven patients under similar ultrasonic guidance also provided concordant results. No complications were observed in this series. This study has clearly shown that ultrasound-guided aspiration biopsy can be a safe and useful means for obtaining materials for pathologic confirmation of Pancoast tumor. It may also assist in defining the tumor extension to pleura and adjacent structures.

Ultrasound-guided pleural biopsy with Tru-Cut needle.

We conducted a study of ultrasound (US)-guided pleural biopsy with a Tru-Cut needle and made a comparison with the results of a traditional pleural biopsy with an Abrams needle. A total of 49 patients with unilateral pleural effusion were included in this study. Twenty-four patients underwent a traditional pleural biopsy with an Abrams needle, and 25 patients underwent a US-guided pleural biopsy with a Tru-Cut needle. The age, sex, and underlying diseases in both groups were compatible. The amount of effusion was much less in the Tru-Cut group. In the patients who underwent the US-guided pleural biopsy with a Tru-Cut needle, the diagnostic sensitivity in pleural tuberculosis was 86 percent (6/7) and in pleural neoplasia it was 70 percent (7/10). In the patients who underwent traditional pleural biopsy with an Abrams needle, the diagnostic sensitivity in pleural tuberculosis was 20 percent (2/10) and in pleural neoplasia it was 44 percent (4/9). The result of US-guided pleural biopsy with a Tru-Cut needle was better than that of pleural biopsy with an Abrams needle, especially in pleural tuberculosis. No complication was found in the Tru-Cut group, but breakage and dislodgment of the tip of an Abrams needle occurred in one patient. The higher diagnostic yield in the Tru-Cut group may be attributed to the US guidance that can delineate the focal pleural abnormalities for biopsy. In conclusion, US-guided pleural biopsy by using a Tru-Cut needle was simple, safe, and well tolerated. It was particularly useful for patients with pleural tumor, thickened pleura, small amounts of pleural effusion, or loculated pleural effusion.

Catamenial hemoptysis from tracheobronchial endometriosis: reappraisal of diagnostic value of bronchoscopy and bronchial brush cytology.

OBJECTIVES: To analyze the clinical data of four patients with a diagnosis of tracheobronchial endometriosis, and to reappraise the diagnostic value of bronchoscopy and bronchial brush cytology in these patients. METHODS: We conducted a retrospective study of four patients with documented tracheobronchial endometriosis treated at National Taiwan University Hospital from 1994 to 1998. The complete histories, diagnostic time interval, results of physical examinations, laboratory data, bronchoscopic findings, cytologic results, chest radiographs, and chest CT of these patients were analyzed. RESULTS: These patients tend to be younger and nonmultiparous as compared to other patients with thoracic endometriosis. Bronchoscopic examination performed within 1 day or 2 days of menses disclosed multiple purplish-red submucosal patches bilaterally that bled easily when touched. Cytologic evaluation of the brushing specimens demonstrated clusters of small cuboid cells consistent with an endometrial origin. Follow-up bronchoscopic examination in the middle of the menstrual cycle showed disappearance of the previous tracheobronchial lesions. The mean diagnostic interval was 3.25 months. All four patients were successfully treated with danazol therapy. CONCLUSIONS: Tracheobronchial endometriosis consists of a special subgroup of patients with thoracic endometriosis. Proper timing of bronchoscopic examination plays an important diagnostic role in these patients. Cytologic features as well as cyclic changes in bronchoscopic findings are sufficient to warrant the diagnosis. The results of treatment with danazol in these patients seemed favorable.

Immunosuppressive acidic protein in patients with lung cancer.

Using a single radial immunodiffusion method, serum immunosuppressive acidic protein (IAP) was determined in 117 patients with primary lung cancer, 34 patients with benign lung disease, and 45 healthy control subjects. The mean value of IAP for patients with lung cancer was significantly higher than that of normal control subjects. There were no significant differences in IAP levels among different histologic types and among different stages of lung cancer. It was concluded that serum IAP level was elevated in patients with lung cancer, especially during the early postoperative period, and serial measurements of serum IAP were of value in monitoring lung cancer patients.

Clearance of theophylline by hemodialysis in one patient with chronic renal failure.

