[Surgical technique and long-term follow-up of laminoplasty using titanium miniplates]

Problems concerning a spinal deformity due to simple laminectomy and the usefulness of laminoplasty are often reported recently. In our hospital, laminoplasty with titanium miniplates for spinal operations has been used in all cases since 1992. We started to use this method after we encountered several cases of post-operative spinal deformity following multiple-level laminectomy. We reviewed two different subgroups of patients. Group A consisted of 38 cases who were operated on using simple laminectomy. Group B consisted of 32 cases who were operated on using laminoplasty with titanium miniplates. Postoperative spinal deformity occurred in 5 patients of Group A (13%), and in none of Group B (0%). In particular, postoperative spinal deformity occurred in one child case of Group A (33%), and in none of Group B (0%). Laminoplasty is a very simple and efficient technique, and advantages are the presentation of stability of the posterior column and curvature of the laminae, as well as protection of the spinal cord. Compatibility with magnetic resonance imaging (MRI) is another advantage of titanium miniplates, because long follow-up using MRI is always necessary in these cases. In conclusion, laminoplasty with titanium miniplates for spinal operations are a very useful and safe technique.

[A case of primitive neuroectodermal tumor of the kidney]

A primitive neuroectodermal tumor (PNET) is a solid tumor originating from the neural crest. This tumor is known to occur in the central nervous system and soft tissue, but recently determined to also invade the kidney. Although primary renal PNET is very rare, we encountered a case of primary renal PNET with multiple lung metastasis. This case was a 35-year-old man with a chief complaint of macroscopic hematuria, which he noticed in January 1996. He was hospitalized because of right renal tumor detected with ultrasonography. On CT scan, a low-density solid tumor with a maximum diameter of 8 cm was visualized in the right kidney. Low-signal and high-signal tumorous lesions were demonstrated in the same region on T 1-weighted and T 2-weighted MR images, respectively. Then right radical nephrectomy was performed on Feb. 5, 1996. On histopathological observation, the tumor was composed of small tumor cells with solid growth. Immunohistochemical staining revealed that the tumor was positive for CD 99. Thus our final diagnosis was primary right renal PNET. Although 2 metastatic lesions with a diameter of about 1 cm were observed in the right lower lung before the time of surgery, pulmonary metastatic lesions markedly increased in number 3 months after surgery. Thus we initiated CAP chemotherapy with cyclophosphamide, doxorubicin, and CDDP. After 3 cycles, pulmonary metastatic lesions disappeared at CT scan, indicating complete remission. However, a tumor with a maximum diameter of about 10 cm recurred in the retroperitoneum 7 months after complete remission. Although 2 cycles of CAV/PE therapy with cyclophosphamide, doxorubicin, vincristine, CDDP, and VP-16 were performed following resection of the retroperitoneal tumor, he showed no response and decreased 24 months after surgery.

Adult Leigh syndrome with mitochondrial DNA mutation at 8993

Adult onset Leigh syndrome with a nucleotide (nt) 8993 mutation in mitochondrial (mt) DNA is reported. A 43-year-old woman with a 6-year-history of insulin-resistant diabetes mellitus developed muscular weakness, intractable nausea and vomiting, and anemia. These were followed vertigo, blindness, and deafness with nystagmus. Magnetic resonance imaging (MRI) revealed abnormal high intensities in the bilateral medial regions of the thalamus and periaqueductal gray matters. Autopsy disclosed well-demarcated necrotizing lesions with prominent capillaries in the areas detected by MRI, which were sufficiently diagnostic for Leigh syndrome. MtDNA analysis performed on DNAs extracted from formalin-fixed tissues including liver, heart, brain, muscle, kidney and pancreas showed a T-->G mutation at nt 8993. This is the first case of adult Leigh syndrome demonstrating on mtDNA mutations.

