Surgical resection of solitary adrenal metastasis from esophageal carcinoma following esophagectomy.

The prognosis of esophageal carcinoma following esophagectomy is poor due to a high frequency of metastasis to periesophageal lymph nodes and distant organs. However, we experienced a case with good prognosis following resection of a solitary adrenal metastatic tumor. The patient was a 70-year-old man diagnosed with type 2 esophageal cancer (Lt-Ae, T2N1M0, Stage IIB) who was treated with esophagectomy. Eight months following surgery, solitary adrenal metastasis was detected by CT, and was resected. At 42 months follow-up he has had a good quality of life in the community without evidence of recurrence. To the best of our knowledge, only five cases with resected solitary adrenal metastases including our case, have been reported, and show a greater than 1-year survival. Consequently, we suggest that resection of solitary organ metastases is a good alternative, even following esophagectomy.

Successful endoscopic resection of intramural metastasis after esophagectomy for esophageal cancer: a case report.

Carcinoma of the esophagus is often accompanied by intramural metastasis (IM) at the time of diagnosis, and the prognosis of patients with such metastasis is very poor. Here we report the case of a 60-year-old man who presented with a submucosal tumor in the wall of the cervical esophagus at 2 years after esophagectomy for thoracic esophageal cancer. The tumor was resected endoscopically and was histologically shown to be an IM of esophageal cancer. He has shown no recurrence and no metastasis during 2 years of follow-up after endoscopic resection and radiation therapy.

Effective intra-arterial chemotherapy for acinar cell carcinoma of the pancreas.

A 41-year-old man with a huge pancreatic tumor (acinar cell carcinoma) was treated by intra-arterial infusion chemotherapy with 5-fluorouracil (5-FU), mitomycin C (MMC) and cisplatin (CDDP). The tumor was significantly reduced, and he underwent a pancreaticoduodenectomy with complete excision of the tumor. Unfortunately multiple metastatic liver tumors were noted 5 months after resection. These tumors could also be markedly reduced by intra-arterial chemotherapy and the survival period was prolonged to 18 months. He suddenly died of sepsis but not from the pancreatic carcinoma. This case shows that intra-arterial infusion chemotherapy with 5-FU, MMC and CDDP can be an effective regimen for the treatment of acinar cell carcinoma of the pancreas.

A unique method of closure for an aortocaval fistula in association with a ruptured abdominal aortic aneurysm: report of a case.

We report herein the case of a 78-year-old man in whom an aortocaval fistula caused by spontaneous rupture of an abdominal aortic aneurysm (AAA) was successfully treated by a unique surgical technique. The aortocaval fistula had been revealed by an aortography after the patient presented with high-output heart failure. During the operation, massive bleeding from the fistula was evident. The fistula measured 2 cm in diameter, and was located between the right posterior wall of the AAA and the inferior vena cava (IVC). Direct suturing of the defect in the IVC failed to close the fistula because the tissue around it would not hold together due to degeneration. However, the bleeding was finally able to be controlled by plugging the fistula with isolated and properly trimmed omentum packed within the excluded aneurysmal sac. Unfortunately, the patient died due to respiratory failure on the 201st postoperative day. A pathological autopsy revealed that the aortocaval fistula had been closed by fibrous tissue and that the IVC was patent. Although such a drastic operative measure to repair an aortocaval fistula has never before been reported, it could be an alternative when direct closure proves unsuccessful.

Successful treatment of an esophageal hemangioma by endoscopic injection sclerotherapy: report of a case.

We report herein the case of a 46-year-old man in whom an esophageal hemangioma was successfully treated by endoscopic injection sclerotherapy (EIS). The patient was admitted to hospital after a routine upper gastrointestinal series demonstrated a filling defect in the esophagus. Endoscopy, computed tomography (CT) images, and magnetic resonance imaging (MRI) subsequently revealed a hemangioma in the middle esophagus. EIS was performed using 99% ethanol and 1% polydocanol, and 4 weeks later, the tumor had almost disappeared. This patient has since been followed up carefully with periodic endoscopy and barium studies and additional sclerotherapy will be performed if necessary.

Acute radiation thyroiditis.

