Palliative lumboperitoneal shunt for leptomeningeal metastasis-related hydrocephalus: A case series.

BACKGROUND: Leptomeningeal metastasis-related hydrocephalus causes distress to patients with end-stage cancer through headache and other symptoms by elevating intracranial pressure, thus reducing quality of life. Ventriculoperitoneal shunt has been used as a treatment option in palliative care. We review four cases of patients who underwent lumboperitoneal shunt for leptomeningeal metastasis-related hydrocephalus. CASES: All patients suffered from severe headache and nausea. The primary lesion was histologically diagnosed as lung adenocarcinoma in each case. The duration from diagnosis to onset of hydrocephalus symptoms ranged from 0 to 52 (mean 26) months. Cerebrospinal fluid pressure in every case was above the normal range due to high intracranial pressure. Case management: Conventional procedures for lumboperitoneal shunt were employed for all patients. Adjustable pressure valves were retrofitted into the shunt system. Case outcome: Three patients demonstrated significant improvement of clinical symptoms and quality of life after placement of lumboperitoneal shunts. In two cases, not only did performance status improve to independent daily activity but also comparatively long-term survival was achieved due to subsequent chemotherapies after surgery. No symptoms of peritoneal dissemination by floating cancer cells in cerebrospinal fluid were seen in any patients. CONCLUSION: Lumboperitoneal shunt appears to improve quality of life if the patient is suffering from symptoms of leptomeningeal metastasis-related hydrocephalus. Compared to ventriculoperitoneal shunt, lumboperitoneal shunt is less invasive and simpler, providing a suitable option for frail patients with end-stage cancer. Adjustable pressure shunt valves can cope with varying symptoms and ventricle sizes.

Case of concurrent benign metastasizing leiomyoma in the lung and retroperitoneum, with a focus on its etiology.

We report a rare, simultaneous occurrence of benign metastasizing leiomyoma in the lung and retroperitoneum in a 49-year-old woman who had previously undergone myomectomy at 35 years of age and hysterectomy at 45 years of age for multiple recurrences of histologically benign uterine leiomyomas. At 49 years of age, computed tomography-guided biopsy indicated benign metastasizing leiomyomas in the lung. In addition, a retroperitoneal leiomyoma was found that was resected along with both the ovaries via laparotomy. No sign or symptom of recurrence was observed 5 years later. The coexistence of benign metastasizing leiomyoma in the lung and retroperitoneum following surgery for conventional leiomyomas has rarely been reported. Further, the nature and etiology of benign metastasizing leiomyoma are still not well understood. This case is therefore worth reporting, and exploring its etiology is important.

Repeated episodes of ischemic stroke over a short period in a patient with essential thrombocythemia on anticoagulant therapy.

A 69-year-old man who had essential thrombocythemia, for which he was taking no medications, suddenly developed aphasia and right hemiplegia and was admitted to the hospital. He was thought to have had an embolic stroke and was initially treated with warfarin. Although the international normalized ratio was in the therapeutic range, he had 3 additional ischemic stroke episodes with the same symptoms after the index stroke. Magnetic resonance angiographic examinations revealed serial changes in middle cerebral artery stenosis. After administration of an antiplatelet agent and hydroxyurea, he had no additional strokes.

Epilepsy and takotsubo cardiomyopathy: a case report.

A 60-year-old woman with a history of symptomatic seizures secondary to a subarachnoid hemorrhage was admitted to hospital because of a generalized seizure. The following day, her electrocardiogram showed negative T waves in II, III, (a)V(F), and V(2-6), and the echocardiogram showed an impaired left ventricular ejection fraction with ventricular apical akinesia. Head magnetic resonance imaging showed no acute brain injury, but single photon emission computed tomography (SPECT) showed hyperperfusion which affected the left temporal cortex in particular. Hyperactivity of the temporal lobe might cause autonomic nervous system dysfunction and might be related to takotsubo cardiomyopathy.

[A case of lumboperitoneal shunt as an effective palliative tool in a patient with leptomeningeal metastasis].

