Is the addition of extranodal extension and lymph node yield of pN0 to the lymph node ratio useful as a prognostic parameter for patients with oral squamous cell carcinoma?

We investigated the value of the weighted lymph node ratio (WLNR), a new marker in pN0 patients that incorporates the number of metastatic lymph nodes with extranodal extension and the lymph node yield, for the prognosis and postsurgical management of oral squamous cell carcinoma (OSCC). We designed a retrospective study and enrolled patients with OSCC who were treated by neck dissection (ND). The predictor variable was WLNR, and the outcome variable was overall survival (OS). The Cox proportional-hazards model was used to identify independent prognostic factors. In 133 patients with OSCC, the WLNR cut-off value for predicting OS was 0.0363 (area under the curve 0.723, p<0.001). When stratified according to WLNR, there was a significant difference in OS (88.4% for low WLNR and 63.0% for high WLNR, p<0.001). Univariate analyses showed close associations between OS and age, dissection area, postoperative management, extranodal extension, number of positive lymph nodes, pN stage, WLNR, and nodal disease area. Cox multivariate analysis identified the WLNR as an independent predictive factor for OS (HR 3.273, 95% CI 1.227 to 8.731, p=0.018). As a predictive factor, a high WLNR (≥0.0363) in patients with pN0 disease, which included the addition of extranodal extension and lymph node yield to the LNR, was associated with diminished survival.

Postoperative delirium after reconstructive surgery for oral tumor: a retrospective clinical study.

The aim of this study was to perform a statistical evaluation of the risk factors for postoperative delirium after oral tumor resection and reconstructive surgery. The records of 69 consecutive patients who underwent major head and neck tumor resection and reconstructive surgery, and who received postoperative management in the high care unit (HCU) or intensive care unit (ICU) of Tsukuba University Hospital between January 2013 and December 2017, were analysed retrospectively. Delirium was diagnosed in 23 patients (33.3%) after surgery. There were significant differences in age, sex, history of diabetes mellitus and chronic obstructive pulmonary disease, recent hospitalization history, sedation period, duration of ventilator use, length of ICU/HCU stay, postoperative blood tests (haemoglobin and potassium), and postoperative medication with a major tranquilizer between those with and without delirium. Logistic regression analysis of selected independent variables revealed a hazard ratio (95% confidence interval) of 1.42 (1.09-1.86) for the sedation period. Delirium was hyperactive type in 15 cases, hypoactive type in five, and mixed type in three. There was no obvious difference in postoperative day of onset or delirium period according to subtype. In conclusion, a history of diabetes and the sedation period were found to be related to postoperative delirium. However, this study was small and retrospective, so further investigation is necessary.

Ureteroarterial fistula in a patient with a single functioning kidney.

A rare case is reported of a fistula between the left internal iliac artery and the left ureter in a patient whose left kidney was the only functioning kidney. Internal iliac artery embolization was initially successful in stopping the bleeding, but the fistula recurred when the ureteral stent was removed. Even after embolization, the tissue surrounding a fistula remains very fragile, so the fistula may easily recur as a result of slight injury or inflammation.

Management of renal cell carcinoma with inferior vena cava tumor thrombus.

OBJECTIVE: The prognostic implication of radical nephrectomy with inferior vena cava tumor thrombectomy for renal cell carcinoma is still controversial. We investigated the type of renal cell carcinoma with vena cava tumor thrombus for which surgical resection was beneficial. MATERIALS AND METHODS: We retrospectively reviewed the records of 16 patients with renal cell carcinoma and inferior vena cava tumor thrombus. Of these, 10 received surgical treatment and 6 did not. We evaluated the association between the pretreatment serum C-reactive protein (CRP) level and the efficacy of surgery. RESULTS: Among the 8 patients with an elevated pretreatment serum CRP level (CRP > or = 1.0 ng/ml), there was no significant difference of the median disease-specific survival between those who did (20.2 months) and did not undergo surgery (8.2 months; p = 0.1946). On the other hand, among the 8 patients who had a pretreatment serum CRP level within normal limits (CRP < 1.0 ng/ml), the median disease-specific survival of those who did not undergo surgery (80.6 months) was significantly better than that of those who did (50.2 months; p = 0.0136). CONCLUSION: This study suggested that conservative treatment can be recommended for patients with renal cell carcinoma and inferior vena cava tumor thrombus when the pretreatment serum CRP level is normal because tumor progression is usually slow and surgical treatment may actually worsen the prognosis.

