Adrenalectomy for a solitary adrenal metastasis from lung cancer

Intrathecal sufentanil provides approximately 2 h of excellent labor analgesia with minimal motor blockade. Epidural sufentanil has received less scrutiny but may provide the same benefits as intrathecal sufentanil. In this study, we compared epidural sufentanil 40 microg after a lidocaine with an epinephrine test dose with intrathecal (i.t.) sufentanil 10 microg with respect to onset and duration of analgesia, degree of motor block, side effect profile, and mode of delivery. Seventy ASA physical status I or II parturients in early labor (< or = 4 cm cervical dilation) were randomized to receive either i.t. sufentanil 10 microg with a combined spinal-epidural technique (CSE) or epidural sufentanil 40 microg (e.p.) after epidural catheter placement and testing with 3 mL of 1.5% lidocaine with epinephrine (15 microg). After the administration of analgesia, pain scores and side effects were recorded for each patient at 5, 10, 15, 20, and 30 min, and every 30 min thereafter, by an observer blinded to the technique used. The study period was completed when the patients requested additional analgesia. All patients, except one, achieved adequate analgesia with the initial study dose and satisfactorily completed the study. There were no demographic differences between the two groups. Pain relief was rapid for all patients; pain scores were significantly lower at 5 and 10 min in the i.t. group versus the e.p. group. The mean duration of analgesia was similar between the e.p. group (127 +/- 40 min) and the i.t. group (110 +/- 48 min). No patient experienced any motor block. Side effects were similar between the two groups, except for pruritus-both the incidence and severity were significantly more profound at 5, 10, 15, 20, and 30 min in the i.t. group. There was no difference in time from analgesic to delivery, incidence of operative or assisted delivery, or cervical dilation at the time of redose. For early laboring patients, epidural sufentanil 40 microg after a lidocaine test dose provides analgesia comparable to that of i.t. sufentanil 10 microg with less pruritus. Implications: We compared the efficacy and side effects of intrathecal sufentanil with epidural sufentanil with a local anesthetic test dose for analgesia during labor. Analgesia was equally good, although the intrathecal group experienced more itching.     

Massive hemorrhage of the digestive system secondary to ulcerated colonic malacoplakia

The presence of an earlier latency of 12 msec of a somato-sensory evoked potential elicited by the stimulation of the median nerve at the wrist was discovered in 1963 by Liberson and Kim. They suggested its origin in the cervical spine or in the brain stem and possibly the cerebellum. Liberson, Voris and Uematsu recorded directly these potentials from the cervical spine and from the mesencephalon during surgery for pain in 1969 and published some of the findings in 1970. Cracco and Bickford confirmed in 1968 the findings of Liberson and Kim.     

Massive lower gastrointestinal haemorrhage secondary to metastatic squamous cell carcinoma of the lung

Clinically significant symptoms due to gastrointestinal metastases from primary lung cancers is rare. A case of life-threatening lower gastrointestinal haemorrhage secondary to metastatic squamous cell carcinoma of the lung is reported. Previous reports of such metastases are reviewed, with reference to management and prognosis. After resection of colonic metastases from squamous cell lung cancer, survival is similar to that for primary disease. It is suggested that patients with known or suspected squamous cell lung cancer presenting with lower gastrointestinal symptoms be managed as aggressively as those with no previous history of disease.     

Peripheral bone metastasis of a rare lung cancer

This article describes the case of a 54 year-old man with a rare large cell cancer of the lung who presented with a metastasis to the right hand. Radiography showed destruction of the phalanx, and histology study confirmed a metastasis of the lung cancer. Metastatic spread is discussed and compared to other metastatic diseases of the hand.     

Definitive adrenal insufficiency due to bilateral adrenal hemorrhage and primary antiphospholipid syndrome

Histologic examination of the human myocardium has been performed several days, weeks, and months after transmyocardial laser revascularization. We performed microscopic examinations 2 hours postoperatively. In addition to the patent channel (diameter, 1 mm) and a 1-to 2-mm rim of necrosis, a 1- to 3-mm zone of myofibrillary degeneration was found. This additional reversible injury immediately after transmyocardial laser revascularization could explain the higher mortality rate in patients with reduced left ventricular function.     

