[Four cases of adrenal tumor discovered through examination before surgery for lung cancer]

Preoperative CT and Ultrasonography (US) showed adrenal tumors in four patients with lung cancer. Although metastasis of the cancer to the adrenal gland was suspected, a definitive diagnosis could not be made by CT and US alone. MRI is as ineffective as CT and US. Needle biopsy is useful if tumor cells are detected, but not unless they are discovered. Surgery, therefore, is necessary to establish the final diagnosis. (Adrenalectomy was performed on all cases, one of which had metastasis). No particular complications occurred after adrenalectomy. Adrenalectomy was considered unavoidable to determine stage and treatment policies in patients suspected of metastasis in imaging diagnosis.

Primary Budd-Chiari syndrome due to complex venous anomalies

A 35-year-old woman with clinical features of Budd-Chiari syndrome is presented. Abdominal ultrasonography, computed tomography, and venography disclosed that the venous congestion in this patient resulted from complex venous anomalies including azygos-hemiazygos continuation, absent superior hepatic veins, and retroaortic transposition of the left renal vein.

Effective high-dose chemotherapy followed by autologous peripheral blood stem cell transplantation in a patient with the aggressive form of cytophagic histiocytic panniculitis

A 20-year-old Japanese man developed generalized, subcutaneous, painless nodules, fever, abnormal liver function, serosal effusions, hepatosplenomegaly, lymphadenopathy and anemia. Skin biopsies revealed lobular panniculitis with a morphologically benign histiocytic infiltration and prominent phagocytosis. Atypical T lymphocytes were also present in the skin and liver. The diagnosis given was aggressive cytophagic histiocytic panniculitis (CHP) or aggressive subcutaneous panniculitic T cell lymphoma (SPTCL). He received cyclophosphamide, doxorubicin, and vincristine on day 1, prednisolone on days 1-5, and etoposide on days 1, 3 and 5 (CHOP-E), with the support of granulocyte colony-stimulating factor. This regimen was repeated every 2 weeks and complete clinical remission (CCR) was attained after three cycles of CHOP-E. As the clinical course of aggressive CHP is recurrent and often fatal, he was given high-dose chemotherapy followed by autologous peripheral blood stem cell transplantation (APBSCT), after five cycles of CHOP-E. He has remained in CCR for 12 months after APBSCT. High-dose chemotherapy followed by APBSCT is considered to be one of the most beneficial therapies for patients with aggressive CHP and aggressive phase SPTCL.

Ictal EEG and single photon emission computed tomography in a patient with cortical dysplasia presenting with atonic seizures

PURPOSE

Ictal studies of atonic seizures in children with epilepsy are rare. To clarify the neurophysiologic mechanism of such seizures, we describe a cluster of atonic seizures in a 6-year-old girl with cortical dysplasia.

METHODS

Ictal activity was recorded as slow-wave bursts beginning over the right frontocentral regions, where the cortical dysplasia was detected by magnetic resonance imaging (MRI), and propagating to the left hemisphere.

RESULTS

The polygraphic recording demonstrated that the atonia indicated by the sudden interruption of electromyogram (EMG) discharges corresponded to the bilaterally synchronous spike-and-wave complexes. An ictal single photon emission computed tomography (SPECT) study with 99mTc hexamethyl propylene amine oxime ([99mTc]HMPAO) simultaneously performed during EEG recording showed marked bilateral mesial frontal and right frontoparietal hyperperfusion.

CONCLUSIONS

Our findings suggest that the neurophysiological mechanism of the atonic seizures may be produced by a strong inhibition in the bilateral motor cortexes. Ictal SPECT is valuable in demonstrating the pathophysiology of both atonic seizures and secondary bilaterally synchronous spike-and-wave complexes in the EEG.

Migration of Gianturco expandable metallic stents in the upper trachea

Endotracheal expandable metallic stents have been shown to be useful in treating malignant tracheobronchial stenosis. We report two cases of early stent migration in the upper trachea after what appeared to be a successful stent placement. We conclude that care should be taken when placing Gianturco stents across short, extrinsic, stenotic lesions with smooth mucosa located in the upper trachea because they have a tendency to migrate.