[Malignant fibrous histiocytoma originating in a renal capsule: a case report].

We report a case of malignant fibrous histiocytoma originating in a renal capsule. A 43-year-old woman was admitted with a chief complaint of right lower abdominal pain. Physical examination was unremarkable. Serum C-reactive protein and erythrocyte sedimentation rate increased to 3.8 mg/dl and 60 mm/hr., respectively. Computed tomography (CT) and magnetic resonance image (MRI) showed a heterogeneous enhanced mass, 4 x 9 x 13 cm in size, in contact with the lateral part of the right kidney. Selective right renal arteriography revealed a hypovascular tumor, the main feeding artery of which was the right adrenal artery. Preoperative clinical diagnosis was a retroperitoneal sarcoma and transabdominal tumor resection was performed. The adhesion between the tumor and the right kidney was so severe that right nephrectomy was also necessary for a radical surgery. The tumor, measuring 13 x 9 x 6 cm, was located laterally adhering to the right renal capsule. Microscopic examination of the tumor demonstrated spindle-shaped fibroblast-like cells arranged in a storiform pattern with fibrous stroma and clusters of rounded histiocyte-like cells and pleomorphic giant cells with bizarre nuclei. Histopathological diagnosis was malignant fibrous histiocytoma arising from the renal capsule and there was no tumor invasion to renal parenchyma. No adjuvant therapy was performed but she has remained well for 31 months since the operation without evidence of disease.

Nicorandil affords cardioprotection in patients with acute myocardial infarction treated with primary percutaneous transluminal coronary angioplasty: assessment with thallium-201/iodine-123 BMIPP dual SPECT.

BACKGROUND: It has been reported that nicorandil restores blood flow to reperfused myocardium in patients with acute myocardial infarction. However, whether nicorandil might decrease infarct size remains unclear. The aim of this study was to assess the effect of nicorandil on infarct size with thallium-201/beta-methyl-p-iodophenyl pentadecanoic acid (BMIPP) dual-isotope single photon emission computed tomography. METHODS: A total of 62 patients were randomly assigned to receive intravenous nicorandil (4 mg in 5 minutes at admission, immediately followed by 6 mg/hr over a 24-hour period) or placebo. All patients were divided into 4 groups: Group N-a, 16 patients with preexisting angina treated with nicorandil; N-b, 15 patients without preexisting angina treated with nicorandil; C-a, 14 patients with preexisting angina given placebo; C-b, 17 patients without preexisting angina given placebo. Tl-201/BMIPP imaging was performed in the 62 patients within 7 days after admission. Dual-isotope single photon emission computed tomographic images were quantified by severity index with a polar map. RESULTS: The BMIPP severity index was similar among the 4 groups. Only the thallium severity index in the N-a group was significantly less (P<.05). The ratio of the thallium severity index to that of BMIPP in the N-a group was significantly decreased compared with those of the other groups. CONCLUSION: Nicorandil has a protective effect in patients with acute myocardial infarction and preexisting angina treated with primary balloon angioplasty.

Predicting pathological stage of localized prostate cancer using volume weighted mean nuclear volume.