A 64 year-old woman with a diagnosis of lung adenocarcinoma was admitted to our neurosurgical division in February, 2007, suffering from severe headache and dizziness. Systemic chemotherapy had been repeated for multiple metastases to the bone and cerebral cortex since 7 months before. Reexamination with MRI revealed mild hydrocephalus without cortical metastasis. Cytological analysis of the cerebrospinal fluid (CSF) provided the diagnosis of leptomeningeal metastasis. Removal of 8 ml of CSF dramatically alleviated the patient's symptoms. To improve the quality of her remaining life, she underwent lumboperitoneal (L-P) shunt using a Strata adjustable pressure valve. Severe headache disappeared and other symptoms gradually improved after the operation. She survived for 10 months after the shunt placement, perticipating in family life for 6 months. Pressure level of the Strata valve was changed twice according to the degree of hydrocephalus and functioned well while her life lasted. The present case showed that L-P shunt is one of the effective palliative procedures and an adjustable pressure valve is available for this kind of CSF shunt in patients with leptomeningeal metastasis.

[A case of primary posterior mediastinal chordoma].

A 49-year-old man, with a tumor shadow overlapping the heart on chest X-ray film was followed for 5 years. He was admitted because the tumor shadow enlarged. Chest CT scan showed a 6 x 7 cm in diameter extrapulmonary tumor at the Th8 and Th9 level, and a defect of the anterior margin of the thoracic vertebra is observed. Because thoracic CT-guided needle biopsy was not successful, total resection combined with thoracic vertebrae was performed. The tumor was under the parietal pleura and did not involve into the intrathoracic organs. Histological examination showed small round cells arranged in sheets and cord-like fashion in a mucinous stroma. On immunohistochemistry, the tumor cells were positive for S-100 protein, vimentin, AE1/3. CAM5.2, EMA and Alcian blue staining. Thus, we confirmed the diagnosis of chordoma. Chordoma is a rare malignant bone tumor that originates from notochordal remnants and accounts for about 1-4% of all malignant bone tumors. Intrathoracic mediastinal chordomas is extremely rare, representing only 3% of all chordomas.

Primary peripheral adenoid cystic carcinoma of the lung and literature comparison of features.

Adenoid cystic carcinoma arising from the peripheral lung is rare. Here, we describe adenoid cystic carcinoma that developed in the peripherally in S(9) of the right lower lobe of an 84-year-old woman. Cell blocks prepared from the bronchial wash specimens exhibited the cribriform formation. An immunohistochemical examination of the surgically resected tumor revealed positive thyroid transcription factor-1 and c-kit staining. Exons 9 and 11 of c-kit in tumor cells were not mutated. We compared the clinical features of this patient with those of 10 others described in the English-language literature.

Peptic ulcer-induced acute aortogastric fistula occurring 7 years after a pharyngogastrostomy following a resection for carcinoma of the esophagus: report of a case.

A 46-year-old woman underwent a pharyngogastrostomy, following a laryngoesophagectomy for esophageal carcinoma. Although she had been disease-free for 7 years, she subsequently was admitted to undergo a workup due to fever along with chest and back pain. A few days after admission, the patient suddenly vomited a large volume of blood and went into shock. Bleeding was stopped with a Sengstaken-Blakemore tube, and an emergency thoracotomy was performed. A fistula between the thoracic aorta and an ulcer of the gastric tube was identified. We decided to close the aortic lesion directly because the adhesions were extremely dense and her blood circulation was poor. One week later, we resected the thoracic part of the gastric tube, debrided the fistula, and wrapped the aortic lesion with a patch. However, on the 18th postoperative day, she developed massive hematemesis due to rupture of an infected pseudoaneurysm in the thoracic aorta and died.

[Appropriate duration of postoperative oral adjuvant chemotherapy with HCFU for colorectal cancer].