Scan findings of various myocardial SPECT agents in a case of amyloid polyneuropathy with suspected myocardial involvement

A 31-year-old male having familial amyloid polyneuropathy underwent a Tc-99m(V)-DMSA study to evaluate the myocardial involvement. The patient also underwent T1-201, I-123-BMIPP and I-123-MIBG myocardial SPECT studies to evaluate blood perfusion, fatty acid metabolism and sympathetic function of the heart, respectively. Tc-99m(V)-DMSA SPECT showed uptake to the myocardium indicating myocardial involvement of amyloidosis. Both T1-201 and I-123-BMIPP studies showed normal uptake indicating normal blood perfusion and fatty acid metabolism but I-123-MIBG SPECT showed no uptake to the heart, indicating severe impairment of sympathetic function.

[Application of measuring 99mTc-MAG3 plasma clearance based on one-compartment model (MPC method) to pediatric patients]

Measurement of 99mTc-MAG3 plasma clearance based on 1-compartment model (MPC method) were applied to 12 pediatric patients and evaluated for the factors which might affect the calculated results. Depth correction is a critical factor for the measurement of renal uptake. Three different equations for estimating renal depth were compared with the real depth measured by ultrasonography. The equation proposed by K. Itoh was suitable though the equations by T. Ito and Raynaud were insufficient. Estimation of distribution volume, which is regarded as circulating plasma volume (CPV), is also critical for the calculation of MAG3 clearance by MPC method. Precisely, hematocrit measured by venous sampling and circulating blood volume (CBV) calculated as 7.5% of body weight are used for estimation of CPV. However, assumed CPV as 5% of body weight was acceptable if the hematocrit was not severely deviated from the normal value. Simplified MPC method utilizing two factors mentioned above gave a positive correlation with Russell's one point sampling method. In conclusion, MPC method is applicable for pediatric patients.

[A case of uretero-aortic fistula]

We report a case of uretero-aortic fistula. A 69-year-old man with rectal cancer underwent a pelvic exenteration and a double--barreled cutaneous ureterostomy in the right lower abdomen. Stomal stenosis necessitated continuous indwelling of double J stents in the two ureters. Two years postoperatively, massive bleeding occurred during exchange of double J catheters. Occlusive ureterogram demonstrated a uretero-aortic fistula at the crosspoint between the left ureter and the aorta. The surgical repair consisted of closure of the aortic fistula, ligation of the left ureter proximal to the fistula and percutaneous left nephrostomy.

Ion transport systems in the uptake of 99Tcm-tetrofosmin, 99Tcm-MIBI and 201Tl in a tumour cell line

The kinetics, intracellular distribution and effects of ion transport inhibitors on the uptake of 99Tcm-tetrofosmin, 99Tcm-methoxyisobutyl isonitrile (99Tcm-MIBI) and 201Tl were investigated in a tumour cell line. Both uptake and washout of the tracers were measured at specific intervals. Cells were treated with ouabain, dimethyl amiloride (DMA) and bumetanide to observe the effects on uptake, while carbonyl cyanide m-chlorophenylhydrazone (CCCP) was used to study the release of the tracers. The tracers showed similar uptake and washout kinetics. Ouabain inhibited 55-67% of 201Tl, 16-22% of 99Tcm-tetrofosmin and 8-14% of 99Tcm-MIBI. DMA inhibited the uptake of both 99Tcm-tetrofosmin (30%) and 99Tcm-MIBI (21%). Bumetanide stimulated the uptake of 99Tcm-tetrofosmin and 99Tcm-MIBI but inhibited that of 201Tl (37%). When cells were pretreated with various combinations of these ion transport inhibitors, the uptake of 201Tl was related to Na+,K+ pump, Na+,K+, 2Cl- co-transport systems, whereas the uptake of both 99Tcm-tetrofosmin and 99Tcm-MIBI was related to the Na+,K+ pump, Na+/H+ antiport systems. Addition of CCCP released 55% and 90% of accumulated 99Tcm-tetrofosmin and 99Tcm-MIBI respectively, indicating that the percentage released was related to mitochondrial uptake.

Prediction of pKa values of phenolic and nitrogen-containing compounds by computational chemical analysis compared to those measured by liquid chromatography

The pKa values of 64 phenolic and 50 nitrogen-containing compounds were obtained by reversed-phase liquid chromatography and computational chemical calculation. The chromatographically obtained values of phenolic compounds were equal to pKa values from references and Hammett's equation, and those of nitrogen-containing compounds were lower than the reference values. It appeared difficult to calculate the properties of the ortho effect and nitro group by the computational calculation method. However, the calculation was simpler than selecting different constants of Hammett's equation for a variety of compounds.

