BACKGROUND: Total obstruction of the left main coronary artery is a common cause of sudden death but is rarely seen in patients who survive to undergo diagnostic evaluation or treatment. METHODS: During twenty six-year period, we encountered 5 patients with chronic total obstruction of the left main coronary artery out of about 4,000 patients who underwent coronary angiography. RESULTS: All patients have undergone coronary bypass surgery. These patients present with increasingly severe angina. A right dominat coronary anatomy is always found, usually with well-developed right-to-left collaterals. Left ventricular function was severely impaired in two patients out of five patients. CONCLUSIONS: The results of surgical revascularization in our patients and others described in the literature can support the safety and efficacy of this approach.
Coronary Angiography ; Coronary Vessels* ; Death, Sudden ; Humans ; Ventricular Function, Left

BACKGROUND: Glucocorticoid-induced osteoporosis is characterized by decreased osteoblastic activity and replacement of bone marrow with adipocytes. Since osteoblast and adipocytes are derived from the same mesenchymal stem cell, one might speculate that there is an interaction between these two cells types. In fact, leptin that is secreted from adipocytes is known to stimulate differentiation of osteoblasts, while it inhibits the differentiation of adipocytes. Furthermore, it has been demonstrated that PPAR is present in osteoblasts and it is increased by leptin in adipocytes. However, the role of PPAR and leptin remains unknown in glucocorticoid-induced osteoporosis. The aims of this study are to investigate the effect of glucocorticoid on bone mineral density and gene expression in osteoblasts and adipocytes, and to study the role of PPAR and leptin in the mechanism of glucocorticoid-induced osteoporosis. METHODS: Methylprednisolone, 1 mg/200 g-weight, was injected into five rats (steroid group) and saline was given to five rats (control group) for eight weeks. The bone mineral density was determined by dual energy X-ray absoptiometry. Gene expression of osteocalcin, alkaline phosphatase, lipoptrotein lipase, and PPAR -2 was assessed by RT-PCR. Serum leptin level was measured using a commercial radioimmunoassay kit. RESULTS: 1) The body weight of the steroid group was significantly lower than that of the control group (451.4+/-12.9 g vs. 247.6+/-19.8 g, p<0.05). The bone mineral density of the steroid group tended to be lower than that of the control group (0.27+/-0.01 g/cm2 vs. 0.26+/-0.01 g/cm2, p>0.05). 2) In the steroid group, the gene expressions of osteocalcin (1.00+/-0.08 vs. 0.23+/-0.16, p<0.05) and alkaline phosphatase (0.47+/-0.07 vs. 0.33+/-0.18, p<0.05) were decreased significantly compared to those in controls. 3) In the steroid group, the gene expression of lipoprotein lipase (0.23+/-0.06 vs. 0.39+/-0.12, p>0.05) and+/-PAR 2 (0.17+/-0.08 vs. 0.22+/-0.12, p>0.05) tended to be increased compared to that in the contol group. 4) The serum leptin level of the steroid group tended to be lower than that of the control group (0.20+/-0.12 g/L vs. 0.10+/-0.09 g/L, p>0.05). CONCLUSION: These data suggest that long-term administration of a large dose of glucocorticoid suppresses differentiation of osteoblasts and enhances the differentiation of adipocytes, which may be mediated by increased expression of PPAR and decreased synthesis of leptin.
Adipocytes ; Alkaline Phosphatase ; Animals ; Body Weight ; Bone Density ; Bone Marrow* ; Gene Expression ; Leptin ; Lipase ; Lipoprotein Lipase ; Mesenchymal Stromal Cells* ; Methylprednisolone ; Osteoblasts ; Osteocalcin ; Osteoporosis ; Peroxisome Proliferator-Activated Receptors ; Radioimmunoassay ; Rats