PURPOSE: Radiation-induced thyroid dysfunction is considered a late effect. We prospectively assessed acute reactions of the thyroid to external neck irradiation. METHODS AND MATERIALS: This study included 22 patients in whom the thyroid was incidentally exposed to therapeutic doses of radiation. Thyroid function tests included measurements of serum thyroid stimulating hormone (TSH), free and total triiodothyronine (T3) and thyroxine (T4), thyroglobulin, and antithyroid antibodies. These tests were performed before radiotherapy (baseline values), after approximately 40 Gy had been administrated, 2 weeks after the end of radiotherapy, and 3 and 6 months after the beginning of radiotherapy. RESULTS: Mean serum levels of TSH were 1.53, 0.55, 0.78, 2.14, and 7.57 microU/ml before radiotherapy, after 40 Gy irradiation, 2 weeks after the end of radiotherapy, and 3 and 6 months after radiotherapy, respectively. Thus, levels of TSH exhibited two phases: a significant decrease during radiotherapy (thyrotoxic phase) and an increase after radiotherapy (hypothyroid phase) (baseline vs. 40 Gy: p < 0.0001, baseline vs. 6 months: p = 0.003). Increases of thyroid hormones were subtle during radiotherapy. CONCLUSIONS: We believe that radiation promotes release of excessive amounts of thyroid hormones during radiotherapy owing to suppression of TSH secretion. In addition to the late damage (hypothyroidism), thyrotoxicosis occurs when the thyroid gland receives a therapeutic doses of external radiation.

A prospective analysis of subacute thyroid dysfunction after neck irradiation.

PURPOSE: Exposure of the thyroid to therapeutic doses of external irradiation has been demonstrated to induce thyroid dysfunction. This study was designed to assess the relationship between irradiation and early thyroid dysfunction, prospectively. METHODS AND MATERIALS: Twenty patients in whom the thyroid was incidentally exposed to therapeutic doses of irradiation were studied. The dose given to the thyroid was 40-54 Gy over 4-7 weeks. Thyroid function tests, including serum thyroid stimulating hormone (TSH), free thyroxine (free T4), free triiodothyronine (free T3), antithyroglobulin antibody, and antimicrosomal antibody, were performed prior to irradiation and at 3, 6, and 12 months after radiotherapy. RESULTS: Serum TSH levels did not change significantly at 3 months after irradiation (mean TSH level: 1.33 microU/ml before irradiation, 1.74 microU/ml at 3 months, p = 0.11). However, a significant elevation was noted at 6 months (mean TSH: 3.50 microU/ml at 6 months, p = 0.0001, vs. preirradiation), when TSH levels were higher than preirradiation levels in 19 of 20 patients. After irradiation, 13 patients remained in a euthyroid state (euthyroid group), while in the other 7 patients hypothyroidism occurred (hypothyroid group) and thyroid hormone-replacement therapy was performed. After 6 months, elevation of TSH was less significant in the euthyroid group, whereas elevation of TSH persisted continuously and exponentially in the hypothyroid group. Thyroid autoantibodies did not turn positive in any patient during follow-up. CONCLUSIONS: Damage of the thyroid develops in most patients when the organ is exposed to radiation. This radiation-induced damage is initially manifested within 6 months after irradiation.

Infrequent replication errors at microsatellite loci in tumors of patients with multiple primary cancers of the esophagus and various other tissues.

Patients with esophageal cancer are at high risk of developing other primary tumors, especially squamous cell carcinoma in the head and neck. Heavy smoking and excessive consumption of alcohol are considered to be crucial environmental risk-factors for development of these multiple primary cancers. To investigate whether any genetic background, such as defects in the DNA-mismatch repair system, may influence the development of these multiple primary tumors, we examined replication errors (RER) at six microsatellite loci in DNAs of 46 tumors from 33 patients who had developed primary cancers in various tissues in addition to the esophagus. RER(+) (RER-positive) phenotype was observed in three tumors in two patients of the 33 patients examined. Our results suggested that development of multiple primary tumors in these patients would not be affected by an abnormality in the DNA repair system(s) detected as the RER phenotype. However, it is noteworthy that a single patient who developed multiple cancers revealed RER(+) phenotypes at multiple microsatellite loci in both tumors, indicating that a defect in the DNA repair gene(s) may have played an important role in the development of the tumors in this patient.

[A case of spontaneous rupture of the esophagus].

