Makoto Miyakawa

Study of intraglandular dissemination of thyroid cancer

Pathohistologic studies were carried out for 186 nodules in 171 cases of thyroid cancer treated in the surgical clinic during the last 14 years. No definite relationship was found between the intraglandular dissemination and the size of cancer nodules. In the relationship between the intraglandular dissemination and histologic type of cancer, frequency of the intraglandular dissemination is definitely low in papillary adenocarcinoma. In the relationship between the intraglandular dissemination and the degree of histologic extension, advance in extension is accompanied by the increasing of the frequency of the intraglandular dissemination. In the cases with positive lymph node metastasis, the frequency of the intraglandular dissemination was higher than in the cases with negative metastasis. The intraglandular dissemination was definitely more frequent in the cases with recurrence or multiple occurrence than in the cases with single occurrence without recurrence. Based on these facts, recurrence is probably due to leaving the disseminated lesions in the remaining tissue, and the cases of multiple occurrence develop as die result of the growth of the intraglandular dissemination.

Malignant tumor, of the gastrointestinal stromal tumor type, in the greater omentum.

We report herein a rare case of gastrointestinal stromal tumor (GIST) type, arising from the greater omentum. A 65-year-old man who had a large abdominal tumor was referred to our hospital. Ultrasonography (US) and computed tomography (CT) scans showed a mass occupying almost the entire abdomen anterior to the bowel loops. Abdominal angiography showed that the main feeding artery of the tumor was the right gastroepiploic artery. The preoperative diagnosis was suspected gastric leiomyosarcoma. Laparotomy revealed a large mass arising from the greater omentum, and the tumor seemed to be completely excised. Histopathological and immunohistochemical studies indicated the tumor had the same characteristics as GIST. Twelve months after the operation, the tumor recurred in the peritoneal cavity at the site of the stomach, and was associated with multiple liver metastases. The patient died of hypovolemic shock. Necropsy revealed that rupture of one of the metastatic liver tumors had resulted in a massive intraperitoneal hemorrhage.

Surgical management of left main coronary artery aneurysm

To date only 7 patients with left main coronary artery aneurysm associated with atherosclerosis have undergone surgical treatment. This report reviews a case of atherosclerotic aneurysm of the left main coronary artery with concurrent stenotic coronary artery disease that was successfully treated by direct approach to the left main coronary artery aneurysm and establishment of coronary artery bypass grafts.

Primary squamous cell carcinoma of the breast in a pregnant woman : report of a case

Although reports on primary squamous cell carcinoma of the breast have been increasing in number, the morbidity rate of the disease is comparatively low. Its onset in pregnant women, especially, is quite rare. We herein report a case of primary squamous cell carcinoma of the breast in a pregnant woman. A 33-year-old woman was admitted with a lump in the right breast and an abnormal bloody nipple discharge. The breast mass was 5.6×5.4 cm in size, and both ultrasonogram and CT scanning showed that it consisted of a cystic tumor for the most part. A large amount of bloody cystic fluid was aspirated by fine-needle aspiration; squamous cell carcinoma of the breast was suspected by a cytological study on the fluid. Twelve days after an induced abortion was performed, a modified radical mastectomy was carried out. Histological findings of the resected specimen demonstrated that the tumor was squamous cell carcinoma which had been well differentiated with partial keratinization and cancer pearls. Noninvasive ductal carcinoma was also observed in a very small region of the specimen, which indicated that the tumor was probably originally adenocarcinoma which later transformed into squamous cell carcinoma.

An evaluation of the intraoperative staining technique using methylene blue for the detection of hyperplastic parathyroid glands

Intraoperative staining with methylene blue was employed during parathyroid surgery on 50 glands from 13 patients, 5 with primary and 8 with secondary hyperparathyroidism. Forty-seven out of the 50 glands (94 per cent) were visualized by the staining and 2 out of the 13 patients were revealed to have supernumerary parathyroid glands. Since we started using this technique, there have been no cases of persistent hypercalcemia. The results of this study support the clinical usefulness of this staining procedure for detecting hyperplastic parathyroid glands in both primary and secondary hyperparathyroidism.

