Perioperative Management of a Patient With Cornelia de Lange Syndrome and Tetralogy of Fallot.

This is a case report of a 21-year-old male patient with Cornelia de Lange syndrome (CdL) and unrepaired tetralogy of Fallot scheduled for dental treatment under general anesthesia. Anticipated dental care consisted of restorative treatment and extractions. Surgical correction of the patient's congenital cardiac abnormalities had not occurred by the time of dental treatment. As such, the developed anesthetic plan included the following goals: prevention of any anoxic episodes or spell and preparation for difficult airway management due to micrognathia secondary to CdL. To help ensure adequacy of oxygenation during induction, the normal anesthetic face mask was specially modified with a hole to permit use of the fiberoptic scope during induction and intubation. With preoperative consultation involving a cardiologist as well as the use of the modified mask, general anesthesia was safely administered without any complications.

Papillary thyroid carcinoma expressing CD20.

We identified a case of lymphadenopathy of metastatic papillary thyroid carcinoma (PTC) with CD20 expression, which was also expressed by the primary tumor. CD20 expression was identified using immunohistochemistry (IHC) in metastatic PTC biopsy samples from a 58-year-old woman. CD20 expression was initially determined using a CD20-recognizing L26 clone. To validate this phenomenon, we performed IHC with another antibody that recognizes the N-terminus of CD20 and fluorescent double staining using anti-TTF-1 and anti-CD20 antibodies. Taken together, we concluded metastatic PTC expressed CD20. We also examined 21 additional PTC cases and found four more cases that were CD20 positive. Therefore, five of the 22 (23%) cases were positive for CD20. In the positive cases, four cases were classical papillary thyroid carcinoma and one case was a follicular variant of papillary thyroid carcinoma. CD20 is an important target for molecularly targeted therapy for a subset of B-cell lymphomas. Complement-dependent and antibody-dependent cellular cytotoxicities are important effector mechanisms of anti-CD20 therapy. Here, for the first time, we report PTC with expression of CD20. Our findings provide a rationale for treating CD20-positive PTC patients with anti-CD20 therapy.

A poor prognostic case of mucoepidermoid carcinoma of the thyroid: a case report.

Mucoepidermoid carcinoma (MEC) of the thyroid is very rare and low-grade indolent neoplasm. In past reports of the thyroid MEC, only seven cases were described as poor prognosis. A 91-year-old woman presented with a rapidly growing mass of the left upper neck. She was followed thyroid papillary carcinoma (PC) without operation for two years. Fine needle aspiration cytology (FNAC) showed undifferentiated cells. Total thyroidectomy and bilateral neck dissection were performed. In pathological findings, the tumor had two areas of MEC and PC. The boundary of them was mixed. She died of multiple lung metastases only after four months from the operation. We report a rare case of thyroid MEC which had an aggressive behavior and poor prognosis. This case is a precious in that thyroid MEC occurred during observation of PC and suggests a possibility of the transformation from PC to MEC.

Human mesenchymal stem cells as a stable source of VEGF-producing cells.

Vascular endothelial growth factor (VEGF) is a positive regulator and plays a crucial role in angiogenesis. We demonstrate that VEGF was highly expressed in cultures of human bone marrow-derived mesenchymal stem cells (hMSCs) and the high expression level was maintained during prolonged culture periods (checked up to passage 10). We also confirmed that in vivo hMSCs engrafted into immunodeficient mice could survive and secreted human VEGF. These findings suggest that implantation of hMSCs is a practical means as a source of VEGF production and might be effective in neoangiogenesis.

Multipotent cells from the human third molar: feasibility of cell-based therapy for liver disease.

