A Malignant Tumor in the Calf Muscles Misdiagnosed as a Myofascial Trigger Point

Tumors are rare causes of calf pain and usually present insidiously. A 69-year-old woman developed sudden severe pain and a hard palpable mass in her left calf that persisted for 6 months without a history of trauma. Although a myofascial trigger point was initially suspected, subsequent ultrasonography revealed two well-defined heterogeneous masses in the calf muscle. Magnetic resonance imaging revealed a multi-lobulated mass involving the soleus, tibialis posterior muscle, and deep peroneal neurovascular bundle, suggesting a soft tissue sarcoma. Fluorine-18-fluorodeoxyglucose positron emission tomography revealed a heterogeneous hypermetabolic lesion in the left calf, suggesting malignancy. The patient received an incisional biopsy of her left calf lesion and was diagnosed with leiomyosarcoma. The patient underwent a wide excision with partial fibulectomy of the left calf and received chemotherapy for metastasis in the left upper lobe of the lung. Although rare, soft tissue sarcoma should be considered in the differential diagnosis if calf pain and a palpable mass persist despite conservative management, and imaging studies are essential for distinguishing tumors from other causes of calf pain.

Comparison of Coronary Plaque and Stenosis Between Coronary Computed Tomography Angiography and Virtual Histology-Intravascular Ultrasound in Asymptomatic Patients with Risk Factors for Coronary Artery Disease

OBJECTIVES: The purpose of the study was to compare plaque characteristics by coronary computed tomography angiography (CCTA) with those by virtual histology-intravascular ultrasound (VH-IVUS). METHODS: We enrolled 50 asymptomatic patients with diabetes mellitus or more than two risk factors for coronary artery disease such as hypertension, smoking, and hyperlipidemia. If the patient had a coronary lesion (plaque with more than 50% stenosis or calcium score more than 100), we recommended coronary angiography and VH-IVUS and compared CCTA findings with VH-IVUS findings. RESULTS: 35 patients (70%) had coronary lesions, and we performed both CCTA and VH-IVUS in 23 patients. All 23 patients had multiple risk factors, and the majority of target lesions were located at left anterior descending artery (73.9%), and calcium score of lesion site was 106+/-162 with plaque volume of 232+/-153 mm3 by CCTA. Calcium score of lesion site was significantly greater in diabetic patients (n=14) than non-diabetic patients (n=9) (118+/-159 vs. 88+/-175, p=0.038). By VH-IVUS, plaque volume was 174+/-127 mm3, absolute necrotic core (NC) volume was 22+/-21 mm3, and relative NC volume was 20.8+/-8.7%. Absolute dense calcium (DC) volume and absolute NC volumes were significantly greater in diabetic patients than non-diabetic patients (11.5+/-13.8 mm3 vs. 9.1+/-11.0 mm3, p=0.028, and 23.9+/-24.7 mm3 vs. 18.1+/-14.3 mm3, p=0.035, respectively). Plaque volume by CCTA correlated with that of VH-IVUS (r=0.742, p<0.001), and plaque volume by CCTA correlated with absolute NC volume by VH-IVUS (r=0.621, p<0.001), and calcium score of lesion site by CCTA correlated with absolute dense calcium volume by VH-IVUS (r=0.478, p=0.028). CONCLUSION: Coronary lesion was detected by CCTA in 70% of asymptomatic patients with multiple coronary risk factors, and parameters detected by CCTA correlated well with those detected by VH-IVUS.

The Role of One-Year Endoscopic Follow-Up for the Esophageal Remnant and Gastric Conduit after Esophagectomy with Gastric Reconstruction for Esophageal Squamous Cell Carcinoma

