Elevated levels of soluble fibrin or D-dimer indicate high risk of thrombosis.

BACKGROUND: Fibrin-related markers such as soluble fibrin (SF) and D-dimer are considered useful for the diagnosis of thrombosis. However, the evidence for diagnosis of thrombosis by fibrin-related markers is not well-established. OBJECTIVE: To evaluate the cutoff values of D-dimer and SF in the diagnosis of thrombosis. PATIENTS AND METHODS: Plasma concentrations of SF and D-dimer were measured in 784 inpatients suspected of having thrombosis between 1 August 2003 and 31 December 2004, and then correlated with thrombosis. RESULTS AND CONCLUSIONS: Plasma concentrations of D-dimer and SF were significantly higher in patients with disseminated intravascular coagulation (DIC), deep vein thrombosis (DVT) and cerebral thrombosis, compared with those in patients without thrombosis. When cutoff values of > 3.0 microg mL(-1) for D-dimer and > 6.0 microg mL(-1) for SF were used for the diagnosis, more than 50% of patients (with the exception of liver transplant patients and postoperative patients) had thrombosis. Receiver operating characteristic analysis showed that SF was more useful than D-dimer for the diagnosis of thrombosis (i.e. DVT and DIC). The cutoff value of D-dimer (7.87 microg mL(-1)) was the same for DVT and DIC, while that of SF was slightly lower for DVT (7.05 microg mL(-1)) than for DIC (8.60 microg mL(-1)). Our findings suggest that high levels of plasma fibrin-related markers reflect high risk for thrombosis.

Evaluation of J-pouch reconstruction after total gastrectomy: rho-double tract vs. J-pouch double tract.

OBJECTIVE: Various enteric reservoirs have been advocated to improve the quality of life after total gastrectomy. We evaluated the advantages of pouch reconstruction compared with traditional rho-double tract reconstruction. DESIGN: Prospective randomized study. SETTING: Second Department of Surgery, Hyogo College of Medicine, Japan. SUBJECTS: Forty patients who underwent total gastrectomy for cancer of the stomach were studied. INTERVENTION: Forty patients were randomly divided into two groups: 20 patients received rho-double tract reconstruction (RDT group), and 20 underwent J-pouch double tract reconstruction (PDT group) group. MAIN OUTCOME MEASURES: We compared the body weight, serum nutritional parameters, reflux score, scintigraphic esophageal reflux, food intake, and emptying time of the J-pouch or rho-limb between the two groups. RESULTS: No difference was noted between the two groups with regard to body weight, but food intake tended to be higher in the PDT group than in the RDT group. Total protein and albumin levels were higher in the PDT group than in the RDT group, while scintigraphic reflux was significantly less prominent in the PDT group. CONCLUSIONS: J-pouch reconstruction was superior with respect to protein metabolism, food intake and reduction of reflux esophagitis compared with the traditional RDT method. However, use of pouch reconstruction did not improve postoperative weight gain.

Nutritional status and postoperative cytokine response in colorectal cancer patients.

The present study was designed to investigate the relationship between pre-operative nutritional status and peri-operative regulation of the cytokine network, and to clarify its relation to clinical outcome in colorectal cancer patients. Protein-energy malnutrition was assessed using the creatinine height index. Peripheral venous blood samples were obtained peri-operatively, and the serum concentrations of interleukin (IL-)6, IL-1 receptor antagonist (ra), IL-6 soluble receptor (sR) C-reactive protein (CRP) and the percentage of peripheral neutrophils were determined. Excessive operative blood loss was associated with postoperative morbidity. Pre-operative malnutrition was associated with postoperative mortality when excessive bleeding occurred. Postoperative IL-6 response was exaggerated and postoperative IL-1ra response was suppressed in nutritionally depleted patients. The postoperative serum concentrations of IL-6sR in malnourished patients remained at the lowest levels when excessive bleeding occurred. In these patients, the percentage of peripheral neutrophils remained at high levels even after resolution of the postoperative cytokine storm. A marked activation of the pro-inflammatory cytokine network associated with a decreased antagonistic reaction and an increased consumption of IL-6sR became prominent in malnourished patients when they underwent intense surgical stress. These immunological disturbances may be relevant to neutrophil activation and subsequent clinical outcome.

Lymphangioma of the colon: a case report and review of the Japanese literature.

