Long-Term Outcome of Photodynamic Therapy with Systemic Chemotherapy Compared to Photodynamic Therapy Alone in Patients with Advanced Hilar Cholangiocarcinoma

BACKGROUND/AIMS: Patients with cholangiocarcinoma usually present at an advanced stage, and more than 50% of cases are not resectable at the time of diagnosis. Recently, photodynamic therapy (PDT) has been proposed as a palliative and neoadjuvant modality. We evaluated whether combination of PDT and chemotherapy is more effective than PDT alone. METHODS: In total, 161 patients with cholangiocarcinoma diagnosed between February 1999 and September 2009 were evaluated. Sixteen patients were treated with PDT and chemotherapy (group A), and 58 were treated with PDT (group B). RESULTS: The median survival was 538 days (95% confidence interval [CI], 475.3 to 600.7) in group A and 334 days (95% CI, 252.5 to 415.5) in group B (p=0.05). Lymph node metastasis status, serum bilirubin of pretreatment, tumor node metastasis stage, treatment method (PDT with chemotherapy vs PDT alone), time to PDT and the number of PDT sessions were prognostic factors with statistical significance in the univariate analysis. A multivariate analysis showed that PDT with chemotherapy and more than two sessions of PDT were significant independent predictors of longer survival in advanced cholangiocarcinoma (hazard ratio [HR], 2.23; 95% CI, 1.18 to 4.20; p=0.013 vs HR, 1.79; 95% CI, 1.044 to 3.083; p=0.034). CONCLUSIONS: PDT with chemotherapy results in longer survival than PDT alone.

Cytomegalovirus Jejunitis Diagnosed with Single-Balloon Enteroscopy / 대한소화기학회지

Cytomegalovirus (CMV) infections are usually diagnosed in immunocompromised patients. A 74-year-old male without any significant medical history visited our center because of abdominal pain and diarrhea which began about a month ago. Abdominal computed tomography revealed segmental enhanced bowel wall thickening on jejunum and single-balloon enteroscopy showed multiple geographic shaped ulcerations covered with exudates on proximal jejunum. Biopsy samples taken during endoscopic examination demonstrated necrotic fibrinopurulent tissue debris and benign ulcer. Nested-PCR analysis of CMV DNA from jejunal tissue was positive. The patient was finally diagnosed with CMV jejunitis and was treated by intravenous ganciclovir for 14 days after which, abdominal pain and diarrhea improved. Our case shows that CMV jejunitis can occur in an immunocompetent adult as multiple jejunal ulcers which can be diagnosed using a single-balloon enteroscope.

Hepatic Tuberculosis Granuloma Mimicking Hilar Cholangiocarcinoma Confirmed by Endoscopic Ultrasound-Guided Fine-Needle Aspiration / 대한내과학회지

Hepatic tuberculosis is usually associated with active pulmonary or miliary tuberculosis. The occurrence of an isolated hepatic mass-forming tuberculosis with no evidence of tuberculosis elsewhere is rare. We report a case of a 31-year-old male with a solitary hepatic granuloma mimicking a mass-forming intrahepatic cholangiocarcinoma. Ultrasonography, computed tomography, magnetic resonance imaging, and positron emission tomography of the abdomen showed a malignant tumor-like lesion. We then conducted endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) for confirmation of the hepatic hilar mass, which was found to be a hepatic tuberculosis granuloma as the final diagnosis.

Hepatic Tuberculosis Granuloma Mimicking Hilar Cholangiocarcinoma Confirmed by Endoscopic Ultrasound-Guided Fine-Needle Aspiration / 대한내과학회지

Hepatic tuberculosis is usually associated with active pulmonary or miliary tuberculosis. The occurrence of an isolated hepatic mass-forming tuberculosis with no evidence of tuberculosis elsewhere is rare. We report a case of a 31-year-old male with a solitary hepatic granuloma mimicking a mass-forming intrahepatic cholangiocarcinoma. Ultrasonography, computed tomography, magnetic resonance imaging, and positron emission tomography of the abdomen showed a malignant tumor-like lesion. We then conducted endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) for confirmation of the hepatic hilar mass, which was found to be a hepatic tuberculosis granuloma as the final diagnosis.