PURPOSE: After esophagectomy and gastric reconstruction for esophageal cancer, patients suffer from various symptoms that can detract from quality of life. Endoscopy is a useful diagnostic tool for evaluating patients after esophagectomy. This observational study was performed to investigate the correlation between symptoms and endoscopic findings one year after esophageal surgery and to assess the clinical usefulness of one-year endoscopic follow-up. MATERIALS AND METHODS: From 2001 to 2008, 162 patients who underwent esophagectomy with gastric reconstruction were endoscopically examined one year after operation. RESULTS: Patients suffered from the following symptoms: nocturnal cough (n=10), regurgitation (n=7), cervical heartburn (n=3), lump sensation (n=2), dysphagia (n=20) and odynophagia (n=22). Eighty-five (52.5%) patients had abnormal findings on endoscopic examination. Twelve (7.4%) patients had reflux esophagitis, and 37 (22.8%) patients had an anastomotic stricture. Only stricture-related symptoms were correlated with the finding of anastomotic strictures (p<0.001). Two patients had recurrences at the anastomotic sites, and four patients had regional lymph node recurrences with gastric conduit invasion visualized by endoscopy. Newly-developed malignancies in the esophageal remnant or hypopharynx that were not detected by clinical symptoms and imaging studies were reported in two patients. CONCLUSION: One year after esophagectomy, endoscopic findings were not correlated with clinical symptoms, except those related to stricture. Routine endoscopic follow-up is a useful tool for identifying latent functional and oncological lesions.

Treatment with High Dose Dexamethasone of Severe Thrombocytopenia in Primary Sjogren's Syndrome

Sjogren's syndrome is a systemic autoimmune disease characterized by sicca symptoms and B lymphocyte hyperactivity. Hematological abnormalities are common in Sjogren's syndrome, including anemia, leukopenia, thrombocytopenia, and lymphoproliferative disorders. These hematologic involvements are mostly recognized as mild laboratory abnormalities. Life-threatening, severe thrombocytopenia is very rare. We describe a patient with primary Sjogren's syndrome, who developed very severe thrombocytopenia during the clinical course and successfully treated with high dose dexamethasone therapy.

A Case of Invasive Pulmonary Aspergillosis in a Patient with Rheumatoid Arthritis Treated with Adalimumab

We describe a fatal case of invasive pulmonary aspergillosis in a patient with rheumatoid arthritis receiving the TNF-alpha inhibitor, adalimumab. The use of TNF-alpha inhibitor has been associated with an increased risk of infections, including tuberculosis and other opportunistic infections. Physicians should have a high index of suspicion for opportunistic infection that can develop during TNF-alpha inhibitor treatment.

Clinical Characteristics of Malignant Pericardial Effusion Associated with Recurrence and Survival / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: We evaluated clinical outcomes after drainage for malignant pericardial effusion with imminent or overt tamponade. MATERIALS AND METHODS: Between August 2001 and June 2007, 100 patients underwent pericardiocentesis for malignant pericardial effusion. Adequate follow-up information on the recurrence of pericardial effusion and survival status was available for 98 patients. RESULTS: Recurrence of effusion occurred in 30 patients (31%), all of whom were diagnosed with adenocarcinoma. Multivariate analysis indicated that adenocarcinoma of the lung (hazard ratio [HR], 6.6; 95% confidence interval [CI], 1.9 to 22.3; p=0.003) and progressive disease despite chemotherapy (HR, 4.3; 95% CI, 1.6 to 12.0; p=0.005) were independent predictors of recurrence. Survival rates three months after pericardiocentesis differed significantly with the type of primary cancer; the rates were 73%, 18%, 90% and 30% in patients with adenocarcinoma of the lung, squamous cell carcinoma of the lung, breast cancer and other cancers, respectively. CONCLUSION: Recurrence and survival of patients with malignant pericardial effusion are dependent on the type of primary cancer and response to chemotherapy. Patients with adenocarcinoma of the lung may be good candidates for surgical drainage to avoid repeated pericardiocentesis, but pericardiocentesis is considered effective as palliative management in patients with other cancers.

Pleural Incarceration of the Transverse Colon after Transthoracic Esophagectomy: A case report / 대한흉부외과학회지

A 65 year-old man, who underwent transthoracic esophagectomy for mid-thoracic esophageal squamous cell carcinoma, suffered from an incarcerated herniation of the transverse colon through a defect in the left mediastinal pleura. The patient had a gas collection in the left lower lung field and this then insidiously progressed; the final result was total collapse of the left lung and hemodynamic compromise. The life-threatening herniation of the transverse colon into the pleural cavity after pervious esophagectomy was corrected by emergency laparotomy. Postoperative pulmonary complications after esophagectomy can induce potentially lethal transhiatal herniation because of the danger of intestinal obstruction or strangulation. The optimal approach to transhiatal herniation after esophagectomy is prevention.