Since cases of spontaneous rupture of the esophagus are extremely rare and early symptoms of the disease are similar to those of emergency diseases of the chest and abdomen, the diagnosis and treatments are often delayed, resulting in an unfavorable outcome in some cases. A 49-year-old man had suffered from severe chest pain and postemetic hematemesis after consuming some alcohol. Because the patient was diagnosed as having a spontaneous rupture of the esophagus, the patient was referred to our hospital and underwent surgery 25 hours after the onset. There was a 3-cm vertical perforation in the left wall of the lower esophagus. The ruptured esophageal wall was directly closed by the layer to layer method and reinforced with fundic patch by Thal-Hatafuku. The post-operative course was uneventful and the patient was discharged on the 46th day after operation. This surgical procedure was very useful in the patient. We reviewed 59 cases, including our case, which occurred recently in Japan.

[Two cases of esophageal fistula, in which a fibrin glue preparation was effective].

Two successful cases of endoscopic therapy for esophageal fistula are reported herein. The first case was a 61-year-old man who underwent irradiation, chemotherapy and endoscopic laser beam therapy for esophageal cancer (Im T4N0M0 Stage III). Gastrografin -esophagogram revealed a fistula between esophagus and mediastinum after these therapy. Closure of the fistula was attainable using fibrin glue with a double-channel-fiber scope. The second case was a 43-year-old man who underwent chemotherapy and irradiation for lung cancer (S1,S2 T4N2M0 Stage IIIB) which invaded to mediastinum, trachea and esophagus. Bronchogram revealed a esophago-tracheal fistula one month later. We performed the same procedure as the first case, and confirmed reduction of the fistulous size. The endoscopic fibrin glue injection is an easy, safe and effective technique for the fistula even caused by malignancies, and contributes to the quality of life of these patients.

Quadruple cancer including Bowen's disease after arsenic injections 40 years earlier: report of a case.

This report describes the successful treatment of quadruple cancer including Bowen's disease in a 71-year-old man who had been given injections of salvarsan, an arsenic compound, for syphilis more than 40 years earlier. Resection of a skin lesion on his chest subsequently confirmed a diagnosis of Bowen's disease, 3 years after which he was operated on for concurrent gastric cancer and sigmoid colon cancer. A fourth cancer was discovered on his left vocal cord 2 weeks after this operation; it was resected 2 years later. A discussion of multiple malignant neoplasms and the possible relationship between arsenic and cancer is presented following this case report.

Comparison of postoperative results following terminal esophagoproximal gastrectomy and esophageal transection for esophageal varices.

The results of 44 terminal esophagoproximal gastrectomies (TEPG) and 53 esophageal transections (ET) for esophageal varices, performed during the period between January, 1975 and March, 1989, were retrospectively compared. The results examined prognosis, recurrence of esophageal varices and late postoperative complications. The 5-year survival rates for patients who underwent selective or prophylactic surgery were 85.9% following TEPG and 81.6% following ET. However, the 10-year survival rate for the former group was significantly lower than that for the latter group at 59.3% versus 70.0% (P < 0.05) because of the number of deaths due to hemorrhage and liver failure caused by anastomotic ulcers. The respective 5-year recurrence rates of varices for the TEPG and ET groups were 18.4% and 26.4%, respectively, while the 10-year recurrence rate for the former group was again significantly lower than that for the latter group at 27.1% versus 53.7% (P < 0.01). As for postoperative late complications, reflux esophagitis and/or anastomotic ulcers were found twice as frequently after TEPG as after ET. Thus, although TEPG was more effective for preventing variceal recurrence it left the potential for an anastomotic ulcer to develop, which was the dominant cause of death more than 5 years after surgery.

Primary adult T-cell lymphoma of the breast.

A case of primary adult T-cell lymphoma (ATL) of the breast is described. A 69-year-old woman presented with a painless, rapidly growing lump in her left breast. Staging procedures demonstrated no sign of generalized disease. Following a Patey's mastectomy, 10 courses of adjuvant chemotherapy (CHOP) were successfully administered. The light microscopic, immunohistochemical and molecular genetic analyses of the surgical specimen revealed a primary ATL. Seropositive mothers who breast-feed their children may facilitate the accumulation of T cells carrying HTLV-I in their breasts and thereby increase their risks of developing breast ATL.

[Postoperative brain metastasis from esophageal carcinomas: report of 4 cases].

Out of 83 cases received resection of primary esophageal lesion, 4 patients were affected by metastatic brain tumor which was reported to rarely occur. All 4 patients had symptoms of central nervous system. Three of them were diagnosed by CT and the other one at autopsy. All of the primary esophageal tumors were advanced and of histological stage III or IV. They located in the middle or lower thoracic esophagus. Brain tumor of one case was removed and this case was of progression free at the last presentation. The other 3 cases were not received resection of metastatic brain tumors and died. All of 3 were autopsied and two of them had no metastasis in the lung. Therefore, it was considered that these hematogenic metastases were not through lung filtrations but through other routes, which Batson O. V. experimentally proved and designated as vertebral vein system in 1940. It is concluded that aggressive surgical intervention to metastatic brain tumors was beneficial with regard to prognosis for cases without other metastatic lesions.

