Ledipasvir-Sofosbuvir for 12 Weeks in Children 3 to <6 Years Old With Chronic Hepatitis C

For children under 12 years of age who have chronic hepatitis C virus (HCV) infection, there are currently no approved treatments with direct-acting antiviral agents. We therefore evaluated the safety and efficacy of ledipasvir-sofosbuvir in HCV-infected children aged 3 to <6 years. In an open-label study, patients 3 to <6 years old chronically infected with HCV genotype 1 (n = 33) or 4 (n = 1) received weight-based doses of combined ledipasvir-sofosbuvir as granules (33.75 mg/150 mg for weights <17 kg or 45 mg/200 mg for weights ≥17 kg) for 12 weeks. The primary endpoint was sustained virological response 12 weeks after treatment (SVR12). For the first 14 patients, intensive pharmacokinetic sampling was done on day 10 of treatment. All patients had been infected through perinatal transmission and were treatment naïve. No patients had known cirrhosis. Ten patients (29%) weighed <17 kg. SVR12 was achieved in 97% of patients (33 of 34); the patient who did not achieve SVR12 was 3 years old and discontinued treatment after 5 days because of an adverse event "abnormal drug taste." The most common adverse events were vomiting (24% of patients), cough (21%), and pyrexia (21%). No patients experienced a serious adverse event. Intensive pharmacokinetic analysis of 13 patients for whom data were evaluable confirmed that the doses selected were appropriate. Conclusion: Ledipasvir-sofosbuvir was well tolerated and highly effective in children 3 to <6 years old with chronic HCV infection.

Sofosbuvir and Ribavirin Therapy for Children Aged 3 to <12 Years With Hepatitis C Virus Genotype 2 or 3 Infection

Currently, the only approved hepatitis C virus (HCV) treatment for children aged <12 years is pegylated interferon plus ribavirin. In an open-label study, we evaluated the safety and efficacy of sofosbuvir plus ribavirin for 12 weeks in children aged 3 to <12 years chronically infected with genotype 2 or for 24 weeks in patients with genotype 3. Patients aged 3 to <6 years weighing <17 kg received sofosbuvir 150 mg, and patients aged 3 to <6 years weighing ≥17 kg and all patients aged 6 to <12 years received sofosbuvir 200 mg once daily. Intensive pharmacokinetic sampling conducted in each age group confirmed the appropriateness of sofosbuvir doses. For all patients, ribavirin dosing was determined by baseline weight (up to 1,400 mg/day, two divided doses). The primary efficacy endpoint was sustained virologic response 12 weeks after therapy (SVR12). Fifty-four patients were enrolled (41 aged 6 to <12 years and 13 aged 3 to <6 years). Most were treatment naïve (98%) and infected perinatally (94%). All but one patient achieved SVR12 (53/54, 98%; 95% confidence interval, 90%-100%). The patient who did not achieve SVR12 was a 4-year-old who discontinued treatment after 3 days because of "abnormal drug taste." The most commonly reported adverse events in patients aged 6 to <12 years were vomiting (32%) and headache (29%), and those in patients aged 3 to <6 years were vomiting (46%) and diarrhea (39%). One 3-year-old patient had a serious adverse event of accidental ribavirin overdose requiring hospitalization for monitoring; this patient completed treatment and achieved SVR12. Conclusion: Sofosbuvir plus ribavirin was well tolerated and highly effective in children aged 3 to <12 years with chronic HCV genotype 2 or 3 infection.

The antiapoptotic protein, FLIP, is regulated by heterogeneous nuclear ribonucleoprotein K and correlates with poor overall survival of nasopharyngeal carcinoma patients

Heterogeneous nuclear ribonucleoprotein K (hnRNP K) mediates antiapoptotic activity in part by inducing downstream antiapoptotic genes. To systematically identify hnRNP K targets in nasopharyngeal carcinoma (NPC), affymetrix chips were used to identify genes that were both overexpressed in primary NPC and downregulated by hnRNP K knockdown in NPC-TW02 cells. The resulting gene set included the antiapoptotic gene, FLIP, which was selected for further study. In cells treated with hnRNP K siRNA, TRAIL-induced apoptosis was enhanced and the FLIP protein level was reduced. Promoter, DNA pull-down and chromatin-immunoprecipitation assays revealed that hnRNP K directly interacts with the poly(C) element on the FLIP promoter, resulting in transcriptional activation. Through iTRAQ-mass spectrometric identification of proteins differentially associated with the poly(C) element or its mutant, nucleolin was determined to be a cofactor of hnRNP K for FLIP activation. Furthermore, FLIP was highly expressed in tumor cells, and this high-level expression was significantly correlated with high-level hnRNP K expression (P=0.002) and poor overall survival (P=0.015) as examined in 67 NPC tissues. A multivariate analysis confirmed that FLIP was an independent prognostic factor for NPC. Taken together, these findings indicate that FLIP expression is transcriptionally regulated by hnRNP K and nucleolin, and may be a potential prognostic and therapeutic marker for NPC.

Recombinant arginase as a novel anti-melanoma agent

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Background: BCT-100 is a recombinant arginase comprised of 329 amino acid residues. Arginase converts arginine to urea and ornithine. Previous studies suggested that melanoma cells were auxotrophic for arginine due to absence of argininosuccinate synthetase (ASS) expression. Thus, we hypothesized that recombinant arginase, BCT-100, is cytotoxic to human melanoma cells and its cytotoxicity correlates with absence of ASS expression. Methods: BCT-100 pegylated recombinant human arginase was manufactured by large scale fermentation of a recombinant B. subtilis strain LLC101 encoded with a human arginase gene. Following fermentation, the recombinant protein was extracted, purified, pegylated, and ultra-dialyzed. Ten established human melanoma cell lines were used. Cells were grown to 90% confluence, harvested, and plated at 104 cells per well in a 96-well plate and co-cultured with increasing concentrations of pegylated BCT-100 for 72 hours. CellTiter 96 Aqueous Non-radioactive Cell Proliferation Assay (Promega, Madison, WI) was used to measure percent viability, with absorbances measured at 490 nm. Total cellular RNA was isolated from established melanoma cell lines converted to cDNA at a concentration of 5 ng/ul. Quantitative real time polymerase chain reaction was performed on a 7300 Real Time PCR System, using Gene Expression Assays for ASS and GAPDH (Applied Biosystems). 10,000 fold standard curves were generated for all samples using GAPDH expression. Results: All ten cell lines demonstrated decreased viability as concentrations of BCT-100 increased. Average IC50 value was 0.11 IU/ml. Eight of the 10 cells lines have IC50 values < 0.1 IU/ml. Of the 8 cell lines with IC50< 0.1 IU/ml, all of them have low or undetectable ASS expression using quantitative RT-PCR. Of the 2cell lines with IC50 > 0.1 IU/ml, ASS expression was detected in 1 of 2. Conclusions: Arginine depletion with recombinant arginase, BCT-100, was cytotoxic to melanoma cells in vitro. The cytotoxic effect of BCT-100 on melanoma cells correlated with expression of argininosuccinate synthetase. BCT-100 is a promising novel agent for treatment of melanoma. Further in vivo experiment with BCT-100 is ongoing.

