A case of recurrent intramural uterine stromal tumor with epithelial differentiation effectively treated with oral low-dose administration of etoposide

A 66-year-old woman was diagnosed as having myoma of the uterus and total hysterectomy with bilateral salpingo-oophorectomy was performed. The histopathological findings were puzzling, and the case was finally diagnosed as intramural uterine stromal tumor with epithelial differentiation. Three years after the operation, a firm tumor developed in the pelvic cavity. Laparotomy failed to remove the tumor and neither CAP (cyclophosphamide 500 mg, adriamycin 50 mg, CDDP 70 mg) therapy nor radiation therapy was effective. Oral administration of etoposide (25 mg/day), however, showed PR (50% decrease) as determined by CT scanning, and ultrasonography, and no metastatic lesions were found. This tumor was coincident with the endometrial stromal tumor with epithelial elements classified by Clement and Scully. The histological feature of the tumors and the efficacy of oral etoposide therapy are discussed in this study.

[Clinical study of fluconazole-injectable and -granules in pediatric patients]

In this study, we have investigated the clinical effectiveness of fluconazole (FLCZ) given intravenously or orally to pediatric patients with systemic fungal infections. FLCZ was administered intravenously to two patients with acute leukemia (multiple hepatosplenic candidiasis and aspergillosis) and orally to two mycosis complicated with neuroblastoma and aplastic anemia, respectively. Clinical efficacies were excellent and no side effects were observed in any patients. Pharmacokinetic analysis in 6 neonates revealed that the plasma half-life is 37-41 hours after administration of single dose of intravenous infusion of 3 mg/kg of FLCZ.

Successful peritransplant therapy in children with active hepatosplenic candidiasis

Two pediatric leukemic patients with hepatosplenic candidiasis during multidrug antileukemic chemotherapy successfully underwent bone marrow transplantation (BMT) after aggressive antifungal chemotherapy employing fluconazole and amphotericin B with or without splenectomy. One patient received allogeneic marrow graft and the other received an autologous graft. One patient has been disease-free for more than 21 months after BMT without any recurrence of Candida infection. The other patient showed tentative reactivation of hepatic lesions just after BMT by CT scanning, but these lesions disappeared again by continuous administration of the antifungal agents. The second patient died of leukemia relapse without recurrence of fungal infection. Our cases indicate the possibility of successful BMT once a fungal infection is well controlled by antifungal chemotherapy and surgical resection.

Mature helper T cell requirement for immunoglobulin production by neonatal native B cells injected intraperitoneally into severe combined immunodeficient (SCID) mice

It is accepted that human neonatal naive B cells produce mainly IgM in vivo as well as in vitro. Our previous work has demonstrated that i.p. injection of neonatal B cells together with adult mature T cells induces substantial levels of human IgG in the serum of SCID recipient mice. The present study was further attempted to determine the cellular components required for immunoglobulin production by neonatal B cells in SCID mice. When neonatal B and adult T cells were transferred into the SCID mice, human immunoglobulins, largely of IgG, were maximally detected in the serum around 6 weeks after a cell transfer. Depletion of CD4+ T cells from adult T cells resulted in undetectable levels of human immunoglobulin in the serum. By contrast, CD4+ T cell-enriched populations exhibited an enhancing effect on immunoglobulin production by neonatal B cells. Higher levels of immunoglobulin, including IgA and IgM, were detected in the peritoneal fluid than in the serum as early as 2 weeks after the cell transfer. Human T cells expressing activation antigens such as CD45RO and HLA-DR antigens were identified in the peritoneal lavages. These results suggest that neonatal naive B cells are able to differentiate into cells producing all classes of immunoglobulin in the presence of mature CD4+ T cells in a SCID mouse environment. The peritoneal cavity of SCID mice appears to provide a suitable place for immune responses by human cells, possibly in association with a certain xenogeneic reaction.