Inguinal Hernia Presenting as Scrotal Edema in Patients on Continuous Ambulatory Peritoneal Dialysis / 대한신장학회지

Scrotal edema may develop during continuous ambulatory peritoneal dialysis (CAPD). The two etiologic mechanisms are peritoneo-scrotal communication through a patent processus vaginalis or extravasation of dialysate through a defect of abdominal wall. We report two cases of scrotal edema due to inguinal hernia by peritoneo-scrotal communication during CAPD. The etiology of scrotal edema was confirmed by peritoneal scintigraphy and/or computed tomography. Scrotal edema due to inguinal hernia was completely resolved by a surgical repair of hernia and did not recur despite of resumption of peritoneal dialysis.

Clinical Features of Acute Hepatitis A in Recent Two YearsClinical Features of Acute Hepatitis A in Recent Two Years / 대한소화기학회지

BACKGROUND/AIMS: The purpose of this study was to characterize the clinical features of acute hepatitis A in Seoul and Gyeonggi province during the recent 2 years. METHODS: We reviewed the medical records of 222 patients who were diagnosed as acute hepatitis A between August 2005 and March 2007 at the Konkuk University Hospital and Korea University, Ansan Hospital. The clinical manifestation, serological tests, and image findings were analyzed. RESULTS: Median age of the patients was 28.1 years and the age groups of highest incidence were the second and third decade. The frequent symptoms were anorexia (66.4%), fatigue (49.2%), fever (47.7%), and abdominal discomfort (42.5%). Fourteen cases (6.3%) showed renal insufficiency, and hemodialysis was performed in one. Cholestatic hepatitis in 2 cases, relapsing hepatitis in 4 cases and prolonged hepatitis in 13 cases were observed. However, there was no case of fulminant hepatitis or death. The underlying diseases including chronic hepatitis B, diabetes mellitus and thyroid disorder did not affect the disease severity of hepatitis A. IgM anti-HAV was not detected initially in 6.7% of the patients. Anti-HEV (IgM) was detected simultaneously in 3 of 150 patients. CONCULSIONS: The age of patients with acute hepatitis A has been increased in the recent years. Most patients recovered uneventfully. However, unusual patterns of severe hepatitis and renal insufficiency occurred in considerable number of cases. Follow-up serologic test for IgM anti-HAV is needed in seronegative cases with hepatitis A

A Case of Tuberculosis Presented with Pseudoaneurysm of the Aorta and Acute Respiratory Distress Syndrome / 결핵및호흡기질환

We experienced a case of tuberculosis presented simultaneously with pseudoaneurysm of the aorta and ARDS. A 63-year-old man was admitted with complaints of fever and right upper quadrant abdominal pain for a week. Chest X-ray on admission showed a normal finding. Sub-diaphragmatic abscess on abdomen CT scan was suspected and serosanguinous fluid was aspirated from the abscess pocket. On day 2, he was getting more dyspneic and chest X-ray revealed extensive bilateral infiltration. Aspirated fluid revealed AFB. Later, follow-up abdomen CT scan revealed a leakage of dye from the aneurysmal sac of the descending aorta which was previously diagnosed as sub-diaphragmatic abscess. An aortic stent was placed, covering the opening into the aneurysm. The sputum also showed positive AFB. The patient was successfully weaned from the ventilator, and discharged with anti-tuberculous medication on day 42. Follow-up abdomen CT scan 6 months later showed that the aneurymal sac was completely disappeared.

A case of diffuse alveolar hemorrhage with thoracocervicofacial purpura after a generalized tonic-clonic seizure / 대한내과학회지

A 40-year-old woman presented with hemoptysis and thoracocervicofacial purpura that occurred after a generalized tonic-clonic seizure. Diffuse alveolar hemorrhage is reported relatively rarely in neurogenic pulmonary edema (NPE), which is a life-threatening postictal complication. This clinical setting causes difficulty in the diagnosis, when an accurate diagnosis and proper management are required. Thoracocervicofacial purpura has been described as an unusual setting for an epileptic seizure. Here, we report the first case of postictal diffuse alveolar hemorrhage with thoracocervicofacial purpura.