Diagnostic usefulness of201T1-chloride scintigraphy for preoperative localization of parathyroid tumors

Abstract201T1-chloride scintigraphy was performed in 10 patients with hyperparathyroidism to assess the localization of abnormal parathyroid glands. This approach proved to be useful in 8 of 10 patients. In particular, an intramediastinal ectopic gland was clearly demonstrated in one patient. Several disadvantages were noted, however,201Tl-chloride scintigraphy could be the first choice for preoperative localization of abnormal parathyroid glands. If a negative image is obtained, further examinations such as arteriography or parathyroid hormone assay by selective venous blood sampling should be done.

Myasthenia gravis with thymoma associated with occult thyroid carcinoma

We report herein a case of myasthenia gravis associated with thymoma and occult thyroid carcinoma with metastasis to a cervical lymph node, which was treated in two stages by a total thymectomy and radical dissection of the bilateral neck after a total thyroidectomy. A 48 year old woman was admitted with right blepharoptosis and hypodynamia of the proximal muscles. After various examinations, a diagnosis of myasthenia gravis was made. The association of thymoma was clarified upon CT scanning and a total thymectomy performed. However, after surgery, swelling of the cervical lymph nodes became apparent and a biopsy revealed metastasis of thyroid carcinoma in the lymph nodes. A diagnosis of occult thyroid carcinoma with metastasis to a cervical lymph node was subsequently made and a total thyroidectomy and radical dissection of the bilateral neck performed 37 days after the total thymectomy. The patients postoperative course was uneventful and for the time being, no recurrence is expected. It is considered better to perform two-stage operations for easier and safer postoperative management when myasthenia gravis associated with occult thyroid carcinoma is treated, although it depends on the development of thyroid carcinoma being occult.

Parathyroid imaging: Comparison of201Tl-99mTc subtraction scintigraphy, computed tomography and ultrasonography

From 1982 to 1985, twenty-nine patients with suspected hyperparathyroidism were examined using201Tl-99mTc subtraction scintigraphy (Tl-Tc), computed tomography (CT) and ultrasonography (US). For diagnosing neoplasm (adenoma or cancer), the sensitivities of the three procedures were 80 per cent or more, with no statistically significant differences. For diagnosing hyperplasia of the parathyroid glands, CT scan had the highest sensitivity (47 per cent). The most frequent source of error was minimally enlarged glands, weighing less than 500 mg. The second highest source of error was thyroid nodules, such as adenomatous goiter or cancer. Serum calcium and c-PTH levels were significantly higher in those with a parathyroid neoplasm than in those with hyperplasia (p<0.01, p<0.05, respectively). We concluded that hyperplasia is less easy to detect than neoplasm, and CT scan is superior to Tl-Tc or US scan for localizing hyperplasia.

Reconstruction of the carotid artery using a temporary shunt during an operation for advanced thyroid carcinoma ― A case report

A case of a patient who required reconstruction of the carotid artery during a radical operation for advanced thyroid cancer is reported herein. The patient, a 64-year-old female who had had three previous operations for thyroid cancer, underwent a two-stage operation. In the first stage, the left cervical lymphnodes were dissected, but as a large metastatic node invading the left carotid artery could not be completely removed, some carcinoma tissue was left attached to the wall of the artery. The second stage involved a temporary shunt being set up between the common carotid artery and the internal carotid artery following heparinization, after which the invaded portion was resected, and the defect patched with a saphenous vein graft. Monitoring with a Doppler flow-meter and EEG were conducted throughout the operation. At present, cancer has recurred in the left submandibular and supraclavicular regions.

Clinicopathological studies on thyroglossal duct remnant

The clinicopathological findings in 48 cases underwent complete surgical excision of epithelial tissue of the thyoglossal duct remnants were reviewed. Simple incision of the cyst does not seem to have any therapeutic value and would be followed frequently by recurrence. The widely used Sistrunk procedure2,6 surgical excision of the central portion of the hyoid bone together with fibrous tract extending to the base of tongue, seems to be not warranted in some cases so long as complete eradication of the epithelial tissue can be made.