PURPOSE: With the use of prostate specific antigen (PSA) and transrectal ultrasound guided biopsy of the prostate, increasing numbers of clinically localized prostate cancers have recently been detected. Presently, approximately 60% of men newly diagnosed with prostate cancer are believed to have organ confined disease but at the time of surgery less than 50% are ultimately found to have organ confined disease on final pathological analysis. Prediction of pathological stage before surgery using various prognostic factors is needed to determine whether radical prostatectomy is indicated. We have reported that estimates of volume weighted mean nuclear volume can accurately predict the prognosis of clinically localized prostate cancer treated with androgen ablation. In this study we examine whether estimates of mean nuclear volume can predict the pathological stage of cases treated with radical prostatectomy. MATERIALS AND METHODS: A retrospective, prognostic study of 52 patients with clinically localized prostate cancer (21 cases T1c, 27 T2, 4 T3) diagnosed at Kobe City General Hospital between January 1996 and December 1999 and treated with radical prostatectomy was performed. Unbiased estimates of mean nuclear volume measured from transrectal biopsy specimens were compared with PSA at diagnosis, clinical stage, estimated tumor volume and Gleason score with regard to prediction of pathological stage. RESULTS: Univariate analysis revealed that estimates of mean nuclear volume (p <0.0001), PSA at diagnosis (p = 0.0148) and estimated tumor volume (p = 0.0005) significantly correlated with pathological stage but Gleason score did not (p = 0.2011). In addition, multivariate logistic regression analysis demonstrated that estimates of mean nuclear volume (p = 0. 0073), PSA at diagnosis (p = 0.0277) and estimated tumor volume (p = 0.0197) were significantly independent predictors of pathological stage. CONCLUSIONS: The results of our study suggest that combining PSA and estimated tumor volume with estimates of mean nuclear volume can significantly contribute to the prediction of pathological stage of prostate cancer. We recommend use of these 3 factors to predict pathological stage of prostate cancer before surgery.

[Extensive Fournier's gangrene: a case report].

We report a case of extensive Fournier's gangrene that could not be rescued despite emergent debridement. A 51-year-old man presented at another hospital with cough, diarrhea and abdominal pain. He was diagnosed with acute enteritis and hospitalized. The next morning, he became severely hypotensive and his scrotum was swollen and black. The perineal skin also was black. Septic shock and disseminated intravascular coagulation were suspected. He was transferred to our emergency room, and was immediately diagnosed with Fournier's gangrene and acute peritonitis. Computed tomographic scan revealed soft-tissue gas in the scrotum, the retroperitoneal cavity and the abdominal wall. Emergent debridement and laparotomy was performed. Gangrene was also seen at the intestinal wall and the peritoneum, however, resection of intestine was not done because of his poor performance status. Although potent antibiotics and catecholamine were administered, he died of multiple organ failure 29 hours after the operation. This is the first case of Fournier's gangrene extending into the abdominal cavity reported in the Japanese literature.

Serum immunosuppressive acidic protein and natural killer cell activity in patients with metastatic renal cell carcinoma before and after nephrectomy.

PURPOSE: To our knowledge the impact of nephrectomy on stage M1 renal cell carcinoma remains to be determined. We previously reported that nephrectomy is beneficial in patients with elevated serum C-reactive protein before treatment, and those in whom nadir C-reactive protein decreases postoperatively to within the normal range may expect longer survival when surgery is combined with postoperative immunotherapy. In this study we determine the effect of nephrectomy on the immune response in patients with metastatic renal cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the records of 40 patients with metastatic renal cell carcinoma diagnosed at our institution between 1986 and 1999. These patients underwent nephrectomy before cytokine therapy with interferon. Before and after nephrectomy we measured serum C-reactive protein, serum immunosuppressive acidic protein and peripheral blood natural killer cell activity. RESULTS: In 15 patients with pretreatment serum C-reactive protein within the normal range (less than 1 ng./ml.) there was no significant difference before and after nephrectomy in the serum immunosuppressive acidic protein level or natural killer cell activity (p = 0.4587 and 0.3892, respectively). On the other hand, in 25 patients with serum C-reactive protein elevated before treatment to 1 ng./ml. or greater serum immunosuppressive acidic protein decreased significantly and natural killer cell activity increased significantly after cytoreductive surgery (p = 0.0002 and 0.0286, respectively). CONCLUSIONS: Our study implies that nephrectomy may be beneficial in patients with elevated serum C-reactive protein before treatment. Further evaluation by a prospective study is needed to make a definitive conclusion.

[Clinical evaluation of estramustine phosphate and vinblastine in patients with hormone-refractory prostate cancer].

We evaluated the efficacy of the combination of estramustine phosphate and vinblastine in 13 patients with hormone-refractory prostate cancer. Of 12 patients with an elevated prostate specific antigen (PSA) level at the start of treatment, 5 (42%) had a greater than 50% decrease in PSA level. In a patient with cervical and mediastinal lymph node metastases, about a 57% decrease was observed in bidimensional measurement. Side effects were mild and manageable. The survival rate was not significantly different between patients who showed a greater than 50% decrease in PSA levels or regression of lymph node metastases versus the other patients.