A Case of Intestinal Pseudoobstruction Associated with Systemic Sclerosis Successfully Treated with Erythromycin and Octreotide / 대한류마티스학회지

Systemic sclerosis is an autoimmune disease, characterized by inflammation, microangiopathy and fibrosis in the skin and various intestinal organs. Gastrointestinal involvement is one of the major causes of serious morbidity, and next to the skin, the gastrointestinal tract is the most commonly involved organ. While esophageal involvement is most common gastrointestinal manifestation, the involvement of the small intestine and colon is less common but may lead to life-threatening complications like chronic pesudoobstruction or pneumatosis cystoids intestinalis. Here, we describe a case of progressive systemic sclerosis associated with intestinal pseudoobstruction. 28 year-old male presented abdominal pain and vomiting and he was diagnosed as having intestinal pseudoobstruction. His symptoms were well managed using the combination of octreotide, a long-acting somatostatin analogue, and erythromycin.

A Case of Endobronchial Aspergilloma / 결핵및호흡기질환

Pulmonary aspergillosis presents as the following three different types depending on the immune status of the host: invasive aspergillosis, allergic bronchopulmonary aspergillosis (ABPA), and aspergilloma. Aspergilloma develops as a result of an aspergillus growth inside a pre-existing lung cavity. However, endobronchial aspergilloma without a lung parenchymal lesion is quite rare. We encountered a case of endobronchial aspergilloma that developed in a healthy 75 year-old woman that led to necrotizing pneumonia of the right lower lobe. The chief complaints were fever, cough and yellowish sputum. The chest film revealed haziness with cavity-like shadows on the right lower lobe, and the chest CT scan showed endobronchial calcified density in the basal bronchus of the right lower lobe with peribronchial lymph node enlargement. Bronchoscopy revealed an obstruction of the basal orifice of the right lower lobe by blackish stone-like material, and the aspergilloma was confirmed by the bronchoscopic biopsy. The pneumonia improved after bronchoscopic removal of this lesion. We report this case along with a review of the relevant literature.

A Clinical Study of Branchial Anomaly / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The branchial anomaly is a lateral neck mass commonly seen by otolaryngologists. Although somewhat controversial, almost all surgeons agree that lateral cervical cyst, fistula and sinus are of branchogenic origin. Depending on its anatomic location, branchial anomaly can be classified into first, second, third and fourth. The purpose of this study is to evaluate the clinical and pathologic manifestations of branchial anomaly and to determine proper diagnosis and treatment. MATERIALS AND METHOD: With a review of charts, we retrospectively analyzed 46 cases of the branchial anomaly who had been treated at the Hanyang University Medical Center between 1991 and 2001. Age, sex, site of lesion, classification, surgical therapy, radiologic and pathologic findings and post-operative surgical complications were reviewed. RESULTS: The second branchial cyst was the most common anomaly. Patients were commonly seen in the 3rd and 4th decades. Compared with cysts, the fistulas and sinuses were detected relatively at the younger age. Twenty five per cent of patients were presented in the infected state, and 45 cases were treated with complete surgical excision; there were no major post-operative complications and recurrence. CONCLUSION: An accurate diagnosis is crucial in the management of branchial anomaly to prevent recurrence and multiple surgical procedures. Although clinical examination and history are the most important factors suggesting the diagnosis of branchial anomaly, preoperative radiologic evaluation can be used to determine the nature and extent of the branchial anomaly. After control of acute inflammation or abscess, the complete surgical excision is crucial for a successful outcome.

Usefulness of Buccinator Myomucosal Flap for Intraoral Reconstruction / 대한이비인후과학회지

BACKGROUND: The myomucosal flap from the buccinator muscle is known to be useful for the reconstruction of intraoral defects. We used the buccinator myomucosal flap for the treatment of mild to moderate defects after intraoral tumor resection. This paper represents the versatility of the buccinator myomucosal flap for intraoral reconstruction and to introduce our clinical experience. METHODS: The flap was applied clinically in 5 patients to reconstruct intraoral defects from January, 1999 to December, 1999, with an average follow-up of 6 months. We evaluated these patients retrospectively. RESULTS: The buccinator myomucosal flap was used in the reconstruction of 5 defects of soft palate, retromolar trigone, and posterior pharyngeal wall. All flaps survived completely. There was no flap necrosis and fistula. The results were functionally and esthetically satisfactory. CONCLUSION: The buccinator myomucosal flap was used for mild to moderate intraoral defect reconstruction. It has many advantages and versatilities. It is reliable and safe. It does not require microsurgical technique, and rapid healing can be achieved due to its mucosal nature. The buccinator myomucosal flap, the only myomucosal flap that can be used for intraoral reconstruction, can be widely used.