Wernicke encephalopathy-like symptoms as an early manifestation of Creutzfeldt-Jakob disease in a chronic alcoholic

A case of Creutzfeldt-Jakob disease (CJD) with presenting Wernicke encephalopathy (WE)-like symptoms and severe insomnia is presented. An 80-year-old alcoholic man with a 6 month history of tremors, ataxia, memory loss and confabulation, developed profound insomnia, confusion, and delirium with vivid hallucinations. Polysomnography revealed a marked reduction of sleep time, with central-type sleep apnea. Neither myoclonus nor periodic synchronous discharge (PSD) was observed. An autopsy revealed diffuse spongiform changes and astrocytosis throughout the cerebral gray matter, with severe involvement of the mammillary bodies and thalamus. Prion protein (PrP) immunostaining was positive in kuru plaques in the cerebellum, PrP polymorphism at codon 129 was heterozygous Met/Val, and proteinase K resistant PrP (PrP(res)) was demonstrated by Western blotting. The lack of necrotizing lesions in the mammillary bodies, thalamus, and periaqueductal gray matter could rule out WE. The data suggest that the present case of CJD is consistent with PrP(res) type 2 (CJD M/V 2), but was unique in the lack of some typical CJD signs and the presence of signs of WE and sleep abnormalities.

Allelic variations of the D2 dopamine receptor gene in children with idiopathic short stature

The D2 dopamine receptor (DRD2) plays a major role in growth hormone (GH) secretion. Recent reports indicate that Taq I A DRD2 gene alleles (A1 and A2) are related to the function of DRD2. Idiopathic short stature (ISS) is defined as short stature without accompanying malnutrition, chronic disease, and endocrinological disorders. However, some reports suggest that ISS is associated with a mild disturbance of GH secretion. In this study, we examined the notion that allelic variants of the DRD2 are associated with ISS. We studied 55 children with ISS aged 8.4 (SD 2.9) years; (group I) and 104 age-matched children of normal stature (group II). Informed consent was obtained from each child's parent or guardian. Genomic DNAs were extracted from peripheral mononuclear cells and amplified by polymerase chain reaction (PCR). The PCR products were digested by Taq1 and resolved by electrophoresis. The frequency of the A1 allel was significantly higher in group I (0.42) than in group II (0.26). The insulin-like growth factor (IGF)-I ratio (the ratio of the individual level to the normal mean value according to age at our laboratory center) was significantly lower in group I than in group II. When group I was subdivided into group A (with the A1 allele) and group B (with only the A2 allele), group A had a significantly lower peak GH response to the l-dopa test, lower levels of IGF-I, and retarded bone maturation. These findings indicate that polymorphism of the DRD2 gene may be one genetic factor that affects body height in childhood, acting through the hypothalamus (GH-releasing hormone)--pituitary (GH)--IGF-I axis.

Reoxygenation injury of human brain capillary endothelial cells

1. Many studies have demonstrated that endothelial cells from several species can generate oxygen free radicals when subjected to anoxia and reoxygenation. However, due to the heterogeneity of the endothelium within different organs and species, the effects of superoxide dismutase (SOD), catalase, and allopurinol on reoxygenated cultured cells remain quite controversial. 2. This review outlines the possible sources of oxygen free radicals within brain endothelial cells. 3. We examine the aspects of the effects of SOD catalase and allopurinol on cultured human brain capillary endothelial cells upon reoxygenation. 4. Also, we introduce briefly a method of culturing human brain capillary endothelial cells and present our experimental results on the effects of SOD, catalase, and allopurinol in these cultured cells following anoxia and reoxygenation.

Primary Non-Hodgkin's Lymphoma of the Male Breast: A Case Report

A 69-year-old Japanese man presented with bilateral gynecomastia and a soft, mobile and clearly defined mass beneath the left nipple. A round radiopaque masswas revealed on mammography. The tumor was homogeneous, hypoechoic and measured2.4 x 3.9 cm on ultrasonography. Based on a diagnosis of malignant lymphoma by needle aspiration cytology, a modified radical mastectomy with ipsilateral axillary lymph node dissection was performed. Malignant diffuse large B-cell type lymphoma was diagnosed histologically. Whole body examinations revealed no evidenceof other tumors. Three courses of adjuvant CHOP therapy were subsequently performed. The patient is free of recurrence 12 months after surgery. Primary non-Hodgkin's lymphoma (NHL) of the male breast is extremely rare. The occurrence of lymphoma in this patient could be related to elevated estrogen levels.

