Successful Resuscitation Following Intraoperative Acute Pulmonary Embolism With a Focus on Control of Bleeding After Thrombolytic Therapy: A Case Report.

Acute pulmonary embolism is a serious perioperative complication. Current guidelines focus on hemodynamic stabilization and rapid restoration of pulmonary artery blood flow. However, various complications, most notably bleeding, are associated with treatment of the embolism. We report a case of acute pulmonary embolism with cardiopulmonary arrest during orthopedic surgery. Prompt thrombolysis and gaining control of both thrombolytic therapy-induced bleeding from the wound and a hepatic cyst enabled the patient to recover without neurological deficits.

Evaluation of video-assisted thoracoscopic surgery for pulmonary metastases: 11-years of experience.

BACKGROUND: Although video-assisted thoracoscopic surgery (VATS) has been applied to pulmonary resection for pulmonary metastases, the clinical validity of this approach remains controversial. The purpose of this study was to evaluate the validity and problems of VATS for pulmonary metastasectomy. METHODS: From January 1993 to December 2003, VATS for pulmonary metastasectomy was performed in 53 resections for 48 patients at our institution. The medical records of these patients were retrospectively reviewed. RESULTS: The primary tumor was colorectal cancer in 23 patients, renal cell carcinoma in 6, breast cancer in 6, germ cell tumor in 5, head and neck cancer in 2, and others in 6. Thirty-six cases had a solitary lesion, 8 had unilateral multiple lesions, and 9 had bilateral multiple lesions. The following procedures were performed: 7 lobectomies, 5 segmentectomies, and 41 wedge resections. There was no major postoperative morbidity related to VATS. At a median follow-up period of 29.0 months, 13 patients were alive without recurrences. The 3-year overall survival rate and the 3-year intrathoracic disease-free survival rate were 59.8% and 33.4%, respectively. Five cases had recurrence at the surgical stump or at the port sites, but these recurrences have not been found in the recent period since June 1997. Intrathoracic recurrences within 3 months after VATS occurred in four. CONCLUSION: VATS for pulmonary metastases is not superior to the conventional open thoracotomy and is not recommended as a standard procedure. Further studies with a larger number of cases performed by skilled surgeons familiar with VATS are needed.

[Evaluation of efficacy and safety of adjuvant analgesics for peripheral neuropathy induced by cancer chemotherapy in digestive cancer patients-a pilot study].

After 1990's, the development of new generation anti-cancer agents produced encouraging improvement of prognosis in inoperable or relapsed stomach cancer and colorectal cancer. However, non-hematological toxicity, such as peripheral neuropathies, become a new dose-limiting toxicity. In several new generation drugs, measures for controlling peripheral neuropathy had not been established besides dose modification or schedule modification. We tried to control the peripheral neuropathy induced by anti-cancer agents with the assistance of an adjuvant analgesics ladder. A total of 18 digestive cancer patients who presented with peripheral neuropathy of grade 1 or more(NCI-CTCAE ver 3.0), in the chemotherapy including Taxol or Oxaliplatin, were enrolled. The first stage of the adjuvant analgesics ladder was set as the antidepressant(amoxapin), the second stage was anticonvulsive drugs(valproic acid or clonazepam) and the third stage was antiarrhythmic drug(mexiletine). In each stage, if the drug turned out to be ineffective after two / weeks follow-up, it shifted to the next stage. The response rate of each step was 61.1%(11/18)of the first stage, 50.0%(5/10)of the 2nd stage, 50.0%(2/4)of the 3rd stage, and the overall response rate was 77.8%. The discontinuance of cancer treatment by peripheral neuropathy was observed only in 1 patient 5.5%(1/18)in the Taxol administered group. The toxicity profile was skin eruption and drowsiness, but the skin eruption was observed only in 1 patient at the 3rd stage and the drowsiness in 2 patients at the 2nd stage. It appears that the method to control the peripheral neuropathy induced by anti-cancer agents with the assistance of adjuvant analgesics ladder was effective and safe, but a large-scale clinical trial was warranted.

A ruptured large extraluminal ileal gastrointestinal stromal tumor causing hemoperitoneum.

We describe an 87-year-old woman with a large ileal gastrointestinal stromal tumor (GIST) causing hemoperitoneum. A CT scan demonstrated a large heterogeneous mass measuring about 13 cm multiply 11 cm in the pelvis and hemoperitoneum, with a non-uniform enhancement pattern. The mass was diagnosed as a GIST originating from the gastrointestinal tract. She underwent an urgent laparotomy and an ileal GIST with a rupture was found 130 cm from the anal to the Treitz's ligament. Hemoperitoneum caused by ileal GIST rupture is a rare condition. Bleeding in the large tumor leading to rupture of the capsule might cause hemoperitoneum in the present case.