Adult stem cells have been reported to exist in various tissues. The isolation of high-quality human stem cells that can be used for regeneration of fatal deseases from accessible resources is an important advance in stem cell research. In the present study, we identified a novel stem cell, which we named tooth germ progenitor cells (TGPCs), from discarded third molar, commonly called as wisdom teeth. We demonstrated the characterization and distinctiveness of the TGPCs, and found that TGPCs showed high proliferation activity and capability to differentiate in vitro into cells of three germ layers including osteoblasts, neural cells, and hepatocytes. TGPCs were examined by the transplantation into a carbon tetrachloride (CCl4)-treated liver injured rat to determine whether this novel cell source might be useful for cell-based therapy to treat liver diseases. The successful engraftment of the TGPCs was demonstrated by PKH26 fluorescence in the recipient's rat as to liver at 4 weeks after transplantation. The TGPCs prevented the progression of liver fibrosis in the liver of CCl4-treated rats and contributed to the restoration of liver function, as assessed by the measurement of hepatic serum markers aspartate aminotransferase and alanine aminotransferase. Furthermore, the liver functions, observed by the levels of serum bilirubin and albumin, appeared to be improved following transplantation of TGPCs. These findings suggest that multipotent TGPCs are one of the candidates for cell-based therapy to treat liver diseases and offer unprecedented opportunities for developing therapies in treating tissue repair and regeneration.

A prospective Japanese study of the association between personality and the progression of lung cancer.

OBJECTIVE: To examine predictive values for the effect of the "Type 1" (hopeless and emotion-suppressive, cancer prone), "Type 4" (autonomous, healthy), and "Type 5" (rational/antiemotional, cancer prone) personalities proposed by Grossarth-Maticek on the prognosis of lung cancer patients. METHODS: 68 lung cancer patients were scored on the Types 1, 4, and 5 personality scales of the Short Interpersonal Reactions Inventory and were followed until the date of death or were censored at a maximum of 5.7 years after entry. RESULTS: The stage at diagnosis tended to be higher in patients with a high Type 1 or a low Type 4 score. A univariate Cox proportional hazards model showed that a high tendency toward Type 1 or Type 5 was related to an increased hazard of death. Adjustment for age, performance status, and stage, however, attenuated the relation to Type 1, leaving only Type 5 as a significantly related personality factor. CONCLUSION: A high Type 5 tendency may predict poor survival in lung cancer patients, whereas Types 1 and 4 may not be independent predictors.

Intraoperative parathyroid hormone assay in patients with Graves' disease for prediction of postoperative tetany.

We measured intraoperative parathyroid hormone (IOPTH) levels before and after thyroidectomy in a large group of patients to test whether changes in IOPTH can predict postoperative tetany. Subjects were 111 consecutive patients (94 females and 17 males) with Graves' disease undergoing subtotal thyroidectomy. Blood samples for IOPTH assay were obtained after anesthesia (basal) and following skin closure (postoperative). Data were compared between patients who developed tetany (n = 9) and those who did not (n = 102). There was no significant difference in sex, age, period of antithyroid drug administration, or the weight of the thyroid between the two groups. The preoperative serum calcium level was significantly lower (p < 0.05) and the basal IOPTH significantly higher (p < 0.05) in the tetany group than in the non-tetany group. The IOPTH level was significantly lower (p < 0.005) and the average percent decrease in IOPTH levels was higher (p < 0.001) in the tetany group than in the non-tetany group. A decrease in IOPTH of more than 70% was shown to be 78% sensitive, 94% specific, and 93% accurate, and it has 78% positive predictive value and 94% negative predictive value for the development of tetany. Our study shows that a postoperative decrease of IOPTH level is the most predictive of postoperative tetany of the clinical risk factors investigated. We recommend IOPTH measurement as an adjunct to postoperative management of patients with Graves' disease to assist in preventing hypocalcemia and determining the earliest time for safe discharge.

Thyroid evaluation in patients with primary hyperparathyroidism.

We evaluated the efficacy of preoperative high-resolution ultrasonography (US) for diagnosing possible concomitant thyroid disease which affects the surgical management in patients with primary hyperparathyroidism (pHPT). One hundred and nine patients with sporadic pHPT underwent US with or without ultrasound-guided fine-needle aspiration biopsy (US-FNAB). Diagnosis of concomitant thyroid nodules by US and US-FNAB were compared with the histopathological findings. Of the 109 patients, 19 (17.4%) had malignant thyroid nodules, 26 (23.9%) had benign thyroid nodules alone, and 12 (11.0%) had diffuse goiter. The sensitivity, specificity, and accuracy of diagnosing 72 thyroid nodules were 91.3%, 91.8%, and 91.7% for US, 57.9%, 94.3%, and 81.5% for US-FNAB, and 95.7%, 91.8%, and 93.1% for combined US and US-FNAB, respectively. True positive/false negative ratio of US-FNAB diagnosis was significantly lower in nodules of 5-9 mm than nodules of 10 mm or more. Four unexpected thyroid cancers existed at a different site in 3 of the 39 patients with palpable thyroid disease. Five thyroid cancers were histopathologically confirmed in 5 (7.1%) of 70 patients without palpable thyroid disease. Eight (88.9%) of the 9 non-palpable thyroid cancers were accurately diagnosed by combined US and US-FNAB. Preoperative US is useful for evaluation of possible concomitant thyroid disease, especially for prediction of malignancy.