The clearance of theophylline by hemodialysis was determined in one patient who had polycystic kidney with chronic renal failure and bronchial asthma. The serum levels of theophylline were determined by enzymatic immunoassay on two consecutive days, once on a dialysis day and again on a nondialysis day. Clearance of theophylline by hemodialysis was 119 ml/min, and the extraction efficiency was 0.56. The elimination half-life of theophylline shortened from 5.7 h to 1.6 h during hemodialysis. The dialysis rate constant (Kd) was 0.32/h, and 79 percent of the total body store of the drug was removed during a 4-h dialysis. Patients receiving theophylline who are maintained on hemodialysis should be closely monitored for bronchospasm during and after the hemodialysis procedure. Measurement of serum concentrations of theophylline should be employed to facilitate increases in dosage during hemodialysis.

Ultrasonography and color Doppler imaging of metastatic pulmonary choriocarcinoma.

Chest ultrasound and color Doppler flow imaging were used to assess the pulmonary nodule of a 24-year-old pregnant woman with dyspnea and hemoptysis. The ultrasonogram showed multiple hypoechoic subpleural nodules. Color Doppler imaging of the nodules revealed characteristics of high vascularity and high blood flow. A percutaneous needle aspiration under ultrasonic guidance confirmed the diagnosis of choriocarcinoma.

Needle aspiration biopsy of malignant lung masses with necrotic centers. Improved sensitivity with ultrasonic guidance.

False-negative results from transthoracic needle aspiration biopsy of malignant lung masses may occur if a central necrotic area is present and is the source of the biopsy material. The purpose of this study is to determine if the use of ultrasonic guidance can improve the sensitivity of lung needle biopsies in this circumstance. Sixty patients with malignant lung masses underwent ultrasonic examination in an 18-month period. In 14 cases, ultrasound showed that the mass had a large central necrotic area that was at least half the diameter of the tumor. Under ultrasonic guidance, needle biopsy specimens were taken from the central necrotic area and from the tumor wall in each case. Adequate biopsy specimens were obtained in all 14 patients. In all cases, the mural biopsy material was diagnostic for malignant tumor, while the biopsy specimen from the necrotic center was nondiagnostic in 10 of 14 patients. No complications occurred. We conclude that ultrasonically guided lung biopsy is a useful and safe tool to avoid false-negative needle biopsy specimens in malignant lung tumors with necrotic centers.

Lung sequestration. Diagnosis with ultrasound and triplex Doppler technique in an adult.

The application of chest US with triplex Doppler technique to detect the systemic feeding artery of lung sequestration in an adult patient is described. To our best knowledge, this is the first description of the use of this technique to diagnose pulmonary sequestration in adult patients. This 35-year-old man had necrotizing pneumonia with abscess formation at the left lower lobe. Chest US demonstrated a large tortuous vessel in the central part of the lesion. Spectral wave Doppler analysis showed that this vessel was a systemic feeding artery and had pulsatile arterial wave-form. The color Doppler mapping delineated the blood flow originating from the descending aorta and toward the lesion, thus confirming the diagnosis of pulmonary sequestration. We conclude that chest US with triplex Doppler technique is a valuable method in evaluating a patient with a pulmonary lesion who was thought to have lung sequestration before performing invasive aortography.

Ultrasound-guided aspiration biopsy of small peripheral pulmonary nodules.

We compared the diagnostic yields of ultrasound-guided aspiration biopsy, sputum cytology, and fiberoptic bronchoscopy with biopsy in 30 patients with peripheral pulmonary nodules smaller than 3.0 cm in diameter. Among them, there were 4 minute nodules with diameter less than 1.0 cm, 12 between 1.1 to 2.0 cm, and 14 between 2.1 to 3.0 cm. The final diagnoses in these 30 patients, as confirmed by histologic findings, microbiology, and clinical follow-up, revealed 24 malignant lesions and 6 benign. All of these 30 nodules received ultrasound-guided transthoracic fine-needle aspiration biopsy, and confirmative diagnoses were obtained in 27 (90 percent). Twenty-two (92 percent) of 24 patients with malignant nodules had positive cytology for malignancy and 5 (83 percent) of 6 patients with benign lesions had diagnosis made by cytologic and microbiologic examinations. One patient developed asymptomatic pneumothorax after needle aspiration. The size of the lesions did not affect the diagnostic yield and complication rate. None of the lesions was diagnosed by sputum cytology (0 of 19; 0 percent). Two patients had diagnoses obtained by fiberoptic bronchoscopy with biopsy (2 of 10; 20 percent). We conclude that ultrasound-guided aspiration biopsy is a useful and safe method for diagnosis of peripheral pulmonary nodules, even when the size of the nodule is less than 3 cm in diameter. The diagnostic yield far exceeds that which can be obtained by sputum cytology and fiberoptic bronchoscopy with biopsy.