Ileal schwannoma developing into ileocolic intussusception.

Intussusception is rare in adults. We describe a 47-year-old man with ileal schwannoma that led to ileocolic intussusception. Abdominal ultrasonography, abdominal CT scan and barium enema confirmed an ileal tumor. Colonoscopy revealed a peduncular submucosal tumor (SMT) 75 mm long with an ulcerated apex at the ascending colon. The provisional diagnosis was a gastrointestinal stromal tumor of the terminal ileum. Ileocecal resection was carried out and the tumor was histologically diagnosed as schwannoma. Abdominal pain resolved postoperatively. This case reminds us that ileal schwannoma should be included in the differential diagnosis of intussusception caused by an SMT in the intestine.

Systemic versus coronary levels of inflammation in acute coronary syndromes.

To address a possible link between systemic and coronary inflammation in the setting of acute coronary syndromes, the authors examined both levels of 3 inflammatory mediators such as high sensitive C-reactive protein (hs-CRP), interleukin (IL)-6, and matrix metalloproteinase (MMP)-9 in patients with the early phase of acute myocardial infarction (AMI). In total, 20 patients with AMI showing minimal elevation of cardiac enzymes were studied. Before angioplasty, peripheral blood and culprit coronary thrombus were sampled to compare systemic and coronary levels of hs-CRP, IL-6, and MMP-9. Relation of systemic levels of hs-CRP and IL-6 to culprit coronary morphology was also evaluated by the use of intravascular ultrasound. Systemic and coronary levels of hs-CRP were nearly equivalent (4.3 +/- 5.0 vs 4.7 +/- 5.4 mg/L, p = 0.279), whereas IL-6 and MMP-9 showed higher in coronary levels than in systemic levels (169 +/- 154 vs 93 +/- 107 microg/mL, p = 0.002 and 164 +/- 116 vs 103 +/- 94 ng/mL, p = 0.018, respectively). Systemic levels of hs-CRP were correlated with coronary levels of IL-6 (r = 0.566, p = 0.009). Culprit coronary plaque area demonstrated a positive relation with systemic levels of hs-CRP (r = 0.466, p = 0.038) and also IL-6 (r = 0.707, p <0.001). The present study may provide an important insight into the link between systemic and coronary levels of inflammation, which is also associated with vulnerable coronary morphology in the setting of acute coronary syndromes.

Prevention of positive coronary artery remodeling with statin therapy in patients with coronary artery diseases.

Since positive coronary artery remodeling with large plaque burden is associated with subsequent coronary events, the authors tested their hypothesis that secondary prevention of coronary events by a statin may be associated with inhibition of the process of positive coronary artery remodeling in underlying coronary atherosclerotic lesions in patients with coronary artery diseases. They evaluated the intravascular ultrasound imaging in angiographically normal coronary lesions at baseline and after 6 months of therapy in 64 patients with coronary artery diseases. External elastic membrane area was defined as the vessel area, and the difference between the vessel and lumen area was calculated as plaque area. The relative echogenicity of coronary plaque to adventitia was evaluated as acoustic characteristics of coronary plaque. Twenty-five patients were treated with a statin and 39 patients did not receive a statin. In patients treated with a statin, plaque area decreased by 12% (p = 0.013) compared to an increase in plaque area of 13% (p = 0.023) in those who did not receive a statin. The vessel area was not enlarged in patients treated with a statin but did show positive remodeling in patients who had plaque progression without a statin. The relative echogenicity of plaque was unchanged in patients treated with a statin but significantly decreased in patients not receiving a statin. A statin may prevent positive coronary artery remodeling via inhibition of plaque progression in underlying coronary atherosclerotic lesions in patients with coronary artery diseases.

Objective radiologic analysis of ground-glass opacity aimed at curative limited resection for small peripheral non-small cell lung cancer.