We described a case of a 54-year-old male who presented with dizziness and dyspnea due to cardiac metastasis of leiomyosarcoma. Cardiac metastasis of leiomyosarcoma caused both bradyarrhythmia and tachyarrhythmia in the patient. He was treated with implantation of a permanent pacemaker for management of complete atrio-ventricular block and anti-arrhythmic drug that suppressed ventricular tachycardia successfully.
Bradycardia ; Dizziness ; Dyspnea ; Heart ; Humans ; Leiomyosarcoma* ; Male ; Middle Aged ; Neoplasm Metastasis* ; Tachycardia ; Tachycardia, Ventricular*

Paragonimiasis is an infectious disease caused by trematodes of the genus Paragonimus. This trematode can be treated successfully with praziquantel in more than 90% of the cases. Although praziquantel is generally well tolerated, anaphylactic reactions to this drug have been reported in a few cases. We report here a 46-year-old Korean female with paragonimiasis, presumed to be due to Paragonimus westermani, who displayed an allergic reaction to praziquantel and resistance to triclabendazole treatment. The patient was successfully treated with praziquantel following a rapid desensitization procedure. Desensitization to praziquantel could be considered when no alternative drugs are available.
Animals ; Benzimidazoles/*therapeutic use ; *Desensitization, Immunologic ; Drug Hypersensitivity/etiology/immunology/*therapy ; *Drug Resistance ; Female ; Humans ; Middle Aged ; Paragonimiasis/*drug therapy/immunology/parasitology ; Paragonimus/isolation & purification/physiology ; Praziquantel/*adverse effects/*immunology/therapeutic use ; Treatment Outcome

PURPOSE: Warthin-like papillary carcinomawas named owing to its close histologic resemblance to a tumor encountered in salivary gland, and this tumor is a variant of papillary thyroid carcinoma. Among the variants of papillary thyroid carcinoma, the tall cell variant and diffuse sclerosing variant have more aggressive behavior than the classic papillary carcinoma. But Warthin-like papillary carcinoma arises in a background of thyroiditis and it behaves in an indolent fashion. Since then, a few case have reported in Korea. We report here on the clinicopathologic features of five cases of warthin-like papillary carcinoma. METHODS: From Jan. 1996 to Feb. 2008, five patients who were diagnosed with Warthin-like papillary thyroid carcinoma at YUMC were retrospectively reviewed. RESULTS: All 5 patients whose pathologic features were warthin- likepapillary thyroid carcinoma were women (age range: 34~60 years). The tumor size ranged from 0.6 to 2.4 cm. 3 tumors were confined to the thyroid, but 2 tumors had invaded the strap muscles. 3 of the 5 tumors arose in a background of lymphocytic thyroditis. Central nodal metastases were identified in 2 cases. But no lateral nodal or distant metastasis had occurred. The mean duration of follow- up was 16.5 months (range: 5~50 months). 1 patient died because of lung cancer, and there was no recurrence for the other 4 cases during the follow-up period. CONCLUSION: Although the long-term follow-up data on patients with Warthin-like papillary carcinoma is not available, the clinicopathologic data does not show that Warthin-like papillary carcinoma is any more aggressive than the usual papillary carcinoma.

There are three compartments of regional lymph node to which metastases from thyroid cancers can occur: central, lateral, and mediastinal compartment. The mediastinal metastases from thyroid cancers are extremely rare, comparing the relatively common forms of metastases to central or lateral compartments. The importance of complete surgical lymph node dissection of central or lateral compartment for thyroid cancer has been well described, but mediastinal lymph node dissection has been sporadically reported. For mediastinal compartment metastases, operation techniques consist of sternal split, thoracoscopic surgery, or VATS (Video-assisted thoracoscopic surgery). Robotic surgery system was introduced recently with the objective of enhancing the dexterity and view during procedure that uses a videoscope. Many institutions report the experience with minimally invasive resection of mediastinal mass using robotic surgery system. We report that one case of robot-assisted mediastinal lymph node dissection for metastatic papillary thyroid cancer.
Carcinoma, Papillary ; Lymph Node Excision* ; Lymph Nodes* ; Neoplasm Metastasis ; Thoracic Surgery, Video-Assisted ; Thoracoscopy ; Thyroid Gland* ; Thyroid Neoplasms*