Skip metastasis to the mediastinal lymph nodes in non-small cell lung cancer

BACKGROUND: Whether any difference exists in clinical characteristics between resected non-small cell lung cancer with either skip or ordinary mediastinal lymph node metastases (N2 disease) needs to be clarified. METHODS: There were 110 patients with stage IIIA N2 disease. Thirty-three patients demonstrating no metastasis at the hilar nodes [skip (+) group] were compared with the other 77 patients [skip (-) group]. To investigate the extent of nodal involvement, we classified the mediastinal lymph nodes into three regions (superior, inferior, or aortic). RESULTS: There were no significant differences regarding histologic type, T status, or the site of the primary tumors between the skip (+) and the skip (-) N2 groups. In the skip (+) group, mediastinal node metastasis was found in only one region (level 1) in 30 patients (90.9%) and in two regions (level 2) in 3 (9.1%), whereas 28 patients (36.4%) from the skip (-) group revealed mediastinal metastasis at two or three regions (level 2 or 3). The overall survival rate at 5 years after operation was 35% in the skip (+) group and 12.7% in the skip (-) group (p = 0.054). This favorable clinical outcome in the skip (+) group could be explained partially by the higher proportion of patients with level 1 metastases. Furthermore, regarding patients with level 1 disease, the skip (+) group tended to have a better prognosis than the skip (-) group (p = 0.096). CONCLUSIONS: These results suggest that patients with skip mediastinal lymph node metastases represent a unique subgroup of N2 disease.     

Helical CT for secondary screening of lung cancer

Helical CT was used on a trial basis for secondary screening of lung cancer, and its clinical usefulness is discussed in this report. The subjects 157 patients with abnormal shadows on plain chest X-ray images acquired between November 1993 and August 1994. Imaging parameters used for screening CT were as follows: 50 mA, 120 kV, a couch-top movement speed of 20 mm/s, and a beam width of 10 mm. The entire lung field was scanned during a single breath-hold. Reconstructed images were generated at 10-mm intervals by the 180 degree interpolation method, and films were produced. Images of the entire lung field were made during a single breath-hold in all patients. Abnormal shadows were detected in 73 of 157 patients by screening CT. These 73 patients included 14 with lung cancer, 53 with benign lesions, one under observation, and five others. The average diameter of the tumors was 11.1 mm. The lung cancers detected all arose in the periphery, and were classified into stage I (10 paeitents), stage IIIA (3 patients), and stage IV with bone metastases (1 patient). Lung cancers in clinical stage I (3 patients) and stage IV (1 patient) were difficult to see on plain chest X-ray films. We conclude that screening CT is useful for early diagnosis of lung cancer because the entire lung field can be imaged during a single breath-hold. Therefore, helical CT can be expected to be useful in screening for lung cancer.     

Therapeutic possibilities of surgical treatment of patients with non-small-cell lung carcinoma and adrenal metastasis

Reports on successful surgical treatment of patients with non-small lung carcinoma and adrenal metastasis are infrequent. For this reason the Authors believe interesting to report a case of a patient with non-small lung cancer and single adrenal metastasis who underwent lung superior lobectomy and, after chemotherapy, adrenalectomy. A relapse was observed one year later in the lumbar region and the patient was reoperated undergoing removal of the recurrence associated to splenectomy and pancreas tail resection; thereafter the patient was treated with local radiotherapy. Forty-one months after the first operation the patient is well and disease free.     

Hyperlucent lung secondary to homocystinuria

At 23 months of age, one of a pair of monozygotic twins with radiographic unilateral hyperlucent lung was evaluated by radionuclide ventilation/perfusion pulmonary studies, which revealed a ventilation/perfusion mismatch of an entire lung. This twin died, and autopsy revealed pulmonary arterial thrombosis and histological changes compatible with homocystinuria, which was subsequently shown to be present in the surviving twin as well. A ventilation/perfusion lung scan of the surviving twin revealed multiple ventilation/perfusion mismatched defects, suggestive of pulmonary embolism. The presenting manifestation of homocystinuria in these patients was the pulmonary thrombotic disease. Neither twin had any other stigmata of homocystinuria at the time of initial presentation.     

