The Effect of Cervical Stellate Ganglion Block Using Botulinum Toxin Type A in Intractable Cancer-related Pain: Case Report

OBJECTIVE: For patients who do not relieve with pharmacological intervention, interventional treatment including neurolytic blocks may have a specific role in palliative cancer management.METHOD: We performed cervical stellate ganglion block for the second time with Botulinum toxin type A mixed with 4 ml of normal saline, total 75 IU of Botulinum toxin type A, minimal effective dosage was measured to minimize the possible side effects.RESULTS: About 3 days later, the patient reported that her continuous pain intensity had decreased from 8/10 to 4/10 on the visual analogue scale score. The frequency of the pain attack that required additional morphine injections was also decreased. As a result, her maximum morphine requirement dose per day was significantly reduced.CONCLUSION: In this case, cervical stellate ganglion block with Botulinum toxin hadlonger lasting effect in the continuous pain intensity and resulted in less frequent pain attack. Botulinum toxin can be a possibleintervention material in intractable neuropathic pain related to cancer.

Late-Onset Distant Metastatic Upper Urinary Tract Urothelial Carcinoma Mimicking Lung Adenocarcinoma / 결핵및호흡기질환

Urothelial carcinomas (UCs) can occur in the upper urinary tract or lower urinary tract. Upper urinary tract urothelial carcinoma (UUT-UC) is relatively a rare disease and accounts for only about 5% of UC cases. Sporadic cases of late-onset metastasis, associated with UC of the bladder, have occasionally been reported. In contrast, no late-onset distant metastatic UUT-UC without local recurrence has, to the best of our knowledge, been reported in the English literature. We report an extremely rare case of distant metastatic UC, mimicking lung adenocarcinoma that originated from UUT-UC 12 years previously.

Erlotinib Induced Trichomegaly of the Eyelashes / 결핵및호흡기질환

Epithelial growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) have been widely used for non-small-cell lung cancer patients. Its untoward cutaneous effects are largely well known and developed in many patients treated with EGFR TKIs. However trichomegaly of eyelash is rarely reported. Although trichomegaly is not a drug-limiting side effect, it could be troublesome of continuing the treatment because of cosmetic issue or eyeball irritation by long eyelashes. Therefore clinicians are needed to pay attention to this uncommon effect. We herein describe erlotinib induced trichomegaly of eyelashes in a woman with adenocarcinoma of the lung.

Complete Atrioventricular Block Secondary to Bortezomib Use in Multiple Myeloma

Bortezomib is an inhibitor of 26S proteasome, which is an effective treatment for multiple myeloma. The common adverse effects of bortezomib are asthenic conditions, gastrointestinal disturbances, and peripheral neuropathy. Here we describe a patient with dyspnea and general weakness because of complete atrioventricular block while receiving bortezomib. We immediately stopped bortezomib, and after inserting a permanent VDD pacemaker, the patients' symptoms disappeared.

Complete Atrioventricular Block Secondary to Bortezomib Use in Multiple Myeloma

Bortezomib is an inhibitor of 26S proteasome, which is an effective treatment for multiple myeloma. The common adverse effects of bortezomib are asthenic conditions, gastrointestinal disturbances, and peripheral neuropathy. Here we describe a patient with dyspnea and general weakness because of complete atrioventricular block while receiving bortezomib. We immediately stopped bortezomib, and after inserting a permanent VDD pacemaker, the patients' symptoms disappeared.