[Table: see text]

Apoptosis in primary cardiac tumours

Apoptosis, or programmed cell death, is now recognised as an important cellular event during both normal development and specific disease progression. Apoptosis has been suggested to play a critical role in several cardiovascular diseases, but has not yet been identified as a major influence in primary cardiac tumours. A retrospective review of the achieved material at Chang Gung Memorial Hospital revealed seven patients with cardiac myxoma and one with a tumour originating from the crista terminalis, from January 2002 to December 2002. The medical chart, surgical pathology reports and microscopic slides were available in all cases. All patients, including eight cardiac myxomas and one tumour from crista terminalis, were assessed for apoptosis by terminal deoxynucleotidyl transferase nick-end labelling assay. In this study, apoptosis is well documented in all seven myxoma and has even been reported in tumour from the crista terminalis. Interestingly, apoptosis appears related to the nature of the cell properties rather than the incidence of embolism. In conclusion, apoptosis is important in the progression of the primary cardiac tumours, but the mechanism of cardiac tumour regression still remains uncertain.

Ultrasound-guided core needle biopsy as an initial diagnostic test for palpable breast masses

PURPOSE

To determine the role of ultrasound (US)-guided core needle biopsy as an initial diagnostic test for palpable breast masses.

MATERIALS AND METHODS

Ninety-eight consecutive patients, each with a palpable breast mass, were referred for US-guided core biopsy by a multidisciplinary team of physicians who specialize in the care of breast diseases. All palpable breast masses were clearly visible on high-resolution US. Ninety-nine core needle biopsies were performed under local anesthesia with use of freehand technique, mostly in an outpatient setting. Core needle path through each mass was documented in two orthogonal sections. A mean of 3.4 tissue core samples (range, 1-7) were obtained in each patient.

RESULTS

Core needle biopsy resulted in the diagnosis of 66 malignancies, two cases of atypical ductal hyperplasia (ADH), and 30 benign diseases of the breast. Surgery with curative intent was performed in 63 breast malignancies and excisional biopsies were performed for 10 benign diseases (two cases of ADH and eight benign lesions). Twenty-five breast masses were managed nonoperatively: chemotherapy was performed in three locally advanced breast cancers and 3-year follow-up was conducted for 22 benign lesions. Malignancies were correctly diagnosed in all cases. No malignancy was discovered at surgery or during clinical follow-up of ADH and no benign breast lesions were diagnosed by core needle biopsy. US-guided core needle biopsy is 100% sensitive and specific for palpable breast malignancies, with no false-positive results. A puncture site ecchymosis was the only morbidity or complication noted.

CONCLUSION

US-guided core needle biopsy is a safe and accurate first diagnostic test for palpable breast masses that require tissue proof.

Nasal chondromesenchymal hamartoma in children: report of 2 cases with review of the literature

Hamartoma in the nasal cavity of children is especially rare. Most documented cases occurred in infants, with characteristic histologic features of a mixture of various mesenchymal tissues. McDermott et al designated it nasal chondromesenchymal hamartoma in 1998, and it has since been considered a distinct clinicopathological entity. We report 2 such examples in a full-term male newborn and a 9-month-old boy, respectively. Histologically, both cases were characterized by a mixture of various mesenchymal elements, including spindle cells, collagen fibers, and irregular islands of osseous and chondroid tissue. Immunohistochemical study showed positivity to vimentin and S100 protein. Ultrastructural examination of case 1 demonstrated fibroblastic and myofibroblastic differentiation in tumor cells. There were 11 cases of nasal chondromesenchymal hamartoma in children published to date. The tumor has a benign biological behavior, and complete resection is the treatment of choice. It is apt to be misdiagnosed because of overlapping histologic features shared with a number of benign and malignant soft tissue tumors. Awareness of this entity is essential for correct diagnosis and adequate therapy.

Tumor lysis syndrome in an infant with Langerhans cell histiocytosis successfully treated using continuous arteriovenous hemofiltration

Langerhans cell histiocytosis (LCH) is an enigmatic disease usually occurring in children. Tumor lysis syndrome (TLS) is a clinical syndrome associated with severe metabolic derangement and oliguric acute renal failure. In this report, we present the clinical course of an infant with advanced LCH who had TLS develop after chemotherapy. Treatment with continuous arteriovenous hemofiltration resulted in effective control of serum uric acid, potassium, creatinine, phosphorus, and blood urea nitrogen levels in the blood.

Identifying differentially expressed genes associated with metastasis of follicular thyroid cancer by cDNA expression array

Patients with follicular thyroid carcinoma have a higher incidence of metastasis than papillary thyroid carcinoma when thyroid cancer is diagnosed. The cDNA expression array technology is utilized herein to profile differentially expressed genes from metastatic human follicular thyroid carcinoma and reveal new tumor markers as well as target genes for therapeutic intervention. Tissue samples were obtained during surgical resection of the thyroid follicular carcinoma and metastatic tissue in the brain of the same patient. Two identical Atlas human cDNA expression arrays were hybridized with 32P-labeled cDNA probes derived from RNA of either primary thyroid cancer or metastatic tissue. Parallel analysis of the hybridized signals allowed us to identify the alteration of gene expression in the metastasis process. Eighteen genes significantly overexpressed and 40 genes significantly underexpressed were identified in the metastatic thyroid cancer. Genes that displayed an altered expression were associated with the processes of cell cycle regulation, apoptosis, DNA damage response, angiogenesis, cell adhesion and mobility, invasion, and immune response. An expression profile of genes that are associated with metastasis process of follicular thyroid cancer was also discussed. Further investigation is required to understand the precise relationship between the altered expression of these genes and the metastasis process of follicular thyroid cancer.