Intraabdominal lymphangiomas are rare, although these lesions can occur in the mesentery, omentum, retroperitoneum, or gastrointestinal tract wall. Here we report a case of lymphangioma of the transverse colon and review the other cases reported in the Japanese literature. Our patient presented with lower abdominal pain and barium enema revealed a filling defect in the transverse colon. Colonoscopy disclosed a submucosal tumor, which changed shape with alteration the patient's position and showed the cushion sign. This lesion was covered with normal-looking mucosa. A correct diagnosis was made from these findings. Knowledge of these endoscopic features may help physicians to provide appropriate diagnosis and treatment of colonic lymphangioma.

Intrathyroid thyroglossal duct cyst simulating a thyroid nodule.

A case of intrathyroid thyroglossal duct cyst is reported. A 50-year-old woman presented with a right lateral neck mass that was clinically indistinguishable from a thyroid nodule. Ultrasound-guided fine-needle aspiration biopsy (US-FNAB) revealed normal-looking squamous cells. Right thyroid lobectomy was performed and microscopic examination revealed a cyst lined by squamous epithelium that was consistent with a thyroglossal duct cyst. The lesion was completely surrounded by normal thyroid tissue. Our experience suggests that intrathyroid thyroglossal duct cyst should be remembered in the differential diagnosis of a thyroid nodule. Detection of benign squamous cells by US-FNAB may be useful for ruling out the possibility of a cystic thyroid tumor.

Long-term role of nitric oxide in the enteric nervous system of the transplanted rat intestine.

We investigated the long-term changes of the nitric oxide (NO)-related neural component after syngeneic total small bowel transplantation in rats. In the present study, the NO-related neural component was examined using the electrophysiological and NADPH-diaphorase histochemical technique. The rats were divided into four groups: an untreated young adult control group, an untreated 2-year-old control group, a group killed 1 month after transplantation, and a group killed 2 years after transplantation. A superfusion apparatus was used to evaluate the response of jejunal strips to electrical transmural stimulation. In the presence of adrenergic and cholinergic blockade, the inhibitory effect of L-N(G)-nitro arginine (L-NNA; a nitric oxide synthesis inhibitor) on nonadrenergic, noncholinergic (NANC) relaxation was expressed as a L-NNA-sensitive component. The L-NNA-sensitive component accounted for 41.6 +/- 4.6% (mean +/- SE), 43.1 +/- 3.5%,54.6 +/- 4.1%, and 55.8 +/- 3.5% in the young control group, 2-year control group, 1-month transplant group, and 2-year transplant group, respectively, being significantly higher in the transplant groups (p < 0.05). The actual strength of the L-NNA-sensitive component was 0.24 +/- 0.03 (mean +/- SE), 0.26 +/- 0.02, 0.44 +/- 0.04, and 0.46 +/- 0.04 mg of tension per mg of wet weight, respectively, also being significantly higher in the transplant groups (p < 0.001). In addition, the percentage of NADPH-diaphorase-positive fibers was 24.1 +/- 1.1% (mean +/- SE), 25.5 +/- 1.4%, 31.0 +/- 1.6%, and 30.9 +/- 2.0%, respectively, being significantly higher in the transplant groups (p < 0.05). These results suggest that NO neurons in the intrinsic jejunal nervous system have an adaptive role in maintaining intestinal graft motility.

Diagnostic value of ultrasound-guided fine-needle aspiration biopsy, core-needle biopsy, and evaluation of combined use in the diagnosis of breast lesions.

BACKGROUND: To investigate whether ultrasound-guided core-needle biopsy (US-CNB) has more diagnostic value for breast tumors than ultrasound-guided fine-needle aspiration biopsy (US-FNAB) and to evaluate their combined use in patients with breast tumors. STUDY DESIGN: US-FNAB was carried out in 233 patients with breast tumors (254 lesions); both US-FNAB and US-CNB (combined biopsy) were performed in 81 of these patients (82 lesions). The diagnosis obtained by US-FNAB and US-CNB was compared with the surgical findings and the diagnostic value of US-CNB and combined biopsy were retrospectively evaluated. RESULTS: The sensitivity of US-FNAB was 86.9%, the specificity was 78.6%, and the accuracy was 84%. In contrast, the sensitivity of US-CNB was 86.2%, the specificity was 95.8%, and the accuracy was 89%. The specificity of US-CNB was significantly higher than that of US-FNAB and the inadequate biopsy rate of US-CNB was significantly lower than that of US-FNAB. For combined biopsy, the sensitivity, specificity, and accuracy were all 100%. The sensitivity, specificity, and accuracy of combined biopsy were significantly higher than those of US-FNAB. CONCLUSIONS: These findings suggest that US-CNB is more useful than US-FNAB, and that a combination of US-CNB and US-FNAB can markedly improve the preoperative diagnosis of breast cancer.

