[Thoracoscopic repair of diaphragmatic eventration sustained at knife injury: a case report]

A 46-year-old male taxi driver was stabbed onto the left chest while on duty. On arrival soon after, he was hemodynamically stable. Computed tomography showed omental prolapse into the left thorax through the diaphragm. On the 11th day, he underwent thoracoscopy revealing omental prolapse via a 3-cm rent in the left diaphragm, which was reduced manually. The diaphragmatic orifice was lifted and debrided with suturing using a stapling cutter. The post-operative course was uneventful. Finger palpation through the orifice enabled safe suturing of the left diaphragm facing the omentum, the colon, and the stomach, all of which may suffer iatrogenic injury.

Benign osteoblastoma of the odontoid process of the axis: a case report

BACKGROUND

The majority of benign spinal osteoblastomas arise from the posterior elements of the spine; there have been no published reports of the tumor in the odontoid process of the axis. Accurate preoperative localization of the tumor is important for planning minimally invasive surgery on such benign tumors. However, the magnetic resonance imaging (MRI) findings may be misleading, because peritumoral changes may be confusing.

CASE DESCRIPTION

We report the case of a 20-year-old man, who presented with a 4-year history of protracted left posterior neck pain. Preoperative computed tomography (CT) revealed a discrete mixed-density mass within the odontoid process. MRI showed diffusely abnormal signal intensity and enhancement both in the odontoid process and the body of the axis, including regions from which biopsy specimens were normal or had minimal inflammatory changes. Precise preoperative localization of the tumor margins using CT and biopsy allowed for successful resection of the tumor via a transoral approach with preservation of a part of the axis and the odontoid process. Consequently, stabilization of the spine was unnecessary, and the patient remained symptom-free for 3.5 years.

CONCLUSION

We reported a rare case of benign osteoblastoma of the odontoid process of the axis. The tumor was successfully resected via a transoral approach, preserving a part of the axis and the odontoid process. We have emphasized an advantage of CT over MRI for accurate localization of the tumor.

[Non-small cell lung cancer metastatic to the stomach and the jejunum causing intussusception: a case report]

We report a case of lung cancer metastatic to the stomach and the jejunum. Adenocarcinoma of the lingula (T 4 N 2 M 0) was diagnosed in a 45-year-old man, who then underwent chemoradiotherapy. Bowel obstruction later developed due to jejunal metastasis. Another metastasis was detected in the stomach. Laparotomy revealed jejuno-jejuno-jejunal intussusception caused by the two lesions. The jejunal and gastric lesions were identified as metastatic large cell carcinoma arising from the lung. One month postoperatively, the patient died due to disease. The literature has demonstrated that large cell carcinoma of the lung tends to metastasizes. However, the complex bowel invagination and gastric metastasis seen in our case are rare.

Sarcomatous transformation of pituitary adenoma after bromocriptine therapy

We reported a case of sarcomatous transformation of pituitary adenoma occurring in a 21-year-old woman. She had previously undergone surgery for pituitary adenoma (prolactinoma) 5 years earlier. Since then, she had received only bromocriptine medication therapy. The operation was repeated because of a relapse of the tumors. Histologically, the tumors were composed of adenomatous epithelial nests and fibrosarcomatous spindle cell components intermingled with each other. lmmunohistochemically, adenomatous epithelial cells were stained positively with cytokeratin and prolactin. Fibrosarcomatous spindle cells were stained only with vimentin. The proliferation activity (Ki-67 expression) was much higher in the sarcomatous components than in common pituitary adenoma. p53 immunostaining was also positive in sarcomatous components. This was thought to be the first reported case of sarcomatous transformation of pituitary adenoma not associated with radiation therapy.

Synchronous double primary lung carcinomas associated with multiple atypical adenomatous hyperplasia

A 71-year-old woman with synchronous bilateral primary lung carcinomas accompanied by multiple atypical adenomatous hyperplasias is described. The patient was found to have bilateral tumors during preoperative workup for the previously detected well differentiated adenocarcinoma of the right lung. Thoracoscopic wedge resection of the left upper lobe was performed to obtain a definitive diagnosis of the left lesion. Although intraoperative diagnosis was made by frozen section as atypical papillary lesion, postoperative diagnosis of this lesion was changed to well differentiated adenocarcinoma accompanied by surrounding atypical adenomatous hyperplasia (AAH). We diagnosed that the bilateral lesions were synchronous primary well differentiated adenocarcinomas independent to each other based on the criteria of Martini and Melamed and performed right upper and mediastinal lymph node dissection. The resected lobe contained not only the primary adenocarcinoma but also multiple small gray nodules which were diagnosed as AAHs. In summary, it was diagnosed that the patient had synchronous double primary lung adenocarcinomas of T1 N0 M0 pathological stage and 12 solitary atypical adenomatous hyperplasias. The patient is doing well with no signs of recurrence 24 months after the operation. This case might be an example of the adenoma-carcinoma sequence of lung cancer. A careful follow-up study is mandatory for this patient with special regard to the further development of lung carcinoma in the future.