Expression of sodium iodide symporter in benign and malignant human thyroid tissues

The extent of human sodium iodide symporter (hNIS) expression in different kinds of human thyroid cancer tissues and cell lines remains controversial. In this study, polyclonal antibodies to hNIS were used to analyze the expression of symporter protein in benign and malignant human thyroid tissues. Formalin-fixed, paraffin wax-embedded tissue sections were used. Staining was performed using primary polyclonal antibody of rabbit anti-human hNIS diluted in PBS (1:500). Results showed that 2 of 3 normal tissue, 3 of 6 nodular hyperplasia, one follicular adenoma, 3 of 11 papillary thyroid carcinoma, 1 of 5 follicular carcinoma and none of 3 metastatic thyroid epithelial tissue specimens stained positively for hNIS. A higher percentage of positive staining for symporter protein was found in benign thyroid tissues including normal thyroid tissue, nodular hyperplasia, and adenoma (60%). In contrast, papillary and follicular thyroid carcinomas demonstrated lower symporter protein expression (20%). In conclusion, although the number of tissue samples examined in this study was small, hNIS staining found a higher ratio of symporter protein expression in normal and benign thyroid tissues compared with malignant tissues. Determination of the reason for discrepancies in the expression of hNIS in in vivo and in vitro studies will require further investigation.

Pathologic studies of fatal cases in outbreak of hand, foot, and mouth disease, Taiwan

In 1998, an outbreak of enterovirus 71-associated hand, foot, and mouth disease occurred in Taiwan. Pathologic studies of two fatal cases with similar clinical features revealed two different causative agents, emphasizing the need for postmortem examinations and modern pathologic techniques in an outbreak investigation.

Color and duplex Doppler sonography of hemangiopericytoma

We report the color Doppler sonographic features in a case of hemangiopericytoma of the thigh in a 52-year-old woman. Color Doppler sonography demonstrated the vascularity of the tumor, and spectral analysis showed waveform changes that suggested the presence of intratumoral arteriovenous shunting. The color Doppler findings correlated well with angiographic findings. Color Doppler sonography can demonstrate intratumoral arteriovenous shunting in hemangiopericytoma and may be used to help avoid profuse bleeding when performing a preoperative biopsy.

Diagnostic sensitivity of ultrasound-guided needle biopsy in soft tissue masses about superficial bone lesions

We evaluated the value of ultrasound-guided needle biopsy in 20 soft tissues masses about superficial bone lesions in 20 oncology patients. Sonographically guided needle biopsies were performed without an on-site pathologist. A diagnostic sensitivity of 95% and specificity of 100% in separating a benign or a malignant lesion was obtained. Fine needle aspiration cytology allowed the specific cell type of malignancy to be diagnosed in 80% of cases, while core needle biopsy allowed it in 91%. Real-time ultrasonographic guidance permits precise needle placement into the targets, avoidance of hypervascular areas, and flexibility of patient positioning so that needle biopsy can be performed quickly and safely on soft tissue masses about superficial bone lesions.

Menetrier's disease associated with cytomegalovirus infection in a child

Menetrier's disease is a rare disease with unknown etiology characterized by protein-losing hypertrophic gastropathy and hypoproteinemia. We report on a 4-year-old boy who presented with a 2-week history of vomiting and periorbital edema. Upper gastrointestinal endoscopy revealed prominent gastric rugae, while pathological examination showed hyperplastic mucosa with proliferation, elongation, and basal cystic dilatation of the gastric glands replaced by mucous-secreting epithelium, confirming the diagnosis of Menetrier's disease. Virus isolation from urine revealed cytomegalovirus (CMV); and CMV immunoglobulin G and immunoglobulin M antibodies were detected in the serum. His condition gradually improved under omeprazole, with complete histological recovery after 3 months.

Acute encephalomyelitis during an outbreak of enterovirus type 71 infection in Taiwan: report of an autopsy case with pathologic, immunofluorescence, and molecular studies

We report a fatal case of enterovirus type 71 (EV 71) infection in an 8-year-old girl during a summer outbreak of hand, foot, and mouth disease in 1998 in Taiwan. The clinical course was rapidly progressive, with manifestations of hand, foot, and mouth disease, aseptic meningitis, encephalomyelitis, and pulmonary edema. The patient died 24 hours after admission. Postmortem study revealed extensive inflammation in the meninges and central nervous system and marked pulmonary edema with focal hemorrhage. Brain stem and spinal cord were most severely involved. The inflammatory infiltrates consisted largely of neutrophils involving primarily the gray matter with perivascular lymphocytic cuffing, and neuronophagia. The lungs and heart showed no evidence of inflammation. EV 71 was isolated from the fresh brain tissues and identified by immunofluorescence method with type-specific EV 71 monoclonal antibody. It was also confirmed by neutralization test and reverse-transcriptase polymerase chain reaction with sequence analysis. The present case was the first example in which EV 71 was demonstrated to be the causative agent of fatal encephalomyelitis during its epidemic in Taiwan.

Genetic analysis of enterovirus 71 isolated from fatal and non-fatal cases of hand, foot and mouth disease during an epidemic in Taiwan, 1998

A large scale outbreak of hand-foot-and-mouth disease (HFMD) occurred in Taiwan in 1998, in which more than 80 children died of shock syndrome with pulmonary edema/hemorrhage. Enterovirus 71 was implicated as the cause of this outbreak. In order to understand the virological basis responsible for mortality on this scale, nucleotide sequences of VP1 that is important for serotypic specificity, and the 5'-non-coding region (5'-NCR) that is important for replication efficiency, were analyzed comparatively. Phylogenetic analysis of both VP1 and 5'-NCR of nine EV71 isolates derived from specimens of fatal patients and seven isolates derived from uncomplicated HFMD patients showed that all but one isolate fell into genotype B. The one distinct isolate from a case of uncomplicated HFMD belonged to genotype C that was clustered along with one isolate from Taiwan in 1986. Complete sequence analysis of two selected isolates, one from the spinal cord of a fatal case and one from the vesicle fluid of a patient with mild HFMD, confirmed a high degree (97-100%) of identity in nucleotide sequence throughout the entire genome, except focal regions of 3C and 3'-NCR where the nucleotide homology was 90-91%. The identity of the deduced amino acid sequence in the 3C region that encodes viral proteinase dropped further to 86%, a result of missense mutations at the first nucleotide position of many codons.