Gender Differences in Susceptibility to Smoking among Patients with Lung Cancer

BACKGROUND/AIMS: To determine whether female smokers are more or less susceptible to the detrimental pulmonary-function effects of smoking when compared to male smokers among patients with lung cancer. METHODS: Pack-years and pulmonary function indices were compared between 1,594 men and women with lung cancer ifferences in individual susceptibility to smoking were estimated using a susceptibility index formula. RESULTS: Of the patients, 959 (92.8%) men and 74 (7.2%) women were current smokers. Common histological types of lung cancer were squamous cell carcinoma, adenocarcinoma, and small cell carcinoma, among others. Women had a lower number of pack-years, forced expiratory volume in 1 second (FEV1, liters), forced vital capacity (FVC, liters), and total lung capacity (TLC, liters) compared to those of men (25.0 +/- 19.2 vs. 42.9 +/- 21.7 for pack-years; 1.4 +/- 0.5 vs. 2.0 +/- 0.6 for FEV1; 3.0 +/- 0.7 vs. 2.0 +/- 0.6 for FVC; 4.5 +/- 0.8 vs. 5.7 +/- 1.0 for TLC; all p < 0.001). The susceptibility index for women was significantly higher compared to that of men (1.1 +/- 4.1 vs. 0.7 +/- 1.1; p = 0.001). A significant inverse association was shown between the susceptibility index and TLC and FVC (r = -0.200 for TLC, -0.273 for FVC; all p < 0.001). CONCLUSIONS: The results suggest that the detrimental effects of smoking on pulmonary function are greater in women, as compared to those in men, among patients with lung cancer.

Erlotinib-Related Spontaneous Pneumothorax in Patient with Primary Lung Cancer / 결핵및호흡기질환

Spontaneous pneumothorax (SPTx) associated with primary lung cancer is quite rare, but has been reported as the initial presentation or a complication of disease progression. Moreover, chemotherapy-related SPTx in primary lung cancer occurs at a very low frequency, accounting for less than 0.05% of all cases. Here, we report the first case of erlotinib-related SPTx in a patient with advanced lung adenocarcinoma in Korea. After 3 cycles of cisplatin-based chemotherapy as first-line therapy, erlotinib was administered as second-line treatment. Asymptomatic SPTx accompanied by a significant decrease in tumor size was observed in the left lung 7 weeks later. The patient received continuous administration of erlotinib, without additional treatment. This case showed that SPTx can occur in patients with primary lung cancer receiving erlotinib, and asymptomatic chemotherapy-related SPTx in primary lung cancer may not require therapeutic intervention.

Clinical Analysis for the Postoperative Complications of Pancreaticoduodenectomy in the Recent 5 Years

PURPOSE: Pancreaticoduodenectomy (PD) is known to have high morbidity and mortality rates among the various abdominal operations, but there have been few reported current series of pancreaticoduodenectomy from large volume medical centers. The purpose of this study is to analyze the postoperative complications of PD and to assess the risk factors for postoperative morbidity. METHODS: A total of 398 cases of PD were performed by two surgeons from January 2003 to December 2007 at our institution and we retrospectively reviewed the medical records of these cases. RESULTS: 186 (46.7%) of 398 patients underwent pylorus preserving pancreaticoduodenectomy (PPPD) and 212 patients (53.3%) underwent a classic Whipple procedure. The most common indication for this procedure was pancreatic cancer (151 cases, 37.9%) and the second most common was intraductal papillary mucinous tumor (78 cases, 19.6%). The mean age was 57.2 years, ranging from 12 to 81. The mean postoperative hospital stay was 24.7 days. The most common complication was delayed gastric emptying (11.8%) and next was pancreatic fistula (10.3%), bleeding (6.5%) and new onset diabetes mellitus (DM) (4%). Four patients (1%) died of hospital mortality. The patients' age, gender, DM history, hypertension history and serum bilirubin level had no significant influences on the postoperative morbidity rate. CONCLUSIONS: Pancreaticoduodenectomy can be performed safely with an acceptable complication rate and minimal mortality if the surgeon has sufficient surgical experiences and with the advance in anesthesia and postoperative care.