Assessment of vasoreactivity in brain edema by acetazolamide activation SPECT and PET

Our study was performed to find out cerebrovascular reactivity post acetazolamide administration in patients with peritumoral edema. Adult patients (n = 9) underwent CBF measurement by 99mTc-HMPAO SPECT pre and post 1 gram i.v. acetazolamide. In all patients, this procedure was repeated once again within 10 days of performing tumor removal. Five of these patients also underwent CBF measurement pre and post 1 gram i.v. acetazolamide post surgery only using oxygen-15 labeled H2O PET. Asymmetry index (AI) was calculated as ratio of ROI counts in the peritumoral edematous area and symmetrical ROI on the contralateral normal hemisphere. The AI increased after acetazolamide in edematous gray matter post operatively though the resting AI remained almost same post operatively. AI in edematous white matter showed non-significant increase post operatively both at rest and after acetazolamide. Good linear correlation of AI between PET and SPECT was observed both in gray and white matter. The improvement of vascular reactivity in edematous gray matter after tumor removal suggests that mass effect not only reduces CBF but also suppresses vascular reactivity. White matter vascular reactivity in early post operative period is little improved, possibly due to factors other than mass effect i.e. excess water accumulation in white matter perivascular space.

Induction of matrix metalloproteinases following brain injury in rats

Matrix metalloproteinases (MMPs) are important in various pathophysiological processes related with the tissue remodeling. We planned the experiments to determine whether MMPs participate in disruption and repair of the tissue following brain injury. We have studied induction of MMP-9, a 92 kilodalton (kDa) gelatinase, in traumatic brain tissue, which may be produced by brain residual cells. We speculate that MMP-9 plays a role in post-traumatic brain edema formation.

Responses of cerebral blood flow regulation to activation of the primary somatosensory cortex during electrical stimulation of the forearm

We assessed the cerebral blood flow (CBF) response to electrical stimulation of the contralateral forearm over the primary somatosensory cortex (S-I) in anesthetized cats. CBF was monitored continuously using laser-Doppler flowmetry (LDF). In the first set of experiments, the effects of varying stimulus frequency and intensity were examined. During stimulation, CBF in S-I was increased significantly. At high stimulus intensity, response reached a near-plateau level. In the second set of experiments, the CBF response after introduction of an intracerebral mass was investigated using a mechanical microballoon model to simulate an intracerebral hematoma. A microballoon was inserted into the ventral posterolateral nucleus of the thalamus (VPL). Following gradual balloon inflation, there was a rapid reduction in CBF response. We conclude that CBF regulation to neuronal activation is affected by stimulation parameters, and is impaired by an intracerebral mass obstructing the afferent sensory pathway.

Adeno-associated virus vector containing the herpes simplex virus thymidine kinase gene causes complete regression of intracerebrally implanted human gliomas in mice, in conjunction with ganciclovir administration

Adeno-associated virus (AAV) has attracted considerable interest as a potential vector for gene therapy because of its wide host range, high transduction efficiency, and lack of cytopathogenicity. In this experiment, we evaluated the efficacy of AAV vector containing the herpes simplex virus thymidine kinase (HSV-tk) gene on human gliomas transplanted into the brain of nude mice. Complete regression of the tumors was observed after multiple AAV-tk injections followed by intraperitoneal ganciclovir (GCV) administration, and the survival of mice treated with AAV-tk vector and GCV administration was markedly prolonged. These results suggest that AAV-tk vectors may be useful for gene therapy against malignant gliomas in humans.