Expression of sodium iodide symporter in metastatic and follicular human thyroid tissues

Active iodide uptake across the basal membrane mediated by human sodium iodide symporter (hNIS) has been shown to be a process coupled with the flow of sodium. There is still controversy as to the amount of hNIS expression present in different kinds of human thyroid cancer tissues. In this study, we present a 58-year-old women with follicular thyroid carcinoma with vertebra and skull metastases. 201Tl and 5 mCi 131I scans clearly demonstrated the metastatic lesions in the brain of this patient. Thyroid and metastatic tissues were then obtained for this study, which is aimed at comparing the iodide trapping ability in vivo and in vitro of hNIS, and then comparing their expression in both thyroid tissue and metastatic tissues. Polyclonal antibodies to hNIS and competitive RT PCR were used to analyze the symporter protein and mRNA expressed in follicular human thyroid and metastatic tissues. Positive staining of the symporter protein was performed in the follicular thyroid carcinomas, otherwise, the metastatic tissues could not have demonstrated the protein in the staining. Follicular thyroid carcinoma tissues from thyroid were revealed around 5 pg hNIS expressed in follicular thyroid carcinoma tissues from the thyroid. Otherwise, there was almost an absence of hNIS expression in the metastatic tissue. These discrepancies of the expression in hNIS in vivo and in vitro studies need further investigation.

Localised hyaline vascular type of Castleman's disease mimicking adult-onset Still's disease

A previously healthy 18-year-old boy presented with daily spiking fever, polyarthritis, and evanescent skin rashes, as well as hepatomegaly and Raynaud's phenomena for 2 months. He was initially diagnosed with adult-onset Still's disease (AOSD). During the period of follow-up, intermittent fever and migratory polyarthritis persisted and an insidiously growing mass over the right axillary region was noted 1 year after the diagnosis of AOSD. Excisional biopsy of the mass revealed a group of lymph nodes with histological features of the hyaline vascular type of Castleman's disease. The patient's symptoms disappeared soon after excision of the lymph nodes. evanescent rash, lymphadenopathy, hepatosplenomegaly and serositis [5]. A clinical picture compatible with the diagnosis of AOSD has not been described in the localised hyaline vascular type of Castleman's disease. We report such a case in an 18-year-old male patient who presented prolonged fever and polyarthritis with an initial diagnosis of AOSD. The diagnosis of hyaline vascular type of Castleman's disease was made 1 year later, when the patient developed an insidiously growing mass over the right axilla.

Clinical features and risk factors of pulmonary oedema after enterovirus-71-related hand, foot, and mouth disease

BACKGROUND

In Taiwan, from April to July, 1998, an epidemic of hand, foot, and mouth disease associated with enterovirus 71 (EV71) occurred with fatal complications. We did a clinical study of EV71-related diseases in Taiwan.

METHODS

We studied 154 children with virus-culture confirmed EV71 infection. Children were divided into three groups: 11 patients with pulmonary oedema; 38 patients with central nervous system (CNS) involvement and no pulmonary oedema; and 105 children without complications. We compared the clinical features, laboratory findings, risk factors, and outcome among these three groups.

FINDINGS

Nine children with pulmonary oedema had hand, foot, and mouth disease, one had herpangina, and one had febrile illness with eight children with limb weakness and one with limb hypesthesia. All children had had sudden onset of tachycardia, tachypnoea, and cyanosis 1-3 days after onset of the disease. Nine of 11 children died within 12 h of intubation; one child was braindead within 15 h and died 17 days after intubation; one child was in deep coma and died 3 months later. In children with CNS complication and no pulmonary oedema, one child died of pneumonia after 4 months of ventilator support and four children had sequelae. All 105 children without complications recovered. There was a significant association between CNS involvement and pulmonary oedema (odds ratio 12.4 [95% CI 2.6-60.1], p=0.001). Risk factors for pulmonary oedema after CNS involvement were hyperglycaemia, leucocytosis, and limb weakness. Hyperglycaemia was the most significant prognostic factor for pulmonary oedema (odds ratio 21.5 [3-159], p=0.003).

INTERPRETATION

EV71 can cause hand, foot, and mouth disease, CNS involvement with severe sequelae, and fatal pulmonary oedema. Hyperglycaemia is the most important prognostic factor.

Prenatally detected tumor mass in the adrenal gland

BACKGROUND/PURPOSE

Screening programs using urinary vanillylmandelic acid have detected neuroblastomas in early infancy with some success. With the widespread use of ultrasonography in modern obstetric practice, use of ultrasonography to screen for fetal neuroblastoma seems to be reasonable and practical.

METHODS

Seven fetuses had suprarenal masses detected by maternal ultrasound scan at 32 to 37 weeks' gestation between 1993 and 1998. They were delivered normally if the pregnancy was uncomplicated, especially if it was without maternal preeclampsia or fetal hydrops. Each mass was further confirmed by ultrasound scan, computed tomography, or magnetic resonance imaging in the neonatal period. Tumor excision was performed at the age of 6 to 38 days of life.

RESULTS

The size of the masses measured ranged from 2.0x2.0 cm to 4.5x4.5 cm. The diagnosis was adrenal hemorrhage in 1 neonate, Evan's stage I neuroblastoma in 3, and stage IV-S neuroblastoma in 3. All of the specimens with a diagnosis of neuroblastoma showed a favorable histology by the Shimada classification system. Infants with stage I disease were treated with tumor excision only, and they had survived without disease by 14, 18, and 25 months of follow-up. One infant with stage IV-S neuroblastoma was treated further with minimal chemotherapy and has survived without disease at the 66-month follow-up examination. Another child with stage IV-S neuroblastoma has survived with local recurrence and increasing liver metastasis and was still on chemotherapy at the 2-month follow-up examination. The third child with stage IV-S disease presented with massive hepatomegaly and bone marrow involvement, and disseminated intravascular coagulopathy had developed. The patient died on the 5th day of life without surgical intervention.