Evaluation of Antidepressant Drug Effect in a Depressive Animal Model by Proton MR Spectroscopy / 의학물리

In this study, we observed the alteration of choline signal intensity in hippocampus region of the depressive rat model induced by forced swimming test (FST). The purpose of this study was to evaluate the antidepressant efficacy in the depressive animal model using MR spectroscopy. Fourteen experimentally naive male Sprague-Dawley rats weighting 160~180 g were used as subjects. Drug injection group was exposed to the FST except for control group. The drugs were administered subcutaneously (SC) in a volume equivalent to 2 ml/kg. And three injections were administered 23, 5, and 1 h before beginning the given test. 1H MR spectra were obtained with use of a point resolved spectroscopy (PRESS) localization sequence performed according to the following parameters: repetition time, 2500 ms; echo time, 144 ms; 512 average; 2048 complex data points; voxel dimensions, 1.5x2.5x2.5 mm3; acquisition time, 25 min. There were no differences in NAA/Cr and Cho/Cr ratio between the right and the left hippocampus both normal control rats and antidepressant-injected rats. Also, no differences were observed in NAA/Cr and Cho/Cr ratio between the normal control rats and the antidepressant-injected rats both the right and the left hippocampus. In this study, we found the recovery of choline signals in the depressive animal model similar to normal control groups as injecting desipramine-HCl which was antidepressant causing anti-immobility effects. Thus, we demonstrated that MR spectroscopy was able to aid in evaluating the antidepressant effect of desipramine-HCl.

Compliance with Adjuvant Chemotherapy for Completely Resected Non-small Cell Lung Cancer

PURPOSE : To evaluate the compliance of patients who underwent complete resection of non-small cell lung cancer (NSCLC) with adjuvant chemotherapy. MATERIALS AND METHODS : Between January 2004 and May 2006, patients who underwent a complete resection for NSCLC were referred to oncologists for adjuvant chemotherapy. Three or 4 cycles of platinum-based adjuvant chemotherapy was then performed according to the protocol or the preference of the oncologists. RESULTS : Two hundred and thirty-two patients were enrolled in this study. The median age of the study group was 60.9 years and 76.7 % of the patients enrolled were male. 34.9%, 28.8% and 36.2% of the patients were in stage IB, II and III respectively. In addition, 142 of the patients (61.2%) completed all planned cycles, whereas 65 patients (28%) received no therapy. The causes of start failure for adjuvant chemotherapy consisted of decreased postoperative performance status (n=39), refusal (n=13) and distant metastasis at the initial follow-up (n=2). The causes of cessation during adjuvant chemotherapy included the occurrence of severe adverse effects (n=12), aggravation of the disease with newly developed metastasis (n=4) and others (n=6). The mortality related to the adjuvant chemotherapy was 1.3 % (n=3), all of the fatalities were due to pneumonia and sepsis. Univariate analysis showed that age, postoperative complications and pathologic staging were the significant factors that determined whether the adjuvant chemotherapy was completed. Multivariate analysis demonstrated statistically significant differences in compliance when age and pathologic staging were considered. CONCLUSION : Adjuvant chemotherapy for completely resected NSCLC was performed with satisfactory compliance in approximately 60% of the patients included in this study, and age plays an important role in the compliance of adjuvant chemotherapy. Elderly subsets will be examined to help determine the effect of age on compliance and outcome. In addition, the medical oncologist tended to complete the adjuvant chemotherapy for more advanced cases of lung cancer than for stage IB lung cancer

Conservative Treatment with Octreotide as an Adjunct for Chylothorax after Lung Cancer Surgery: Two Cases / 대한흉부외과학회지

Postoperative chylothorax is a rare but serious complication of thoracic surgical procedures. We report two cases of chylothorax after lobectomy and mediastinal lymph node dissection for lung cancer. The patients were successfully treated with subcutaneous octreotide injection as an adjunct to conservative treatment.