Vasodilator effects on canine basilar artery induced by intracisternal interleukin-1 beta

The effect of interleukin-1 beta (IL-1 beta) on a cerebral artery was investigated in anesthetized dogs. Intracisternal administration of IL-1 beta (0.03 and 0.3 micrograms) dilated the canine basilar artery in a dose-dependent manner, without affecting systemic blood pressure or heart rate. The increase in diameter induced by 0.3 micrograms of IL-1 beta was 28.4% +/- 13.4% of control at 2 hours and was inhibited by 30 micrograms of the IL-1 beta receptor antagonist, zinc protoporphyrin (4.5% +/- 13.5%, P < 0.05). Interleukin-1 beta did not affect the concentration of nitric oxide metabolites in CSF. However, there was an increase in the concentration of eicosanoids in CSF, and the elevation of 6-keto-PGF1 alpha paralleled the vasodilation. Pretreatment with 30 micrograms of the selective inducible cyclooxygenase (COX-2) inhibitor NS-398 also inhibited the IL-1 beta-induced vasodilation significantly (5.9% +/- 9.4% at 2 hours, P < 0.01). Western blot analysis revealed the expression of a 68-kD COX-2-like protein in basilar artery extracts. These findings suggest that the IL-1 beta-induced vasodilator effect is linked to the prostaglandin cascade, predominantly to prostaglandin I2, by induction of COX-2, but not to the stimulation of nitric oxide metabolism.

Results of 55 AVM Cases Treated by Embolization and/or Surgery

SUMMARY

In order to build a data base for future comparison, we summarized the treatment results of cerebral arteriovenous malformation (AVM) patients in our hospital. Fifty five AVM patients who had been treated at Nagoya University Hospital from 1988 to 1995 were enrolled in the study. The patient characteristics were nearly the same as other reported series. Trend of treatment modality was changing in this period and embolization was increasing in its role. Karnofsky score was used to follow the patients' clinical status. It was useful to assess pretreatment clinical status and post treatment status. The results showed the improvement of the embolization procedure.

Determining the Optimal Fluoroscopic View during Aneurysmal Embolization with Rotation DSA

To prevent coil protrusion into the parent artery, the fluoroscopic view during coil packing is quite important. However it is not always easy to find out the optimal fluoroscopic view.

We applied a rotation DSA to predict the optimal fluoroscopic view for the endovascular treatment of 4 cases with a cerebral aneurysm.

Since the trajectory of the C-arm is restricted within 60 degrees only around the patient's head and the number of DSA shots are limited rather than conventional DSA, we employed three dimensional CT angiography (3D-CT angiography) to focus the range of C-arm rotation.

Rotation DSA proved quite useful to determine the optimal fluoroscopic view, when combined with pre-estimation by 3D-CT angiography.

Effect of glycerol on blood flow distribution in tumoral and peritumoral brain tissue

The effect of glycerol on blood flow in tumoral and peritumoral tissue was measured in 32 patients with brain tumor, 17 gliomas and 15 meningiomas. Blood flow before and after the administration of glycerol was measured by stable xenon-enhanced computed tomography. The tumor part of glioma was significantly hypoperfused. In contrast, the tumor part of meningioma was significantly hyperperfused. Peritumoral edema of both glioma and meningioma was hypoperfused. After the administration of glycerol, blood flow increased in all regions except for the tumor part of glioma. Vascular responses to glycerol may be different in these two tumor types. The steal phenomena of blood flow might occur in cases of glioma.

Augmentation of anti-Fas antibody-mediated apoptosis on human glioma cells by liposomes associated with the antibody

We investigated the susceptibility of five human glioma cell lines to anti-Fas antibody. All human glioma cells tested constitutively expressed Fas antigen on their surfaces and the level of the expression varied slightly in each cell line. The cells had a low susceptibility to anti-Fas antibody-mediated apoptosis. There were four moderately resistant cell lines (U251-SP, U251-MG, SK-MG-1, T98) and one highly resistant cell line (U251 nu/nu). For this study we prepared liposomes containing anti-Fas antibody and studied the augmentation of the antibody-mediated apoptosis. The liposomes induced apoptosis significantly more often than did anti-Fas antibody alone. These results indicate that anti-Fas antibody-mediated apoptosis does not require a critical level of cell surface expression of Fas antigen but rather depends on the intensity of Fas signal transduction.