CONCLUSIONS

The increasing use of obstetric ultrasonography has made the prenatal screening of neuroblastomas possible. The prognosis of infants with a suprarenal mass may be improved with this early detection and early surgical intervention.

Diagnosis and management of 34 Hürthle cell tumors

BACKGROUND

Controversies still exist around the diagnosis and management of Hürthle cell tumors. The aim of this study is to reexamine our experience to improve our methods in the future.

METHODS

We treated 34 patients with verified Hürthle cell carcinoma and adenoma at Chang Gung Memorial Hospital, Linkou from 1990 through 1996. Clinical characteristics, thyroid ultrasonogram, 131I, 201Tl, 99mTc-methoxy-isobutyl-isonitrile (MIBI) and 99mTc-thyroid scan, fine needle aspiration cytology (FNAC) and histology results were analyzed.

RESULTS

Female predominance (82.4%) was noticed among our Hürthle cell tumors. Nine (26.5%) patients had carcinoma. The median size of carcinoma was 4.0 cm, which was significantly larger than the median 3.0 cm for adenoma. No significant differences were found between gender, age, multiplicity or echogenicity between two groups. All 12 adenoma and 3 carcinoma patients who received pre-operative 99mTc and/or 131I thyroid scan showed cold nodules. The sensitivity and specificity of detection Hürthle cell carcinoma as indeterminate and malignant using FNAC was 78% and 18% respectively. These improved to 100% and 86% using frozen sections. One carcinoma patient developed neck lymph node metastasis, with normal serum thyroglobulin, negative 131I but positive 201Tl and 99mTc-MIBI whole body scans. Another one showed mediastinum metastasis with elevated serum thyroglobulin, detected using 131I scan, revealed successful regression after 131I therapeutic scan.

CONCLUSION

Tumor size of carcinoma is significantly larger than adenoma. All patients with FNAC suggestive of Hürthle cell tumors should receive surgery for histological diagnosis to differentiate carcinoma from adenoma. Therapeutic radioiodine ablation is indicated whenever there is 131I uptake by tumor cells.

Delivery of a severely anaemic fetus after partial molar pregnancy: clinical and ultrasonographic findings

The incidence of a normal live fetus and a partial molar placenta is extremely rare. Although triploidy is the most frequent association, a fetus with normal karyotype can survive in cases of partial molar pregnancy. We report a case of partial molar placenta in which a live female baby was delivered at 32 weeks gestation by a 30-year-old woman. At the 18th week, ultrasonographic examination revealed a normal fetus with a huge, multicystic placenta. Chromosomal evaluation by amniocentesis revealed a normal female karyotype (46,XX), and serial biometric measurement of the fetus showed normal growth during pregnancy. There were no obstetric complications until the 32nd gestational week when preterm rupture of the membranes occurred. The electronic fetal heart beat tracing showed a repeated sinusoid pattern and late deceleration after admission. The patient underwent emergency Caesarean section and delivered a 1551-g, anaemic female baby with an Apgar score of 1, 4 and 6 at 1, 5 and 10 min, respectively. The baby recovered within 2 weeks after respiratory support and transfusion of packed red blood cells. Although anaemia is one of the risk factors that jeopardize the fetus in the case of partial molar pregnancy, termination is not indicated when the fetus is normal and no complications have occurred.

Congenital malignant rhabdoid tumor presenting as a cutaneous nodule: report of 2 cases with review of the literature

OBJECTIVE

The congenital occurrence of malignant rhabdoid tumor (MRT) is rare. Initial presentation of congenital MRT as a skin tumor is even more rare. We report 2 cases in which a cutaneous nodule appeared prior to the discovery of the primary tumor.

METHODS

Histologic, ultrastructural, and immunohistochemical studies were performed on skin nodules from 2 neonates. Other congenital examples of MRT in the literature were reviewed.

RESULTS

Both neonates were male and both were fullterm. Skin nodules were noted at birth. The tumors were located on the right neck in case 1 and on the right back in case 2. The primary tumors were later found in the kidney and the right chest wall, respectively. The skin biopsy of the first case had been interpreted as undifferentiated sarcoma, and MRT was diagnosed after the renal tumor was examined. In the second case, a correct diagnosis was promptly made based on the skin biopsy owing to experience with the first case.

CONCLUSIONS

Congenital MRT is very uncommon and may present as a skin tumor at birth. Since MRT exhibits various histologic patterns, the diagnosis should be made by a complete pathologic study with proper clinical correlation. To our knowledge, the unique mode of manifestation in these 2 cases is described for the first time. We suggest that MRT should be considered when making the differential diagnosis in such a clinical setting.

Primary pericardial mesothelioma with cardiac tamponade and distant metastasis: case report

Although cardiac tamponade is a well-known complication of malignancy, it is uncommon as the initial manifestation. The antemortem diagnosis is difficult and distant metastasis is extremely rare. The presentations of primary pericardial mesothelioma are nonspecific. Pathologically, mesothelioma is the most common in primary tumors of the pericardium. Radical surgery can be used to treat a localized mesothelioma. However, the therapy for advanced primary pericardial mesothelioma is usually palliative because it is resistant to irradiation, and chemotherapy does not markedly improve the outcome. The prognosis is uniformly poor. The median survival from the onset of symptoms is 6 months. We present a 67-year-old woman with cardiac tamponade 4 months prior to a definitive diagnosis of primary pericardial mesothelioma. A computed tomogram confirmed multiple well-enhanced nodules in the pericardium, lungs and liver. Unfortunately, the patient died of multiple organ failure.