A 50-year-old male visited the outpatient clinic and complained of fever, poor oral intake, and weight loss. A chest X-ray demonstrated streaky and fibrotic lesions in both lungs, and chest CT revealed multifocal peribronchial patchy ground-glass opacities with septated cystic lesions in both lungs. Cell counts in the bronchoalveolar lavage fluid revealed lymphocyte-dominant leukocytosis, and further analysis of lymphocyte subsets showed a predominance of cytotoxic T cells and few T helper cells. Video-assisted wedge resection of the left upper lobe was performed, and the histologic examination was indicative of a Pneumocystis jirovecii infection. Trimethoprim-sulfamethoxazole (TMP-SMX) was orally administered for 3 weeks; however, the patient complained of cough, and the pneumonia was aggravated in the follow-up chest X-ray and chest CT. Molecular studies demonstrated mutations at codons 55 and 57 of the dihydropteroate synthase (DHPS) gene, which is associated with the resistance to TMP-SMX. Clindamycin-primaquine was subsequently administered for 3 weeks replacing the TMP-SMX. A follow-up chest X-ray showed that the pneumonia was resolving, and the cough was also alleviated. A positive result of HIV immunoassay and elevated titer of HCV RNA indicated HIV infection as an underlying condition. This case highlights the importance of careful monitoring of patients with P. jirovecii pneumonia (PCP) during the course of treatment, and the molecular study of DHPS mutations. Additionally, altering the anti-PCP drug utilized as treatment must be considered when infection with drug-resistant P. jirovecii is suspected. To the best of our knowledge, this is the first case of TMP-SMX-resistant PCP described in Korea.
Anti-Bacterial Agents/*administration & dosage ; Drug Resistance, Bacterial ; Humans ; Lung/microbiology/radiography ; Male ; Middle Aged ; Pneumocystis jirovecii/*drug effects/genetics/isolation & purification/physiology ; Pneumonia/*drug therapy/immunology/microbiology/radiography ; Sulfamethoxazole/*administration & dosage ; Trimethoprim/*administration & dosage

PURPOSE: Medullary thyroid carcinoma (MTC) is a rare thyroid tumor and its clinical course is quite variable. The aim of this study was to retrospectively analyze our clinical and laboratory data for 25 years to review the clinicopathologic characteristics, the operation methods, the tumor recurrence and the prognosis of medullary thyroid carcinoma. We also reevaluate the limits of the previous diagnostic and treatment modalities. The positivity for and the location of the RET mutation are also evaluated. Finally, we want to contribute to a systemic approach for the diagnosis, treatment, patient management and clinical study of medullary thyroid carcinoma. METHODS: We conducted a retrospective review of the records of 77 patients with MTC that were seen at our hospital from 1982 to 2007. The medical records were reviewed for the demographic data, the laboratory data and the clinical course, the treatment, the long-term outcome and the RET proto-oncogene mutation. The mean follow-up period was 69.6 months (range: 6~201). RESULTS: There were 50 females and 27 males. The mean patient age was 44.2 years (range: 1~80). There were 16 cases of the sporadic form (79.2%) and 16 cases of the hereditary form. At diagnosis, 73 patients (94.8%) had local disease and 4 patients (5.2%) had distant metastasis. The patients with the hereditary form were younger than the patients with the sporadic form (P=0.004), and they had more muticentric (P=0.002) and bilateral tumor (P<0.001). The initial surgery consisted of total thyroidectomy in 74 patients (96.1%), and lateral neck dissection in 41 patients (53.2%) (therapeutic: 23, prophylactic: 18), except for 3 cases with less than total thyroidectomy. Forty-four patients (57.1%) achieved a long-term remission state, 13 patients (16.9%) had biochemical persistent disease, and 20 patients (26.0%) had metastasis. The 5- and 10-year survival rates were 86.5% and 74.1% respectively. On univariate analysis, tumor size (more than 2 cm), extracapsular invasion, involvement of the neck nodes and distant metastasis at the time of diagnosis were the significant prognostic factors of persistent or recurrence disease. CONCLUSION: Patients with MTC generally have a favorable outcome. The presence of distant metastasis at the time of diagnosis is predictive of persistent or recurrence disease by multivariate analysis. In order to achieve an early diagnosis and administer prompt treatment, we suggest that optimal RET oncogene screening and counseling should be performed for medullary patients and their relatives.
Clinical Study ; Counseling ; Diagnosis ; Early Diagnosis ; Female ; Follow-Up Studies ; Humans ; Male ; Mass Screening* ; Medical Records ; Multivariate Analysis ; Neck ; Neck Dissection ; Neoplasm Metastasis ; Oncogenes ; Prognosis ; Proto-Oncogenes* ; Recurrence ; Retrospective Studies ; Survival Rate ; Thyroid Gland* ; Thyroid Neoplasms* ; Thyroidectomy