Acute cervical spinal epidural hematoma with spontaneous resolution--case report

A 54-year-old male presented with spontaneous acute epidural hematoma in the ventral cervical spine. The neurological deficits gradually improved spontaneously before surgery commenced. Serial magnetic resonance imaging demonstrated disappearance of the hematoma. He was managed conservatively and was discharged without deficits about 1 month after onset. Immediate surgical decompression may not be necessary if neuroimaging and clinical examinations suggest that spinal epidural hematoma will resolve spontaneously.

[Event related potentials and reaction time on auditory discrimination tasks (2nd report)--a study by trial-to-trial analysis]

Latency variability for single trial in the 4 components (N100, P200, N200 and P300) of the auditory event related potentials (ERP) and the temporal relationship to the choice reaction time (RT) were investigated in 11 normal subjects. Identification of each latency on single trials was derived by using a correlational-template procedure. Results showed that the mean value of the single trial latency in the 4 components was close to the peak latency in the averaged waveform. Significantly larger coefficient of variation was obtained for the N100 component and RT, when compared to the other components. Higher correlation between single trial latency and RT was found for N200 and P300 components. The P300 component latency yielded a significant temporal effect across trials (p < 0.05) showing increases in its latency in the later trials, whereas none of the RT did. These results may indicate that the P300 component latency is influenced directly by subtle changes in cerebral activities during an initial stage of human cognitive function occurring in each trial, whereas RT is additionally influenced by greater functional fluctuation during the process of motor execution for making responses.

Malignant paraganglioma presenting as Cushing syndrome with virilism in childhood. Production of cortisol, androgens, and adrenocorticotrophic hormone by the tumor

BACKGROUND

A 12-year-old girl with intractable retroperitoneal paraganglioma experienced increased appetite, acne, obesity, "moon face," and enlargement of the clitoris during the course of the tumor. Plasma cortisol, serum testosterone, and dehydroepiandrosterone sulfate (DHEA-S) levels were increased to 34.1 micrograms/dl, 2.0 ng/ml, and 6.628 ng/ml, respectively. Adrenocorticotrophic hormone (ACTH) levels were not increased, and results of dexamethasone suppression tests were negative. Her condition was diagnosed as Cushing syndrome with virilism. Plasma cortisol levels were increased to a level of 107.1 micrograms/dl before death.

METHODS

Tumor samples were obtained at the time of autopsy. The concentrations of cortisol, androgens, ACTH, and catecholamines were assayed in the tumor extracts. The indirect immunoperoxidase procedure was performed on fixed tissues for cortisol, DHEA-S, testosterone, and ACTH.

RESULTS

Extracts of the tumor masses contained steroid hormones: the amount of immunoreactive cortisol was 1.64 micrograms/g wet weight; the amount of immunoreactive testosterone was 25.60 ng/g wet weight; immunoreactive DHEA-S, 579.00 ng/g wet weight; and immunoreactive ACTH, 891.00 pg/g wet weight in the metastatic mass of the lung. Immunohistochemically, immunoreactive cortisol, testosterone, and DHEA-S were detectable in the tumor cells. The adrenal gland was atrophic.

CONCLUSIONS

The patient is the first reported with malignant paraganglioma with the capacity to produce cortisol, androgens, and ACTH.

Quantification of coronary artery calcification using ultrafast computed tomography: reproducibility of measurements

BACKGROUND

Ultrafast computed tomography (CT) is a non-invasive method of visualizing and quantifying coronary artery calcification; its reproducibility, however, has not been fully elucidated.

METHODS

To assess intra-observer, inter-observer, and inter-study reproducibility, 75 consecutive patients (51 men and 24 women) were studied. CT images were obtained using the volume mode of ultrafast CT (Imatron C-100). A total coronary calcification score (TCS) was calculated from the lesion area (> or = 2 pixels) and its peak CT density (> or = 130 HU).