Influence of diabetes mellitus on left ventricular function in patients undergoing coronary artery bypass grafting.

OBJECTIVES: Left ventricular function was assessed by two-dimensional echocardiography before and one year after coronary artery bypass grafting(CABG) in a series of patients with severe coronary artery disease with diabetes mellitus(DM) and without DM(non-DM). METHODS: Twenty-three patients with DM and 50 patients without DM, all with no previous myocardial infarction, underwent two-dimensional echocardiography before CABG and one year after CABG, in a non-matched study. For a matched study, 31 patients without DM who had almost the same left ventricular function as DM patients at the baseline were selected to and compare the rate of improvement in left ventricular function between the DM group and the "matched" non-DM group. RESULTS: In the non-matched study, patient characteristics were not significantly different between the 2 groups except for the incidence of congestive heart failure within one year before CABG, which was significantly higher in the DM group. Fractional shortening was significantly lower in the DM group at the baseline(p < 0.05) and also one year after CABG(p < 0.0001). Significant improvement in fractional shortening was seen in the non-DM group(p < 0.001), but not in the DM group. The left ventricular end-diastolic diameter(LVDd) was significantly larger in the DM group at the baseline(p < 0.01), and was still significantly larger in the DM group at one year after CABG(p < 0.01). No improvement in LVDd was seen in the DM group. In the matched study, fractional shortening of the non-DM group also showed significant improvement after CABG(p < 0.001). Moreover, the rate of improvement in fractional shortening was higher in the non-DM group than in the DM group(p < 0.05). LVDd tended to be larger in the DM group(p = NS). CONCLUSIONS: Left ventricular dysfunction and left ventricular impaired improvement were seen in the patients with DM, and CABG improved left ventricular function in the patients without DM with poor left ventricular function. These findings indicate that CABG therapy may be inadequate for improving left ventricular function in patients with DM and severe left ventricular dysfunction at the baseline.

The role of volume weighted mean nuclear volume in predicting the prognosis of patients with primary transitional cell carcinoma of the upper urinary tract: a report of 102 new cases.

PURPOSE: We compare estimates of volume weighted mean nuclear volume (MNV) with histological grading to determine the prognosis of primary transitional cell carcinoma of the upper urinary tract using a Cox proportional hazards model. MATERIALS AND METHODS: We retrospectively reviewed 102 patients who underwent nephroureterectomy for primary transitional cell carcinoma of the upper urinary tract at our hospital between April 1981 and March 1997. Traditional prognostic factors, such as patient age, sex, stage and grade, multiplicity and unbiased estimates of MNV were analyzed with respect to disease recurrence and survival. RESULTS: Estimates of mean nuclear volume were significantly larger for patients with than without lymph node metastasis (p = 0.0031). No prognostic factor significantly correlated with recurrence of transitional cell carcinoma of the bladder. For pTxN0M0 cases univariate analysis revealed that histological grade (p = 0.0018), pathological T stage (p = 0.0030) and estimates of MNV (p = 0.0001) correlated significantly with disease specific survival, and multivariate stepwise regression analysis revealed that estimate of MNV was the only powerful predictor of prognosis (p = 0.0007). CONCLUSIONS: Our results indicate that estimate of MNV is an important predictor of prognosis for transitional cell carcinoma of the upper urinary tract. We recommend MNV estimate as a supportive method for subjective histological grading.

Kinetic resolution of alpha-acetoxy carboxylic acids with homochiral SuperQuats.

Preliminary investigations focused on the kinetic resolution of (+/-)-alpha-acetoxy mandelic carboxylic acid chloride with isopropyl SuperQuat and isopropyl Evans' homochiral auxiliaries. The addition of 2 equiv. of the acid chloride to the lithium salts of the auxiliaries (SuperQuat and Evans') at -100 degrees C in the THF afforded the corresponding N-acyl auxiliaries in high chemical yields (95% and 89%) and d.e.'s of 66% and 40%, respectively. Using the same mandelic acid chloride but incorporating SuperQuat auxiliaries derived from (S)-phenylglycine and (S)-phenylalanine yielded the corresponding N-acyl SuperQuats in 86% and 90% and d.e. 's of 66% and 30%, respectively. Substituting the phenyl group within the alpha-acetoxy mandelic acid chloride for a n-butyl, tert-butyl and cyclohexyl group changed the d.e. significantly when kinetically resolved with isopropyl SuperQuat. The yields were all similar, i.e., approximately 90% but the d.e.'s varied considerably, with values of 20%, 50%, and 82%, respectively. Attempted kinetic resolution of alpha-methoxyphenylacetyl chloride using the lithium salt of isopropyl SuperQuat revealed a diasteroselectivity of 45%, significantly lower than that obtained with the corresponding alpha-acetoxy carboxylic acid chlorides.

