Tumor lysis syndrome following letrozole for locally advanced breast cancer: a case report.

BACKGROUND: Letrozole, an aromatase inhibitor, is used to treat breast cancer in postmenopausal women. Tumor lysis syndrome (TLS) is a complication that can trigger multiple organ failure caused by the release of intracellular nucleic acids, phosphate, and potassium into the blood due to rapid tumor cell disintegration induced by drug therapy. TLS is uncommon in solid tumors and occurs primarily in patients receiving chemotherapy. Herein, we report a rare occurrence of TLS that developed in a patient with locally advanced breast cancer following treatment with letrozole. CASE PRESENTATION: An 80-year-old woman with increased bleeding from a fist-sized left-sided breast mass presented to our hospital. Histological examination led to a diagnosis of invasive ductal carcinoma of the luminal type. The patient refused chemotherapy and was administered hormonal therapy with letrozole. Seven days after letrozole initiation, she complained of anorexia and diarrhea. Blood test results revealed elevated blood urea nitrogen (BUN) and creatinine (Cr) levels, and she was admitted to our hospital for intravenous infusions. On the second day after admission, marked elevations of LDH, BUN, Cr, potassium, calcium, and uric acid levels were observed. Furthermore, metabolic acidosis and prolonged coagulation capacity were observed. We suspected TLS and discontinued letrozole, and the patient was treated with hydration, febuxostat, and maintenance hemodialysis. On the third day after admission, her respiratory status worsened because of acute respiratory distress syndrome associated with hypercytokinemia, and she was intubated. On the fourth day after admission, her general condition did not improve, and she died. CONCLUSIONS: Although TLS typically occurs after chemotherapy initiation, the findings from the present case confirm that this syndrome can also occur after hormonal therapy initiation and should be treated with caution.

Emergency Resection of a Bleeding Ruptured Malignant Phyllodes Tumor of the Breast.

Ruptured phyllodes tumors, though extremely rare, can necessitate emergency surgery in certain cases, particularly those with active bleeding. A 51-year-old woman presented to our hospital with a newly identified mass in her right breast that developed over the past two months. The tumor had ruptured through the paramammary nipple. While initially diagnosed with a phyllodes tumor and scheduled for elective surgery, she experienced active bleeding from the ruptured tumor, leading to a drop in hemoglobin levels. An emergency right simple mastectomy was performed to control the bleeding. Postoperatively, no complications or recurrences were observed. Phyllodes tumors, which are characterized by rapid growth, may present with active bleeding following rupture and may require emergency surgery.

IgG4-related mastitis managed without excision or steroid therapy.

IgG4-related mastitis is an extremely rare IgG4-related sclerosing disease involving the breast that must be differentiated from breast cancer. There is currently no consensus regarding the optimal treatment strategies. Here, we report a case of IgG4-related mastitis followed up without excision or steroid therapy. Although the association between IgG4-related mastitis and breast cancer remains unclear, regular follow-up imaging and measurement of serum concentrations of disease activity markers may allow for follow-up without excision or steroid therapy.

[Marginal zone lymphoma of mucosa-associated lymphoid tissue of the parietal pleura; report of a case].

An 76-year-old man was referred to our hospital due to right hydrothorax. The diffuse thickening of parietal pleura with increased fluoro-2-deoxy-D-glucose (FDG) uptake was noted by computed tomography (CT) and positron emission tomography (PET). Surgical biopsy was performed and the tumor was diagnosed as mucosal associated lymphoid tissue (MALT) lymphomas of parietal pleura origin by pathology. Complete remission was achieved by postoperative chemotherapy (R-CHOP), and the patient is now alive without recurrence.

[Lymphoepithelioma-like carcinoma（ LELC） of the lung].

A 77-year-old woman was admitted to our hospital with abnormal chest shadow detected on a medical checkup. Chest computed tomography(CT)showed a well-defined tumor in the upper lobe of the right lung. On positron emission tomography by fluorodeoxyglucose(FDG),the tumor revealed to be positive. We performed right upper lobectomy with hilar and mediastinal lymph node dissection. The histopathological diagnosis was lymphoepithelioma-like carcinoma (LELC). In the past 25-years, 41 cases have been reported in Japan. The average age is 64 years old, including 25 male cases and 16 female cases. Among these cases, more than half were in the early resectable stage.

[Sarcoidosis with right middle lobe atelectasis initially suspected of malignant lymphoma; report of a case].

60-year-old woman was admitted with an abnormal shadow on the chest roentgenogram. Computed tomography showed atelectasis of the right middle lobe and hilar and mediastinal lymphadenopathy. Bronchoscopic examination revealed an obstruction at the orifice of the right middle lobe bronchus and biopsy was performed. The biopsy suggested malignant lymphoma. A diagnosis of methotrexate-associated lymphoproliferative disorders was suspected because the patient was administered methotrexate to treat the rheumatoid arthritis. The video-assisted thoracoscopic surgery was performed. Histological examination showed no malignancy and sarcoidosis in the peribronchial lymph nodes. The compressed middle lobe bronchus by enlarged lymph nodes was consider to be the cause of the middle lobe atelectasis.