Acute acalculous cholecystitis in a patient on total parenteral nutrition: case report and review of the Japanese literature.

Acute acalculous cholecystitis (AAC) is a rare and dangerous complication of various medical and surgical conditions. We report on a male patient with bile panperitonitis caused by gangrenous AAC, which developed while he was on total parenteral nutrition (TPN) for ileus related to obstructive colon cancer. We also review the relevant Japanese literature on AAC associated with TPN. Our patient suddenly developed right hypochondrial pain after 3 days of TPN while waiting for colon cancer surgery. We diagnosed acute AAC by ultrasonography, and salvaged the patient by cholecystectomy plus left colectomy. Early diagnosis by ultrasound is important for this critical condition. Knowledge of the risk of acute gangrenous cholecystitis during TPN may allow the physician to provide an appropriate diagnosis and treatment.

Massive pleural effusion and ascites resulting from esophagectomy with extensive lymphadenectomy for cancer of the abdominal esophagus.

Chylothorax is an uncommon but well recognized complication of esophagectomy. We present the case of a 57 year-old man with squamous cell carcinoma of the abdominal esophagus who underwent subtotal esophagectomy by right thoracotomy. Post-operatively, the volume of pleural effusion from the right chest was increased (1600-2000 ml/day). The effusion was straw colored, not changing to milky after meals. The characteristics and composition of the pleural fluid were similar to those of chyle. We therefore treated this patient using methods for treatment of chylothorax, conservatively, by administration of OK-432 and minocycline/hydrochloride into the pleural cavity from the chest tube with success. We discuss the pathophysiology of this unusual condition and its treatment.

Ultrasound-guided fine-needle aspiration biopsy for breast tumors: needle guide versus freehand technique.

BACKGROUND: We retrospectively studied whether a needle guide is necessary when performing ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in patients with breast tumors. METHODS: A total of 47 patients (50 lesions) with breast tumors underwent US-FNAB with a needle guide and 127 patients (143 lesions) underwent the procedure without a needle guide (freehand biopsy). The diagnoses obtained by US-FNAB were compared with the surgical findings. RESULTS: The sensitivity of freehand biopsy for tumors < 3 cm in diameter was significantly higher than that of the needle guide technique. CONCLUSIONS: We recommend performing US-FNAB without a needle guide (freehand biopsy) in order to maximize the correct preoperative diagnosis rate, especially in patients with tumors < 3 cm in diameter.

Accessory breast cancer: a case report and review of the Japanese literature.

The case of a 31-year-old woman with accessory breast cancer in the left axilla is described. She had noticed a swelling in the left axilla during her three pregnancies. The preoperative diagnosis of accessory breast cancer was made on the basis of ultrasound-guided fine-needle aspiration biopsy (US-FNAB) and clinical history. She was treated by wide local resection and regional lymph node dissection. Although cancer originating from accessory breast tissue has been reported very rarely, knowledge of this disorder may facilitate the correct diagnosis of axillary tumors. US-FNAB is a useful and simple technique for the tissue diagnosis of axillary tumors.

Thyroid cancer in uremic patients.

BACKGROUND: The combination of thyroid cancer and secondary uremic hyperparathyroidism has thus far been reported in only 25 cases. METHODS: Here we report our experience of 19 patients with secondary hyperparathyroidism who underwent parathyroidectomy. RESULTS: Thyroid nodules were present in five patients (26.3%), including one with a benign nodule and four with papillary thyroid cancer (21.1%). CONCLUSION: Our experience suggests that, in order to make a correct diagnosis, clinicians should consider the possibility of thyroid cancer in uremic patients with secondary hyperparathyroidism.

Comparison of variant expression of estrogen receptor mRNA in normal breast tissue and breast cancer.

To investigate whether estrogen receptor abnormalities are associated with resistance of breast cancer to endocrine therapy, we compared estrogen receptor mRNA between normal breast tissue and carcinoma. Using the RT-PCR, paired cancer and normal breast tissue specimens from 15 patients were analyzed. Exon-deleted variants were found in both tumor and normal tissue, with differences of variant expression between normal and tumor tissue being observed. One patient showed multiple deletions in the hormone-binding domain. Alterations in the amount and/or kind of variant ER expression may be important in determining the response of breast cancer to endocrine therapy.

Evaluation of ultrasound-guided fine-needle aspiration biopsy for thyroid nodules.