A Parkinsonism as a Component of Sylvian Aqueduct Syndrome: Effect of Floating Cranioplasty and Distal Catheter Elongation

The sylvian aqueduct syndrome is a global rostral midbrain dysfunction induced by a transtentorial pressure gradient through the aquaeductus. Several months after ventriculoperitoneal shunt, a patient with hydrocephalus began experiencing a constellation of midbrain dysfunction symptoms, including bradykinesia, medial longitudinal fasciculus syndrome, third nerve palsy, and mutism. These were indicative of cerebral aqueduct syndrome. In addition, the patient showed posture-dependent underdrainage or overdrainage. All symptoms were resolved after distal catheter elongation and floating cranioplasty. We present a case of reversible parkinsonism, which developed in a patient with shunted hydrocephalus and aqueductal stenosis, and discuss the diagnosis and treatment of the sylvian aqueduct syndrome. We also review the literature to address problems of drainage and potential treatment modalities.

Occipital Intradiploic Epidermoid Cyst with Intracranial Hypertension

Intradiploic epidermoid cysts of the cranium are rare, benign and slow growing lesion. However, these cysts may cause neurologic deficits due to mass effect. Intradiploic epidermoid cysts are thought to be derived from persistent ectodermal remnants present in the cranial bones during embryogenic development. Here, we report a case of an occipital intradiploic epidermoid cyst with posterior fossa extension. The patient developed intracranial hypertension associated with hydrocephalus due to aqueductal stenosis, and venous congestion secondary to compression of the torcular and the transverse sinus. The imaging studies included a computerized tomography(CT) venogram, which is essential for determining the pathophysiological mechanism of the clinical spectrum and for surgical planning. Near total removal was accomplished and the postoperative course was uneventful. Postoperative imaging studies demonstrated a reversal of the neural structures, but no patency of the sinus, which was presumably indicative of prolonged sinus stenosis. The patient gradually improved and was discharged free of symptoms.

Esophagectomy for Esophageal Cancer in Elderly Patients Over 70 Years of Age / 대한흉부외과학회지

BACKGROUND: Advanced age in Esophagectomy increases the risk of postoperative morbidity and mortality. However, the recent development of operative technique and perioperative care might have decreased the postoperative morbidity and mortality after esophagectomy. MATERIAL NAD METHOD: From March 2001 to July 2004, 174 patients underwent esophageal resection for esophageal cancer in the Center for Lung Cancer, National Cancer Center. The patients were divided into two groups : group 1 consisted of 27 patients aged 70 years or more, and group 2 consisted of 147 patients under 70 years of age. The two groups were compared according to preoperative risk factors, postoperative morbidity, operative mortality and survival. RESULT: The mean age was 63.4. There were 159 men. On histopathological examination, 93.1% had squamous cell carcinoma. On the locations, 78.7% were in mid and lower esophagus. Curative resections for esophageal cancer were possible in 162 (93.1%) patients. Mean hospital stay was 19.4 days with out difference between the groups. The overall postoperative morbidity were occurred in 61 patients (35.1%). The most frequent morbidity was pulmonary complication in 30 (17.2%). Preoperative incidence of hypertension, cardiac and pulmonary dysfunction were more common in Group I. However, there was no difference in overall postoperative morbidity, operative mortality and survival rate between the two groups. CONCLUSION: Esophagectomy for esophageal cancer could be carried out safely in patients over 70 years of age with satisfactory short-term results. Advanced age is no longer a risk factor for esophagectomy.

Effect of Postoperative Pulmonary Morbidities on the Survival in Patients with Non-small Cell Lung Cancer

