Chronic Encapsulated Intracerebral Hematoma Associated with Cavernous Malformation

Chronic encapsulated intracerebral hematoma (CEIH) is a rare cerebrovascular disease that behaves as a slowly expanding lesion with a gradual onset. It is well established that CEIH is associated with arteriovenous malformations; however, CEIH associated with cavernous malformation (CM) is extremely rare. We herein report a case of CEIH associated with CM, and discuss its pathogenesis. A 12-year-old female was admitted to our hospital because of a one week history of progressive headache and nausea. Brain computed tomography scan and magnetic resonance imaging showed an intracerebral hematoma surrounded by edema in the right frontal lobe. One week later, her headache and nausea worsened, and a brain computed tomography scan revealed the enlargement of hematoma. A right frontal craniotomy was performed. The capsule, mass, and hematoma were totally removed. Histological examination confirmed the diagnosis of CEIH associated with CM. Immunohistochemical analysis revealed increased expression of vascular endothelial growth factor (VEGF) and the VEGF receptor-1 in the endothelium and fibroblasts. Our findings suggest that the activated VEGF pathway might have positively contributed to development of CEIH in the present patient.

IgG4-Related Intracranial Hypertrophic Pachymeningitis : A Case Report and Review of the Literature

Hypertrophic pachymeningitis is an uncommon disorder that causes a localized or diffuse thickening of the dura mater. Recently, the possibility that IgG4-related sclerosing disease may underlie some cases of intracranial hypertrophic pachymeningitis has been suggested. We herein report the tenth case of IgG4-related intracranial hypertrophic pachymeningitis and review the previous literature. A 45-year-old male presented with left-sided focal seizures with generalization. Magnetic resonance imaging (MRI) revealed a diffuse thickening and enhancement of the right convexity dura matter and falx with focal nodularity. The surgically resected specimens exhibited the proliferation of fibroblast-like spindle cells and an infiltration of mononuclear cells, including predominantly plasma cells. The ratio of IgG4-positive plasma cells to the overall IgG-positive cells was 45% in the area containing the highest infiltration of plasma cells. On the basis of the above findings, IgG4-related sclerosing disease arising from the dura mater was suspected. IgG4-related sclerosing disease should be added to the pachymeningitis spectrum.

A Case Report of a Laparoscopic Operation for a Patient with Endometrial Cancer / Journal of Rural Medicine

The purpose of this article is to describe our initial experience using laparoscopy to perform surgery for endometrial cancer. The patient was 59 years old with 2 para and was diagnosed as having a clinical endometrial adenocarcinoma in FIGO Stage Ia or Ib. Hysterectomy, bilateral salpingo-oophorectomy and lymph node sampling were performed using a laparoscopic procedure. We analyzed the problems and advantages of the procedure in this case.

A Case Report of Laparoscopic Resection of a Large Leiomyoma of the Ovary That Required an Operation Time of Seven Hours / Journal of Rural Medicine

Uterine leiomyoma is a common benign tumor. This report concerns a rare case of laparoscopic resection of a unilateral, ovarian leiomyoma requiring seven hours of surgery. A 66-year-old woman (para 2) was referred to Kochi Health Sciences Center because of a pelvic tumor. Transvaginal ultrasonographic examination revealed a pelvic tumor suspected of being a uterine leiomyoma in the cul-de-sac. Total laparoscopic hysterectomy and bilateral salpingo-oophorectomy was performed. A morcellator was used to reduce the volume of the leiomyoma. The uterus and right adnexa were removed via the vagina. When the left ovarian leiomyoma was diminished, it was also removed via the vagina.

A Case in which Laparoscopic Bilateral Salpingo-Oohorectomy was Indispensable due to Bilateral Tubo-Ovairan Abscesses in a Young Woman / Journal of Rural Medicine

Tubo-ovarian abscess (TOA) requires admission to hospital, i.v. antibiotics and, possibly, aspiration or surgery. A 35-year-old woman who was G2P1 was brought into the emergency department because of acute abdomen. A transvaginal ultrasonography demonstrated bilateral cystic adnexal tumors and a moderate amount of ascites suspected to be puss. Laparoscopic examination revealed that the left and right adnexa each formed an inflammatory mass. The left and right tubo-ovarian abscesses both formed masses, and the ovaries were indistinguishable from the tubes and other inflammatory tissues. Laparoscopic bilateral salpingo-oophorectomy was indispensable. Bacterial culture showed no bacterial growth. Performance of laparoscopic bilateral salpingo-oophorectomy was indispensable due to bilateral tubo-ovarian abscesses in this patient.