Anaplastic thyroid carcinoma (ATC) is a rare disease that shows very aggressive behavior. Most ATCs arise from pre-existing thyroid carcinomas. However, anaplastic transformation occurring in metastatic cervical nodes is extremely rare. We report herein on 3 cases of anaplastic transformation of metastatic lateral cervical lymph nodes from primary papillary thyroid carcinoma (PTC), which happened long after the initial surgical treatment. All the patients died of disease within 4 months in spite of aggressive treatment for the lesions. Our experience supports that appropriate lymph node dissection is mandatory at the time of initial surgery even for differentiated thyroid carcinomas.
Humans ; Lymph Node Excision ; Lymph Nodes* ; Rare Diseases ; Thyroid Carcinoma, Anaplastic ; Thyroid Gland* ; Thyroid Neoplasms*

PURPOSE: The techniques for minimally invasive surgery in various surgical fields have recently become markedly developed. The endoscopic surgical methods for head and neck surgery have been introduced somewhat later due to some technical limitations. However, various endoscopic techniques have been remarkably developed during the last 10 years. We also introduced a novel method of gasless endoscopic thyroidectomy using the trans-axillary approach. The aim of this study is to evaluate the feasibility and surgical outcome of this method for treating patients with benign thyroid tumor. METHODS: From Jan. 2002 to Dec. 2007, 171 patients with benign thyroid tumors underwent gasless endoscopic thyroidectomy via an axillary approach. We retrospectively analyzed the clinical and pathologic characteristics of the patients, the type of operation, the operative time, the post-operative hospital stay and the post-operative complications. RESULTS: Among the 171 patients, the mean age of the patients was 33.3±10.0 years and the gender ratio was 1: 84.5 (males-2, females-169). The type of operation was classified according to the extent of surgery and there was no conversion to open thyroidectomy. The mean operation time and the mean length of the post-operative hospital stay were 129.7±51.6 minutes and 3.3±1.7 days, respectively. The mean tumor size was 2.70±1.18 cm and the most common pathologic diagnosis was adenomatous hyperplasia (106 cases, 62%). For the post-operative complications, transient hoarseness occurred in 6 patients, transient hypocalcemia occurred in 1 patient and trachea and esophageal injury occurred in 1 patient each. A tumor size larger than 5 cm and concurrent thyroiditis at time of the operation both increased the mean operation time (P= 0.009, P=0.023). CONCLUSION: According to our experience, gasless endoscopic thyroidectomy using a trans-axillary approach is a feasible and safe method for treating benign thyroid tumor. Moreover, the cosmetic benefits can be maximized by this method as compared with the other methods. Endoscopic thyroid surgery has become a new treatment modality for selected patients with benign thyroid tumors.
Diagnosis ; Head ; Hoarseness ; Humans ; Hyperplasia ; Hypocalcemia ; Length of Stay ; Methods ; Minimally Invasive Surgical Procedures ; Neck ; Operative Time ; Retrospective Studies ; Thyroid Gland* ; Thyroidectomy* ; Thyroiditis ; Trachea