Fumikazu Takeda

A suprasellar embryonal carcinoma producing alpha-fetoprotein and human chorionic gonadotropin; treated with combined chemotherapy followed by radiotherapy

A case of primary suprasellar embryonal carcinoma that produced alpha-fetoprotein and human chorionic gonadotropin in a 12-year-old girl is reported. Partial removal of the tumor and cis-platinum-based combined chemotherapy followed by local radiotherapy resulted in a definite regression of the tumor and improvement from clinical signs and symptoms. After these treatments, the concentrations of alpha-fetoprotein and human chorionic gonadotropin in both serum and cerebrospinal fluid decreased to undetectable levels. Serum basic fetoprotein, another tumor marker, can be a tool for evaluating the clinical course following postoperative chemotherapy.

Multiple brain metastases from adenoid cystic carcinoma of the parotid gland: Case report and review of the literature

BACKGROUND Adenoid cystic carcinoma is a slow-growing malignant tumor occurring in the head and neck. Intracranial involvement usually results from direct skull invasion from adjacent primary sites. To our knowledge, this is the first reported case of multiple brain parenchymal metastases manifesting with hemorrhage. CASE DESCRIPTION A 60-year-old male experienced sudden onset of hemiparesis caused by an intracerebral hematoma in a brain metastasis from adenoid cystic carcinoma. The primary parotid tumor was treated 15 months before the appearance of the brain metastases. The hemorrhagic metastasis was resected, and cranial irradiation was performed. The brain metastasis had increased cellular atypism compared with the primary tumor. The patient remained well and free of neurologic dysfunctions until 5 months after the radiotherapy was completed; he died of systemically advanced disease 8 months after the craniotomy. CONCLUSION Hematogeneous brain metastases of adenoid cystic carcinoma are quite rare and cannot be distinguished from those of other cancers radiologically. We assume that the intratumoral hemorrhage is related to the tendency of the tumor to spread around the vessels. Although radiation therapy is not curative, it is beneficial in controlling tumor regrowth.

Simple management of cerebrospinal fluid rhinorrhea after pituitary surgery

A simple procedure for managing postoperative cerebrospinal fluid rhinorrhea after pituitary surgery is described. Under local anesthesia, a needle is introduced manually through a nostril toward the sella turcica and EDH adhesive or fibrin glue is injected into the sellar cavity or sphenoid sinus, or both. This procedure is simple and safe to perform, acceptable to the patient, and can be done in a short hospital stay.

Management of polyuria subsequent to pituitary surgery based on the diurnal pattern of urinary excretion

Polyuria subsequent to pituitary surgery was studied in 64 cases. Most cases of postoperative polyuria were due to diabetes insipidus. These cases showed a triphasic pattern in daily urinary volume. Observation of hourly urinary volume in polyuria revealed four diurnal patterns of urinary excretion: rhythmic, continuous, transient, and unspecific. Clinical observation of diurnal patterns has an advantage, in terms of simplicity of procedure, in immediately determining the nature of the polyuria, prognosticating diabetes insipidus, and eliminating inappropriate procedures in treatment. Indomethacin suppository is considered to be a favorable agent in reducing polyuria without disturbing the diurnal pattern in diabetes insipidus.

Transsphenoidal Selective Removal of the Functioning Pituitary Microadenomas

From December 1974 to October 1977, 11 transsphenoidal microsurgical operations were performed on 11 patients with functioning pituitary microadenomas. Of these patients, 6 had symptoms of hypersecretion of human growth hormone (acromegaly with or without diabetes mellitus), and the remaining 5 showed symptoms due to hypersecretion of prolactin (galactorrhea with or without amenorrhea). Preoperatively, elevated serum HGH concentration was observed in the acromegalic patients (12-86 ng/ml), and they were responsive to intravenous TRH. Elevated serum prolactin (PRL) concentration was also observed in 3. The secretional function of other anterior pituitary hormones was normal or slightly decreased. Elevated serum PRL concentration was noticed in all of the patients with galactorrhea (200-1050 ng/ml), and they were variably responsive to intravenous TRH. The other anterior pituitary hormones were normal or slightly decreased. Neuroradiological examination revealed that each adenoma was an enclosed tumor without suprasellar extension. The sella turcica was of almost normal size, but discrete bulging of the sellar wall was seen. Anteroposterior tomograms showed unilaterally depressed sellar floor, and lateral projection revealed double contour of the sellar wall. Selective gross total removal was attempted through the transsphenoidal procedure. The adenomas were found within the pituitary gland just adjacent to the discrete bulging of the sellar floor. The size of the tumor varied from 5 to 10 mm in diameter. A small cyst was found within the adenoma tissue in 2 patients with galactorrhea, who, as others, had not undergone prior therapy. Diabetes inspidus was a postoperative hazard in 4 cases. Neither operative deaths nor complications were recorded. Postoperatively, a marked decrease of serum HGH concentration below 5 ng/ml and relief of clinical symptoms was obtained in 4 acromegalic patients. In one of the other 2 patients, because of insufficient reduction of serum HGH concentration, postoperative irradiation was given, but no responsiveness was noted. In the patients with galactorrhea, the elevated serum PRL concentration was significantly reduced immediately after the operation, and there was no further lactation. During follow-up period ranging from 1 to 34 months, regular menstration was observed in 6 out of 9 female patients, biphasic basal body temperature in 2, and pregnancy in 1 patient. In the patients who underwent removal of the microprolactinoma, there was a tendency of gradual increase of serum PRL concentration, and galactorrhea recurred in 1 patient. Ethanol fixation of the tumor bed should have been undertaken during surgery.

Multicentric Gliomas: Report of Three Autopsied Cases and a Review of the Criteria of Multicentricity

Three cases out of 153 histologically verified gliomas in the Department of Neurosurgery, Gunma University, were pathologically considered as multicentric gliomas. The clinical and autopsy findings were described and the pathological criteria of multicentricity of gliomas (gliomas of multifocal origin) were discussed. 1. In Case I, a 55-year-old male, discrete tumors were observed at autopsy in the right frontal and left posterior temporal lobe, respectively. The histological diagnosis was anaplastic astrocytoma. The patient died 18 months after the onset. Surgical intervention was not performed, but irradiation was given. 2. In Case 2, a 53-year-old female, hemorrhagic-necrotic masses were found in the right parietal and occipital lobe, respectively. Histologically, both tumors were anaplastic astrocytoma. Neither operation nor irradiation was given. The patient died 5 months after the onset. 3. In Case 3, a 56-year-old male, discrete tumors were found in the splenium of the corpus callosum and the cerebellar vermis. Ventriculoperitoneal shunt was performed and irradiation was given, but the patient died 3 months after the onset. Autopsy revealed that both tumors were separately situated, and histologically were glioblastomas. 4. Though a local meningeal and ependymal invasion of each tumor existed at autopsy, there were no secondary diffuse meningeal and ependymal deposits which would suggest dissemination of the growth through cerebrospinal fluid pathways. Serial sectioning of the specimens disclosed the discontinuity between each discrete tumor. Anatomical relationship of the vascular distribution of each tumor did not support the possibility of hematogeneous spread. These findings strongly suggested the multicentricity of the gliomas, as in the cases in the literature. 5. In the available literatures are listed more than 200 cases with multicentric gliomas, including 5 cases reported in Japan. Plural neoplasms within the cranial cavity are considered to be of multifocal origin when the histology of the neoplasms is different from each other, but debatable when the histology is similar. The criteria of the multicentricity of gliomas are, at present, no more than an elimination of metastasis and extension of the growth through various possible pathways. It should be improved by the further study of still unreported cases and by accumulation of future cases.