OBJECTIVE: The aim of this study was to evaluate the efficacy of the objective radiologic analysis of high-resolution computed tomographic images of small peripheral non-small cell lung cancer and to select the candidates for curative limited resection. METHODS: High-resolution computed tomographic images of 146 surgically resected T1 N0 M0 peripheral non-small cell lung cancers were analyzed by using National Institutes of Health image software and classified on the basis of the percentage of ground-glass opacity within the tumor. RESULTS: Eighty-seven percent of tumors with ground-glass opacity ratios of 90% to 100% (type I) were diagnosed as noninvasive bronchioloalveolar carcinoma, whereas 55.6% of tumors with ground-glass opacity ratios of 50% to 89% (type II) consisted of adenocarcinoma. Tumors with ground-glass opacity ratios of 50% or more (type I/II) had no nodal involvement, whereas nodal metastases were identified in 20.0% of tumors with ground-glass opacity ratios of 10% to 49% (type III) and 24.4% of tumors with ground-glass opacity ratios of less than 10% (type IV). No tumors with ground-glass opacity ratios of 50% or more showed vessel infiltration, except for one lesion with a ground-glass opacity ratio of 50%. The 3-year disease-free survival was 97.7% for type I/II, 86.1% for type III, and 78.5% for type IV tumors. CONCLUSIONS: The objective quantitative radiologic analysis with National Institutes of Health image software exhibited a good correlation with the histologic classification, pathologic invasiveness, and postoperative outcome of small peripheral lung cancer. Patients with tumors that have ground-glass opacity ratios of greater than 50% are considered to be possible candidates for limited pulmonary resection.

Expression of eukaryotic initiation factor 4E in atypical adenomatous hyperplasia and adenocarcinoma of the human peripheral lung.

The overexpression of eukaryotic initiation factor 4E (eIF4E), a key regulator of protein synthesis, is involved in the malignant progression of various human cancers. We investigated eIF4E expression in atypical adenomatous hyperplasia (AAH) and adenocarcinomas of the human peripheral lung. On the basis of the WHO criteria with minor modifications, adenocarcinomas were classified as bronchioloalveolar carcinoma (BAC), mixed subtypes with a bronchioloalveolar pattern and minor invasion (early MX), and mixed subtypes with a papillary pattern and marked invasion (overt MX). eIF4E immunohistochemistry was performed in 143 tissue samples (31 AAH, 38 BAC, 43 early MX, and 31 overt MX). Both tumoral and stromal eIF4E levels were elevated from AAH, BAC, and early MX to overt MX and significantly associated with histological grade (P < 0.001 and P < 0.001, respectively). Tumoral and stromal eIF4E staining intensities were significantly correlated (P < 0.01). Immunoblot analysis of 51 tissue samples (2 AAH, 11 BAC, 18 early MX, and 20 overt MX) demonstrated that eIF4E expression in adenocarcinomas was 3.4-7.4-fold higher than in normal lung and that its expression progressively increased in the following order: AAH (lowest expression), BAC, early MX, and overt MX (highest expression). Multiple regression analysis revealed that both tumoral and stromal eIF4E expressions were significant independent factors for the histological subtype (P < 0.01 and P < 0.01, respectively). These results suggest that translational control is dysregulated during the development of peripheral lung adenocarcinoma and that progressive increases of tumoral and stromal eIF4E may be part of a positive feedback loop for malignant progression.

Two cases with long-term disease-free survival after resection and radiotherapy for solitary brain metastasis from breast cancer with extensive nodal metastases.

Two rare cases, each with a solitary brain metastasis from breast cancer with extensive nodal metastases as the first site of distant metastasis, were locally treated with surgery and irradiation. The outcome of the two treated cases indicated an excellent and non-recurrent post-therapeutic survival period of more than 3 and 8 years, respectively. In a 50-year-old woman (Case 1), a solitary brain metastasis was found to have developed after standard radical mastectomy and adjuvant chemotherapy with doxorubicin and tegafur-uracil (UFT) and hormonal therapy with tamoxifen for left breast cancer. The brain metastasis was treated twice surgically followed by radiotherapy. One year and 6 months later, local recurrence of the brain metastasis appeared and was treated surgically again. No other treatment was done thereafter. Since then, no other distant or lymph node metastasis occurred, and to date her outcome has been non-eventful for 8 years and 5 months. In a 63-year-old woman (Case 2), a solitary brain metastasis was found to have developed after standard radical mastectomy and adjuvant chemotherapy with cyclophosphamide, epirubicin and fluorouracil (CEF) for right breast cancer. The brain metastasis was treated locally with surgery and irradiation of 50 Gy. She thereafter received no further treatments. Since then neither distant metastases nor local recurrence have developed, and to date the post-treatment outcome has been uneventful for 37 months. Our findings suggest that patients who developed a solitary brain metastasis as the first site of distant metastasis from breast cancer have a chance of achieving long-term disease-free survival when treated with aggressive local therapy, even in the presence of extensive lymph node metastases at the primary surgery site for breast cancer.