Hydrocephalus secondary to intracranial hemorrhage in premature infants

Premature (low birth weight) infants are particularly susceptible to intracranial hemorrhage. This frequently arises from the subependymal area and may dissect into the brain or into the ventricles. If the infant survives, hydrocephalus is a frequent sequela. Because of major improvements in the care of premature infants in recent years and the proliferation of intensive care nurseries, increasing numbers of low birth weight infants are surviving and developing hydrocephalus. Seven cases are described of infants who developed hydrocephalus following intracranial bleeding. Initially, ventricular and lumbar punctures were done to attempt to control head growth but this was unsuccessful. Two were treated with temporary external ventriculostomy which did not permanently control the hydrocephalus. Definitive treatment included ventriculo-atrial shunts using an expandable 'telescopic' cardiac catheter in two and ventriculoperitoneal shunts in five. The pathogenesis and management of the condition are discussed.     

Diffuse alveolar hemorrhage secondary to oral anticoagulant use

We report a case of alveolar haemorrhage in all probability, attributable to the use of anti-vitamin K. The favourable outcome of this type of disease has rarely been reported with anticoagulants and fibrinolytics, most frequently in a disturbed haematological setting with disseminated intravascular coagulation or profound thrombocytopaenia. One should not forget this diagnosis in cases of acute respiratory failure in association with an alveolar syndrome in an exposed patient due to the fact that the outcome is generally favourable after correcting the disturbed coagulation.     

Skip mediastinal lymph node metastasis in non-small cell lung cancer

We retrospectively investigated 186 non-small cell lung cancer cases with N2 disease in order to clarify the significance of skip metastasis. Of the 186 patients with N2 disease, negative N1 nodes recognized to be skip metastasis were seen in 62 patients (33%). The incidence of skip metastasis was not statistically different regarding histology, T status, or M status. The incidence of the skip metastatic site consisted of 35 cases (56%) at sites 1, 2 and 3, while 8 cases (13%) were found at sites 8 and 9. Among the patients with right lung cancer, the skip metastatic incidence for site 7 (subcarinal) was higher in patients with either middle lobe or lower lobe cancer than in those with upper lobe cancer (P < 0.05). The 5-year survival rates of all N2 patients in comparison to those with skip metastasis were 22% and 24%, respectively. When the sites of mediastinal lymph nodes were classified as superior, aortic, and inferior, the 5-year survival rates of the patients with superior skip metastasis, aortic metastasis, and inferior metastasis were 23%, 36%, and 15%, respectively. No statistical difference was observed. The 5-year survival rate of the skip N2 patients with only aortic region involvement was 50% (n = 7). However, no statistically significant difference was found between the two groups (P = 0.08). Our results thus suggested that mediastinal involvement for the aortic region alone might have a better prognosis than the others. We thus conclude that a dissection of the complete hilar and mediastinal lymph nodes should be the procedure of choice in standard operations for non-small cell lung cancer because of the high frequency of skip metastasis.     

Direct intracerebral invasion from skull metastasis of large cell lung cancer

A 56-year-old Japanese woman was referred to us for the treatment of lung cancer. On admission, the patient showed multiple bone metastases, including the skull, without brain metastasis. During chemoradiotherapy for the primary tumor and bone metastasis involving the thoracic spine, she suffered a fatal intracerebral hemorrhage. Since the patient had no risk factors for intracerebral hemorrhage, the skull bone metastasis was thought to be responsible for this event. At autopsy, penetration of the metastatic tumor from the skull bone into the dura, with direct invasion of the brain tissue, was confirmed histologically. A hematoma also was identified at the same site adjacent to the skull bone metastasis. To our knowledge, direct tumor invasion to the brain from a skull metastasis of non-small cell lung cancer has not been previously reported.     

Massive hepatic necrosis secondary to treatment of hepatocellular carcinoma by percutaneous alcoholization

This study assesses the ability of plasma from women with pre-eclampsia to induce altered endothelial function in myometrial resistance vessels from normotensive women. Vessels from normotensive pregnant women (n = 7) were incubated with plasma from other pregnant women who were normotensive (n = 6) or had pre-eclampsia (n = 7). A wire myograph was used to test the endothelium-dependent relaxatory response to bradykinin of preconstricted vessels. The relaxation in vessels incubated with plasma from women with pre-eclampsia was markedly less than in vessels incubated with plasma from normotensive pregnant women (P = 0.039). This supports the theory that a plasma-borne factor contributes to the endothelial changes seen in pre-eclampsia.