RESULTS

There was no intra-observer variability in two experienced observers. The TCS provided by these observers disagreed in 18 out of 75 (24%) cases, and the differences were -5.1 +/- 53 (mean +/- SD) for TCS and 0.014 +/- 0.13 for In(1 + TCS). They resulted from either 10 incorrect identifications of small coronary branches, or eight variations in determination of the ostial margin. The former was much smaller than the latter in TCS (0.66 +/- 3.0 and -48 +/- 165, respectively), but both were quite similar in In(1 + TCS) (0.082 +/- 0.31, 0.017 +/- 0.22, respectively). Between two scans, 50 out of 75 patients (67%) had different TCS values. The mean differences (95% confidence interval) were 1.8 +/- 106 (-210 to 214) in TCS, and -0.015 +/- 0.46 (-0.94 to 0.91) in In(1 + TCS). Because the differences increased with the mean values, the determination of TCS assumed a constant variance with increasing mean level. A comparison of scan images indicated that partial volume effects were responsible for this constant variance.

CONCLUSION

Partial volume effects play a key role in producing the variability of TCS determination, and log transformation should be used to interpret TCS values. Thus, for clinical purposes, we recommend that two scans be performed in rapid succession, and that the average of these two scans be used to determine TCS.

Assessment of proliferating cell nuclear antigen (PCNA) immunoreactivity in exocrine pancreatic carcinomas

Twenty patients with exocrine pancreatic carcinomas were studied immunohistochemically, using a monoclonal antibody against PCNA. The percentage of tumor cells with positive staining was defined as PCNA Labelling Index (L.I.), and ranged from 13.8% to 92.8%. PCNA LI was found to correlate significantly with grading and more specifically with mitotic activity and degree of nuclear anaplasia. No correlation was found with glandular differentiation or with vessel invasion, lymphatic vessel invasion, lymph node metastasis, perineural invasion or size of tumor. Our results indicate that mitotic activity and degree of nuclear anaplasia might be the most important parameters to take into consideration, when studying the role of PCNA in exocrine pancreatic carcinomas.

Synthesis and characteristics in tumor-bearing mice of N-[11C]methyl-1-deoxynojirimycin and N-[11C]methyl-1-deoxymannojirimycin

N-[11C]Methyl-1-deoxynojirimycin ([11C]MDNM) and N-[11C]methyl-1-deoxymannojirimycin ([11C]MDMM) were prepared by 11C-methylation of 1-deoxynojirimycin (DNM) and 1-deoxymannojirimycin (DMM), which are specific inhibitors of glucosidase and mannosidase, respectively. In mice bearing Ehrich ascitic tumor, the highest uptake of the [11C]MDNM was observed in the kidney, followed by the liver and small intestine, while the tumor uptake was moderate. By MDNM loading, saturable uptake was observed in these tissues. In homogenates of the kidney and tumor tissues, a considerable amount of radioactivity was detected in a high-molecular weight fraction. These results demonstrate that the [11C]MDNM has a potential for imaging the glucosidase activity by positron emission tomography. On the other hand, [11C]MDMM showed lower uptake than [11C]MDNM in the kidney, liver and small intestine and no effect of carrier DMM, suggesting that the [11C]MDMM would not reflect mannosidase activity.

Increased levels of urinary interleukin-6 in Kawasaki disease

Kawasaki disease (KD) often presents with abnormal urinary findings, such as aseptic pyuria, mild proteinuria and microscopic haematuria. In this study, we measured urinary interleukin-6 (IL-6) by a sensitive sandwich ELISA assay using mouse monoclonal antibodies against recombinant IL-6 to elucidate the role of IL-6 in the pathogenesis of renal lesions in KD. Serum IL-6 levels were increased in acute KD as well as in febrile controls. Importantly, urinary IL-6 levels were consistently elevated in patients with acute KD, but much lower in febrile controls. Urinary IL-6 levels returned steadily to normal during the convalescent phase. In addition to IL-6, urinary levels of N-acetyl-beta-D-glucosaminidase (NAG) and beta 2-microglobulin (beta 2-mg) were also elevated during the acute phase of this disease. Eosinophils and macrophages were identifiable in urinary sediments from these patients. The increased levels of urinary IL-6 in combination with increased NAG and beta 2-mg seemed to suggest the presence of certain renal parenchymal lesions with cellular infiltration during the acute phase of the disease. IL-6 may serve as clinically useful parameter for the detection and monitoring of the renal involvement in KD.