A rapid nylon-fiber syringe system to deplete CD14+ cells for positive selection of human blood CD34+ cells. Use of immunomagnetic microspheres

To achieve a rapid and an efficient purification of CD34+ cells, we devised a nylon-fiber syringe (NF-S) and we manipulated it to deplete adherent cells from normal human blood mononuclear cells (MN cells). The cells processed by NF-S were further purified as the CD34+ fraction, using CD34 monoclonal antibody, immunomagnetic microspheres and chymopapain treatment to detach the microspheres. When steady-state human peripheral blood MN cells were processed by NF-S at 24 degrees C for 5 min, the frequency of monocytes (CD14+ cells) significantly decreased from 22.0 +/- 5.2% to 2.5 +/- 0.4%, with a 73% recovery of CD34+ cells. The subsequent immunomagnetic positive selection achieved preparations of 91 +/- 8% pure CD34+ cells with a 86 +/- 23% yield. The overall yield of CD34+ cells was 44 +/- 11%, and the time required for all procedures was 5 h. There was a tight and an inverse correlation (P < 0.0001) between the frequency of CD14+ cells in the initial cell population and the purity of CD34+ cells in the final preparation. A recommended frequency of CD14+ cells for achieving preparations of over 90% pure CD34+ cells was less than 4.4%. When combining NF-S and immunomagnetic microspheres, efficient bench-top separation of CD34+ cells in steady-state peripheral blood can be done in any laboratory, and fluorescence-activated cell-sorting is not required.

Compartmental analysis of asialoglycoprotein receptor scintigraphy for quantitative measurement of liver function: a multicentre study

A multicentre study on multicompartmental analysis of hepatic scintigraphy using technetium-99m labelled galactosyl serum albumin (GSA), which binds to the asialoglycoprotein receptor, was carried out at seven institutions in Japan. Seventy-four patients with liver disease received 3 mg (185 MBq) of 99mTc-GSA by intravenous injection. Sequential scanning was performed 30 min after injection to obtain anterior images of the heart and liver, followed by single-photon emission tomography (SPET). The indices included in this analysis were hepatic blood flow (Q) and maximal receptor binding rate (Rmax), which showed a good correlation with semiquantitative ratio indices for 99mTc-GSA, namely the retention rate in blood (HH15) and the hepatic uptake rate (LHL15). Q and Rmax also showed a significant correlation with other measures of hepatic function. When patients were grouped according to the severity of chronic liver damage (hepatocellular functional damage), Q was reduced in the moderate and severe groups, while Rmax was reduced in proportion to the functional stage. Both parameters showed no inter-institution difference using analysis of co-variance with the functional stage as a co-variant. With regard to the hepatic uptake rate, anterior planar images and SPET images gave similar results for Q and Rmax. Acquisition times of 15 or 30 min provided the same results. The multicompartmental model analysis permitted comparable results to be obtained at institutions using different gamma cameras, and is therefore considered a universally applicable method. These results indicate that Q and Rmax are useful general indices for evaluating the functional reserve capacity of the liver.

Tc-99m-MIBI scintigraphy for detecting parathyroid adenoma and hyperplasia

We performed scintigraphy with technetium-99m-methoxyisobutylisonitrile (MIBI) in 10 patients with parathyroid adenoma (7 lesions) or hyperplasia (9 lesions). Correlation between an amount of accumulation of MIBI and histological types of the lesions were evaluated with special reference to an amount of oxyphilic cell in the lesions. Selected lesions were also evaluated for mitochondrial density by electromicroscopy and showed increased mitochondrial density in the oxyphilic cells. All lesions equal to or above 220 mg showed positive scintigraphic results despite differences in cell types. Undetected lesions were all equal to or below 100 mg. The scintigraphic results for 2 lesions with abundant oxyphilic cells were both positive although those for 11 lesions with abundant chief cells only 6 were positive, probably because these lesions were smaller in the hyperplasia group. In conclusion, MIBI uptake in parathyroid lesions was not dependent on the cell type but either on the size or functional state of the lesions.

