Successful treatment for intractable chylous ascites in a child using a peritoneovenous shunt.

Intractable post-operative chylous ascites had been managed successfully using a peritoneovenous shunt (PVshunt). A 4-year-old girl with neuroblastoma originated from the right adrenal gland was admitted to our hospital. Following the preoperative chemotherapy, tumor resection, and lymph node dissection of the abdominal paraaortic region were carried out. Post-operative radiation therapy 9.6 gray to the tumor bed and to the paraaortic region and a high dose chemotherapy supported by auto bone marrow transplantation were completed. Three months later some enlarged lymph nodes along the duodeno-hepatic ligament were detected and these had gradually increased in size. Lymph node dissection along the hepatic artery and the abdominal aorta was carried out. Pathological examination of the specimen showed reactive lymph node swelling. Chylous ascites developed several days after surgery. Despite the medium-chain triglycerides meal or total parental nutrition, the ascites persisted for more than 80 days. Multiple paracenteses were mandatory. A PV shunt was implanted and the ascites was resolved by the fourth post-operative day. Thirty months later, the vascular end tube of the shunt was ligated. As ascites had not accumulated for 2 weeks, the PV shunt was removed. The patient has been doing well without recurrence of ascites or neuroblastoma for 12 years. As PV shunts were mostly used for long lasting disease, it has not been referred as to how to know when the shunt should be removed. If the shunt is inserted for transient management of ascites, less invasive methods of investigation to know when to remove the shunt need to be developed.

Pathophysiology and treatment of streptococcal toxic shock syndrome.

We have recently encountered three cases of streptococcal toxic shock syndrome, each of which had a different cause. All the patients had inflammation of soft tissue in the lower extremities, and developed shock and multiple organ failure immediately after the clinical visit. The inflammation of soft tissue was necrotising fasciitis in one case, myositis in one case, and phlegmon in one. In the first case the debridement was incomplete, which resulted in an extensive ulceration. Wary of repeating this experience, we made an early diagnosis and did a thorough debridement in the second case. The patient was ultimately discharged without complications. It is rare that a patient with extensive myositis survives without amputation of the extremity. The third patient responded well to early treatment with antibiotics.

Efficacy of 3D-MR mammography for breast conserving surgery after neoadjuvant chemotherapy.

BACKGROUND: One of the main roles of neoadjuvant chemotherapy for breast cancer is to shrink large tumors to increase patient eligibility for breast conserving surgery. Three dimensional MR Mammography (3D-MRM) can detect tumor extension more accurately compared with mammography and Ultrasonography (US). Therefore, the shrinkage pattern observed on 3D-MRM was analyzed with regard to several pathological factors. METHODS: A total of 27 breast cancer cases were examined by 3D-MRM before and after neoadjuvant chemotherapy. The volume reduction and shrinkage patterns were assessed and compared with the pathological diagnosis. RESULTS: There were two shrinkage patterns. Twelve of 25 evaluable breast cancers (48%) showed a concentric shrinkage pattern while 13 cases (52%) showed a dendritic shrinkage pattern. The cases with concentric shrinkage were good candidates for breast conserving surgery, But tumors showing dendritic shrinkage often had positive margins necessitating mastectomy. Pathologically, tumors with a papillotubular pattern, Estrogen receptor (ER) positivity, low nuclear grade and c-erbB 2 negativity tended to show dendritic shrinkage. CONCLUSIONS: 3D-MRM is a useful modality for evaluating whether breast conserving surgery can be safely done in the neoadjuvant setting.