Antitumor activity of recombinant human tumor necrosis factor-alpha (rH-TNF alpha) and liposome-entrapped rH-TNF alpha

The antitumor activities of recombinant human tumor necrosis factor-alpha (rH-TNF alpha) and liposome-entrapped rH-TNF alpha were evaluated in various glioma cell lines and a rat brain T9 gliosarcoma model. rH-TNF alpha had a direct cytotoxic activity against various glioma cell lines in vitro, and indirect cytotoxic activity against gliosarcoma (T9) in vivo. Liposome-entrapped rH-TNF alpha had increased direct cytotoxic activity in vitro, and against experimentally induced brain tumors in vivo. The effects in vivo were probably due to vascular damage of the tumor vessels as shown by histological examination and activation of cytotoxic macrophages as shown in vitro. These results indicate that the general or local administration of liposome-entrapped rH-TNF alpha may become a useful adjunct treatment for malignant brain tumor.

Nitric oxide metabolites in the cisternal cerebral spinal fluid of patients with subarachnoid hemorrhage

OBJECTIVE

To investigate nitric oxide (NO) metabolism after subarachnoid hemorrhage (SAH).

METHODS

We measured the concentrations of the NO metabolites, nitrite and nitrate, in cerebrospinal fluid (CSF) obtained from the cisternal drainage of patients with SAH. Studies were performed for 31 patients who had undergone surgical obliteration of bleeding aneurysms within 3 days of their hemorrhage. The concentrations of nitrite and nitrate in the CSF were measured for 14 days using a nitrate/nitrite kit and samples that were obtained on a daily basis from the cisternal drainage.

RESULTS

Compared with the control values in the CSF (2.6 +/- 0.4 mumol/L, n = 14) obtained from patients with hemifacial spasm, trigeminal neuralgia, or nonruptured aneurysms, the concentrations of nitrite and nitrate in the CSF were significantly elevated in the acute stage of SAH and remained elevated. The concentration of NO metabolites may correlate with the amount of bleeding, inasmuch as the values in patients in Fisher Group 3 (n = 25) were higher than those in patients in Fisher Group 2 (n = 6). The concentration of nitrate was higher than that of nitrite, suggesting that NO in the subarachnoid space is mainly absorbed by hemoglobin and degraded to nitrate. No differences were demonstrated in patients treated with high doses of methylprednisolone (n = 17) compared with those treated with usual-dose steroids (n = 14). Steroids are known to prevent the formation of inducible NO synthase mediated by inflammatory cytokines.

CONCLUSION

NO metabolism in the brain is stimulated after SAH. Nitrate is the dominant NO metabolite in CSF after SAH. The involvement of inducible NO synthase in the pathophysiology of NO metabolism after SAH was not clearly suggested based on the present data.

Experimental use of semiconductor diode laser for neuroendoscopic surgery

The authors demonstrate an experimental use of the newly developed high power aluminium-gallium-arsenide (AlGaAr) diode laser (DIOMED 25, Olympus Optical Company, Tokyo, Japan). The unit consists of a compact body and fiberoptic probes with small accessories. There are two types (contact and non-contact) of probes. Tissue effects on rat liver, femoral artery, and brain tissue were examined. Adding that, we measured the thermal changes on the liver surface produced by the laser beam with a thermography system. For coagulation with the contact probe, 5 or 7 W was adequate but 10 W was too excess because of tissue adhesion. For cutting, low absorption of the laser in less vascularized tissue like brain white matter provided a deeper tissue damage compared with more vascularized tissue. The temperature at the center reached over 100 degrees C during 10 seconds after laser treatment with the cutting probe. These findings suggest that this system proved to be a good candidate for endoscopic hemostasis and cutting with meticulous maneuver.

[A case of traumatic cardiac contusion accompanied by the rupture of pericardium]

We experienced a case of traumatic cardiac contusion accompanied by the rupture of the pericardium after multiple blunt trauma sustained in a traffic accident. A 26-year-old woman who had suffered from blunt chest and abdominal trauma was admitted to our hospital, being unconscious with multiple severe injuries including pelvic fracture, bilateral hemothorax, and multiple fractures in the extremities. The patient was in a shock status. We performed the transcatheter arterial embolization of the internal iliac arteries to control the bleeding, when aortography showed that the contrast media extravasated toward the left thoracic cavity. Immediately, an operation for blunt chest trauma was performed. Blood was flooding out of the ruptured pericardium because of the contusion of myocardium. The postoperative course was uneventful. Blunt chest trauma is usually accompanied by multisystem injury. Therefore, it is imperative to determine the priority of treatment based on preoperative examination in patients having multiple injuries.

Granulocyte colony stimulating factor-producing tongue carcinoma

BACKGROUND

Leukocytosis without infection in patients with malignancies is known as the leukemoid reaction. The mechanisms involved in this phenomenon remain uncertain.