Close phylogenetic relationship between Vestimentifera (tube worms) and Annelida revealed by the amino acid sequence of elongation factor-1 alpha

To clarify the phylogenetic position of Vestimentifera (tube worms), 346-bp fragments of the elongation factor-1 alpha (EF-1 alpha) gene (939-1286 according to the numbering of the human gene) of a vestimentiferan, Lamellibrachia sp., a sternaspid polychaete, Sternaspis scutata, an earthworm, Pheretima sp., and a gastropod, Alviniconcha hessleri, were sequenced. From the amino acid sequences of these EF-1 alpha, and those of two other vertebrates and two arthropods, phylogenetic relationships were deduced by the maximum likelihood (ML) method, by which the phylogenetic tree can be inferred without assuming constancy of the molecular evolutionary rate. For the ML tree and all of seven alternative trees, whose log-likelihoods could not be discriminated from that of the ML tree by the criterion of the standard error, the vestimentiferan, the polychaete, and the oligochaete formed a clade, excluding the arthropods and the gastropod as outgroups. This result is convincing evidence that Vestimentifera are protostomes that are closely related to Annelida. The ML tree suggests that Vestimentifera are more closely related to Polychaeta than to Oligochaeta, though the data were not sufficient to discriminate these three groups at a significant level. From recent evidence such as morphological characteristics and molecular information, it may safely be said that vestimentiferans should be included in the Annelida provided this phylum contains polychaetes and oligochaetes.

The auditory evoked middle-latency responses (MLRs): their normative variation and generators

Auditory evoked middle-latency responses (MLRs) to clicks were recorded in 68 normal adults (ages from 21 to 59 year-old) at 16 scalp locations, all referred to a balanced non-cephalic reference. Both Na and Pa components were clearly demonstrated in all the subjects studied through the digital high-pass filtering. Both Na and Pa components were distributed dominantly over the frontal area in all subjects. The amplitudes of Na and Pa were significantly higher with binaural stimulation than with a monaural stimulation, and the existence of binaural interaction was also suggested. Binaural effect was more prominent in Pa than in Na component. When the data recorded from F3 and F4 electrodes were compared, most of F3/F4 amplitude ratios of Na and Pa were included between 0.7 and 1.5. The F3/F4 ratio should be useful indices for the diagnosis of excessive laterality. We also demonstrated gradual phase shifts of Na and Pa between the frontal and temporo-occipital area in about one-third of the records. This phenomenon strongly suggests that both Na and Pa components are derived from complex generators.

[Modes of spread and surgical strategy for gallbladder carcinoma with subserosal invasion]

The mode of spread and the prognosis were investigated in 22 patients with resected gallbladder carcinoma invading the subserosal layer. By the Kaplan-Meier method, the 5-year survival rate was 68.8% in patients receiving curative or relatively noncurative resection. On the other hand, no patient survived for more than 3 years after noncurative resection. The mode of subserosal infiltration was classified according to the general rules for gastric cancer study. At least systemic lymph node dissection (R2) should be performed in patients with ss alpha cancer, because lymph node metastasis in these patients were confined to the 1st group. More extensive lymph node dissection (R2 with 9, 16) is essential for patients with ss beta and ss gamma, because lymph node metastasis to at least the 2nd group were seen in 75% of them. The surgical margin was positive for cancer in all patient with infiltration of the hepatoduodenal ligament. Therefore, it was considered that hepatoligamentectomy should be performed in these patients to obtain a cancer free surgical margin. Among patients undergoing curative or relatively noncurative resection, the recurrence rate was 43% in those with lymph node metastasis and 50% in those with DNA aneuploidy. Therefore, it appears that adjuvant chemotherapy should be given to such patients.