Hypothalamic hamartoma associated with multiple congenital abnormalities. Two patients and a review of reported cases

We report 2 patients with hypothalamic hamartoma associated with multiple congenital abnormalities and analyze 42 (including our own) reported cases, including our 2 cases, of hypothalamic hamartoma or hypothalamic hamartoblastoma with multiple congenital abnormalities, to understand the timing of their occurrence and clarify the prognosis. To this end, we classified them into lethal and nonlethal cases. We found poly- and syndactyly, cleft or high-arched palate and nose abnormalities to be important manifestations of this syndrome. Major organ abnormalities and CNS and endocrine abnormalities occurred frequently among the lethal cases, very likely indicative of a disturbance of embryogenesis between gestational days 34-37 and thus implicated in a negative prognosis.

In vitro inhibition of binding of tumor necrosis factor (TNF)-alpha by monoclonal antibody to TNF receptor on glioma cell and monocyte

The use of monoclonal antibodies to the tumor necrosis factor (TNF) receptors, the TNF-p55 receptor (TNF-p55R) and the TNF-p75 receptor (TNF-p75R), was evaluated to reduce the effects of TNF caused by binding to TNF-p75R. Competitive binding of anti-TNF-p55R (mAbp55R) and anti-TNF-p75R monoclonal antibodies (mAbp75R) with iodine-125-labeled TNF-alpha to GL-9 glioma cells and U937 histiocytic lymphoma cells was evaluated. The effects of mAbp55R and mAbp75R on the growth suppression by TNF-alpha of GL-9 cells and TNF-alpha production in U937 cells were also examined. mAbp75R bound to U937 cells competitively with TNF-alpha and suppressed TNF-alpha production by U937, but had no effect on the growth inhibition of GL-9 human glioma cell by TNF-alpha in vitro. These findings suggest that co-administration of TNF-p75R antagonist with TNF-alpha may decrease the toxicity of TNF-alpha administration resulting in a better therapeutic result.

Hirschsprung's disease in an adult patient with familial occurrence: report of a case

Hirschsprung's disease is almost always associated with newborns or infants; however, we report herein the unusual case of a 46-year-old woman in whom the symptoms of Hirschsprung's disease emerged late in adult life. The involved rectosigmoid region was successfully removed by performing Duhamel's operation with a diverting colostomy. After the colostomy was closed, she regained normal defecatory function. She had one male child affected by Hirschsprung's disease of the total colon type who was operated on as a 12-month-old baby. The genetic predisposition of Hirschsprung's disease has been reported, but its mode of inheritance has not yet been clarified. Moreover, most papers on the familial occurrence of this disease have reported that siblings were affected. Our patient was unique for the definite occurrence of the disease in successive generations. The features of Hirschsprung's disease in adults and the familial occurrence are discussed with a review of the literature.

The riddle of the large loss in bite force after fast jaw-closing movements

In unloading experiments (in which the resistance to a forceful static bite is suddenly removed), it is shown that the residual bite force (when the jaw system is arrested shortly after the unloading) is remarkably small. For example, of a 100-N initial bite force, only 18 N is left after a jaw travel distance of 5.0 mm. The present experiments were designed to study whether the magnitude of the low residual bite force is dependent on the initial bite force, the initial degree of mouth opening, and the distance of jaw travel. Furthermore, we analyzed whether the low magnitude of the residual force can be attributed to reflex events of the jaw muscles or to the force-length properties of the jaw-closing muscles. It was found that the residual forces are largely dependent on the distance of jaw travel and are barely sensitive to variations in initial mouth-opening. The relative residual forces are independent of the magnitude of the initial bite force. The maximum residual forces are on the order of 25% of the initial bite force after a jaw travel of 4.5 mm. The low values of the residual forces cannot be attributed to reflex events, because it took about 80 ms for the masseter muscles to decrease their force to a 50% level after their excitation was switched off. Furthermore, it was shown that the force-length properties of the jaw-closing muscles are not responsible for the small values of the residual forces, since over the trajectories used in the present experiments, the sarcomere lengths of the jaw-closing muscles were beyond their optimum. It is suggested that the low residual forces are brought about by (1) a non-uniform sarcomere behavior of the jaw-closing muscles when contracting, or (2) a long-lasting change in the myofilament system of the closing muscles induced by the sudden shortening of muscle fibers.