Kadish stage C olfactory neuroblastoma successfully treated by chemoradiotherapy: report of two cases

Olfactory neuroblastoma is an uncommon tumor. It is usually diagnosed at advanced stages. Most of the patients have an indolent clinical course with slow progression, late recurrence and relative infrequency of distant metastasis. Because of the rarity and lack of a randomized clinical trial of patients with olfactory neuroblastoma, there is no standard treatment for the disease. The survival period has increased as treatments have been improved since 1980. Conventional treatments mainly consist of surgery and/or radiotherapy. Chemotherapy was only administered to a few patients; however, it achieved good response. More clinical experience is needed to improve the treatment strategy in order to reduce the possibility of disease recurrence, and also for rescue therapy. We present 2 patients with Kadish C tumors treated using chemotherapy followed by radiotherapy. Both patients demonstrated rapid and excellent response to induction chemotherapy, and have been free of disease for more than 5 years and 2 years after treatment, respectively.

Pemphigus vulgaris

Pemphigus vulgaris is an autoimmune vesiculobullous disease of the skin and the mucous membrane. It most commonly involves the population of the fifth and sixth decades, and is extremely rare in children. We report a case of this disease in a 13-year-old boy, who was documented to have pemphigus vulgaris with historical, histopathological, and immunological criterion. He received corticosteroid and immunosuppressive drugs and a good response was achieved. We concluded that pemphigus vulgaris is a rare disease in children, but it should be kept in mind as a differential diagnosis of oral ulceration along with skin manifestation in children.

Successfully treated sulphasalazine-induced fulminant hepatic failure, thrombocytopenia and erythroid hypoplasia with intravenous immunoglobulin

We report the simultaneous development of fulminant hepatic failure, thrombocytopenia and erythroid hypoplasia in a child treated with sulphasalazine. A 12-year-old girl with juvenile rheumatoid arthritis developed fulminant hepatic failure, thrombocytopenia and erythroid hypoplasia, which was confirmed by liver histology and bone marrow examination, 2 weeks after initiation of sulphasalazine therapy. The patient recovered after administration of high doses of intravenous immunoglobulin. This is the first reported case of the concurrent development of these complications associated with sulphasalazine hypersensitivity. The use of intravenous immunoglobulin may have helped in the treatment of this rare adverse effect of sulphasalazine.

Video-assisted minimal access in excision of left atrial myxoma

BACKGROUND

Minimal access surgery with video-assisted endoscopy has been applied to the correction of intracardiac lesions. We report our experience using this technique in surgical excision of left atrial myxoma in 3 patients.

METHODS

From November 1995 to March 1997, 3 female patients, ages 45 to 80 years (mean, 62.7 years), received emergency operations for excision of left atrial myxoma. These operations were performed through a right anterior submammary minithoracotomy or right parasternal incision with the assistance of endoscopy during femoro-femoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with fibrillatory arrest or cardioplegic arrest with aortic cross-clamping.

RESULTS

All the tumors were excised completely through the right atrial approach. The bypass time was 92 to 148 minutes (mean, 111 minutes). The operation time was 3.2 to 4.4 hours (mean, 3.7 hours). There were no hospital deaths. Follow-up, which ranged from 6 to 19 months (mean, 10.5 months), was complete in all patients. Transthoracic echocardiographic examination showed good ventricular function without any residual tumors. Patients were found to be in New York Heart Association functional class I or II. They were satisfied with the good cosmetic healing of the incision.

CONCLUSIONS

Our experience demonstrates that minimal access surgery is a technically feasible, safe, and effective procedure in surgical excision of left atrial myxoma.

Association of fungal colonization and invasive disease in very low birth weight infants

BACKGROUND

Fungi are common pathogens of nosocomial infections in the very low birth weight (VLBW) infants. The purpose of this study was to investigate the fungal colonization rate in VLBW infants and the association between fungal colonization and systemic fungal diseases.

MATERIALS

Between January 1, 1996, and December 31, 1996, 116 infants with birth weight < 1500 g admitted to the neonatal intensive care unit of Chang Gung Children's Hospital in the first day of life were included in this prospective study.

METHODS

Cultures from oropharynx, rectum, skin (groin and axilla), bag urine and endotracheal aspirates were obtained in the first 24 h after birth and weekly thereafter throughout their neonatal intensive care unit stay. Medical records were reviewed weekly.

RESULTS

Fungal colonization was detected in 25 infants, among whom 17 infants developed colonization by 2 weeks of life. Candida albicans (61%) and Candida parapsilosis (29%) were the 2 most common organisms. The rectum (76%) was the most frequent site of colonization. Factors significantly associated with colonization were prolonged administration of antibiotic therapy, parenteral nutrition and intralipid emulsion. Three of 116 infants developed fungemia. The association between colonization and subsequent fungemia was demonstrated in 1 infant, representing 4% of colonized infants.

CONCLUSION

Fungal colonization was detected in one-fifth of VLBW infants and represents a risk factor for fungemia. Because disease occurred in the absence of apparent colonization, factors other than colonization may contribute to invasive candidiasis.

Successful treatment of Sjögren's syndrome with cyclophosphamide pulse therapy: report of one case

The treatment of Sjögren's syndrome (SS) is very controversial, though several therapeutic regimens have been proposed. Cyclophosphamide pulse therapy has been widely used in many disease entities. However, reports concerning its clinical application in SS were very rare. We report a 17-year-old girl presenting with lupus nephritis and SS, which was refractory to corticosteroid therapy but successfully treated with cyclophosphamide pulse therapy. The improvement of clinical features was confirmed by Schirmer's test and minor salivary gland biopsy.

