Pancreatic neuroendocrine tumor with metastasis to the spleen: a case report.

BACKGROUND: Long-term term survival in patients with pancreatic neuroendocrine tumors has been reported, even in patients with metastatic disease. Metastases to the spleen are extremely rare, but have been reported from a number of primary malignancies, such as breast cancer, lung cancer, melanoma and ovarian cancer. This is the first report of a splenic metastasis from a primary pancreatic neuroendocrine tumor. CASE PRESENTATION: The patient presented as a 53 years old white male with anemia and fatigue. Physical examination revealed a left upper quadrant fullness and computed tomography showed a 24 cm left upper quadrant mass with multiple liver metastases, splenomegaly and a 1 cm mass in the spleen. Resection of the primary pancreatic tumor (T4N0M1) was accompanied by gastrectomy, splenectomy and resection of adherent bowel. The spleen contained a metastatic lesion 1.0 cm in diameter, consistent with a primary neuroendocrine tumor of the pancreas. This operation was followed 8 months later, by delayed resection of liver metastases. The patient receives monthly administration of somatostatin long-acting analogue and has undergone several ablations of liver lesions with percutaneous radiofrequency ablation as well as a second liver resection. The patient is alive seven years after initial presentation, with no evidence of disease on imaging studies. CONCLUSIONS: This is the first report of a splenic metastasis from a primary pancreatic neuroendocrine tumor. The patient initially presented with synchronous multiple liver metastases and a single splenic metastasis. After resection of the primary tumor and spleen, the patient has undergone aggressive cytoreductive surgery/ablation of liver lesions and somatostatin therapy with resulting long-term survival.

[Clinical Features of the Pediatric Acquired Cholesteatoma Based on the Staging Criteria for Cholesteatoma 2010 Japan].

In this study, we retrospectively evaluated the clinical features of the pediatric acquired cholesteatoma based on the staging criteria for cholesteatoma 2010 Japan. Between 2001 and 2012, total of 36 pediatric patients underwent otologic surgery at our hospital, 29 patients (29 ears) with pars flaccida cholesteatoma and 7 patients (7 ears) with pars tensa cholesteatoma. The age range was 4 to 15 years, (median was 10.5 years). Stage 11 was the most common for both the pars flaccida and pars tensa. A staged operation was performed in 24 ears with pars flaccida cholesteatoma, and 4 ears with pars tensa cholesteatoma. The success rate of hearing improvement was 72% (21/29) in pars flaccida cholesteatoma and 57% (4/7) in pars tensa cholesteatoma. Hearing improvement decreased in advanced cases. In staged operations, residual cholesteatoma was found in 11 ears (46%) with pars flaccida cholesteatoma and 2 ears (50%) with pars tensa cholesteatoma. These results suggest that the residual rate of cholesteatoma in the pediatric population is high. In conclusion, a high rate of residual cholesteatoma in the pediatric population was observed in our study. Thus a staged operation would be the recommended treatment approach in pediatric acquired cholesteatoma.

A Comparison of Analgesic Effect between Loxoprofen and Celecoxib and the Frequency of the Hemorrhage Following Tonsillectomy.