PURPOSE: The purpose of this study was to identify the effect postoperative pulmonary complications (PPCs) in patients with non-small cell lung cancer undergoing pulmonary resection on survival. MATERIALS AND METHODS: The study involved a retrospective review of 635 patients over a 4-year period who had undergone curative lung resection for non-small cell lung cancer. The patient group included 504 (79.4%) males, and the overall mean age was 61.3 years. Patients were classified as those who had experienced PPCs (PPCs group, n=105, 16.5% of all patients) or those who had not (no PPCs group, n=530 patients). RESULTS: The surgical procedures performed were 101 (15.9%) pneumonectomies, 505 (79.5%) lobectomies and 29 (4.6%) lesser resections. Cancer types comprised 330 (52.0%) squamous cell carcinomas, 255 (40.2%) adenocarcinomas and 50 (7.8%) others. Overall survival 3 years after surgery was 68.2% in the no PPCs group and 38.8% in the PPCs group (p<0.0001). Regardless of tumor staging, overall survival differed significantly between the PPCs and no PPCs groups, while disese-free survival did not. Seventy-six patients (14.9%) in the no PPCs group and 24 patients (27.3%) in the PPCs group died during the follow up period. The primary cause of death was the recurrence of the primary lung cancer in both groups (68 patients in the no PPCs and 14 in the PPCs). The second most frequent cause of deaths was respiratory failure in the PPCs group (9 patients : 10.2%). Respiratory failure was less observed in the no PPCs group. In contrast, the incidence of respiratory failure leading to death constantly increased in the PPCs group. CONCLUSION: Patients who had postoperative pulmonary complications have taken the risk of poor survival. We emphasize on the fact that patients who experienced postoperative pulmonary complications need careful and frequent shortterm follow-up to improve overall survival

Inhibitory Effects of Toxoplasma Antigen on Proliferation and Invasion of Human Glioma Cells

OBJECTIVE: Currently available therapies for human malignant gliomas have limited efficacy. Toxoplasma gondii, an obligate intracellular protozoan parasite, and Quil-A are nonspecific, potent immune stimulants. T. gondii is shown to have antitumor activity in some types of cancers. Therefore, this study is undertaken to evaluate the antitumor effect of Toxoplasma lysate antigen (TLA), alone or in combination with Quil-A, on human glioma U373MG and U87MG cells. METHODS: The in vitro effects of TLA alone or in combination with Quil-A on the proliferation, invasion, and apoptosis of glioma cells were tested using MTT, Matrigel invasion, and DNA fragmentation assays, and the in vivo effects on the growth of gliomas were evaluated in athymic nude mice transplanted with glioma cells. RESULTS: Treatment with TLA resulted in the suppressed proliferation and invasion of both U373MG and U87MG cells, in a dose-dependent manner. In addition, at high concentration, TLA induced glioma cell apoptosis. When TLA was administered in the mouse glioma model, malignant glioma growth was decreased. The combined treatment of TLA with Quil-A significantly inhibited the proliferation and invasion of cultured cells as well as tumor mass of implanted mice. CONCLUSION: TLA inhibits the proliferation and invasion of glioma cells in vitro and in vivo, and these antitumor effects of TLA are significantly enhanced by the addition of Quil-A.

Modulation of Cytotoxicity by Nitric Oxide Donors during Treatment of Glioma with Anticancer Drugs

OBJECTIVE: Nitric oxide(NO) is implicated in a wide range of biological processes in tumors and is produced in glioma. To investigate the role of NO and its interaction with the tumoricidal effects of anticancer drugs, we study the antitumor activities of NO donors, with or without anticancer drugs, in human glioma cell lines. METHODS: U87MG and U373MG cells were treated with the NO donors sodium nitroprusside(SNP) and S-nitroso-N-acetylpenicillamine(SNAP), alone or in combination with the anticancer drugs 1, 3-bis(2-chloroethyl)-1-nitrosourea(BCNU) and cisplatin. Cell viability, cell proliferation, DNA fragmentation, nitrite level, and the expression of Bcl-2 and Bax were determined. RESULTS: NO was markedly increased after treatment with SNP or SNAP; however, the addition of the anticancer drugs did not significantly affect NO production. NO donors or anticancer drugs reduced glioma cell viability and, in combination, acted synergistically to further decrease cell viability in a dose- and time-dependent manner. Cell proliferation was inhibited and apoptosis were enhanced by combined treatment. Bax expression was increased by combined treatment, whereas Bcl-2 expression was reduced. The antitumor cytotoxicity of NO donors and anticancer drugs differed according to cell type. CONCLUSION: BCNU or cisplatin can inhibit cell viability and proliferation of glioma cells and can induce apoptosis. These effects are further enhanced by the addition of a NO donor which modulates the antitumor cytotoxicity of chemotherapy depending on cell type. Further biological, chemical, and toxicological studies of NO are required to clarify its mechanism of action in glioma.