Advanced endocrine cell carcinoma of the gallbladder: a patient with 12-year survival

Gallbladder carcinoid is a rare disease. In previous reports, classical carcinoid, an entity with a good prognosis, has not been distinguished from endocrine cell carcinoma, a tumor associated with marked cell atypia and mitosis, and a poor prognosis. The patient was a 66 year old woman who presented to our hospital with a chief complaint of jaundice. Pre-operatively, she was diagnosed as having advanced gallbladder carcinoma invading the liver and the hepatic hilus. The patient underwent right hepatic trisegmentectomy with en bloc resection of the caudate lobe and extrahepatic bile ducts, extended lymph node clearance and left hepaticojejunostomy. Histopathological examination showed positive Grimelius staining, marked mitosis, and intense atypism, hence, the tumor was diagnosed as an endocrine cell carcinoma. Twelve years after surgery, the patient is healthy, without any sign of recurrence. We present this novel case of long-term survival and review the literature.

Reactive oxygen species in reoxygenation injury of rat brain capillary endothelial cells

OBJECTIVE

To clarify the mechanism of anoxia/reoxygenation (A/R) injury of rat brain capillary endothelial cells (BCEC).

METHODS

BCEC isolated from Sprague-Dawley rats by enzymatic treatment and centrifugation were subjected to anoxia (95% N2, 5% CO2) for 20 minutes and then to reoxygenation (95% air, 5% CO2) for 3 hours. Enzyme inhibitors, including oxypurinol, indomethacin, and N(G)-nitro-L-arginine methyl ester, or specific free-radical scavengers, such as superoxide dismutase, catalase, and the ferric iron chelator deferoxamine, were added before A/R injury. The BCEC were incubated in a range of Ca2+ concentrations from 1 to 0.01 mmol/L during A/R injury. Cytotoxicity was assayed by release of intracellular lactate dehydrogenase (LDH).

RESULTS

With A/R injury, LDH release from the control group (no protective agents) significantly increased (44.8 +/- 3.3%), compared with a small increase in a normoxic group. BCEC treated with oxypurinol, indomethacin, or N(G)-nitro-L-arginine methyl ester showed suppression of LDH release. LDH release was almost totally suppressed by superoxide dismutase and partially by catalase or deferoxamine. The LDH release was partly dependent on calcium concentration.

CONCLUSION

BCEC subjected to A/R become potent generators of free radicals, especially superoxide anion. Free radical production depends on both xanthine oxidase and cyclooxygenase pathways. Peroxynitrite and extracellular Ca2+ both contribute importantly to reoxygenation injury of BCEC.

Combined transpetrosal and fronto-orbito-zygomatic approach to a giant skull based meningioma: a case report

BACKGROUND

Recently, various surgical approaches to skull base lesions have been developed. Skillful use of the combination of two standard approaches make possible the removal of large brain lesions, which conventionally had been considered inoperative. In this study, we present a case of a giant meningioma located in the cerebellopontine angle and middle cranial fossa. A near total resection was achieved using a combined transpetrosal and fronto-orbito-zygomatic approach.

CASE REPORT

A 15-year-old boy presented with a meningioma that caused a left hearing loss, dysarthria, and cerebellar ataxia. Preoperative magnetic resonance imaging revealed a giant meningioma located in the right cerebellopontine angle, middle fossa, and cavernous sinus. The patient underwent a near total resection of the tumor through a combined transpetrosal and fronto-orbito-zygomatic approach. He experienced a marked improvement postoperatively and entered high school the following year.

CONCLUSIONS

An approach from several angles was necessary for the giant skull based tumor presented here. A combination approach was selected for obtaining a wide operative field with minimal brain compression during resection of neoplasm. According to the individual features of each case, selection of the operative approach, decisions regarding the extent of excision, and postoperative treatment regimens should be adequately planned in the preoperative period.

Predicting the prognoses of breast carcinoma patients with positron emission tomography using 2-deoxy-2-fluoro[18F]-D-glucose

BACKGROUND

Positron emission tomography (PET) with 2-deoxy-2-fluoro[18F]-D-glucose (FDG) can provide quantitative information about tumor glucose metabolism. The prognostic value of this technique was evaluated for breast carcinoma patients.