Brugada syndrome characterized by the appearance of J waves.

We describe a patient with Brugada syndrome. The ST-segment elevation in precordial leads was revealed during admission, but the appearance of J waves was characteristic before ventricular fibrillation (VF), rather than ST-segment elevation. J waves have been reported to be associated with the presence of an Ito-mediated prominent action potential notch in the epicardium. It is considered that one of the mechanisms of this VF is due to heterogeneous distribution of the refractory period according to changes in K+ channels including Ito.

[A case of unilateral and metachronous occurrence of renal tubulopapillary adenoma and renal cell carcinoma].

A 50-year-old male underwent a nephron-sparing surgery for a small renal incidentaloma, which was atypical for renal cell carcinoma in diagnostic images. The tumor was pathologically diagnosed as renal tubulopapillary adenoma. Three years later, another tumor was pointed out in the ipsilateral kidney, and he underwent a radical nephrectomy. The latter was diagnosed as clear cell carcinoma. We report this very rare case of unilateral and metachronous occurrence of renal tubulopapillary adenoma and renal cell carcinoma.

Prognosis of primary testicular seminoma: a report on 57 new cases.

Most urologists perform adjuvant radiation therapy for stage 1 (TxN0M0) testicular seminoma after orchiectomy, although the majority of patients with clinical stage 1 seminoma do not have occult metastases and therefore do not require elective nodal irradiation. However, there are currently no clinical or histological parameters that can be used to distinguish patients who need radiation therapy from those who do not. We reported previously that estimates of volume-weighted mean nuclear volume (MNV) were a better predictor of the prognosis of prostate cancer and renal cell carcinoma than subjective histological grading. Here, we examined the usefulness of estimation of MNV for predicting the prognosis of primary testicular seminoma. A retrospective study of 57 patients with testicular seminoma diagnosed between April 1981 and March 1997 at Kobe City General Hospital was performed. Unbiased estimates of MNV data were compared for prognostic value with the level of beta-human chorionic gonadotropin (beta-HCG), alpha-fetoprotein (AFP), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH). Fifty patients were stage 1 (TxNoMo), and 7 patients were stage 2 (TxN1-2M0). All patients received orchiectomy, followed by radiation therapy. Estimates of MNV of stage 2 patients were significantly larger than that of stage 1 patients (P = 0.0142). Although the LDH level was also significantly higher in stage 2 (P = 0.001), there were no significant differences between stages 1 and 2 with respect to beta-HCG (P = 0.997), ALP (P = 0.226), and AFP (P = 0.467). Multivariate logistic regression analysis revealed that the estimate of MNV was the only variable predicting lymph node metastasis (P = 0.0315). In stage 1 patients, only the estimate of MNV was significantly correlated with progression-free survival (P = 0.0118). These findings indicate that the estimate of MNV may be an important prognostic indicator for testicular seminoma. Estimates of MNV may also be useful for excluding patients from surveillance protocols.

Prostate-specific antigen levels and clinical response to flutamide as the second hormone therapy for hormone-refractory prostate carcinoma.