Multicenter genetic study of retinitis pigmentosa in Japan: I. Genetic heterogeneity in typical retinitis pigmentosa

A nationwide, multicenter study of typical retinitis pigmentosa (RP) was carried out in collaboration with 18 hospitals throughout Japan to obtain current information for genetic counseling. We analyzed the genetic heterogeneity of RP based on the parental consanguinity of 434 probands registered during a 6-month period in 1990. A gradual decline in the frequency of consanguineous marriage was recognized among the normal parents of RP patients. The relative frequencies of inheritance patterns were estimated as: autosomal recessive, 25.2%; autosomal dominant, 16.9%; X-linked, 1.6%; and simplex, 56.3%. A comparison of these results with previous reports in Japan revealed a decline in the relative frequency of autosomal recessive cases and an increase in simplex cases. This suggests a decrease in the incidence of autosomal recessive retinitis pigmentosa in Japan, as well as the necessity for exhaustive investigations aimed at identifying inheritance patterns for RP patients seeking genetic counseling.

Multicenter genetic study of retinitis pigmentosa in Japan: II. Prevalence of autosomal recessive retinitis pigmentosa

Retinitis pigmentosa (RP) is a group of genetically heterogeneous diseases with autosomal recessive (AR), autosomal dominant, and X-linked modes of inheritance. Autosomal recessive retinitis pigmentosa (ARRP) is the most common form in Japan. A genetic analysis was done to determine the prevalence of ARRP indirectly, to provide an estimation of changing trends in the overall prevalence of RP. Data on the frequency of consanguinity and marriage year of normal parents of 59 ARRP patients were obtained from a nationwide multicenter survey of typical retinitis pigmentosa conducted in 1990. The gene frequency of ARRP was 0.01145 (Dahlberg's formula). In 1990, the number of young symptomatic ARRP patients decreased, while the number of patients aged 40 years and older increased. The total number of symptomatic ARRP patients in 1990 was nearly 21% higher than in 1970. Despite a dramatic decline in consanguinity in recent decades in Japan, the number of ARRP patients has increased. This increase is attributed to greater longevity and overall population growth. Our results suggest that the total number of RP patients has not decreased, and may even have increased.

[Effectiveness of the radioactive strontium (89Sr) chloride agent, SMS.2P for pain palliation in patients with metastatic bone tumor in phase III multicenter clinical trial]

The phase III clinical trial of strontium-89 chloride agent (SMS.2P) was performed in 90 patients with painful bone metastases secondary to prostate (53), breast (18) and other types of cancer (19). Some patients experienced a transient increase in pain or nausea and vomiting. However both symptoms subsided and serious side effects were not observed in any of the patients. As reported, we confirmed some abnormal changes in peripheral blood picture. A decrease in the number of white blood cells and platelets was considered to be partly a result of bone marrow suppression due to 89Sr irradiation. Pain was substantially improved after 89Sr therapy in 58% of the patients and there was some alleviation in 12%. The release from pain was accompanied by an improved quality of life for these patients including sleep patterns and morbidity. Some patients were able to resume their former life styles. Most of the improved patients experienced pain relief from days to one week following 89Sr therapy and in half cases, this remained effective for 2 or 3 months. There were even cases in which the pain relief continued over an observation period of time of clinical study.

Production, binding characteristics and protective immunity of monoclonal antibody to pneumococcal type-9V conjugate

A monoclonal antibody (MAb) to pneumococcal type-9V polysaccharide (PS) was produced using PS conjugated to inactivated pneumolysin as the immunogen. The MAb to 9V PS was of the IgG1 subclass. The antigen-antibody reaction increased rapidly at low concentrations and reached a plateau at 10 micrograms PS/ml as measured by nephelometry of the group 9 PS against 9V MAb binding. In contrast, the binding of group 9 PS against rabbit 9V antiserum (AS) increased proportionally and continued to increase up to the highest concentration of PS tested (20 micrograms PS/ml). The 9V MAb reacted with all group 9 PSs (9A, 9L, 9N and 9V) by immunodiffusion. In the homologous 9V Ag-MAb reaction, there were marked differences in the inhibition of binding by the cross-reactive 9L PS (19.2% inhibition) and the 9N PS (0.2%). In contrast, inhibition of the homologous 9V Ag-rabbit AS binding by cross-reactive 9L and 9N PSs ranged from 57.8 to 62.7%. Removal of the O-acetyl group from 9V PS by alkali hydrolysis resulted in decreased binding with rabbit 9V AS. However, the binding reaction with 9V MAb was less affected by the loss of O-acetyl content. The 9V MAb was both opsonic and passively protected young mice against challenge with type-9V pneumococci.