Three-year follow-up on the effects of a smoking prevention program for elementary school children with a quasi-experimental design in Japan.

OBJECTIVE: We performed the follow-up tests for three years for junior high school students by the quasi-experimental design to investigate the medium-term effect of smoking prevention education in the elementary school. METHODS: The intervention group consisted of 106 school students of three elementary schools and received a smoking prevention program in the elementary school. Moreover, the follow-up tests were conducted at each grade of junior high school, and the booster program was mailed. The comparison group consisted of 193 school students of another three elementary schools without the program. RESULTS: The intervention effects were recognized on knowledge up to the second grade of junior high school for boys and up to the third grade for girls, on awareness of the importance of not smoking at the second grade, and on the intention of smoking at the age of 20 for girls up to the first grade. On the other hand, the intervention effects were not recognized on smoking experience for boys and girls. However, increase of the rate of smoking experience was not significant in the intervention group, while it was significant in the comparison group. CONCLUSION: The effect of the program for three years was judged to be moderate.

A case of breast cholesterol granuloma accompanied by cancer.

Cholesterol granuloma of the breast is a very rare benign disease with clinical and imaging features that are often indistinguishable from cancer preoperatively. We report a case of breast cholesterol granuloma accompanied by cancer. The patient was a 78-year-old woman who complained of a lump in her right breast. Mammography and ultrasonography showed a well-circumscribed mass. Fine needle aspiration cytology showed many cholesterol crystals and inflammatory cells without malignancy. With a diagnosis of cholesterol granuloma, tumor extirpation was performed. Histopathologic examination revealed cholesterol granuloma together with breast cancer, and additional partial mastectomy was subsequently performed. It is noted that breast cholesterol granuloma could be accompanied by cancer.

A comparison of trends in the incidence rate of lung cancer by histological type in the Osaka Cancer Registry, Japan and in the Surveillance, Epidemiology and End Results Program, USA.

Trends in the incidence rate of lung cancer by histological type were examined, based on data from the Osaka Cancer Registry (OCR), Japan and the Surveillance, Epidemiology and End Results Program (SEER), USA. Among males, an increasing trend was observed for adenocarcinoma in both registries. In the OCR, the incidence rate of adenocarcinoma has recently overtaken that of squamous cell carcinoma, whereas in the SEER, adenocarcinoma had already taken the lead since 1990-93. For squamous cell carcinoma, the decreasing trends in the OCR were consistent with a previous study, whereas in the SEER, the decline was earlier and steeper. For small cell carcinoma, the incidence rate was leveling off in the OCR, whereas it was already in decline in the SEER. For large cell carcinoma, the decreasing trend began earlier in the SEER. Among females in both registries, the incidence rate of adenocaricinoma has clearly been on the increase, whereas in other histological types the incidence rates were decreasing or at least leveling off. As for the age-specific incidence rate, different patterns were observed between the two registries: in the OCR, the incidence rate was on the increase in older age groups such as 70-74 years and also in younger age groups such as 45-49 years, whereas it decreased in intermediate age groups such as 55-59. In contrast, stable decreasing trends were observed in the SEER, except for adenocarcinoma. The increase in incidence rate observed among younger age groups in the OCR should be carefully monitored.

Endoscopic neck surgery: current status for thyroid and parathyroid diseases.