BACKGROUND: Some authors have recently reported that maximum androgen block (MAB), in which the nonsteroidal anti-androgen, flutamide, is used together with conventional hormone therapy such as castration or luteinizing hormone-releasing hormone analogue, is more effective for prostate cancer than conventional methods. However, others have reported that the effect of MAB on survival is minimal, and definite conclusions concerning MAB remain unclear. Conversely, using flutamide as a second-line hormone therapy after recurrence is also considered, but few authors have reported whether this therapeutic option is effective or for which patients it is effective. MATERIALS AND METHODS: 124 patients with prostate cancer were diagnosed and followed at Kobe City General Hospital between 1995 and 1997. Twenty-two of these cases developed recurrence during first-line hormone therapy, and flutamide was prescribed in these cases. The prognostic value and effectiveness of flutamide were evaluated by measurement of serum prostate-specific antigen (PSA) at diagnosis, posttreatment nadir PSA level, PSA at the time of flutamide use, histological grade, recurrence-free time after firstline hormone therapy and age at the time of diagnosis. RESULTS: Six of 9 cases whose post-treatment nadir PSA levels after initial hormone therapy were within the normal limit (<4 ng/ml) achieved complete remission (CR) with flutamide use, but no patient whose post-treatment nadir PSA level remained elevated achieved CR. PSA at diagnosis and PSA at the start of flutamide use were significantly lower for patients with CR. However, the results of multivariate logistic regression analysis demonstrated that only the post-treatment nadir PSA level was significantly correlated with prognosis of flutamide use. CONCLUSIONS: Flutamide use as second-line hormone therapy should be limited to cases in which first-line hormone therapy has been highly effective and for whom the post-treatment nadir PSA level was within normal limits, and other patients should undergo other therapies. By limiting flutamide use to patients in whom the effect of flutamide is considered to be maximal, the incidence of complications and medication costs can be decreased.

Angiotensin-converting enzyme inhibitor therapy affects myocardial fatty acid metabolism after acute myocardial infarction.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitor therapy has an early mortality benefit in unselected patients with acute myocardial infarction (AMI). However, the effects of ACE inhibition on myocardial fatty acid metabolism in this patient population have not been studied. We tested the hypothesis that ACE inhibitor therapy improves myocardial fatty acid metabolism and decreases mortality rate in patients after AMI. METHODS: Forty-two patients after first anterior AMI and primary angioplasty were randomly assigned to titrated oral enalapril (n = 24) or placebo therapy (n = 18). Iodine 123-labeled 15-(p-iodophenyl)-3-(R,S)-methylpentadecanoic acid (BMIPP) single photon emission computed tomography imaging was performed an average of 4.8 days after AMI and 1 month after AMI. BMIPP abnormalities were quantified as a severity index by a polar map. RESULTS: There were no significant changes in baseline characteristics, cardiac function, and angiographic findings between patients in the enalapril group and patients in the placebo group. However, BMIPP severity index from acute phase to chronic phase was significantly decreased in the enalapril-treated group (118+/-48 to 82+/-36, P<.05), but not in the placebo group (123+/-65 to 115+/-58, P not significant). CONCLUSION: ACE inhibition therapy improved myocardial fatty acid metabolism and regional left ventricular function in patients after anterior AMI. BMIPP single photon emission computed tomography findings imply that this better outcome may be attributable to an improvement of cellular function with ACE inhibitors.

[In vitro activities of carbapenem antibiotics against the various clinical isolates].

The annual changes of antibacterial activities of beta-lactam antibiotics, mainly carbapenem antibiotics, were investigated against 5 bacterial species, S. aureus (MSSA), methicillin-resistant S. aureus (MRSA), Klebsiella pneumoniae, Serratia marcescens, Pseudomonas aeruginosa, which had been isolated from the clinical materials at Toho University Omori Hospital during the period of 1995 to 1997. In addition, antibacterial activities against other main bacterial strains isolated from the clinical materials during 1997 were also determined. The five bacterial species on which annual changes of the sensitivity were investigated did not show any remarkable trend to increase in resistance to the carbapenem antibiotics tested. The antibacterial activities of the carbapenem antibiotics against MRSA were weak, and MIC90 values were between 25 and 50 micrograms/ml. In S. marcescens and P. aeruginosa on which high resistance by the production of metallo-beta-lactamase has become a problem in recent years, there were no remarkable changes in annual changes of sensitivities. Especially, MIC90 valuses of the carbapenem antibiotics against P. aeruginosa were between 12.5 and 25 micrograms/ml, 4 to 8 times better than that of PIPC, like the case of CAZ. Furthermore, the carbapenem antibiotics showed strong antibacterial activities against clinically important 16 bacterial species, from Gram-positive to Gram-negative bacteria.