Geographic clustering of myeloma in Tokushima.

Between 1978-1988, seven cases of multiple myeloma were found in T Town (population 9,000), which is located at the mouth of a large river within the boundaries of Tokushima City, Japan. This is a significantly high incidence, 7.06 per 100,000 as compared with an incidence of 1.20 in Tokushima City itself and 1.53 in Japan as a whole. The clinical and laboratory features of these patients were typical of myeloma. Although the causes of this small but apparent cluster of multiple myeloma remain obscure, the fact that five of the seven patients had been working for long periods as fishermen was notable.

[IBL-type lymphadenopathy after infection of rubella virus].

A 52-year-old woman presented slight fever, diffuse papular skin rash and painful cervical lymph node swelling. Her lymph node swelling generally up to 3 cm in diameter, with petechiae on the lower legs and hepato-splenomegaly within a few weeks. ESR was 45 mm/h, Hb 10.0 g/dl, RBC 345 x 10(4)/microliter, WBC 22,600/microliter (atypical lymphocyte 47%), PLT 1.0 x 10(4)/microliter, GPT 91 U/L, gamma-globulin 34.3%, EBV-VCA x 2,560, EBNA x 20, and anti-rubella antibody x 512. The biopsied cervical lymph node showed histologic features of effacement of nodal architecture by an exuberant vascular proliferation accompanied with infiltration of the immunoblasts, and was diagnosed as immunoblastic lymphadenopathy (IBL)-type lymphadenopathy. The pulse therapy of methylprednisolone and high dose of gamma-globulin improved lymphadenopathy, thrombocytopenia and anemia. IBL-type lymphadenopathy after infection of rubella virus may be different from true IBL, but is important to discuss the pathogenesis of IBL.

[Spontaneous complete remission in a patient with acute monocytic leukemia].

A spontaneous complete remission was observed in a 47-year-old female with acute monocytic leukemia. Resolution of all abnormalities, including systemic papule, thrombocytopenia, increased numbers of immature monocytoid cells in the peripheral blood and bone marrow, elevation of serum lysozyme and LDH, and trisomy 8 on chromosome analysis, occurred without any treatment. Moreover, the remission was not associated with any infection or blood transfusion, and is persistent for 12-month duration.

[Myelodysplastic syndrome (RAEB-T) occurring after adjuvant chemotherapy for colon and rectum cancers].

A 67-year-old man was admitted to our hospital because of bleeding tendency and high fever. The patient had a past history of gastrectomy and transverse colectomy for cancer of transverse colon at age 57, and rectum resection for rectum cancer at age 59. After these operations, Tegafur 645 g, MMC 56 mg, and Ara-C 560 mg were administered for about 6 years. Hematological examinations revealed hemoglobin of 7.7 g/dl, white cell count of 9,500/microliters with 8% myeloblasts, and platelet count of 7,000/microliters. A diagnosis of myelodysplastic syndrome (RAEB-T) was made from the finding of bone marrow smear, which showed 28% myeloblasts, and neutrophils and megakaryocytes with morphologically abnormal nuclei and cytoplasms. Chromosomal banding study of the bone marrow cells revealed -5, -8, 7q- in all analyzed cells. These findings suggest that the preceding adjuvant chemotherapy is probably related to the occurrence of myelodysplastic syndrome.

[Malignant pericardial effusion after esophageal cancer surgery successfully treated by intrapericardial instillation of CDDP].

The patient is a 63-year-old male with pericardial effusion who fell into cardiac tamponade one year and eight months following radical operation for esophageal cancer (stage IV). Because the cytological diagnosis for the punctured specimen of pericardial effusion indicated class V, we recognized it as pericardial recurrence and instilled CDDP 20 mg and 25 mg into the pericardial cavity. The pericardial effusion disappeared completely. There are many reports of CDDP instillation into the pleural cavity or the peritoneal cavity, but few into the pericardial cavity. For esophageal cancer, this is the first report in Japan. The patient is still alive at present after fourteen months have passed. It is considered that this method is effective for malignant pericardial effusion due to advanced esophageal cancer.