Risk of metachronous recurrence after endoscopic submucosal dissection of esophageal squamous cell carcinoma.

Development of endoscopic submucosal dissection (ESD) improves the en bloc resection rate of superficial esophageal squamous cell carcinoma (SESCC). Although the background mucosa after ESD remains malignant potential, esophageal (sub)circumferential ESD, in cases where the mucosal defect is greater than three-fourths of the circumference, might induce refractory stricture, and it may disturb early detection of the recurrence. Therefore, we aimed to elucidate whether the patients treated by (sub)circumferential ESD for SESCC may remain at risk of metachronous recurrence. In a single-center retrospective study, we collected data from 154 consecutive patients who were treated with curative ESD for SESCC from 2002 to 2013 and followed by surveillance for longer than 12 months. Metachronous recurrence was defined as histologically proven SESCC at other site of the ESD scar or abnormal nodal swelling was detected later than 12 months after ESD. The primary endpoint was to identify the risk of metachronous recurrence using multivariate analyses. The secondary endpoint was to investigate difference in clinical pathological features between patients with and without the recurrence. The overall rate of metachronous recurrence was 14.9% during 40.5 median months after the initial ESD. 24.1% and 9.0% of overall metachronous recurrence were observed in patients treated with (sub)circumferential ESD and non-subcircumferential ESD, respectively, despite no significant difference in their observation duration. After the application of a stepwise regression model that included all variants, a Cox proportional hazards regression model identified (sub)circumferential ESD as the only risk for the recurrence (hazard ratio (HR): 1.48, 95% confidence intervals (CI): 1.04-2.08, P = 0.028). The cumulative recurrence rate revealed a significant difference between patients treated by (sub)circumferential ESD and those by nonsubcircumferential ESD (HR: 3.094, 95% CI: 1.33-7.52, P = 0.009), despite no significant difference in their cause-specific survival. Additionally, the session numbers of the follow-up endoscopy until the detection of metachronous recurrence after the non-subcircumferential ESD were significantly less than those after the (sub)circumferential ESD (7.8 ± 1.8 vs. 15.2 ± 1.5 P = 0. 005), despite no significant difference in their cancer-free duration. In conclusion, we demonstrated that patients treated by curative (sub)circumferential ESD for SESCC might be high risk for metachronous recurrence. Therefore, we should establish a risk-stratified surveillance program after (sub)circumferential ESD and preventive strategies for post-ESD stricture.

Neurogenic pulmonary edema and large negative T waves associated with subarachnoid hemorrhage.

We describe a 72-year-old woman with hypertension who developed acute neurogenic pulmonary edema and giant negative T waves on electrocardiography (ECG) due to subarachnoid hemorrhage. The patient was alert and complained of precordial chest discomfort, dyspnea and shoulder stiffness. Echocardiography demonstrated normal left ventricle contraction with hypertrophy. Computed tomography (CT) and subsequent cerebral angiography revealed subarachnoid hemorrhage and saccular aneurysm at the anterior communicating artery. It is important to consider the possibility of subarachnoid hemorrhage when a patient shows pulmonary edema and ECG abnormalities even without typical clinical signs of subarachnoid hemorrhage.

Chronic hypernatremia derived from hypothalamic dysfunction: impaired secretion of arginine vasopressin and enhanced renal water handling.

We analyzed the disorder of water metabolism in a 32 year-old female with chronic hypernatremia. She had meningitis at 4 years, and ventriculo-peritoneal shunt operation at 13 years because of normal pressure hydrocephalus. At 14 years hypernatremia of 166 mmol/l was initially found and thereafter hypernatremia ranging from 150 to 166 mmol/l has been persisted for the last 18 years. Physical and laboratory findings did not show dehydration. Urine volume was 750-1700 ml per day and urinary osmolality (Uosm) 446-984 mmol/kg, suggesting no urinary concentrating defect. Plasma arginine vasopressin (AVP) levels ranged from 0.4 to 1.2 pmol/l despite hyperosmolality of 298 through 343 mmol/kg under ad libitum water drinking. There was no correlation between plasma osmolality (Posm) and plasma AVP levels, but Uosm had a positive correlation with Posm (r=0.545, P < 0.05). Hypertonic saline (500 NaCl) infusion after a water load increased Uosm from 377 to 679 mmol/kg, and plasma AVP from 0.2 to 1.3 pmol/l. There was a positive correlation between Posm and plasma AVP levels in the hypertonic saline test (r=0.612, P<0.05). In contrast, an acute water load (20 ml/kg BW) verified the presence of impaired water excretion, as the percent excretion of the water load was only 8.5% and the minimal Uosm was as high as 710 mmol/kg. Urinary excretion of aquaporin-2 remained low in concert with plasma AVP levels. No abnormality in pituitary-adrenocortical function was found. These results indicate that marked hypernatremia is derived from partial central diabetes insipidus and elevated threshold of thirst, and that enhanced renal water handling may contribute to maintenance of body water in the present subject.

[A case of alveolar soft-part sarcoma with cerebral metastases].

A case of alveolar soft-part sarcoma with multiple cerebral metastases in addition to multiple lung and bone metastases is reported. This is a rare tumor which thus far has only been recognized as a malignant soft tissue tumor with great uncertainty. A 24-year-old man with a chief complaint of left frontal headache was admitted to our unit on September 26, 1994. A tumor of the right forearm had been surgically removed 9 years previously, and surgery had been followed by two courses of chemotherapy with vincristine, cyclophosphamide and actinomycin-D and subsequent irradiation for bone metastasis. The chemotherapy, however, did not have any clear effect. Neurological examination at the time revealed only bilateral papilledema, but CT and MRI scan of the brain showed a round mass in the left occipital lobe with homogeneous enhancement and another small mass was detected in the right occipital lobe. A cerebral angiogram showed a vascular tumor. The preoperative diagnosis was multiple cerebral metastases of alveolar soft part sarcoma. Left occipital craniotomy was performed on October 12, 1994, and the tumor was completely removed by lobectomy. Specimens of the tumor showed typical histological features of alveolar soft-part sarcoma. Whole-brain radiotherapy was administered postoperatively, and the patient is well neurologically without right homonymous hemianopsia. The clinical features of alveolar soft-part sarcoma are discussed. Only a few cases have been reported in the literature, but the most frequent site of the primary lesion has been the lower extremities, and cerebral metastasis has not been rare. All efforts should be focused on discovering this tumor in the early stage because surgical removal can yield good results, and radiotherapy is thought to be effective in terms of patient "quality of life".

[Rhinogenous retrobulbar optic neuritis: a case report].

Rhinogenous retrobulbar optic neuritis is characterized by neuritis secondary to paranasal sinusitis. A case of rhinogenous retrobulbar optic neuritis that was successfully treated by surgery is reported. A 40-year-old man complained of progressive right visual disturbance. The clinical course and neurological examination suggested right retrobulbar optic neuritis. CT and MRI scans demonstrated a massive tumor-like lesion near the right optic canal. Fifteen days after the onset, decompression of the right optic nerve was performed using a right pterional approach. After surgery, visual disturbance improved, and after about 1 month, the symptom had disappeared. Operative findings, histological examination and the postoperative course were consistent with the characteristics of rhinogenous retrobulbar optic neuritis. We consider decompression of the optic nerve to be effective for the treatment of rhinogenous retrobulbar optic neuritis.