Multiple endocrine neoplasia type 1 in Japan: establishment and analysis of a multicentre database.

OBJECTIVE: Multiple endocrine neoplasia type 1 (MEN1) is less well recognized in Asian countries, including Japan, than in the West. The clinical features and optimal management of MEN1 have yet to be clarified in Japan. The aim of this study was to clarify the clinical features of Japanese patients with MEN1. DESIGN/PATIENTS: We established a MEN study group designated the 'MEN Consortium of Japan' in 2008, and asked physicians and surgeons to provide clinical and genetic information on patients they had treated. Of 680 registered patients, 560 were analysed. MEASUREMENTS: Clinical and genetic features of Japanese patients with MEN1 were examined. RESULTS: Primary hyperparathyroidism, gastroenteropancreatic neuroendocrine tumours (GEPNET), and pituitary tumours were seen in 94·4%, 58·6% and 49·6% of patients, respectively. The prevalence of insulinoma was higher in the Japanese than in the West (22%vs 10%). In addition, 37% of patients with thymic carcinoids were women, while most were men in western countries. The MEN1 mutation positive rate was 91·7% in familial cases and only 49·3% in sporadic cases. Eight novel mutations were identified. Despite the availability of genetic testing for MEN1, the application of genetic testing, especially presymptomatic diagnosis for at-risk family members appeared to be insufficient. CONCLUSIONS: We established the first extensive database for Asian patients with MEN1. Although the clinical features of Japanese patients were similar to those in western countries, there were several characteristic differences between them.

[Human pulmonary dirofilariasis].

The patient was a 60's-year-old man, who was incidentally pointed out a coin lesion in the right lung by chest radiogram. Chest computed tomography showed a round-shaped, well defined nodule of 2.5 cm in size in the right S1. Positron emission tomography did not show the accumulation of fluorodeoxyglucose in the nodule. We considered the tumor to be benign, but the patient chose surgical treatment. Partial resection of the lung was performed by thoracoscopic surgery. Histopathological diagnosis was human pulmonary dirofilariasis.

[Adult Bochdalek hernia combined with pneumothorax].

A 71-year-old man, who had been given a diagnosis of Bochdalek hernia in infancy, was referred to our hospital for dyspnea The chest X-ray and computed tomography (CT) showed left pneumothorax with bullas and intestines in his left thoracic cavity. He was admitted to our hospital and a chest tube was inserted into the left pleural cavity. The left lung expanded immediately and air leakage was stopped. He became asymptomatic and he was discharged from the hospital on the 8th day. Most Bochdalek hernias are observed in infancy, and adult cases combined with pneumothorax and bullas are very rare.

Three-dimensional ultrasonography before minimally invasive focused parathyroidectomy: the importance of coronal images.

PURPOSE: To evaluate the usefulness of three-dimensional (3D) ultrasonography (US) as a noninvasive preoperative localization procedure before performing minimally invasive focused parathyroidectomy in patients with primary hyperparathyroidism (pHPT). METHODS: Seventy-six patients with a solitary adenoma detected by US underwent minimally invasive focused parathyroidectomy. The value of 3D US was assessed by dividing patients into a 2D group and a 3D group. Age, the preoperative serum intact parathyroid hormone (PTH) level, operative time, length of skin incision, and weight of the resected specimen were compared between the groups, and multivariate analysis of the operative time was performed. RESULTS: There were no significant differences between the 2D group and the 3D group in age, the preoperative intact PTH level, length of skin incision, or weight of the resected specimen, but the mean operative time was significantly longer in the 2D group (P < 0.01). Multivariate analysis revealed that 3D US and the weight of the resected specimen were correlated with the operative time (P < 0.05). CONCLUSION: The coronal images obtained by 3D US assist in the precise localization of parathyroid masses in patients with pHPT undergoing minimally invasive focused parathyroidectomy for a solitary adenoma.

Cervical approach by lifting the superior sternum for mediastinal parathyroid adenoma.

We report our experience with sternum lifting method in 5 patients with a retrosternal large parathyroid gland around an innominate vein. There were 2 men and 3 women aged 35 to 81 years. All patients showed a retrosternal large parathyroid gland around an innominate vein. Under general anesthesia, the patient is placed in a supine position with the neck extended. About 3 to 4 cm cervical incision is made above the sternal notch. Two hooks are placed at both sternoclavicular junctions. After the sternum is retracted upward, the anterior mediastinum can now be well visualized with the surgeon at the head of the table. When the direct vision is not clear, using the video imaging provides the physician with a clear, magnified view of the area under deep sternum. All patients underwent complete cervical excision using our method without any complications. The average operative time was 61 minutes and blood loss was minimal. Excellent postoperative outcomes were observed. The patients had no pain or other complications. All patients were discharged 4 days after the surgery. We believe that cervical excision using our method is a better alternative in those patients with anterior mediastinal parathyroid glands around an innominate vein.