[Percutaneous transhepatic cholecystoscopic lithotomy (PTCCSL)]

We have performed percutaneous transhepatic cholecystoscopic lithotomy (PTCCSL) in 37 cases of cholecystolithiasis and have succeeded in the removal of the stones in all cases without any serious complications. The average period from gallbladder puncture until the completion of lithotomy was 11.8 days and PTCCSL was performed an average of 2.1 times. The follow-up period after lithotomy ranged from one to 60 months, with an average of 24.7 months. Gallbladder function returned to the pretreatment level. However, gallstones recurred in 7 cases (18.9%). In comparison with both cholecystectomy by laparotomy and laparoscopic cholecystectomy, PTCCSL is less invasive, but recurrence may occur in a relatively short period with PTCCSL. Therefore PTCCSL is particularly indicated for high-risk patients who cannot undergo general anesthesia.

Neural cell adhesion molecule (NCAM) and perineural invasion in bile duct cancer

Perineural invasion is associated with tumor spreading and an unfavorable prognosis in a variety of cancers. Recently, neural cell adhesion molecule (NCAM) has been reported to be affinitive to neural tissues, which suggests some relationship between NCAM and perineural invasion. This study was designed to elucidate the role of the expression of NCAM on the development of perineural invasion in bile duct cancer. A histopathologic study was performed on 24 patients with bile duct carcinoma who underwent resections. The overall incidence of NCAM expression in the resected specimen was 66.7% and that of perineural invasion was 87.5%. Furthermore, NCAM expression was shown to be positive in 16 (76%) out of 21 cases in whom perineural invasion was observed. A significant positive correlation was found between the expression of NCAM and perineural invasion in bile duct cancer. These results highlight an important role of NCAM in the development of perineural invasion in bile duct cancer.

Mast cell quantitation in nasal polyps, sinus mucosa and nasal turbinate mucosa

The distribution and abundance of mast cells in nasal polyps, the maxillary sinus mucosa of patients with sinusitis and the turbinate mucosa of allergic rhinitis was microscopically examined using different methods of fixation. In the epithelium of the surface and the ducts of nasal polyps (n = 8), the mean number of mast cells was over 20,000 per mm3 using Mota's fixation and the increase was correlated with the epithelial thickness (P < 0.05). On the other hand those of the maxillary sinus mucosa (n = 6) and the nasal turbinate mucosa (n = 7) were less than 6,000 per mm3. In the subepithelial layer or areas deeper than the area with the glands, however, mast cell counts were less than 3,200 per mm3 in all diseases. More than 70-90 per cent of all mast cells in the epithelium of the mucosal surface and the ducts of the polyp, the maxillary sinus mucosa and nasal turbinates were formalin sensitive. Most of the mast cells in the subepithelial and deeper areas were formalin resistant in all diseases. These results suggest that conditions for mast cell growth differ between polyps and the other diseases, and that the conditions which affect mast cells may contribute to polyp development.

[A case of chorea-acanthocytosis associated with low glycohemoglobin A1c]

We reported the first case of chorea-acanthocytosis associated with low glycohemoglobin A1c. Fasting blood sugar, daily profile of blood sugar, serum fructosamine and 75 g glucose tolerance test were all within normal limits. While abnormal hemoglobins were not detected, red blood cell half-life was sharply reduced to 13.4 days. These findings suggest that the low glycohemoglobin A1c in this case is highly ascribable to the reduction of red blood cell half-life rather than to continuous hypoglycemia. However, we can not rule out that the abnormalities of red blood cell membrane, suggested factors in this disease, may be related to the low glycohemoglobin A1c value. Further investigations on chorea-acanthocytosis cases with normal red blood cell half-life are necessary in order to elucidate whether an abnormal glycohemoglobin A1c value is a specific indication regarding this disease.

