Digestive Decolonization of Colorectal Carriage of Vancomycin-resistant Enterococcus faecium in a Japanese Adult.

Patients with vancomycin-resistant Enterococcus (VRE) colonization should be managed in an isolation room with contact precautions. We herein report a patient whose colorectal carriage of VRE was successfully decolonized using concomitant bowel irrigation with polyethylene glycol, probiotics, and oral antimicrobials, linezolid and orally-administered daptomycin, for release from isolation and contact precautions. We therefore would like to suggest a potential strategy for managing patients with VRE colonization.

Endoscopic Endonasal Transinfraturbinate Approach With Nasoseptal Window for Removal of the Pterygopalatine Fossa Tumor.

ABSTRACT: Recent advances in endoscopic intranasal technology have allowed for a safe approach to the pterygopalatine fossa lesion. However, we consider that there is still scope of improvement to approach a broader area with better operability and minimal invasiveness. A 51-year-old man underwent endoscopic endonasal surgery due to the recurrence of chordoma at the left pterygopalatine fossa. To access the lower and lateral part of the pterygopalatine fossa, we performed endoscopic endonasal transmaxillary removal via an inferior turbinate incision. During surgery, a wide operative field and good operability could be secured by inserting an endoscope from the right nostril through a window of the nasal septum. Subtotal removal of the tumor was achieved without any complication during the surgery. Endoscopic endonasal transinfraturbinate approach with nasoseptal window was effective in the removal of the pterygopalatine fossa tumor because it is less invasive and provides a good surgical view with better operability.

Medulloblastoma in Older Adults: A Case Report and Literature Review.

BACKGROUND: Medulloblastoma is a malignant tumor of the posterior fossa and is predominantly seen in children younger than 15 years of age. This tumor is uncommon in adults, especially those older than 40 years of age, and reports of cases in patients older than 60 years of age are particularly rare. Although surgery and radiotherapy play important roles in treatment of medulloblastoma in adults, addition of chemotherapy is controversial, especially prior to radiotherapy. CASE DESCRIPTION: We present a case of a 63-year-old woman with an atypical medulloblastoma in the cerebellum and a lesion in the suprasellar area that did not appear to be a metastasis of the medulloblastoma. The patient underwent a subtotal resection of the cerebellar medulloblastoma, which was classified histologically as classic subtype and molecularly as non-Wingless/non-Sonic hedgehog subtype in World Health Organization 2016 classification. Then she underwent postoperative chemotherapy followed by radiotherapy. We administered chemotherapy to facilitate therapeutic diagnosis of the suprasellar lesion. The combination treatment resulted in the disappearance of the cerebellar medulloblastoma with treatment toxicity well tolerated. Additionally, the suprasellar lesion remains under control. CONCLUSIONS: Even in adults over 60 years of age, medulloblastoma should be included in the differential diagnosis of a cerebellar mass. Chemotherapy for adult medulloblastoma has the potential to be efficacious and tolerable.

[Blister-like Aneurysm Originating from the Anterior Communicating Artery:A Case Report].

Blister-like aneurysms(BLA)are morphologically thin-walled fragile structures that are associated with a high risk of intraoperative rupture. BLAs presumably originate from an arterial dissection and often stem from a non-branching site on the supraclinoid segment of the internal carotid artery. We report a rare case of a patient who was successfully treated for a ruptured BLA originating from the anterior communicating artery(Acom). A 60-year-old woman presented with severe headache and loss of consciousness. Computed tomography(CT)showed diffuse subarachnoid hemorrhage(SAH), which was observed to be particularly dense in the interhemispheric fissure around the Acom. CT angiography and three dimensional-digital subtraction angiography(DSA)did not show any aneurysms along the Acom. Follow-up DSA performed on day 13 showed a small aneurysmal dilatation of the Acom, which was surgically treated via interhemispheric approach. Intraoperatively, a BLA observed to be originating from the Acom was wrapped with a piece of temporal fascia using fibrin glue. Postoperatively, this patient showed a good clinical course without re-rupture. Follow-up DSA performed 5 months after the occurrence of the SAH demonstrated disappearance of the BLA originating from the Acom. The findings in this patient strongly suggest that the pathomechanism of BLAs is attributable to an arterial dissection, which can often show morphological changes on short-term angiographic follow-up, and they demonstrate spontaneous repair. Thus, the therapeutic strategy to be utilized for the management of a BLA of the Acom should be carefully considered, because aneurysmal neck clipping or trapping can injure the Acom perforators and cause cognitive deficits. Further studies are needed to establish the optimal treatment strategy for the management of BLAs of the Acom.