Actinobacillus actinomycetemcomitans pneumonia with chest wall involvement and rib destruction.

There are four cases of Actinobacillus actinomycetemcomitans pulmonary infections reported in the English literature prior to 1990. We report a case of A actinomycetemcomitans pulmonary infection with invasion of overlying soft tissue, rib, and sternum. This manifestation has not been previously reported. The clinical manifestation is similar to that of Actinomyces israelii, which may be misinterpreted as malignancy initially. The portal of entry of A actinomycetemcomitans may be via hematogenous spread or aspiration. The diagnosis depends on culture after prolonged incubation of the involved tissue obtained by aspiration or biopsy. Elevated serum antibody is helpful for diagnosis of active infection. A actinomycetemcomitans is susceptible to most antibiotics, but is frequently resistant to penicillin, vancomycin, clindamycin, and erythromycin. Isolation of the organism and an in vitro drug sensitivity testing are important in managing the patient. Our patient recovered after a three-month regimen of penicillin.

Evaluation of ultrasonically guided biopsies of mediastinal masses.

Eighty patients with roentgenographic evidence of mediastinal abnormalities were examined with ultrasonography. Fifty-four lesions were malignant, and 26 lesions were benign. The histologic diagnoses were confirmed by ultrasonically guided fine needle aspiration/cutting needle (Tru-Cut) biopsy, surgical specimens, or transbronchial biopsy. There were no unique ultrasonographic features for diagnosis of specific tumors. Ultrasonically guided aspiration biopsies (UGAB) were performed in 44 of the malignant lesions and in 14 of the benign lesions (nine of the noncystic lesions and five of the cystic lesions). Cytologic diagnosis of malignancies was obtained in 34 (77 percent) of these 44 malignancies; however, accurate histologic classifications of malignancies were achieved in only 24 (55 percent). Accurate diagnoses were achieved in only three (33 percent) of the nine noncystic benign lesions. Ultrasonically guided cutting biopsies (UGCB) were performed in 24 malignant and five benign lesions. All attempts yielded satisfactory specimens for histologic diagnosis. Using UGAB and UGCB together, a positive diagnosis was achieved in 89 percent (39/44) of the malignancies, and accurate histologic diagnosis was achieved in 89 percent and 78 percent (7/9) in malignant and benign noncystic lesions, respectively. Correct histologic diagnosis with UGAB alone is lower in thymoma (55 percent [6/11]) and lymphoma (30 percent [3/10]) but higher in lung cancer (67 percent [8/12]) and metastatic cancer (78 percent [7/9]). There were no complications in this series. We conclude that ultrasonography with UGAB has a high diagnostic yield in diagnosing mediastinal tumors, and UGCB is necessary for thymic tumors, lymphoma, and benign lesions.

Late survival of non-small cell lung cancer patients with brain metastases. Influence of treatment.

The presence of brain metastasis in lung cancer patients is a highly unfavorable event that usually allows only palliative treatment. A retrospective study was conducted to evaluate the prognostic factors in patients with non-small cell lung cancer (NSCLC) associated with brain metastases. From July 1984 through June 1990, a total of 50 patients with NSCLC associated with symptomatic brain metastasis seen at National Taiwan University Hospital were included. Patients who had incomplete cancer staging workup or loss of follow-up were excluded. Several possible prognostic variables were analyzed initially with univariate analysis and subsequently with multivariate analysis with maximal partial likelihood ratio test in the Cox model. In the univariate analysis, several factors, including number of brain metastases, treatment for brain metastasis with brain tumor resection (BTR) or whole brain radiation therapy (WBRT), and chemotherapy (C/T) after brain metastasis were found to have significant influence on the survival. However, in the multivariate analysis, patients receiving BTR, WBRT, and/or C/T lived significantly longer. The median survival of patients treated with BTR was nine months, eight months in patients with C/T, and seven months in patients with WBRT. Taken together, these patients had a median survival of seven months, which was significantly longer than patients treated with supportive care only (with a median survival of two months). Treatment of brain metastases with WBRT, BTR, C/T, or in combinations also improved the quality of life. We conclude that NSCLC patients with brain metastases should be more aggressively treated with WBRT, BTR, C/T, or in combinations than supportive care only.