Liquid ventilation for treatment of meconium aspiration syndrome in a piglet model

We tested the hypothesis that liquid ventilation (LV) with perfluorocarbon (PFC) can remove aspirated meconium and improve lung function in experimental meconium aspiration syndrome (MAS). PFC (FC-77) was used as the medium in LV. Sixteen piglets were divided into control and LV groups (8 animals/group). All animals received slurry meconium (20% in normal saline) via endotracheal instillation at baseline. Thirty minutes later, the LV group received 15 cycles of LV. Pulmonary mechanics, arterial blood gases, and hemodynamic values were recorded at baseline, and 30, 60, 120, 180, and 240 minutes after meconium instillation. Chest radiographs and lung sections were taken and scored at the end of the study. The percentage of meconium cleared by LV was calculated as the ratio of the dry weight of washings to that of meconium instilled, multiplied by 100. The procedure was tolerated well by the animals. LV cleared 25% +/- 7% of the instilled meconium. Tidal volume (9.5 +/- 2.0 vs 7.1 +/- 0.8 mL/kg, p = 0.012), respiratory system compliance (2.32 +/- 0.60 vs 1.60 +/- 0.24 mL/cmH2O, p = 0.01), PaO2 (65 +/- 7 torr vs 55 +/- 6 torr, p = 0.0067), and arterial to alveolar oxygen ratio (0.14 +/- 0.01 vs 0.12 +/- 0.01, p = 0.0077) were improved in the LV group at 60 minutes after meconium instillation compared with those of the control group. The scores of exudative debris (1.7 +/- 0.3 vs 2.1 +/- 0.2) and visible meconium (1.4 +/- 0.5 vs 2.1 +/- 0.5) were significantly lower in the LV group. In conclusion, short-term L.V with FC-77 can partially remove aspirated meconium from the lungs and improve pulmonary function transiently.

Primitive neuroectodermal tumor of the lingual nerve: a case report

This is a report of a primitive neuroectodermal tumor (PNET) arising from the lingual nerve of a 5-year-old girl. Twelve months after surgical excision and postoperative chemotherapy, the patient remained alive without any evidence of recurrence or metastasis. The occurrence of PNETs in the head and neck region in children is rare. This is the first case report in the literature of a PNET originating from a cranial nerve in a child. Because of its aggressive nature and poor prognosis, aggressive surgical and medical treatment regimens are needed. Surgeons should be mindful to include PNET in the differential diagnosis of head and neck tumors.

Neonatal ileoileocolic intussusception associated with ileal polyp: report of one case

Neonatal intussusception is an uncommon disease. We report a case of neonatal ileoileocolic intussusception led by an ileal polyp in a female neonate. The patient presented with irritable crying, bilious vomiting and frank bloody stool on the 26th day of life. On physical examination, a mobile abdominal mass was palpated. Abdominal sonography demonstrated a long segment intussusception; associated with a low echogenic mass. At laparotomy, ileoileocolic intussusception led by an ileal polyp was found. Pathology confirmed the diagnosis of polyp. Because intestinal obstruction is the primary manifestation, neonatal intussusception is initially indistinguishable from obstructions due to other reasons like intestinal atresia, congenital bands, necrotizing enterocolitis or midgut volvulus. Our experience showed that although uncommon, intussusception should be considered in the differential diagnosis of intestinal obstruction during the newborn period.

Infantile myofibromatosis: a solitary lesion involving the upper lip

Infantile myofibromatosis is a rare disease characterized by myofibroblastic proliferation, and typically occurs in early infancy. There is a wide spectrum of clinical presentation, which may involve various kinds of tissues in the body. Skin and subcutaneous lesions were the types of tissue most often seen. Although a multicentric form may behave aggressively, a solitary form of the tumor is benign with the possibility of spontaneous regression. Conservative management is justified after proper pathological diagnosis if the tumor involves an aesthetically important area. A case of solitary infantile myofibromatosis involving the upper lip is presented. Partial excision for biopsy was performed and long-term observation was undertaken. The tumor disappeared 3 years postoperatively.

Correlation of fine needle aspiration cytology and frozen section biopsies in the diagnosis of thyroid nodules

AIMS

To evaluate the correlation of fine needle aspiration (FNA) cytology and frozen section biopsy in the diagnosis of thyroid nodules.

METHODS

The medical records of 662 patients who underwent FNA cytology of the thyroid and thyroid surgery were analysed. Frozen section biopsies were taken from 586 of the 662 patients. The diagnostic correlations of FNA cytology, frozen section, and both FNA cytology and frozen section with definitive histological assessment were evaluated.

RESULTS

Among the 662 patients who received FNA cytology, there were 356 cases (53.8%) diagnosed as benign, 114 cases (17.2%) as malignant, 148 cases (22.4%) as indeterminate, and 44 cases (6.6%) as unsatisfactory. The positive predictive value for the detection of malignancy by FNA cytology was 92.1% and the negative predictive value was 95.2%. The incidence of malignancy in the indeterminate cytological diagnosis was 23%. The diagnosis from frozen sections was benign in 445 cases (75.9%), malignant in 134 cases (22.9%), and deferred in 7 cases (1.2%). By frozen section, the positive and negative predictive values were 97% and 95.5%, respectively. Diagnostic accuracy up to 98% was achieved when FNA cytology and frozen section diagnoses were in agreement. No false positives were observed when FNA cytology and frozen sections were both positive for malignancy. When FNA cytology and frozen section diagnoses were discordant, frozen section showed a higher accuracy (78.9%) than FNA cytology (21.1%). In the face of an indeterminate or unsatisfactory cytological diagnosis, the diagnostic accuracy of frozen sections reached 92.6%.

CONCLUSIONS

The results confirm that FNA cytology is a useful tool in the initial evaluation of thyroid nodules. Intraoperative frozen section is a valuable procedure to confirm the cytological diagnosis and identify malignancy in patients with indeterminate or unsatisfactory cytological diagnosis. With reliance on frozen sections as an intraoperative guide of thyroid surgery, the possibility of unnecessary extensive surgery and the need for the second operation are considerably lower.

Oral acyclovir prophylaxis of varicella after intimate contact

OBJECTIVES

Whether oral acyclovir (ACV) given in late incubation can prevent clinical varicella or not.

MATERIALS AND METHODS

Twenty-seven healthy infants and children susceptible to varicella received oral ACV (40 mg/kg daily in four divided doses) for 5 days, starting 9 or 11 days after exposure from the index case in the family (2 in the classroom). The clinical features were compared with 13 control children who did not receive ACV. Enzyme-linked immunoassay was used to detect varicella-zoster virus (VZV) antibody and, in follow-up immunologic studies, lymphocyte proliferative response was added. In some cases, blood culture and polymerase chain reaction with Southern hybridization were used for detection of viremia.

RESULTS

Among the 27 children in the treatment group, two (7.4%) developed the disease and seroconversion was observed in 17 subjects (63%). Follow-up immunologic studies in 12 of these 17 seroconverted subjects 30 months later showed persistent cellular and/or humoral immunity to VZV. Only one subject, bled 11 days after exposure, had positive VZV DNA and blood culture for VZV. On the other hand 10 of 13 (77%) control subjects developed clinical varicella.