METHODS

FDG PET was performed on 70 patients with primary breast carcinoma, and the differential absorption ratio (DAR) was calculated as an index of FDG uptake. Overall and relapse free survival curves were created by the Kaplan-Meier method, and differences between the curves were analyzed with the log rank test. For multivariate analysis, the Cox proportional hazards regression model was used.

RESULTS

The mean DAR was 2.61+/-1.61 standard deviation (range, 0.65-9.39). According to the grade of DAR, patients were then classified into high DAR (> or =3.0) and low DAR (<3.0) groups. The high DAR group had significantly worse prognoses for both overall and relapse free survival (P < 0.0005 and P < 0.0001, respectively). In multivariate analysis, DAR was an independent predictor of the relapse free survival of breast carcinoma patients (P=0.0377).

CONCLUSIONS

DAR, as determined by FDG PET, may be useful as a prognostic indicator for patients with primary breast carcinoma.

Morphometry in the cytologic evaluation of thyroid follicular lesions

BACKGROUND

The current study was undertaken to evaluate the quantitative estimation of cytologic features on aspirated smears for the preoperative differential diagnosis of follicular lesions of the thyroid.

METHODS

The subjects were 60 patients with follicular lesions of the thyroid (including 20 follicular carcinomas, 15 follicular adenomas, and 25 adenomatous goiters) whose histopathologic explorations were conducted fully postoperatively. Using a microscope connected to a computerized video system, the mean nuclear area, the mean nuclear perimeter, the circular rate, the largest to the smallest dimension ratio (LS ratio) of the nuclei, and the coefficient of variation of the nuclear area (NACV) were measured and analyzed.

RESULTS

Among the quantitative morphometric parameters of nuclei, the circular rate was significantly higher in the group with adenomatous goiters than those with follicular carcinomas (P < 0.00001) and adenomas (P < 0.005). The group with follicular carcinomas had a higher LS ratio than the group with adenomatous goiters (P < 0.0005). The NACV value increased as the malignant potential of the lesion increased and showed significant differences between the groups. When a NACV of 21.5% was chosen as the cutoff point, the incidence of malignancy was significantly higher in patients with high NACV values than in those with low NACV values (P < 0.00001). Using this borderline value, it was possible to distinguish malignant from benign diseases with a sensitivity of 85.0%, a specificity of 82.5%, and an accuracy of 83.3%.

CONCLUSIONS

Preoperative quantitative estimations of cytologic nuclear features are useful for the preoperative differential diagnosis of follicular lesions of the thyroid.

Idiopathic spinal cord herniation. Report of two cases and review of the literature

The authors describe two occurrences of idiopathic spinal cord herniation, an entity that has been reported previously in only 11 cases. The patients described in this report presented in midlife with Brown-Séquard syndrome. Computerized tomography myelography and magnetic resonance (MR) imaging showed ventral displacement of the spinal cord with no apparent dorsal mass. Intraspinal cerebrospinal fluid (CSF) flow studies in which phase-contrast pulse sequence cine MR imaging was used displayed a normal pattern dorsal to the spinal cord. Percutaneous intrathecal endoscopic observation did not disclose dorsal intradural cysts, but ventral adhesions were seen between the spinal cord and the dura. Microsurgical intradural exploration revealed ventrolateral herniation of the cord and a ventral root through a dural defect into an epidural arachnoid cyst. The adhesions were released, the cord was repositioned intradurally, and the dural defect was patched. The patients showed gradual improvement postsurgery, as did most of the patients in the previously reported cases. The CSF flow and endoscopic studies were found to be particularly informative, and dural patching with surgical membrane is recommended.

An improved ultrastructural double-staining method for rat growth hormone and its mRNA using LR White resin: a technical note

An improved new method for the simultaneous visualization of mRNA and encoded protein in LR White resin-embedded specimens is described. This pre-embedding electron microscopical in situ hybridization (procedure) localized rat growth hormone mRNA specifically as high electron-density products on the polysomes of the rough endoplasmic reticulum. A subsequent post-embedding immunoreaction, using protein A colloidal gold particles, identified growth hormone as gold particles both in the cisternae of the rough endoplasmic reticulum and on the secretory granules. In our previous report, we used Epon resin for tissue embedment, which required an etching process using hydrogen peroxide or sodium periodate for immunoreactivity retrieval. In general, osmification and embedment in Epon resin are reported to decrease the immunoreactivity of the targeted protein, and the etching process using hydrogen peroxide or sodium periodate results in deosmification and shades off the signals of mRNA. To resolve these problems, we have recently used LR White resin for tissue embedment. In LR White resin-embedded tissues, retrieval of immunoreactivity using hydrogen peroxide or sodium periodate is not required, and, therefore, the gradation of the signals of mRNA can be avoided.