Diagnostic accuracy of late iodine enhancement on cardiac computed tomography with a denoise filter for the evaluation of myocardial infarction.

We evaluated the image quality and diagnostic performance of late iodine enhancement (LIE) in dual-source computed tomography (DSCT) with low kilo-voltage peak (kVp) images and a denoise filter for the detection of acute myocardial infarction (AMI) in comparison with late gadolinium enhancement (LGE) magnetic resonance imaging (MRI). The Hospital Ethics Committee approved the study protocol. Before discharge, 19 patients who received percutaneous coronary intervention after AMI underwent DSCT and 1.5 T MRI. Immediately after coronary computed tomography (CT) angiography, contrast medium was administered at a slow injection rate. LIE-CT scans were acquired via dual-energy CT and reconstructed as 100-, 140-kVp, and mixed images. An iterative three-dimensional edge-preserved smoothing filter was applied to the 100-kVp images to obtain denoised 100-kVp images. The mixed, 140-kVp, 100-kVp, and denoised 100-kVp images were assessed using contrast-to-noise ratio (CNR), and their diagnostic performance in comparison with MRI and infarcted volumes were evaluated. Three hundred four segments of 19 patients were evaluated. Fifty-three segments showed LGE in MRI. The median CNR of the mixed, 140-, 100-kVp and denoised 100-kVp images was 3.49, 1.21, 3.57, and 6.08, respectively. The median CNR was significantly higher in the denoised 100-kVp images than in the other three images (P < 0.05). The denoised 100-kVp images showed the highest diagnostic accuracy and sensitivity. The percentage of myocardium in the four CT image types was significantly correlated with the respective MRI findings. The use of a denoise filter with a low-kVp image can improve CNR, sensitivity, and accuracy in LIE-CT.

Cardiac sympathetic nerve activity can detect congestive heart failure sensitively in patients with hypertrophic cardiomyopathy.

STUDY OBJECTIVES: Cardiac sympathetic nerve dysfunction is related to poor clinical outcome in patients with several different heart diseases. However, it is not clear whether cardiac sympathetic nerve activity is useful for predicting the onset of congestive heart failure (CHF) in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to examine the prognostic value of performing (123)I-labeled metaiodobenzylguanidine (MIBG) scintigraphy in patients with HCM in comparison with other conventional prognostic variables. METHODS: (123)I-labeled MIBG images were obtained from 84 HCM patients without prior CHF. After measurement of cardiac function, the patients were followed up for 9 to 86 months in our hospital. RESULTS: According to the cutoff values for the heart/mediastinum ratio (H/M) on delayed images of control subjects (ie, mean - 1 and 2 SDs), the patients were subdivided into the following three groups: group A (H/M, > 2.11; 34 patients); group B (H/M, < 1.86 to

Focal ground-glass opacity detected by low-dose helical CT.

OBJECTIVE: Focal ground-glass opacity (GGO) has been detected increasingly by low-dose helical CT. Although focal GGO suggests in situ neoplastic lesion in the peripheral lung, it remains controversial how to manage these lesions. The purpose of this study was to evaluate the pathologic and radiologic characteristics of focal GGO in order to develop a standard of treatment for these lesions. PATIENTS: Forty-three patients with persistent focal GGO < or = 2 cm in size from January 1998 to September 2000 were studied. Thoracoscopic lung biopsy was performed consecutively for persistent focal GGO following a several-month observation period (mean, 3.7 months). RESULTS: The histologic diagnoses were bronchioloalveolar carcinoma (BAC) in 23 patients, adenocarcinoma with mixed subtypes in 11 patients, and atypical adenomatous hyperplasia (AAH) in 9 patients. None of 34 carcinoma patients had lymph node involvement. All of 17 lesions > or = 1 cm in size were malignant. GGO with solid components on high-resolution CT were highly associated with adenocarcinoma (malignant rate, 93.3%). CONCLUSIONS: Persistent focal GGO after observation for several months was a finding of early adenocarcinoma or its precursor. Especially, lesions > or = 1 cm in size or GGO with solid component were significant signs of malignancy. We concluded lung biopsy should be attempted for persistent focal GGO.

Pulsating renal blood flow distribution measured using power Doppler ultrasound: correlation with hypertension.