CONCLUSIONS

Oral ACV administration to healthy susceptible subjects at the beginning of secondary viremia in the late incubation period (9 days after exposure) can effectively prevent or modify clinical varicella.

Diagnosis of occult thyroid carcinoma by thyroid ultrasonography with fine needle aspiration cytology

OBJECTIVE

To assess the role of ultrasonography and fine needle aspiration cytology (FNAC) in preoperative diagnosis of patients with occult thyroid carcinoma (OTC).

STUDY DESIGN

Data on 768 thyroid carcinoma patients receiving primary treatment at Chang Gung Medical Center were retrospectively reviewed. Of these patients, 97 had OTC. To detect small thyroid nodules early and define the characteristics of clinically palpable nodules, thyroid ultrasonography with FNAC were performed on 67 histopathologically proven OTC patients. Analysis for diagnostic value was done for ultrasonography and FNAC.

RESULTS

In the 67 patients receiving ultrasonography with FNAC, 23 were preoperatively diagnosed as having papillary thyroid carcinoma and 1 as having follicular carcinoma. The tumor size of these 24 preoperative FNAC-proven OTC was 0.81 +/- 0.23 cm (mean +/- SD). In the remaining patients, 10 presented pictures suspicious for malignancy, with a mean tumor size 0.63 +/- 0.24 cm, and 33 (49.3%) were diagnosed as having benign thyroid lesions in preoperative FNAC. The tumor size in these 33 lesions was 0.58 +/- 0.24 cm. Fifty-seven of the 67 OTC patients received frozen sections. Thirty-eight papillary thyroid carcinomas and four follicular carcinomas were correctly diagnosed on frozen sections.

CONCLUSION

Although the rate is not high, high-resolution ultrasonography and FNAC is the best approach to preoperative diagnosis for OTC patients today.

Prenatal diagnosis of congenital cystic adenomatoid malformation of the lung: four cases report

Congenital cystic adenomatoid malformation of the lung (CCAML) is a rare pulmonary lesion, characterized by excessive overgrowth of the terminal respiratory bronchioles. Prenatal detection and serial sonographic study of fetuses with CCAML can provide information about the natural history of these lesions and reveal most of the nature history of pathophysiologic features which are likely to affect the clinical outcome. This information is crucial to the formulation of a prognosis and a management strategy. We report on four cases of CCAML, three of which involved macrocystic lesions including two cases of type I and one case of type II. Only one microcystic lesion, a type III CCAML, was identified in these patients. All of the cases were diagnosed by ultrasound between the 21 and 24 weeks of gestation. Fetal hydropic change was noted in all four cases. All of the parents opted for termination of pregnancy before fetal viability. Post-mortem examination confirmed the diagnosis in all four cases.

Lymphoepithelioma-like salivary gland carcinoma in Taiwan: a clinicopathological study of nine cases demonstrating a strong association with Epstein-Barr virus

AIMS

Lymphoepithelioma-like carcinoma (LELC) of the salivary glands is a rather rare tumour. Previous studies have shown its strong association with Epstein-Barr virus (EBV) among Chinese and Eskimos. We tested this observation with nine Chinese patients with salivary gland LELC in Taiwan including one with coexisting nasopharyngeal carcinoma (NPC) and studied the prognostic significance of their histopathological features.

METHODS AND RESULTS

This series showed a predilection for female patients and parotid glands with a median age of 50 years. Three patients died 18.5-26 months after the diagnosis including the case with NPC. Six patients were alive without recurrence for 14-45 months with a median follow-up of 34.5 months. Histopathologically, the tumours showed either lobular or diffuse growth pattern. Granulomas and/or germinal centres were observed in most cases and both B- and T-cells were found in the lymphoid infiltrates, indicating that the salivary gland LELC was capable of inducing a strong host immune reaction. Microscopic growth pattern, lymph node metastasis, and presence or absence of granulomas and/or germinal centres seemed to be important prognostic factors. Both salivary gland LELC and NPC shared similar histopathological appearance and positive immunostaining for epithelial membrane antigen and cytokeratin AE1 but not AE3. Granulomas and amyloid might occur in both tumours. A nasopharyngeal examination is indicated in patients with salivary gland LELC to exclude the possibility of coexisting or metastatic NPC. All nine cases showed positive nuclear signals for EBV-encoded RNA by in situ hybridization including the case with NPC.

CONCLUSIONS

Our study and the previously published studies show that the association of salivary gland LELC and EBV is strongly related to racial and geographical factors.

Thyroid follicular neoplasms diagnosed by high-resolution ultrasonography with fine needle aspiration cytology

OBJECTIVE

To investigate the final results of cases with preoperative diagnoses of thyroid follicular neoplasms by fine needle aspiration cytology (FNAC).

STUDY DESIGN

A retrospective review of 6,499 patients who received thyroid ultrasonography with FNAC at Chang Gung Memorial Hospital. Among 6,499 patients, 209 (3.2%) were diagnosed by FNAC as having follicular neoplasms, of which 84 received surgical treatment. Eighty-two of the 84 cases had a frozen section prepared during the operation.

RESULTS

Thyroid malignancy was confirmed histopathologically in 164 cases. Among 84 thyroid follicular neoplasm patients, 21 cases were diagnosed as malignant tumors, including papillary thyroid carcinoma, follicular thyroid carcinoma, medullary thyroid carcinoma and Hürthle's cell carcinoma. Ultrasonography on these 21 patients revealed that 16 cases (76.2%) had low echo density in the thyroid nodule. The percentage was statistically significantly different from that in benign cases, 23.8% (P < .05). A higher incidence of malignancy was found in males, but the data did not reach statistical significance (P = .0586).

CONCLUSION

Most of the follicular neoplasms revealed by FNAC were benign lesions. Low echo density on ultrasonography and male sex carried a higher risk of malignancy.

The detection of right-sided congenital diaphragmatic hernia in monozygotic twins on prenatal ultrasonography

The diagnosis of a pair of monozygotic twins with right-sided diaphragmatic hernia under ultrasound is described. Aspects of heredity, diagnosis and management are discussed.