A Case of Harlequin Ichthyosis / 대한주산의학회잡지

Harlequin ichthyosis, which is one of lamellar ichthyosis, is a severe and fatal congenital keratinization disorder with autosomal recessive inheritance. The cause of this disorder is not clear but related to transglutaminase-1 gene mutation. It is characterized by an extremely thickened keratin layer of skin, flattened ears and diffuse platelike scales. Pathologic findings include prominent hyperkeratosis and severe acanthosis. Prenatal sonographic diagnosis has been described, with findings of a persistantly open mouth, echogenic amnionic fluid and fixed flexion of the extremities. We experienced a case of Harlequin infant who showed typical clinical and pathologic findings but non-specific antenatal studies performed in other hospital. We report the case of Harlequin ichthyosis with a brief review of the literature.

A Clinical Analysis of Anaplastic Oligodendroglioma

OBJECTIVE: The author evaluate the efficacy of surgery, radiation therapy and chemotherapy as a treatment methods for anaplastic oligodendroglioma patients to provide the standardized treatment option. METHODS: A retrospective analysis of ten pathologically proven cases of anaplastic oligodendroglioma was performed. RESULTS: The ten patients comprised four males and six females. The mean age at diagnosis was 34.4 year (8-70). The mean follow-up was 40.5 months, and two patients died of tumor progression during the follow-up (70, 86 months, respectively). All patients had craniotomy and the tumors were removed as much as possible. The tumos were resected totally in five cases, only subtotally in the rest. Radiation therapy was applied to seven patients, and PCV (procarbazine-CCNU-vincristine) based chemotherapeutic agent was administered to five patients. In the group with PCV therapy, complete remission was observed in two, partial remission was in one, stable disease in one, and disease progression in one who were died of tumor extension. During the follow-up, tumor recurrences were observed in four patients, and they were treated with additional operation and/or chemotherapy. CONCLUSION: Anaplastic oligodendrogliomas respond to the surgical and radiological treatment and especially to the chemotherapy, and have a relatively good prognosis. PCV is an effective and safe regimen for suppressing tumor growth, and is feasible for recurrent cases. PCV chemotherapy should be considered for primary treatment method for anaplastic oligodendroglioma patients.

A Case of Endometrioid Stromal Sarcoma of ovary / 대한산부인과학회잡지

Endometrioid stromal sarcoma of ovary is so rare that it has been reported 45 cases in the world. Endometrioid stromal sarcoma of ovary is concomitant with endometriosis at 40%, with same tumor in uterus at 30%. The age of pateint is between 11 and 76, half of them are fifties and sixties. Most frequent presenting symptom is abdominal distension and abdominal pain. Surgery, chemotherapy, radiotherapy, progesterone was helpful, but any management do not result in conclusion because of rarity of cases. Clinical course is indolent because lesion is well-differentiated and grows slowly, so only cytoreductive surgery will be effective. Progesterone may be effective in residual or recurrent low-grade endometrioid stromal sarcoma of ovary. If endometriotic tissue is origin of tumor, estrogen play a role in malignant transformation. We had experienced a case of endometrioid stromal sarcoma of ovary of 42 years old woman. We managed by TAH and BSO, radiotherapy, progesterone therapy. Until now no recurrence was found for 15 months. So, we report this case with review of the literature.

Clinical Experience with the Programmable Valve for Hydrocephalus Patients

OBJECTIVE: The goal of this study is to establish the value of the programmable valve system. METHODS: The authors conducted a single center retrospective study of 41 consecutive patients who had undergone ventriculoperitoneal shunt with programmable valve for hydrocephalus of various etiology from March 1999 to February 2002. RESULTS: In 10 patients(24%), valve pressure adjustment was required at least 3 times or more for the reason of underdrainage or overdrainage. The range of pressure reprogramming was 10 to 120mmH2O. The clinical symptoms improved in 37 patients(90%). The radiologic improvement was obtained in 88%. Shunt was minimally functioning in 3 cases without any clinical effect at the pressure of 30mmH2O. CONCLUSION: The programmable valve has been particularly useful in changing ventricular size for the correction of overdrainage or underdranage by the easy control of valve pressure without any invasive procedure. The authors' preference is to use the programmable valve system for all conditions.