BACKGROUND: We retrospectively studied whether ultrasound-guided fine-needle aspiration biopsy (US-FNAB) showed improved sensitivity in patients with palpable thyroid nodules. METHODS: A total of 70 patients (72 lesions) with thyroid nodules underwent US-FNAB and 94 patients (94 lesions) underwent FNAB guided by manual palpation (standard FNAB). The diagnoses obtained by US-FNAB were compared with the surgical findings. RESULTS: The sensitivity of US-FNAB for palpable thyroid nodules was 62% the specificity was 74% the accuracy was 68% the positive predictive value was 100%, the negative predictive value was 70% and the inadequate biopsy rate was 17%. In contrast, the sensitivity of standard FNAB was 45%, the specificity was 51%, the accuracy was 48% the positive predictive value was 96, the negative predictive value was 55, and the inadequate biopsy rate was 30%. The accuracy of US-FNAB was significantly higher than that of standard FNAB. For tumors < or = 2 cm in diameter, the sensitivity and accuracy of US-FNAB were both significantly higher than those of standard FNAB. CONCLUSION: These findings suggest that US-FNAB can improve the preoperative diagnosis of thyroid cancer, especially in patients with tumors < or = 2 cm in diameter.

Germline p53 mutation at codon 133 in a cancer-prone family.

We identified four families in which we suspected the presence of genetic factors predisposing them to cancer. We examined one family with features suggesting Li-Fraumeni syndrome for the presence of a germline p53 mutation in 13 of its members. To detect germline p53 mutations we performed polymerase chain reaction/nonradioisotopic single-strand conformation polymorphism and DNA sequencing analysis on exons 4-9 of the p53 gene. Mutated polymerase chain reaction-restriction fragment length polymorphism analysis was also performed on exon 5 to confirm the mutation identified by the sequencing analysis. A novel germline p53 mutation was identified at codon 133 (ATG-->AGG) in exon 5, resulting in the substitution of arginine for methionine, in all four cancer-affected individuals and in three apparently healthy individuals. We also analyzed tumor specimens for additional p53 mutations in the wild-type alleles using the same methods. However, heterozygosity was retained, and no other additional mutations in the wild-type allele were identified in any of the tumor tissues. It is possible that additional mutations in the wild-type allele are not always necessary for the loss of tumor suppressor functions. This study presents serious clinical and ethical problems about the predictive value of identifying germline p53 mutations in presymptomatic carriers. However, accurate predictive testing will be very useful in identifying unaffected individuals who are at increased risk of developing cancer and in detecting cancer at an early stage.

Usefulness of ultrasound-guided, fine-needle aspiration biopsy for palpable breast tumors.

OBJECTIVE: To investigate whether ultrasound (US) guidance improves the sensitivity of fine-needle aspiration biopsy (FNAB) in patients with palpable breast tumors. DESIGN: A retrospective study. SETTING: A university hospital. PATIENTS: A total of 107 patients with breast tumors (114 lesions) underwent US-guided FNAB and 138 patients (143 lesions) underwent FNAB guided by palpation (standard FNAB). MAIN OUTCOME MEASURES: The diagnoses obtained by FNAB were compared with the surgical findings and the diagnostic value of US-guided FNAB was evaluated. RESULTS: The sensitivity of US-guided FNAB was 89.3%, the specificity was 82.9%, and the accuracy was 86.9%. In contrast, the sensitivity of standard FNAB was 61.1%, the specificity was 73.3%, and the accuracy was 65.0%. For breast tumors 2.0 cm or less in diameter, the sensitivity and accuracy of US-guided FNAB were significantly higher than those of standard FNAB. CONCLUSION: Ultrasound-guided FNAB can improve the preoperative diagnosis of breast cancer, especially in patients with tumors that are 2 cm or less in diameter.

Dermatomyositis and malignancy: case report and review of the Japanese literature.

The first reported association of dermatomyositis with malignancy was by Stertz in 1916, who described a patient with proximal muscle weakness, eyelid changes, and evidence of myositis on muscle biopsy as well as a coexisting gastric carcinoma. In the same year, Kankeleit described a patient with dermatomyositis and breast cancer--the seeds of a controversy were thus sewn. We report a female patient with multiple cancer who developed dermatomyositis and review the relevant Japanese literature. Our patient suffered from metachronous bilateral breast cancer and thyroid cancer. She underwent curative resection of all 3 tumors. Our experience suggests that clinicians should perform extensive screening of dermatomyositis patients to salvage those with occult cancer, although the issue of cost effectiveness also has to be considered.