The Usefulness of Endoscopic Ultrasonoraphy for Discriminating Gastric Mucosal Cancer from Submucosal Invasion / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic ultrasonography (EUS) has been used to discriminate gastric mucosal cancer (T1m) from submucosal invasion (T1sm). Thus the aims of this study are 1) to determine the accuracy of EUS for diagnosing tumor depth, 2) to compare the accuracy of EUS with the endoscopic impressions of variously experienced endoscopists and 3) to compare the accuracy of performing EUS by one doctor according to the experience. METHODS: The EUS and pathologic reports of early gastric cancer patients were analyzed. The same endoscopic images were reviewed again by 3 endoscopists, who had one-, three- and five-years experience, respectively. The accuracies of EUS and conventional endoscopy were analyzed. RESULTS: 77 patients were included from November 2003 to October 2005. The kappa of the EUS for actual examiner and conventional endoscopy for reviewer 1, reviewer 2 and reviewer 3 were 0.421, 0.134, 0.359 and 0.307, respectively and accuracies were 68.8%, 45.5%, 67.5% and 62.3%, respectively. Of the 52 T1m patients, 23 (44.2%) were overstaged as T1sm with performing EUS. But of 25 T1sm patients, only 1 (4.0%) was understaged as T1m with performing EUS. The accuracy and kappa of the EUS for one doctor during the first-year experience were 60.6% and 0.316, respectively, and they were 75.0% and 0.508, respectively during the second-year experience. CONCLUSIONS: EUS is useful for complementing the conventional endoscopic discrimination of gastric mucosal cancer from submucosal invasion. Yet physician should keep in mind the relatively common overstaging.

Incidence and Risk Factors of Acute Hepatic Failure after Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma / 대한소화기학회지

BACKGROUND/AIMS: Although transcatheter arterial chemoembolization (TACE) is a major treatment modality for unresectable hepatocellular carcinoma (HCC), acute hepatic failure after TACE is not rare. However, reports dealing with this important complication are not good enough and results are often variable. The purpose of this study was to evaluate the incidence and associated risk factors of acute hepatic failure after TACE. METHODS: From January 2001 to November 2004, six hundred and thirtytwo TACE sessions were performed in 377 patients (294 men and 83 women). Adriamycin mixed lipiodol solution and gelfoam were used for TACE. Various clinical and radiological factors before and after the procedure were reviewed retrospectively. Univariate and multivariate analyses were performed to evaluate the risk factors associated with the development of acute hepatic failure after TACE. RESULTS: Acute hepatic failure occurred in 76 (12.0%) of the 632 TACE sessions within 14 days. Univariate analysis revealed that Child-Pugh class, 1st TACE, total bilirubin level, number of involved segments, total size of tumor, presence of right portal vein thrombosis (PVT) or main PVT, involvement of segment 1, 5, 6, 7, modified UICC stage, and doses of chemotherapeutic agent were significantly different between the patients with or without hepatic failure after TACE. Among them, elevated total bilirubin (p=0.001, E (beta)=1.449), presence of right (p=0.035, E (beta)=2.109) or main (p=0.011, E (beta)=4.067) PVT were independently associated factors in multivariate analysis. CONCLUSIONS: The incidence of acute hepatic failure after TACE was 12.0%. Elevated bilirubin level and portal vein thrombosis could be considered as the predictive factors for acute hepatic failure after TACE in HCC patients.

Clinical Significance of C4d-Positivity in Renal Transplant Recipients with Acute Rejection / 대한이식학회지

PURPOSE: C4d detection in peritubular capillaries in acute allograft rejection has been regarded as a poor prognostic factor for graft kidney survival. We investigated the clinical importance of C4d positivity in renal transplant recipients with acute rejection. METHODS: Forty eight renal allograft biopsies were selected, which were available for immunofluorescence study. The samples were divided into two groups, one which was diagnosed as acute rejection clinically (n=30), the other which underwent protocol biopsy 2 weeks after transplantation (n=18). Among the acute rejection group, C4d staining was positive in 50% of acute rejection cases (C4d (+), n=15) and negative in the others. (C4d (-), n=15). We compared the C4d (+) group and the C4d (-) group in terms of clinical parameters and graft survival duration. RESULTS: Renal function was reduced in the C4d (+) group compared to the C4d (-) group. In the C4d (+) group, 8 of 15 cases resulted in graft loss, but only one graft loss developed in the C4d (-) group. Graft survival duration after kidney biopsy was reduced in the C4d (+) group compared to the C4d (-) group. CONCLUSION: Renal transplant recipient with C4d-positive acute rejection shows inferior graft survival duration. So tight management in addition to steroid pulse therapy should be considered for these patients.

