Kazuo Mizumoto

Fluorescence navigation with indocyanine green for detecting sentinel nodes in extramammary Paget's disease and squamous cell carcinoma.

The radioisotope navigation method, which has usually been used for identification of sentinel nodes, is less useful in locating sentinel nodes close to primary lesions in cases of extramammary Pagets disease because of overlapping radioactivity from the primary site. We applied fluorescence navigation with indocyanine green (ICG) in two patients with skin cancer to cover this defect. The use of a charge‐coupled device camera enabled real‐time visualization of dynamic lymph flow without skin incision. The inguinal skin over the identified sentinel node with a handheld gamma probe was in accordance with the point detected by ICG fluorescence in a patient with squamous cell carcinoma of the foot. Sentinel node biopsy using fluorescence navigation with ICG proved to be easy and reliable.

Standing posture at work and overweight exacerbate varicose veins: Shimane CoHRE Study

Varicose veins (VV) in legs are commonly observed in the general global population. However, the prevalence of and risk factors for VV in Japan are not clear. This study aimed at clarifying the risk factors for VV in traditional rural areas of Shimane prefecture. Subjects (113 men and 205 women aged ≥45 years) were recruited from health examinations in those areas in 2012. VV were defined as a reflux of blood in the great and/or small saphenous vein and incompetent perforating veins detected by ultrasonography. Risk factors for VV were analyzed using logistic regression models that included various parameters. We also investigated the possible interaction between standing at work and overweight and calculated the synergistic index. VV were found in 20.1% of the subjects (12.4% of men and 24.4% of women). The previously known risk factors of prolonged upright standing posture during work, higher body mass index (BMI), female sex, and age were also significant factors for VV. There was a significant combined effect of overweight (BMI ≥25) and prolonged upright standing posture at work [adjusted odds ratio = 3.42; 95% confidence interval (CI), 1.07–10.89], although the synergistic effect was not significant [synergistic index = 1.3; 95% CI, 0.2–8.7]. The prevalence of VV in the traditional rural area of Shimane prefecture was comparable to that reported previously in European countries. Our results confirm that exposure to both prolonged standing at work and overweight exacerbate VV development. This finding is useful to develop strategies for VV prevention.

Case of carbamazepine-induced hypersensitivity syndrome associated with human leukocyte antigen-A*3101

modulate the l-opioid receptor making it possible to change the sensorium of pruritus. Pregabalin shows faster treatment response than gabapentin and it does not bind to plasma protein, so has the advantage of use in patients with low plasma protein and hepatic failure. Our study has several limitations. First, this was an open-label uncontrolled study and the effect of pregabalin could be attributed to a placebo effect. Second, we used pregabalin in a fixed dose of 150 mg ⁄ day. It is known that pregabalin may be used in higher doses up to 300 mg ⁄ day within 1 week based on efficacy and tolerability. Third, pregabalin also works for underlying neuropathic pain and anxiety, and so it could affect these accompanying symptoms and may lead to an overall improvement.

Successful treatment of leg ulcer caused by cryofibrinogenemia by using a systemic corticosteroid and warfarin.

Cryofibrinogenemia is a rare hematologic disorder where plasma, not serum, forms a cryoprecipitate. The cryoprecipitate consists of fibrinogen, fibrin, fibronectin, factor VIII, and smaller amounts of various plasma proteins. Cryofibrinogen precipitates at a low temperature (4 C) but, typically, redissolves on warming to 37 C. Skin manifestations observed in patients with cryofibrinogenemia are variable. Some patients are asymptomatic, while others have purpura, livedo reticularis, and more severe clinical forms such as ulceration, gangrene, and necrosis resulting from thrombosis. We report a case of severe leg ulceration caused by cryofibrinogenemia, which was successfully treated with a systemic corticosteroid and warfarin.

Usefulness of sentinel lymph node biopsy for the detection of metastasis in the early stage of extramammary Paget’s disease

BackgroundInvasive cases of extramammary Paget’s disease have a poor prognosis, owing to its rapid progression and resistance to irradiation and chemotherapy. Morton et al. introduced a technique to identify sentinel lymph nodes by local injection of vital dyes and reported its benefit for managing the progress of malignant melanoma.ObjectivesSince the rate of lymph node metastasis of extramammary Paget’s disease is not uncommon (reported from 8.5% to 26%), this study tested the hypothesis that sentinel lymph node biopsy would be useful to detect lymph node metastasis in the clinically early stage of extramammary Paget’s disease.Materials & MethodsEighteen patients with primary extramammary Paget’s disease were enrolled in the study. The precise location of sentinel lymph nodes was visualized using either intraoperative patent blue dye injection or indocyanine green dye injection in combination with a hand-held gamma-detecting probe after a 99mTc phytate injection.ResultsOf the 18 patients, sentinel lymph node metastasis was identified in 2 (Cases 2 and 15) of the 2 patients with deep invasion and in 1 (Case 12) of the 7 patients with minimal dermal invasion, however, it was absent in 9 patients who had been categorized into the intraepidermal group.ConclusionThis study demonstrates that extramammary Paget’s disease possibly causes metastasis via regional lymphatic systems to which the lesion belongs, even in the early stages of no nodule or tumor formation, and that sentinel lymph node biopsy is useful to detect lymph node metastasis.

Evaluation of the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) scoring system in elderly patients with pressure sores undergoing fasciocutaneous flap-reconstruction

The aim of the present study was to predict operative morbidity in elderly patients with deep pressure sores by using the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) scoring system. Fifteen patients over 70 years old were retrospectively reviewed who had undergone gluteus maximus fasciocutaneous flap‐reconstruction for pressure sores of the sacral region from 1 April 2005 to 31 March 2007. Complications were seen in six cases (40%) after operation. Four were wound infection, one was chest infection and another was septicemia. The subjects were divided into two groups by the presence (complicated group) or absence (non‐complicated group) of postoperative complications. Each item of physiological scores, physiological score (PS), operative severity score (OS) and predicted morbidity rate (R) were calculated and compared between two groups. As a result, hemoglobin (P = 0.0276), PS (P = 0.0023) and R (P = 0.0078) differed significantly between the two groups. It is noteworthy that the PS were over 25 in all of the complicated group, but in only one of nine in the non‐complicated group (P = 0.0014). Our study suggests that, for pressure sores in the sacral region in elderly patients, gluteus maximus fasciocutaneous flap‐reconstruction can be employed in patients whose PS are under 24 in the POSSUM scoring system.

Stage IV malignant melanoma successfully treated with OK-432 and percutaneous ethanol injection therapy after mass reduction surgery

Dear Editor, The prognosis for patients with stage IV malignant melanoma has usually been poor because of a lack of effective chemotherapy. However, immunotherapy is known to enhance survival of stage IV malignant melanoma in association with appearance of skin depigmentation or leukoderma. Autoimmunity against melanocyte differentiating antigens has been considered to underlie the skin depigmentation/leukoderma and prolonged survival. A 70-year-old man was referred to our department complaining of a painful subcutaneous tumor in the left inguinal region in January 2007. Upon consultation, a black macule was seen on the nail bed. Gallium scintigraphy showed isotope accumulation in the left inguinal, left pelvic and para-