Surgical Treatment Outcomes in Patients with Stage pT1a and pT1b1 Cervical Cancer / Journal of Rural Medicine

Objective: The object of this study was to assess the outcomes of surgical treatment of stage pT1a and pT1b1 cervical cancer.Method: The medical records of 59 patients at our institution with pT1a and pT1b1 cervical cancer who underwent an operation as their primary treatment between January 1996 and September 2006 were analyzed retrospectively.Results: Ten patients underwent an operation which was less aggressive than the current operative modality at our institution. Three patients had recurrence. No patients had recurrence resulting from insufficient operations. No patients had any histologic subtype of adnexal metastasis in the resected specimens. Two of the five patients with squamous cell carcinoma and lymph node metastases at the initial operation had recurrence. Only one patient had a histologic subtype of adenosquamous carcinoma. The patient with adenosquamous carcinoma had recurrence.Conclusion: The results suggest that the surgical procedure did not affect prognosis in the cases we analyzed by surgical modalities. The current evidence suggests that a patient in an early stage can undergo less aggressive surgery than the current operative modality requires.

Retrospective Investigation of Patients with Cervical Cancer and its Prognostic Factors / Journal of Rural Medicine

Background: The purpose of this study were to investigate the survival rate of patients with cervical cancer who were treated at our institution and to analyse its prognostic factors.Methods: One hundred twenty-two patients who underwent treatment for primary cervical cancer at Kochi Municipal Hospital between January 1996 and August 2003 (7 years 8 months) were retrospectively reviewed. There were 59 patients (48.4%) with stage 0 disease. Sixty-three patients (51.6%) had stage I-IV cervical cancer. The mean age was 56.7±15.6 years, and the median follow-up period was 31 months.Results: The overall 5-year suvival rate was 96.4% and 77.1% in stage I and II, respectively. The overall 3-year survival rate was 56.3% in stage III, and the 30-month survival rate was 0% in stage IV. Among the risk factors of histologic cell type, clinical parametrial involvement, clinical vaginal involvement and pelvic lymph node metastasis, clinical parametrial involvement had the lowest p value (p=0.0717) in a multivariate Cox proportional hazards regression analysis.;;Multivariate analysis using the Cox proportional hazard regression model showed that among the risk factors of histologic cell type, clinical parametrial involvement, clinical vaginal involvement and pelvic lymph mode metastasts, the lowest p value (p=0.0717) was for clinical parametrial involvement.Conclusion: Although there was no statistical significance comparing the prognostic factors in multivariate analysis, it was presumed that clinical parametrial involvement was the most influential factor among those which were analyzed in this study on the prognosis of patients with stage I-IV cervical cancer.

Retrospective Investigation of the Patients with Endometrial Cancer / 日本農村医学会雑誌

The purpose of this study was to review the outcome and recurrence pattern of patients operated on for endometrial cancer with regard to its prognostic factors.Forty-two patients who underwent surgery for primary endometrial cancer at the Kochi Municipal Hospital from January 1996 to August 2002 (6 years 8 months) were retrospectively reviewed. The Kaplan-Meier survival plot was used to draw disease-free survival.Five of 42 patients had the events in which one patient died of the disease three months after the operation and four had recurrence. All recurrence parts were vaginal stump. Four of 32 patients who underwent pelvic lymphadenectomy had lymph node metastasis in which one patient in stage IV had a recurrence. The estimated 3-year disease-free survival rates of patients in stages I, II and III were 87.4%, 75.0% and 100%, respectively. The disease-free survival rate of patients in stage IV was 0% at 6 months.In Patients with endometrial cancer especially in stages I and II, prevention of the vaginal stump recurrence might have improved the disease-free survival.

Retrospective Study of Malignant and Borderline Malignant Ovarian Tumor Cases in Our Institution / 日本農村医学会雑誌

The purpose of this study was to examine the outcome of the patients operated on for malignant and borderline malignant ovarian tumors to search prognostic factors.<BR>A total of 26 patients who underwent surgery for malignant and borderline malignant ovarian tumors in our hospital between April 1993 to September 2000 were enrolled for this study. Medical records of the patients were reviewed.<BR>Of 26 patients, 24 patients had primary tumors. The outcomes of the patients withprimary tumors were analyzed. The average age of the patients was 60.0 years (range, 30-81). The most frequent cell type was serous tumor. After initial cytoreductive surgery, macroscopic lesions were present in 10 of the 24 patients. There were six postoperative deaths. In the 10 patients in whom tumor removal was incomplete at the firstoperation, two patients underwent a complete operation after chemotherapy. In the eight patients, macroscopic tumors remained. An estimated 5-year survival rate was 100% in stage II, 53.7% in stage III and 0% in stage IV. The patients in stages from IIto IV having the complete operation in the first or second surgery were all alive. However, the 3-year survival rate of those patients having the incomplete operation was25.0%.<BR>Our findings suggested that an increment of the rate of complete operation leads to longer survival.