The role of calcium ion in anoxia/reoxygenation damage of cultured brain capillary endothelial cells

Capillary endothelial cells are critical targets in both ischemia and reperfusion of the brain. Arachidonic acids and oxygen free radicals have been shown to cause disruption of blood-brain barrier (BBB) by destruction of capillary endothelial cell membrane. However, the exact mechanism of BBB breakdown by cerebral ischemia/reperfusion remains undetermined. The aim of the present study is to clarify the mechanism of intracellular calcium ion ([Ca2+]i) change in brain capillary endothelial cells under anoxia/reoxygenation. Brains capillary endothelial cells were isolated from ten male Sprague-Dawley rats by a two step enzymatic process. [Ca2+]i was measured by means of a confocal laser scanning microscope using Indo 1-A/M as a calcium indicator. The endothelial cells were subjected to anoxia and reoxygenization under different conditions. [Ca2+]i increased gradually during anoxia and slightly decreased after reoxygenation. Indomethacin and SOD suppressed the elevation of [Ca2+]i during anoxia. NG-nitro-L-arginine methyl ester and catalase moderately suppressed the elevation, however nifedipine did not suppress it at all. In this model, rapid [Ca2+]i change was not observed during the reoxygenation phase. The results indicate that the anoxia induced elevation of [Ca2+]i in the brain capillary endothelial cells depends on superoxide and peroxynitrite generation.

The mechanism of reversible osmotic opening of the blood-brain barrier: role of intracellular calcium ion in capillary endothelial cells

Despite clinical and experimental interest in the osmotic opening of the blood-brain barrier (BBB), the mechanism underlying the phenomenon remain undetermined. The aim of this study is to investigate the mechanism of intracellular Ca2+ change in brain microvascular endothelial cells subjected to hyperosmotic stress. Cultured rat brain capillary endothelial cells were obtained by two-step enzymatic purification. Intracellular Ca2+ was measured by a confocal laser scanning microscope. After exposing the endothelial cells to 1.4 M mannitol for 30 seconds, the change of intracellular Ca2+ concentration was monitored. Intracellular Ca2+ concentration increased rapidly and reached its peak value within 10 seconds after the application of mannitol. The Ca2+ concentration returned to the basal level within 200 seconds. A calcium channel blocker nifedipine (100 microM, 10 microM) did not block the increase. A specific blocker (KB-R7943) of Na+/Ca2+ exchange did not affect the rapid elevation of intracellular Ca2+. However, it blocked the return phase almost completely. The results indicated that the Na+/Ca2+ exchanger pumped out the increased intracellular Ca2+ during the return phase. Reversible osmotic disruption and reconstruction of the BBB is not due to simple mechanical shrinkage of the endothelial cells but is due to the intracellular Ca(2+)-activated complex mechanism. The manipulation of the reconstruction phase, which depends on Na+/Ca2+ exchanger, may have clinical implications.

Impaired learning of active avoidance in water-intoxicated rats

Brain edema is an important clinical condition. Pathophysiological findings on behavioral changes may be helpful for a comprehensive understanding of brain edema. However, only few reports on behavioral studies of brain edema have so far appeared. Experiments using psychological techniques on animals are rather time-consuming and may not be suitable for the study of transient conditions, as brain edema caused by trauma, vascular accidents, or others. We have developed a method for avoidance learning of rats using a running wheel apparatus with computer assistance. This model was employed in studies on brain edema from water introxication in rats. As a result, avoidance learning was significantly impaired by water intoxication. Either direct overhydration of the brain or indirect effects, as a decrease in cerebral blood flow, or both, are suggested as mechanisms underlying the impairment of behavior.