Hemorrhage following tonsillectomy is still a major complication despite the progress in medical technology. Celecoxib is a selective COX-2 inhibitor and has a lower effect of platelet aggregation compared with conventional non-steroidal anti-inflammatory drugs (NSAIDs). We investigated whether or not the selection of celecoxib would reduce the risk of hemorrhage and provide a good analgesic effect following tonsillectomy in comparison with the use of loxoprofen (a conventional NSAID). 　We divided 107 cases of tonsillectomy into two groups by the kind of analgesic prescribed; the celecoxib group (n=55) and the loxoprofen group (n=52). Regarding the effective rate of the analgesic effect, the loxoprofen group scored 93.3% and the celecoxib group scored 68.6%. There was a significant difference between them (p=0.0003). Regarding side effects, the celecoxib group showed no side effects, whereas 8.0% of the loxoprofen group developed abdominal pain. There were no statistically significant differences between the changes in the VAS scale regarding the pain (p=0.834), the prescription periods of analgesic (p=0.485), the amount of food intake during the hospitalization (p=0.579), the rescue dosage rate (p=0.585), periods of usage (p=0.198) and the last dosage day. As for the tendency and the grade of postoperative hemorrhage, there were no statistically differences between the two groups (p=0.220). The rates of occurrence of late-onset hemorrhage (i.e. after the postoperative eleventh day) were 0.0% (0/11) in the the celecoxib group (n=11) and 31.2% (5/16) in the the loxoprofen group showing a statistically differences between them (p=0.049). 　Our results suggest that Celecoxib might reduce the risk of late-onset hemorrhage after the postoperative eleventh day with few side effects, so it could be a useful analgesic drug following tonsillectomy. However, it might be necessary to consider administration in combination with acetaminophen because Celecoxib has insufficient analgesic effect following tonsillectomy.

[Submucosal Partial-turbinectomy (SPT) Preceding an Endoscopic Sinus Surgery (ESS) Procedure].

Preceding a endoscopic sinus surgery (ESS), we have proposed performing a submucosal partial-turbinectomy (SPT) which removes a part of the inferior nasal concha bone attached to maxillary sinus with an antrostomy. By this method, we could not only make a large antrostomy but also obtain good maneuverability by opening the middle nasal meatus in ESS. We performed SPT preceding ESS in 140 cases (261 sides) between January 2012 and June 2014. The stenosis rates of the middle nasal meatus were 14.2% (37 sides from 261 sides) in one month, 7.4% (18 sides from 243 sides) in three months and 3.7% (6 sides from 163 sides) in 6 months after surgery. The closing rates of the antrostomy were 1.5% (4 sides from 261 sides) in one month, 2.9% (7 sides from 243 sides) in three months and 6.7% (11 sides from 163 sides) in 6 months after surgery. We considered that the SPT method would contribute to secure sufficient ventilation routes for wound healing of sinusitis following surgery on the mucous membrane. In addition, the SPT method has merit from the point of deceasing risks of atrophic rhinitis and empty nose syndrome by preserving most of the inferior nasal concha.

[The Significance of Resection of the Cricoid Cartilage as a Surgical Procedure in Laryngotracheal Surgery].

The cricoid cartilage has been regarded as an extremely important organ because it plays important role in both of phonation and breathing. We herein report on two different types of surgical procedure for laryngotracheal diseases with aggressive resection of the cricoid cartilage. The first procedure is a tracheostomaplasty by partial resection of the cricoid cartilage. A tracheostoma is made by resection of the cricoid cartilage in the range of approximately a one-third front. This method is effective for such cases having difficulty in tracheostomy owing their backgrounds with such condition as neck stiffness, obesity, higher displacement of the brachiocephalic artery, short neck, thyroid disease and so on. We applied this procedure for eight cases with such difficult backgrounds. In all cases, we were able to make a good tracheostoma and the postoperative courses were uneventful. The second procedure is a glottic closure with resection of the cricoid cartilage and thyroid cartilage. We applied this procedure for six cases with intractable dysphagia. One case had a postoperative bleeding. We were able to make good conditions in all cases with a large tracheostoma and no pharyngeal-tracheal leakage. In conclusion, the surgical procedure involving resection of the cricoid cartilage can be applied to some laryngotracheal diseases.

[Clinical study of secondary cholesteatoma].