A Case of Intraluminal Gallbladder Hematoma after Percutaneous Liver Biopsy / 대한간학회지

Percutaneous liver biopsy is valued in the diagnosis of diffuse or localized liver disease. Serious complications after ultrasonography-guided liver biopsy are rare. We report a case of a 69-year-old man who underwent a percutaneous liver biopsy for the evaluation of his underlying liver disease with subsequent late complication of intraluminal gallbladder hematoma.

A Case of Gastric Metastasis from Breast Carcinoma Manifested by Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

Breast carcinoma is common malignancy in women and frequently metastasize to multiple organ such as lung, bone, lymph node and liver. But metastasis to gastrointestinal tract is rare and only two cases have been reported in Korea. We experienced a case of upper gastrointestinal bleeding caused by gastric metastasis from ductal carcinoma of breast and report this case with review of several literatures.

Two Cases of Primary Esophageal Small Cell Carcinoma / 대한소화기내시경학회지

Primary extrapulmonary small cell carcinoma have been described in the esophagus, stomach, pancreas, salivary gland, paranasal sinus, small bowel, uterus, urinary bladder and skin. Primary small cell carcinoma of the esophagus has rarely been reported since McKeown had reported the first 2 cases of small cell carcinoma of the esophagus in 1952. Primary small cell cancer of esophagus is extremely aggressive tumor with grave prognosis. Because of the highly malignant potency, multimodality treatment including chemotherapy for the primary therapy is accepted generally. We experienced 2 cases of small cell carcinoma of the esophagus. One patient was a 57 year-old male without metastasis and we treated him with a multi-drug regimen (cisplatin and VP-16) being used in small cell carcinoma of the lung at our hospotal. But the other patient was a 67 year-old male with bone metastasis, and he refused all management.

A Case of Duodenal Tuberculosis Conceived as Submucosal Tumor Accompanied by Tuberculous Lymphadenitis / 대한소화기내시경학회지

In spite of decrease in prevalence, yet tuberculosis is not rare disease in Korea and the morbidity is over one percent. Because extrapulmonary tuberculosis is less common than that of lung, quick and accurate diagnosis is not easy and there may be some problems in selecting the methods and the times to treat it. Especially, each or combination of abdominal lymphadenitis and duodenal tuberculosis are so rare that differential diagnosis from other common or rare diseases is difficult, and much attention is required to diagnose and treat those. Recently we experienced a case of tuberculous lymphadenitis accompanied by duodenal bulbar tuberculosis which had been conceived as submucosal tumor at endoscopy and diagnosed by explorative operation. So we report this case with review of related literatures.

A Case of Carcinoid Tumor of the Rectum / 대한소화기내시경학회지

Carcinoid tumor primarily affects the intestinal tract, which arise from the Kulchitsky cells found at the base of the crypts of Lieberk hn. Rectal carcinoids are relatively uncommon lesions, representing only 1.3 percent of all rectal tumors. Rectal carcinoids have benign course and are usually asymptomatic. While their prognosis is generally favorable, it is known that about 15% of these tumors metastasize. Rectal carcinoid tumors should be treated appropriately and aggressively when indicated. Present-day treatment programs call for radical cancer resection only for lesions larger than 2 cm in diameter and local resection for all others. We have experienced a case of carcinoid tumor of the rectum treated by endoscopic polypectomy.