Intratumoral gene expression of 5-fluorouracil pharmacokinetics-related enzymes in stage I and II non-small cell lung cancer patients treated with uracil-tegafur after surgery: a prospective multi-institutional study in Japan.

OBJECTIVES: This investigation was conducted to assess the use of the intratumoral mRNA expression levels of nucleic acid-metabolizing enzymes as biomarkers of adjuvant chemotherapy for non-small cell lung cancer (NSCLC) using uracil-tegafur in a multi-institutional prospective study. MATERIALS AND METHODS: 236 patients with a completely resected NSCLC (adenocarcinoma and squamous cell carcinoma) of pathological stage IA (maximum tumor diameter of 2 cm or greater), IB, and II tumors were given a dose of 250 mg of uracil-tegafur per square meter of body surface area per day orally for two years after surgery. Intratumoral mRNA levels of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), orotate phosphoribosyltransferase (OPRT), and thymidine phosphorylase (TP) genes relative to an internal standard, ß-actin, were determined using laser-capture microdissection and fluorescence-based real time PCR detection systems. RESULTS AND CONCLUSION: Among 5-FU target enzymes, TS was the only one that showed a significant difference in the level of gene expression between the high and low gene expression groups, for both disease-free survival (DFS) and overall survival (OS), when patients were divided according to median values; 5-year DFS rates in high/low TS gene expression were 60.4% and 72.6%, respectively (p=0.050), 5-year OS rates were 78.1% and 88.6%, respectively (p=0.011). Cox's proportional hazard model indicated that the pathological stage and TS gene expression level were independent values for predicting DFS. The TS gene expression level was shown to be an independent predictive factor for DFS in stage I and II NSCLC patients who were treated with uracil-tegafur following surgery.

[Choice of induction with, or standby of, extracorporeal lung assist (ECLA) in anesthetic management of bronchoscopic yttrium-aluminium-garnet (YAG) laser treatment of airway tumor].

Bronchoscopy with an yttrium-aluminium-garnet (YAG) laser is often used to resect benign and malignant airway tumors and for relief of associated airway stenosis. Complications of this procedure include airway obstruction and hemorrhage. Partial extracorporeal circulation for YAG laser resection in the airway may be helpful in minimizing these complications. Extracorporeal lung assist (ECLA) should be available for such bronchoscopic surgery, although it is not always required. We managed the general anesthesia for bronchoscopic YAG laser resection of airway tumors in two patients. The first case was a 60-year-old man with a right bronchial tumor that had invaded into the trachea across the carina. The narrowest inner diameter of the part of the trachea affected by the lesion was 3 mm. ECLA was initiated for a bronchoscopic YAG laser resection. The second case was a 74-year-old woman with a metastastic lung tumor from osteosarcoma. The narrowest inner diameter of the lesion in the right truncus intermedius was 4 mm. ECLA was kept on standby for possible complications in the bronchoscopic YAG laser resection. These treatments were completed successfully in both patients without any adverse events. ECLA is a useful supporting technique for performing bronchoscopic YAG laser treatment safely ECLA is recommended where a bronchial lesion invades the trachea and crosses the carina, and where a tracheal lesion will not allow passage of a tracheal tube under the bronchoscope. However, ECLA may be kept on standby for a airway tumor limited to one main bronchus, and for a peripheral bronchial lesion, and even for an invasive tracheal lesion through which the tracheal tube under the bronchoscope can pass. Whether it is used or kept on standby depends on the location and severity of airway compromise caused by the airway lesions.