Evaluation of a Surgical Instrument with Right-triangle Mounts for Diathermic Conization of the Uterine Cervix / 日本農村医学会雑誌

Evaluation of a surgical instrument with right-triangle mounts for diathermic conization of the uterine cervix.<BR>Objective: The purpose of this study was to evaluate a surgical diathermic instrument with right-triangle mounts for conization of the uterine cervix.<BR>Method: Twenty-five patients who received conization with the surgical instrument were enrolled for this study. Conization feasibility, complications, histopathologic interpretability and therapeutic outcome were assessed.<BR>Results: The mean operating time and amount of bleeding were 10.6±4.1 minutes and 6.8±9.0g, respectively.<BR>There were two cases of post-operative stenosis of the uterine cervical canal. Another two cases had positive margins in cone biopsies. Post-operative smears were postive in still another two cases.<BR>The mean follow-up period was 9.4±11.6 months.<BR>Conclusion: A surgical instrument with right-triangle mounts for diathermic conization of the uterine cervix proved to be usefull.

Evaluation of Usefulness of MRI Short Inversion Time Inversion Recovery Sequences in Routine Examination for Gynecologic Tumors: Comparison with T1- and T2- Weighted Spin Echo / 日本農村医学会雑誌

OBJECTIVE: The Short Inversion Time Inversion Recovery (STIR) is a magnetic resonance imaging (MRI) technique that minimizes fat signals and produces images different from those obtained by T1-and T2-weighted spin echo (SE). In imaging of gynecologic tumors, T1-and T2-weighted SE sequences have been routinely used. However, the usefulness of STIR in routine MRI examinations for detecting gynecologic tumors has not been reported. So we studied the STIR images in comparison with T1- and T2-weighted SE images.<BR>METHODS: One hundred twenty-one patients with uterine tumors, normal uterus and ovarian tumors who were examined with T1-and T2-weighted SE and STIR between December 1997 and October 1998 were enrolled as subjects. Results of MRI using both techniques were evaluated and images were graded CLEAR, SLIGHTLY CLEAR and UNCLEAR.<BR>RESULTS: As for boundaries between the uterus with uterine tumors, normal uterus, and the pelvic organs, CLEAR accounted for 68.7% of the images on T1- weighted SE, 42.2% on T2-weighted SE and 74.7% on STIR. There were significant differences between T2-weighted SE, and T1-weighted SE (P<.0001) and STIR (P<.0001). In identification of the inner structure of the uterine tumors, CLEAR was 6.3% on T1-weighted SE, 82.5% on T2-weighted SE and 82.5% on STIR. There was no significant difference between T2-weighted SE and STIR. In identification of the inner structure of the tumors, the cases, one is CLEAR and the other is UNCLEAR, are 7 (T2- weighted SE, CLEAR) and 6 (STIR, CLEAR) (total 13) in uterine tumors and 3 (T2- weighted SE, CLEAR) in ovarian tumors.<BR>CONCLUSION: STIR imaging should be used more in a routine MRI examination for gynecologic tumors in addition to ordinary spin echo sequences for T1-and T2- weighted images.

Serum Lactate Dehydrogenase Levels and Degenerative Patterns in Ultrasonography for Differential Diagnosis between Uterine Leiomyomas and Leiomyosarcomas / 日本農村医学会雑誌

Background: It is difficult to distinguish clinically between leiomyoma and leiomyosarcoma. The prognosis of the latter is poor. In patients with uterine leiomyosarcomas, high serum lactate dehydrogenase (LDH) levels have been reported to be elevated. However, little is known about serum LDH levels in patients with benign leiomyomas, or about the relationship between serum LDH levels and ultrasonographic findings. We therefore explored serum LDH levels and degenerative patterns of the tumor in ultrasonography (USG) in patients with various smooth muscle tumors of the uterus.<BR>Methods: Clinical history, serum LDH and alkaline phosphatase (ALP) levels, images produced by USG, and pathological findings were reviewed in 232 patients with uterine leiomyoma, three with uterine leiomyosarcoma, one with lipoleiomyoma, and one with metastasis of the breast cancer into uterine leiomyoma treated, at Kochi Nokyo General Hospital from September 1988 to August 1996. Relationship between serum LDH levels and the presence of degenerative pattern in USG or uterine weight was also analyzed.<BR>Results: Serum LDH levels were abnormally elevated preoperatively in one of 232 patients with uterine leiomyoma, two of three with leiomyosarcoma, one with lipoleiomyoma and one with metastasis of the breast cancer into uterine leiomyoma. A degenerative pattern in USG was found in 15/232 of leiomyomas, 2/3 leiomyosarcomas, 1/1 lipoleiomyoma and 1/1 metastasis of the breast cancer into uterine leiomyoma. All cases with abnormally elevated serum LDH levels showed a degenerative pattern in USG. There was a significant difference in serum LDH levels between leiomyoma with degenerative pattern in USG and without it (p=0.0320). No significant relationship was found between the weight of the uterus and serum LDH levels in patients with leiomyoma.<BR>Conclusion: The uterine tumor associated with both degenerative pattern in USG and elevated LDH levels in the patients' serum is strongly suspected to be leiomyosarcoma. The patients with presumed uterine leiomyoma should be examined for not only degenerative patterns in USG, but also serum LDH levels.