During the last 3 years, 59 patients underwent endoscopic neck surgery. We started the video-assisted neck surgery with the gasless skin-lifting method for benign thyroid and parathyroid diseases to avoid complications of carbon dioxide (CO2) insufflation. Hemithyroidectomy was performed for benign thyroid tumors and subtotal thyroidectomy was selected for Graves' disease. Parathyroid adenomas were extirpated for primary hyperparathyroidism with precise preoperative localization by imaging modalities. In order to obtain a better visual field and to improve the cosmetic results, we have adopted the complete endoscopic method via breast approach with low CO2 insufflation pressure since August 2001. An intraoperative parathormone assay was introduced recently to confirm the complete removal of parathyroid adenomas. Both gasless and insufflation methods are feasible for endoscopic neck surgery with excellent cosmetic results.

Detection of auto-antibodies against a 70 kDa protein derived from vascular smooth muscle cells in patients with Kawasaki disease.

UNLABELLED: The aetiology and pathogenesis of Kawasaki disease (KD) remain unknown. To investigate the pathogenesis of vasculitis in KD, we tested for the presence of auto-antibodies against a component of vascular smooth muscle cells in the sera of patients with KD. Sera from 48 patients with KD, as well as sera from 14 sick children and from 22 healthy children, were examined for reactivity to both coronary arterial wall tissues and cultured smooth muscle cells (CSMC) derived from human coronary artery, using immunofluorescence and Western immunoblot assay techniques. Sera from 16 of 48 patients with KD gave positive immunoreactions to the vascular walls of coronary artery with fluorescein isothiocyanate-labelled rabbit anti-human IgA antibodies. In Western immunoblot assays, the sera from 15 of 34 and 10 of 31 patients with KD showed positive reactions against a 70 kDa protein from CSMC with IgA and IgM antibodies, respectively. Positive immunoreactivity of sera from patients with KD, determined either by immunofluorescence studies or by Western immunoblotting, was detected more frequently ( P<0.05) and more intensely ( P<0.005) in patients with coronary arterial lesions (CAL) than in those without CAL. Positive immunoreactivity of sera was prominent before intravenous immunoglobulin therapy and decreased dramatically thereafter. CONCLUSION: these data suggest that auto-antibodies against a 70 kDa protein from vascular smooth muscle cells may cause coronary arteritis and systemic vasculitis in KD.

Video-assisted thyroid lobectomy through a small wound in the submandibular area.

BACKGROUND: Endoscopic thyroidectomy has not gained wide acceptance because of the expertise required, the long operation time, the wide dissection, and the extra cost of specialized instruments. We developed a video-assisted hemithyroidectomy procedure that requires only one small incision at the upper neck. METHODS: Hemithyroidectomy was performed through a 25 to 30 mm transverse incision made in the upper lateral neck for the treatment of benign thyroid nodule. No gas or external lift dissection was needed. RESULTS: The mean age of 39 patients was 33.8 years. The tumor size ranged from 1.9 to 5.5 cm (mean 3.1 cm). All patients underwent total lobectomy without conversion to traditional cervicotomy. The mean operation time was 56 minutes (range 36 to 90). Follicular adenoma was the final pathologic diagnosis in 25 patients and adenomatous goiter in 14. Transient recurrent laryngeal nerve palsy was seen in 1 patient. CONCLUSIONS: Our technique is safe, minimally invasive, less time consuming, and cosmetically excellent.

Is a bilateral modified radical neck dissection beneficial for patients with papillary thyroid cancer?

PURPOSE: We previously reported a poor prognosis in papillary thyroid carcinoma patients with recurrence in the contralateral cervical lymph nodes after thyroidectomy and ipsilateral modified radical neck dissection (MRND) with a curative intent. The aim of this study was to investigate whether bilateral MRND improved prognosis in patients at risk for contralateral nodal recurrence. METHODS: We retrospectively reviewed the cases of 86 patients with contralateral nodal metastasis who underwent a thyroidectomy with bilateral MRND (group 1) and the cases of 32 patients who suffered contralateral nodal recurrence after a thyroidectomy with ipsilateral MRND (group 2). RESULTS: Although tumor progression was considered similar in patients from groups 1 and 2, group 1 developed fewer distant metastases than group 2 (6.8% vs 31.1%), thus resulting in a lower cancer death rate (5.8% vs 28.1%). Group 1 had a better 10-year survival rate than of group 2 (97.1% vs 83.7%). CONCLUSION: Bilateral MRND during initial surgical management is thus considered to improve the prognosis of some papillary carcinoma patients at risk for recurrence in the contralateral cervical lymph nodes.