Hashimoto's thyroiditis.

Goiters were often associated with iodine deficiency in European mountain areas, with some goiters being quite disfiguring. However, some goiters seem not to be related to iodine deficiency. One of the types of goiter that are unrelated to iodine deficiency is the disease described by Hakaru Hashimoto in 1912. Hashimoto described it as a special characteristic of a new type of lymphomatous thyroid tumor in Japan, and this entity was recognized as an autoimmune disease of the thyroid many years later. Hashimoto published his article in a German journal because that was the scientific language of the time, and he thought that writing in German would make the work more widely available around the world. Patients with Hashimoto's thyroiditis are usually asymptomatic, and some patients develop goiters with or without hypothyroidism. The goiters and hypothyroidism usually respond to treatment with thyroid hormone. The dose of thyroid hormone must be carefully titrated because there may be autonomous thyroid function resulting from thyroid-stimulating antibodies despite the hypothyroid state.

The role of quick bio-intact PTH(1-84) assay during parathyroidectomy for secondary hyperparathyroidism.

OBJECTIVE: The role of the quick PTH assay in surgery for secondary HPT is unclear because of overestimation of intact PTH(1-84) values due to the cross-reactivity of currently available first-generation PTH assays with non-PTH(1-84) fragments that accumulate in renal failure. In this study, we used a second-generation quick PTH immunometric assay that are claimed to detect the biologically active PTH(1-84) molecule with no cross-reactivity with PTH fragments to investigate the potential utility of the assay during parathyroidectomy for secondary HPT. MATERIAL AND METHODS: The study was performed on 18 patients (12 women, 6 men) between October 2004 and March 2005. EDTA serum samples were drawn via a peripheral venous catheter after induction of anesthesia (basal), and at 5, 10, and 30 min after excision of diseased parathyroid glands. Serum active PTH(1-84) was measured by the quick Bio-Intact PTH(1-84) assay, which is a two-site chemiluminometric assay. RESULTS: At 30 min the quick Bio-PTH(1-84) level of 16 patients was under 45 pg/mL. Four parathyroid glands were removed macroscopically from 12 of the 16 patients, and three glands were removed from the other four patients. All patients were cured of their HPT. Four enlarged parathyroid glands were removed from a patient whose Bio-Intact PTH(1-84) at 30 min had not fallen below 45 pg/mL, and no other glands were found by further exploration. At the 6 mo follow-up examination, the first-generation intact PTH level of this patient was over 45 pg/mL, but several diagnostic imaging methods did not reveal any enlarged parathyroid glands. Three enlarged parathyroid glands from the other patient, and exploration led to the identification of an ectopic parathyroid gland at the carotid bifurcation. CONCLUSIONS: The results of this prospective study show that quick Bio-Intact PTH(1-84) monitoring is a valuable new tool for use in the surgical treatment of secondary HPT. An intraoperative, quick Bio-Intact PTH(1-84) assay will be of value for the adequate prediction of surgical cure.

Significance of monitoring Bio-Intact PTH (1-84) during parathyroidectomy for secondary hyperparathyroidism.

BACKGROUND: The Bio-Intact PTH (1-84) assay has recently been developed to specifically measure the intact PTH (1-84) molecule, and in this study we used it to investigate sequential changes in serum Bio-Intact PTH (1-84) levels during parathyroidectomy for secondary HPT. MATERIAL AND METHODS: The subjects of this study were 70 patients (41 women, 29 men) who underwent parathyroidectomy between April 2002 and March 2005. Ethylene diamine tetraacetic acid serum samples were drawn via a peripheral venous catheter after induction of anesthesia (basal), and at 5, 10, and 30 min after diseased glands excision. Serum active PTH (1-84) was measured by the Bio-Intact PTH (1-84) assay, which is a two-site chemiluminometric assay. RESULTS: When 4 or more diseased parathyroid glands were removed, the basal of Bio-Intact PTH (1-84) level in patients without persistent HPT (52 cases) was 539 +/- 355 pg/mL. The level of the Bio-Intact PTH (1-84) at 30 min after sufficient parathyroidectomy had decreased to less than 45 pg/mL, whereas the Bio-Intact PTH (1-84) level in patients with persistent HPT at 30 min was greater than 45 pg/mL (3 cases). After removal of three or fewer diseased parathyroid glands (15 cases), the Bio-Intact PTH (1-84) at 30 min in patients without persistent HPT (13 cases) was less than 45 pg/mL. The 2 patients whose the Bio-Intact PTH (1-84) at 30 min was greater than 45 pg/mL underwent reoperation, and residual enlarged parathyroid gland in the neck was removed. CONCLUSIONS: The Bio-Intact PTH (1-84) level at 30 min after parathyroidectomy seems to be useful for judging whether the parathyroidectomy is complete irrespective of the number of glands removed from patients with secondary HPT. When only three diseased parathyroid glands are removed, the surgeon can decide whether to continue or stop neck exploration according to the level of Bio-Intact PTH (1-84) at 30 min.