METHODS

We describe the clinical, biochemical and immunohistochemical findings in a patient with recurrent tongue carcinoma accompanied by marked leukocytosis as high as 96200/ mm3.

RESULTS

The serum granulocyte colony stimulating factor (G-CSF) concentration was increased to 204 (normal: < 30) pg/ml, which paralleled to the elevation of white blood cell (WBC) count and the tumor growth. The G-CSF content of the tumor tissue was also elevated (131 pg/mg protein) compared to that in control patients (6.63 +/- 2.63 pg/mg protein). Production of G-CSF from the tumor was evidenced by immunohistochemical staining with monoclonal antibody against human recombinant G-CSF.

CONCLUSIONS

We suggest that the G-CSF production of the tumor participates in the mechanisms of the leukemoid reaction.

Retroviral introduction of the p16 gene into murine cell lines to elicit marked antiproliferative effects

The p16 gene is a candidate tumor suppressor, because mutation of the gene has been reported in many transformed cell lines and some primary tumor tissues. We have examined this possibility in murine cell lines (NIH3T3 and RSV-M) which lack p16 gene expression. Full-length human p16 cDNA was obtained from a HeLa cell line using polymerase chain reaction amplification. We constructed two separate retrovirus vectors carrying this p16 cDNA. First, we transduced the p16 cDNA into the murine cell lines using a retrovirus vector harboring the neomycin-resistance gene. The p16 gene-transduced cells formed no colonies after selection with G418, in contrast to the vector-transduced cells. Next, we used another retrovirus vector that expresses both the p16 cDNA and the Lac Z gene, which enabled us to distinguish affected cells from unaffected ones. Proliferation of the p16 gene-transduced cells was markedly inhibited and morphological change in the cells was also observed. Thus, we concluded that the p16 gene has an antiproliferative effect on the cell cycle and that the loss of its function may play a major role in dysregulated proliferation of the cells.

Effects of adrenomedullin on rat cerebral arterioles

The effects of adrenomedullin on isolated rat intracerebral arterioles were investigated and compared with those of calcitonin gene-related peptide (CGRP) and amylin. Adrenomedullin produced dose-dependent vasodilation (maximum dilation 27.1 +/- 2.1% at 3 x 10(-7) M, median effective dose (EC50)) 1.6 x 10(-9) M). CGRP produced similar vasodilation (19.8 +/- 4.1%) at 10(-7) M with a lower EC50 of 2.8 x 10(-11) M. Amylin did not cause vasodilation at concentrations up to 10(-6) M. Adrenomedullin-induced vasodilation was significantly suppressed by CGRP-(8-37). These data suggest that adrenomedullin is a potent vasodilator for arterioles in the cerebral microcirculation that acts through CGRP receptors.

[Gene therapy for brain tumors]

Patients with glioma(which constitute 33% of all brain tumor cases) still have a poor prognosis, especially in the case of malignant(anaplastic astrocytoma and glioblastoma). This poor prognosis is related to the fact that malignant glioma cells aggressively infiltrate into normal brain tissues, making total removal of the tumor impossible. The median survival time of glioblastoma patients is less than 2 years, despite multimodality treatment with extensive surgical resection and adjuvant therapies using radiation and immunochemotherapy. In order to overcome this formidable neoplasm, the effectiveness of molecular neurosurgery using gene therapy has been investigated since 1992. In this paper, the current state of gene therapy for malignant brain tumors are described, and the future direction of this fascinating approach is discussed.

Granulocyte colony stimulating factor-producing tongue carcinoma

BACKGROUND

Leukocytosis without infection in patients with malignancies is known as the leukemoid reaction. The mechanisms involved in this phenomenon remain uncertain.

METHODS

We describe the clinical, biochemical and immunohistochemical findings in a patient with recurrent tongue carcinoma accompanied by marked leukocytosis as high as 96200/ mm3.

RESULTS

The serum granulocyte colony stimulating factor (G-CSF) concentration was increased to 204 (normal: < 30) pg/ml, which paralleled to the elevation of white blood cell (WBC) count and the tumor growth. The G-CSF content of the tumor tissue was also elevated (131 pg/mg protein) compared to that in control patients (6.63 +/- 2.63 pg/mg protein). Production of G-CSF from the tumor was evidenced by immunohistochemical staining with monoclonal antibody against human recombinant G-CSF.

CONCLUSIONS

We suggest that the G-CSF production of the tumor participates in the mechanisms of the leukemoid reaction.