Arterial compliance is associated with the first stage of hypertension and atherosclerosis. We propose here a compliance index, which measures pulsating renal blood flow distribution using a power Doppler ultrasound (US). We assessed the relationship between the compliance index and blood pressure and between the compliance index and risk factors of atherosclerosis. The subjects consisted of 136 consecutive patients (96 males, 40 females) who underwent a physical checkup. Ages ranged from 40 to 60 years with a mean of 50.1 years. Patients with past renal disease and/or renal dysfunction were excluded. Using a power Doppler US combined with an ECG-gated and echo-tracking system, we recorded the vascular distribution of the renal parenchyma at 8 to 10 time points during an interval of the R wave of the ECG. Using a color pixel counting technique, we calculated the area (A) corresponding to the colored vascular distribution at power Doppler US. The relationships between A and the time points (t) were fitted to a quadratic equation. The compliance index of renal parenchymal vessels was obtained by twice differentiating the quadratic equation obtained above (d2A/dt2), and taking the result as a new hemodynamic index. In the univariate correlation analysis, the compliance index was correlated with age (r=-0.26, p=0.002), systolic blood pressure (r=-0.33, p=0.0001), diastolic blood pressure (r=-0.45, p<0.0001), serum uric acid (r=-0.28, p=0.001), and body mass index (r=-0.32, p=0.0002). On the multivariate stepwise regression analysis, the compliance index was significantly correlated with diastolic blood pressure (beta=-0.36, p<0.0001) and body mass index (beta=-0.18, p<0.0001). In conclusion, the compliance index is a candidate for a new hemodynamic marker of renal blood flow abnormality caused by hypertension.

Prospective study of thoracoscopic limited resection for ground-glass opacity selected by computed tomography.

BACKGROUND: With recent advances in low-dose helical computed tomography (CT), detection of ground-glass opacity (GGO) has increased. The aim of this study was to correlate high-resolution CT (HRCT) findings with pathologic features and to evaluate the efficacy of thoracoscopic limited resection for focal GGO, which were selected based on HRCT findings. METHODS: Focal GGO lesions were classified into two subtypes based on HRCT findings: pure type and mixed type. Ninety-six patients with persistent GGO 2 cm or less in diameter underwent pulmonary resection from January 1997 to December 2001. Among these, thoracoscopic wedge resection was performed prospectively between June 2000 and December 2001 in 33 patients with pure GGO lesions that were 1 cm or less. RESULTS: Thoracoscopic wedge resection was completed with complete safety. The histologic diagnoses of these 33 lesions were adenocarcinoma in 1, bronchioloalveolar carcinoma (BAC) in 23, and atypical adenomatous hyperplasia (AAH) in 9. No patients have had any evidence of tumor recurrence to date. Of the total 96 GGO lesions, 93.0% (53/57) of pure GGO 1 cm or less were BAC or AAH, whereas 38.5% (15/39) of pure GGO larger than 1 cm or mixed GGO were adenocarcinoma. CONCLUSIONS: Pure GGO 1 cm or less was characteristic of noninvasive lesions. Thoracoscopic limited resection for small GGO lesions selected by HRCT was valid.

Expression of cyclooxygenase-2, Fas and Fas ligand in pulmonary adenocarcinoma and atypical adenomatous hyperplasia.

BACKGROUND: Atypical adenomatous hyperplasia (AAH) has been reported to be a precancerous lesion of pulmonary adenocarcinoma. Cyclooxygenase-2 (COX-2), Fas and Fas ligand (FasL) are believed to be involved in the pathogenesis and progression of cancer. PATIENTS AND METHODS: We examined the expression of COX-2, Fas and FasL in 31 tissue specimens of adenocarcinoma and 9 of AAH using an immunohistochemical method. RESULTS: COX-2 staining was observed in 20 (65%) specimens of adenocarcinoma and 2 (22%) of AAH. There was a significant difference in incidence of expression between these two groups (p = 0.025). All tumor specimens obtained from three patients with simultaneous multiple adenocarcinoma showed positive COX-2 staining. In two patients having both adenocarcinoma and AAH, COX-2 expression was detected in adenocarcinoma but not in AAH. Fas was expressed in 5 (16%) adenocarcinoma and 2 (22%) AAH specimens. FasL was detected in 3 (9.7%) adenocarcinoma and 1 (11%) AAH specimen. CONCLUSION: These findings suggest that COX-2 might play a role in the progression from AAH to adenocarcinoma.

Unsuspected primary pulmonary malignant lymphoma.