18F-FDG-PET/CT findings in primary pulmonary mixed squamous cell and glandular papilloma.

A 55-year-old female had an abnormal shadow on chest radiograph. Computed tomography (CT) revealed a 26-mm tumor mass in the left upper lobe. No malignant findings were obtained by bronchoscopic cytology or histopathological diagnostics, but on positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) examination the maximum SUV was 9.01 in accordance with the tumor mass shadow on CT. Video-assisted thoracoscopic surgery was performed as clinically suspected of lung cancer, and the diagnosis was pulmonary mixed squamous cell and glandular papilloma (PMSGP). Primary PMSGP is extremely rare, and this is the first to describe the PET findings of this disease.

Therapeutic outcomes in thymectomied patients with myasthenia gravis.

PURPOSE: Transsternal thymectomy is well established in the treatment of myasthenia gravis (MG). The objectives of this study were to evaluate the influence and prognostic factors of thymectomy as treatment for MG. PATIENTS AND METHODS: Surgical results of 54 patients with MG who underwent transsternal thymectomy were retrospectively reviewed. We investigated clinical outcomes of extended transsternal thymectomy in MG, and we analyzed the data to clarify the effect of prognostic factors on clinical outcome. RESULTS: A total of 54 patients, including 28 males and 26 females, were analyzed. At their last visit, 5 patients (9%) were in complete remission; 36 (67%) reported clinical improvement; and 18 (33%) had no change. There were no operative or late deaths. Clinical improvement was not detected by a patient's age, sex, presence or absence of thymoma, or acetylcholine receptor (AchR) antibodies titer. Patients in which the duration of illness before operation was equal to or less than 24 months (p = 0.018), and patients in the advanced Myasthenia Gravis Foundation of America (MGFA) stage (p = 0.014), showed a greater degree of clinical improvement. CONCLUSION: Transsternal thymectomy for MG is safe and effective. Those patients with severe symptoms and a shorter duration of illness showed more benefits from thymectomy.

Expression of maspin in non-small-cell lung cancer: correlation with clinical features.

PURPOSE: Maspin is a member of the serpin (serine protease inhibitor) family and has been shown to be a suppressor of tumor growth and metastasis in several types of tumors. The objective of this study was to evaluate whether maspin is a prognostic factor in patients with non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: We investigated maspin expression in 181 patients with curatively resected NSCLC by means of immunohistochemistry. We also determined whether expression of maspin correlates with the microvessel density (MVD) level. RESULTS: The incidence of strong maspin expression in patients with squamous cell carcinoma was significantly higher than that in patients with other histology (46 of 70 [65.7%]; P < .0001). There was no significant difference between maspin expression status and MVD. Prognosis was defined as progression-free survival (PFS) and overall survival (OS). There was no difference in PFS or OS between patients with strong and weak maspin expression among all patients. However, for squamous cell carcinoma, the PFS and OS rates for patients with strong maspin expression were significantly higher than those for patients with weak maspin expression (PFS, P = .004; OS, P = .001). In multivariate analysis on squamous cell carcinoma, strong maspin expression was an independent favorable prognostic indicator (PFS, P = .03; OS, P = .01). CONCLUSION: Strong maspin expression was an independent factor in predicting a favorable prognosis in squamous cell carcinoma of lung.

Hyperthermia-enhanced tumor accumulation and antitumor efficacy of a doxorubicin-conjugate with a novel macromolecular carrier system in mice with non-small cell lung cancer.