We conducted a joint study of different duration of drug administration for oral adjuvant chemotherapy using camphor (HCFU) with patients having advanced colorectal cancer who underwent curative resection. The patients were randomly divided into 2 groups, according to length of HCFU administration (6-month group and 2-year group), and followed up for 5 years postoperatively. In total, 239 patients were originally enrolled, out of which 155 were chosen as subjects for this study. There was significant difference in the overall cumulative 5-year survival rate between the short-term group and the long-term group (78.1% vs 89.6%). Between the respective subgroup that was defined by tumor location (colon or rectum), no differences were observed, but there was significant difference in the subgroup that was defined by the presence/absence of lymph node metastasis (59.4% vs 83.9%). It appears that oral adjuvant chemotherapy with HCFU is more effective when administered for 2 years than for 6 months.

Inhibition of arterial thrombosis by a protease-activated receptor 1 antagonist, FR171113, in the guinea pig.

The antiplatelet and antithrombotic effects of FR171113, 3-(4-chlorophenyl)-2-(2,4-dichlorobenzoylimino)-5-(methoxycarbonyl methylene)-1,3-thiazolidin-4-one, a non-peptide protease-activated receptor 1 (PAR1) antagonist, were evaluated in guinea pigs. FR171113 inhibited Ser-Phe-Leu-Leu-Arg-Asn-NH2 (a synthetic PAR1 agonist peptide)-induced and thrombin-induced aggregation of guinea pig platelets in a concentration-dependent manner in vitro (IC50=1.5 and 0.35 microM, respectively). Subcutaneous administration of FR171113 (0.1-3.2 mg/kg) produced a dose-dependent inhibition of platelet aggregation ex vivo. The ED50 value of FR171113 for platelet aggregation was 0.49 mg/kg s.c. However, FR171113 did not have an inhibitory effect on ADP- or collagen-induced platelet aggregation in vitro and ex vivo. One hour after FR171113 treatment at 1.0 mg/kg s.c., significant inhibition of arterial thrombosis without a prolongation of thrombin time or coagulation time was seen in the FeCl3-induced carotid artery thrombosis model in guinea pigs. Furthermore, FR171113 did not prolong bleeding time even at 32 mg/kg s.c., which is a much higher dose than that required in the thrombosis model. These observations indicate that FR171113 has desirable antiplatelet effects both in vitro and in vivo and that its in vivo antithrombotic activity is efficacious without causing a prolongation of bleeding time.

Malignant pheochromocytoma associated with pseudo-obstruction of the colon.

Effective treatment has not yet been established for intestinal pseudo-obstruction, a rare complication of malignant pheochromocytoma. We report the case of a 41-year-old man who presented with malignant pheochromocytoma associated with pseudo-obstruction of the colon. His serum catecholamine level was markedly elevated, and his large intestine was distended with gas and lodged stool. Laxatives and enemas were not effective in relieving his symptoms. We subsequently performed an ileostomy, after which the patient had good bowel movement and was able to resume oral food intake.

Clinicopathologic features and outcomes of intraductal papillary-mucinous tumors of the pancreas.

BACKGROUND/AIMS: The authors reviewed their experience with resected IPMT (intraductal papillary-mucinous tumor) of the pancreas to clarify the characteristics and prognosis of this neoplasm. METHODOLOGY: Between 1983 and 1998, 30 consecutive patients with IPMT underwent operations at our institution. Their clinicopathological features and postoperative long-term outcomes were analyzed retrospectively. RESULTS: There were 22 males and 8 females, with a mean age of 64 years. Operations performed were duodenum-preserving pancreatic head resection in 12 patients, distal pancreatectomy in 8, segmental pancreatectomy in 6, conventional pancreaticoduodenectomy in 4. Malignancy was found in 10 of 30 (33%). Factors significantly associated with malignancy were tumor size or presence in main pancreatic duct. In 30 resected patients after a mean follow-up of 60 months, tumor recurrence had occurred in 2 cases of invasive carcinoma that infiltrated into the extrapancreatic organ. The overall actuarial 5-year and 10-year survival was 83% and 62%, respectively. CONCLUSIONS: IPMT has a favorable prognosis after adequate resection. Despite slow growth, IPMT has an obvious malignant potential and a poor prognosis when invasive carcinoma has developed. Early recognition and pancreatectomy is the mainstay of treatment for IPMT.