Midline Mandibulotomy: Functional Outcomes / 대한이비인후과학회지

BACKGROUND: Although the oncologic validity and perioperative complications of midline mandibulotomy are well described, little attention has been directed toward the functional problems that may be associated with its use. METHOD: A retrospective evaluation of 14 patients who had undergone this procedure were examined to assess postoperative sensation, temporomandibular joint function, dental occlusion, and cosmesis. RESULTS: All patients had some sequelae but these were minor in nature. Nine of 14 patients had abnormal postoperative sensation, 8 of 14 patients had symptoms of TMJ abnormality, 11 of 14 patients were noted with a changed occlusion, but 71.4% patients had relatively good cosmetic outcomes. CONCLUSION: Although most sequelae are negligible and further treatment is not required, patients who have undergone midline mandibulotomy can expect to experience one or more relatively minor long-term functional sequelae. To minimize this problem, meticulous surgical repair and aggressive postoperative physical therapy are required.

The Value of Routine Frozen Section Examination for Intraoperative Diagnosis of Thyroid Nodule / 대한이비인후과학회지

BACKGROUND: The value of routine frozen section examination for intraoperative diagnosis of thyroid cancer and determination of the extent of thyroidectomy is controversial and needs to be evaluated on an institution to institution basis. METHODS: Thyroidectomy with routine frozen section examination was carried out in 109 patients with nodular thyroid disease, who also underwent FNAB. And these patients were retrospectively studied. A direct comparison of the result of FNAB and frozen section examination with permanent pathologic finding was done. RESULT: The pathologic findings showed carcinoma in 32 patients, adenomatous hyperplasia in 57 patients, adenoma in 19 patients and a Hrthle cell adenoma in one patient. The sensitivity, specificity, and accuracy were 86%, 100%, and 97%, respectively, for frozen section examination, and 76%, 100% and 93%, respectively, for FNAR (p> 0.05). CONCLUSION: For patients who have undergone adequate FNAB, frozen section examination rarely affected the intraoperative decision making in thyroid surgery and its routine use proved neither cost effective nor time saving.

Clinical Characteristics of Subacute Necrotizing Lymphadenitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Subacute necrotizing lymphadenitis or Kikuchi's disease is a self-limiting process of uncertain etiology that predominantly affects young women aged 20-30 years. Epstein-Barr virus (EBV), human herpesvirus-6 and toxoplasma have been suggested as potential etiologic agents. Even though this disease is self-limited, benign process, many cases are misidentified as malignant lymphoma. The purpose of this study is to report the clinicopathologic finding, radiologic finding and many laboratory tests and to elaborate the criteria that are useful in distinguishing this entity from lymphoma. MATERIALS AND METHODS: Authors evaluated 24 patients, who were diagnosed as subacute necrotizing lymphadenitis on excisional biopsy or fine needle aspiration cytology with retrospective chart review. RESULTS: The most common symptoms were cervical lymphadenopathy (96%), fever (76%) and cervical tenderness (72%). The most common site of the involvement of cervical lymph node were the upper, middle jugular and spinal accessary chains. The bilateral involvement of cervical lymph node was 69% and unilateral involvement was 31%. Microscopically, the characteristic finding was the wide area of florid nuclear dusts engulfed by histiocytes or distributed extracellularly and absence of polymorphonuclear leukocytes and plasma cells. CONCLUSION: This disease may be easily mistaken for malignant lymphoma clinically, pathologically, radiologically. So we should consider open biopsy of lymph node in the patients which had localized cervical adenopathy associated with fever and night sweat and all of which were unresponsive to antibiotic therapy, especially in young women.

Treatment of One Case of Elderly Manic Episode Developed after Retirement

The authers reported one case of manic episode that occured after retirement in a 63 year old male patient. There was no psychiatric past history and family history. Also there was no abnormal finding on laboratory examination. This patient had received small doses of antidepressants anxiolytic and hypnotic (amitriptyline 10 mg, lorazepam 0.5 mg, triazolam 0.25 mg) to control insomnia since 3 months ago before admission. This patient showed manic symptoms such as grandious idea, expansive and irritable mood, increased psychomotor activity and insomnia after retirement. Pharmacotherapy (lithium and chloropromazine) supportive psychotherapy and family therapy were administered. Excessive motivation for work after retirement and small dose of antidepressant were suspected to trigger a manic episode in this elderly patient. We also reviewed literatures about pathophysiology of elderly manic disorder.