A novel drug delivery system (DDS) compound was formed by binding doxorubicin hydrochloride (DXR) to the macromolecular carrier carboxymethyldextran polyalcohol (CM-Dex-PA) via the peptidyl spacer (GGFG: Gly-Gly-Phe-Gly). Its use in a murine tumor model confirmed that the DDS (CM-Dex-PA-GGFG-DXR) was retained in the blood and distributed in tumor tissue. The combined use of hyperthermia (HT: 41-42 degrees C for 40 min) and DXR-conjugate (5, 10 or 20 mg/kg i.v.) on tumor accumulation and efficacy was investigated in a murine model of non-small cell lung cancer. Tumor size was measured and the tumor inhibition rate (IR) was calculated. The mean tumor concentration of conjugated DXR in the DXR-conjugate group was 9.40 microg/g compared with 19.04 microg/g in the DXR-conjugate + HT group (p=0.0008). The antitumor efficacy of the DXR-conjugate was significantly enhanced in the groups receiving the combination therapy (p=0.0039, p=0.0250). Significant differences were found between the groups given DXR and those given DXR-conjugate (p=0.0492, p=0.0104). The results demonstrate that the antitumor efficacy of DXR-conjugate is significantly superior to that of DXR alone and the combined use of DXR-conjugate and HT increases the drug's concentration in the tumor, with significant enhancement of antitumor efficacy.

Clinical evaluation of chemosensitivity testing for patients with unresectable non-small cell lung cancer (NSCLC) using collagen gel droplet embedded culture drug sensitivity test (CD-DST).

PURPOSE: In the present study, we prospectively evaluated the clinical feasibility and efficacy of collagen gel droplet embedded culture drug sensitivity test (CD-DST) in unresectable non-small cell lung cancer (NSCLC) without previous treatment. EXPERIMENTAL DESIGN: Eighty patients with unresectable NSCLC, aged less than 81 years old, PS 0-1, and with evaluable tumor lesions, entered the study. If the patient had CD-DST active drugs, more than three cycles of chemotherapy containing these drugs were administered. If the patient did not have CD-DST active drugs, the patient could choose any treatment including best supportive care. RESULTS: Of the 80 patients in this study, CD-DST yielded results successfully in 49 patients (61.3%). CD-DST active drugs were present in 22 patients, and significantly more female patients had in vitro active anticancer agents than male (P=0.0008). All of the patients with CD-DST active agents received chemotherapy including these agents. In these patients, the response rate was 72.7%, and median survival was 15.0 months. In the patients without CD-DST active agents, 11 patients received standard, empirical chemotherapy. In these patients, response rate was 0%, and median survival was 6.0 months. CONCLUSIONS: The results show that CD-DST is capable of selecting the responders and the respective optimal regimens, and also delineating the patients less likely benefit from treatment.

Bcl-2 overexpression enhances in vitro sensitivity against docetaxel in non-small cell lung cancer.

Taxanes (docetaxel and paclitaxel) as well as cisplatin (CDDP) are key chemotherapeutic agents in the treatment of non-small cell lung cancer (NSCLC). Although some indicators of taxane resistance, such as beta-tubulin mutations, P-glycoprotein (P-gp) and Bcl-2, have been reported in malignant cells, the mechanisms of taxane resistance in NSCLCs have yet to be fully elucidated. We evaluated in vitro chemosensitivity to docetaxel (DOC) and CDDP in 87 surgically-resected specimens of NSCLC by collagen gel-droplet embedded culture drug sensitivity test (CD-DST). Bcl-2 and P-gp expression in these specimens were also investigated by immunohistochemistry. We examined the association between Bcl-2 and P-gp expression and in vitro chemosensitivity to DOC and CDDP. Out of the 87 NSCLCs that were examined, Bcl-2 and P-gp were expressed in 32 (36.8%) and 28 (32.2%) of the tumors, respectively. Positive Bcl-2 expression was significantly associated with enhanced DOC sensitivity in NSCLCs (p=0.007) while no apparent association was observed between DOC sensitivity and P-gp expression. Interestingly, although DOC, but not CDDP has been reported to be a substrate of P-gp, P-gp expression was significantly inversely correlated with CDDP sensitivity in pulmonary adenocarcinomas (p=0.03). Positive Bcl-2 expression may be a promising indicator in determining in vitro taxane sensitivity in NSCLCs. On the other hand, positive P-gp expression may be an indicator of enhanced in vitro resistance to CDDP in pulmonary adenocarcinomas.