Acquired middle ear cholesteatoma is considered to be formed by retraction of the tympanic membrane. There are rare cases in which the tympanic membrane epidermis extends into the medial surface of the tympanic membrane from the margin of its perforation, namely so-called secondary cholesteatoma. We studied the cases of secondary cholesteatoma clinically. These cases were found in 13 of 419 ears (3.1%) with acquired middle ear cholesteatoma operated on in our hospital from March 2001 to October 2010. The average age of all the cases was 51.5 years old, with a range of 11-65 years. We adopted the canal wall down tympanoplasty procedure with canal reconstruction in all cases. The postoperative hearing improvement rate was 84.6%. There were no cases of recurrence of the cholesteatoma.

[A case of epiglottic NK/T cell malignant lymphoma].

We report a case of malignant epiglottic natural killer (NK)/T cell lymphoma. A 33-year-old man seen 1-month period for throat pain was found in endoscopic larynx examination to have inflammation with plaques and redness epiglottic. The 4 month period, right epiglottic inflammation showed progressive necrosis. The diagnosis of malignant lymphoma was confirmed by 3 biopsies. Laryngomicrosurgery specimens histologicalily showed moderate leukocytic infiltration mainly of atypical lymphocytes. Neoplastic cells were UHCL1+, CD3+, L26-, CD79a, and EBER-ISHW. Despite 4 units of DeVIC chemotherapy and regional irradiation, the man died of metastatis 1 year and 9 months after initial treatment. Among malignant laryngeal tumors, malignant epiglottic NK/T cell lymphoma is extremely rare, with only one case reported in the literature.

[Evaluation of soft diets using freeze infusion in videofluorography].

A food developed at the Hiroshima Prefectural Food Technology Research Center, Hiroshima, Japan, has proved to be a boon in videofluorography. The food features decreased hardness with retained their shape due to being impregnated with macerating enzymes under reduced pressure after vegetables are defrosted. Samples were removed immediately from the enzyme solution after freeze infusion. All foods tested raging from carrots to chicken contasted well in videofluorography in an evaluation of swallowing in 107 subjects with dysphagia, results for carrots compared well with those for 33% iopamidol, jelly, and yogurt. Only a subjects showed silent aspiration with carrots, compared to 19 with 33% iopamidol. Among 70 subjects showing no residual jelly and/or yogurt, just 12-8 severe and 4 moderate-showed residual carrots in the pharyngeal space. In contrast, among 67 subjects showing no residual carrots in the pharyngeal spase, 9 moderate subjects showing no residual jelly and/or yogurt. We concluded foods such as carrots treated as stated following jelly and/or yogurt as new nutrition sources for subjects with dysphagia.

The cytological characteristics of small cell change of dysplasia in small hepatic nodules.

Small cell change of dysplasia (SCD) is characterized as an initial step in hepatocarcinogenesis. Histopathological diagnosis is an important diagnostic procedure for nodular lesions in the liver. However, the biopsied specimen is so small that it is sometimes difficult to differentiate between regenerative nodules, dysplastic nodules, and hepatocellular carcinoma even histologically. To examine the usefulness of cytology in the differential diagnosis of hepatic nodular lesions, the cellular characteristics of SCD were evaluated using Papanicolaou staining and a micrometer. Sixty-four histologically diagnosed small nodular lesions in the liver were analyzed retrospectively. All cases were histologically classified according to the Terminology of Nodular Hepatocellular Lesions by the International Working party: hepatocellular carcinoma (HCC) (n=17); low-grade dysplastic nodule (LGDN) (n=26); high-grade dysplastic nodule (HGDN) (n=6); large regenerative nodule: (n=15). SCD was noted in all of the histological categories, and the proportion of SCD tended to be higher in W-HCC than in dysplastic nodules. Although the cellular size was the smallest in HGDN, the nuclear size was the largest in well-differentiated HCC (W-HCC). The nuclear/cytoplasmic ratio was higher in HGDN and W-HCC than in other nodular lesions. Hyperchromasia in W-HCC was obviously stronger than that in other nodules. SCD was frequently found in HGDN and W-HCC. The present study showed that detailed cytological findings of SCD are useful for differentiating HGDN from LGDN, and HGDN from W-HCC.