A 70-year-old man referred for treatment of a left lower lung tumor was shown in chest computed tomography to have a homogeneous round tumor 45 mm in diameter with an enhanced thin wall in the lower lobe of the left lung. No specific finding was seen in material obtained by transbronchial and computed tomography (CT)-guided lung tissue biopsy, so the presumptive diagnosis was a lung abscess. Despite antibiotics administered for 2 weeks, radiography showed the tumor had grown, necessitating left lower lobectomy. The permanent section was diagnosed as diffuse large B-cell lymphoma. Because CT findings for the tumor suggested a lung abscess and the central part of the tumor consisted of fibrotic and necrotic tissue, we had difficulty establishing a final diagnosis. The literature showed primary pulmonary lymphomas yielded a variety of findings radiographically, making surgery paramount for ascertaining a final diagnosis.

[Pulmonary resection for metastatic colorectal cancer].

We reviewed the clinical courses of 25 patients who underwent pulmonary resection for metastatic lesions from colorectal cancer between January 1991 and December 2001. The cumulative survivals at 3 and 5 years were 72% and 63%, respectively. Sex, site of the primary tumor, presence of extrapulmonary metastases, disease-free interval, location of pulmonary metastases (PM), number of PM, size of PM, mode of operation, pre-thoracotomy serum carcinoembryonic antigen level, and post-thoracotomy chemotherapy were not found to be statistically significant prognostic factors. Age (70 years < or =) was a predictor of a shorter survival duration by univariate analysis (p = 0.02). Recurrence was observed in 19 patients, 11 of which were lung recurrences. Eight patients underwent repeated pulmonary resection. The median survival in these 8 patients was 23 months after second pulmonary operation. Surgical treatment for pulmonary metastases from colorectal cancer in selected patients might improve prognosis.

[Late phase II study of exemestane in postmenopausal patients with breast cancer resistant to anti-estrogenic agents].

A multi-center trial of exemestane 25 mg, an oral aromatase irreversible inactivator, was conducted to evaluate its efficacy and safety in 33 postmenopausal patients, and to investigate the pharmacokinetics/serum hormone levels in 16 postmenopausal patients, respectively, with breast cancer and anti-estrogen resistance. Exemestane 25 mg was given once daily for up to 48 weeks (maximum). The objective of this study was to confirm the reproducibility of the results shown in two studies in other countries with similar patients, to investigate the possibility of extrapolating the overseas data to Japanese. The response rate (CR + PR) was 24.2% (8.33%), which exceeded the minimum number (6 cases) required to evaluate efficacy. The response rate in this study was very similar to that observed in the two international open studies. Adverse events (subjective/objective symptoms), in which a causal relationship with exemestane administration could not be excluded, were observed in 26 cases (78.8%). Of these, hot flushes, increased sweating, fatigue, and insomnia occurred in more than 10% of patients, which was similar to that observed in the two international open studies. Abnormal laboratory results occurring in more than 10% of patients, in which a causal relationship with exemestane administration could not be excluded, were as follows: lymphocyte count decrease, alkaline phosphate increase, GOT increase, GPT increase, gamma-GTP increase, triglyceride increase, and inorganic phosphate increase, most of which were either grade 1 or 2. A remarkable decrease in serum hormone concentration was observed only for estrogen. The values of AUC0-infinity at day 1 and AUC0-24 h at day 29 (steady state) were similar, suggesting no accumulative effect of exemestane. These results demonstrate the anti-tumor effect and safety of exemestane in postmenopausal anti-estrogen resistant breast cancer patients. The reproducibility of the results of the two foreign studies was verified in Japanese patients, and it is concluded that the foreign trial data on exemestane can be extrapolated to Japanese.

[Beneficial effect of cibenzoline in a patient with hypertrophic obstructive cardiomyopathy complicated with idiopathic interstitial pneumonia].

A 72-year-old woman who had idiopathic interstitial pneumonia was admitted due to general fatigue. Echocardiography revealed asymmetric septal hypertrophy and systolic anterior movement of the mitral valve. In addition, Doppler echocardiography revealed a pressure gradient of 52 mmHg in the left ventricular outflow tract. Hypertrophic obstructive cardiomyopathy was diagnosed. Because she had a respiratory disease, she was treated with cibenzoline instead of beta-blockers. After treatment her pressure gradient decreased to 10 mmHg, but respiratory symptom remained unchanged. This finding suggests that cibenzoline is useful for patients with hypertrophic obstructive cardiomyopathy complicated with respiratory disease.