Experience in twenty patients with carcinoma of hilar bile duct treated by resection, targeting chemotherapy and intracavitary irradiation

Three years ago, we reported a new treatment modality for carcinoma of the hilar bile duct consisting of limited hepatic hilar resection with selective adjuvant therapies by local chemotherapy using a new drug delivery system and by intracavitary 60Co irradiation using a remote after loading system. This treatment was applied in 20 patients by April 1991 and the results are fairly good. The overall one, three and five year survival rates are 80, 33 and 26 percent, respectively, which are better than those reported. No serious complications have been observed after operation and adjuvant therapies. Comparing the survival rate and prognostic factors, it was proved that the prognostic factors were not influential in the 20 patients. For the further improvement of this treatment modality, some special devices will be necessary to treat not only the resection stump but also the excisional surface of the tumor.

[Gonadotrophin-releasing hormone agonist in the treatment of hypogonadotrophic secondary amenorrhoea]

In an attempt to induce ovulation in Clomiphene resistant secondary amenorrhoea patients, the gonadotrophin-releasing hormone agonist (Buserelin) (600-900 micrograms/day) was administered in 13 cases aged 18 to 24 years for one week from day 5 of the menstrual cycle. Serum levels of luteinizing hormone increased in all patients, and estradiol levels increased in 10 of 13 patients in response to Buserelin. However, ovulation was observed in 6 cases, and the response to Clomiphene was recovered in all of these 6 cases in their subsequent menstrual cycles. These results imply the existence of a subgroup who respond to Buserelin in Clomiphene resistant secondary amenorrhoea patients and a possible new approach for the treatment of secondary amenorrhoea.

Anterior segmentectomy with caudate lobectomy for hilar cholangiocarcinoma

When hepatic resection for hilar chol-angiocarcinoma with impaired hepatic function is performed, minimal resection of the involved segment on the basis of the extent of cancer invasion must be selected so as to minimize the risk of postoperative hepatic failure. We describe our experience with anterior segmentectomy with caudate lobectomy for hilar cholangiocarcinoma in two patients with impaired hepatic function and poor general health. These procedures were curative resections histologically, and were not followed by severe postoperative complications. Anterior segmentectomy together with caudate lobectomy was considered appropriate treatment for hilar cholangiocarcinoma without infiltration of the posterior hepatic branch in patients with impaired hepatic function.

[Localization of androgen receptor in male sex organ, accessory sex organs and external genital skin]

Previously, we established an anti-androgen receptor (AR) monoclonal antibody. Using the antibody, we investigated immunohistological AR localization in human testes, epididymides, seminal vesicles and scrotal skins. The testes, epididymides and scrotal skins were obtained from a prostate cancer patient without pre-hormonal therapy undergoing bilateral orchiectomy. The seminal vesicles were obtained from a bladder cancer patient undergoing radical cystectomy. The tissues were immediately frozen in liquid nitrogen and kept at -80 degrees C until used. Cryostat-frozen sections were cut at 5 microns and stained by an indirect method. We obtained the following results. 1) In the testes, nuclei of Leydig cells were stained though Sertoli cells were not stained. AR localization in Leydig cells which produce testosterone suggests autocrine or intracrine mechanism in the testis. 2) In the epididymides, nuclei of epithelial cells of epididymal ducts were stained, while muscles and connective tissues were not stained. In the seminal vesicles, nuclei of glandular epithelial cells were stained. 3) In the scrotal skins, the cells of squamous cell layer have positive stainings. The cells in the upper portion of squamous cell layer were stained more intensely than the cells in the lower portion. The basal layer was not stained. The cells of the outer root sheath of hair follicles in the scrotal skins were also stained. 4) In androgen target organs, AR-positive cells and AR-negative cells were mixed in the epithelium of a glandular duct, which suggests heterogeneity of AR localization in the androgen target organs.