Will thallium-201 replace gallium-67 in salivary gland scintigraphy?

We investigated and compared findings on combined 99mTc pertechnetate-201Tl with those of [99mTc]pertechnetate-67Ga scintiscans to elucidate the advantages of 201Tl in detecting various salivary glands disorders.

METHODS

We studied 23 patients: 6 had sialadenitis, 12 had benign tumors and 5 had malignant tumors. All but four patients had undergone [99mTc]pertechnetate (before and after lemon stimulation), 201Tl (early and delayed) and 67Ga imaging.

RESULTS

Five of six sialadenitis patients showed various degrees of diffuse uptake of 99mTc. All six except one showed early uptake without retention of 201Tl on delayed imaging. The 67Ga scan showed uptake in all patients except one. Nine of 12 benign tumors showed a cold defect on 99mTc scans. Patients with Warthin's tumors and plasmacytoma showed increased 99mTc uptake at the tumor with retention. The 201Tl scan showed early uptake without retention in benign tumors except in three patients, two of whom had Warthin's tumor. Five of the benign tumors, however, were positive on 67Ga scan. None of the malignant tumors showed any uptake of 99mTc. The 201Tl scan showed uptake with tumor retention on delayed images in three patients; three other patients also had positive 67Ga scans. Overall, sensitivity and specificity of 201Tl in detecting malignant tumors were 60% and 73%, respectively, with a negative predictive value of 85%. Sensitivity and specificity for 67Ga were 60% and 47%, respectively, with a negative predictive value of 80%.

CONCLUSION

In view of sensitivity, specificity and convenience of 201Tl as well as future prospects for dual-isotope acquisition, 67Ga may be replaced by 201Tl in detecting salivary gland disorder.

[89Sr Therapy for pain relief in patients with bone metastases]

Radioactive strontium chloride (89Sr) was administered for pain relief in 6 patients with bone metastases (4 prostate cancer and 2 breast cancer patients). Out of 6 patients, 2 showed apparent relief of bone pain and improvement of QOL, and 3 showed slight relief of the pain with or without improvement of QOL; that is, 83% was effective. Side effects were seen in 2 patients; transient deterioration of bone pain in one patient and bone marrow suppression in the other patient. The patient who showed bone marrow suppression had rather more lesions of bone metastasis (diffuse metastasis) and least urinary excretion of the radioactivity. Urinary excretion for 2 days varied 5 to 40% of the administered dose and was less in the patients with more metastatic lesions.

[Analysis of risk factors for development of bronchopleural fistula after pneumonectomy for lung cancer]

Bronchopleural fistulas (BPF) developed in six (7.9%) of 76 patients who underwent a pneumonectomy for treatment of lung cancer. Five patients (18.2%) underwent a right pneumonectomy and one (3.7%) a left pneumonectomy. All patients were male, had squamous cell carcinoma, and were diagnosed as having BPF within one month after pneumonectomy. Their average age was 60.2 years. Univariate analyses related to development of BPF showed that significant risk factors were preoperative infection (Chi-square test; p < 0.001), right pneumonectomy (Chi-square test; p < 0.05), and metastasis to a subcarinal lymph node (Chi-square test; p < 0.05). However, sex, age, operating time, amount of blood loss during surgery, amount of blood transfused during surgery, history of smoking, degree of lymph node dissection, degree of curability, performance of combined resection, histologic type of tumor, tumor size, presence of residual tumor at the bronchial stump, and suturing method were not significant risk factors for development of BPF. Our stepwise regression analysis related to development of BPF showed that preoperative infection, metastasis to a subcarinal lymph node, right pneumonectomy, and combined resection were significant risk factors. Sometimes it is difficult to preserve the bronchial arteries upon the dissection of metastatic subcarinal lymph nodes which tightly adhere to the bronchial sheath. Moreover, after a conventional right pneumonectomy, the bronchial stump protrudes into the pleural cavity and is not covered by any tissue. Ligation of the bronchial arteries or protrusion of the bronchial stump into the right pleural cavity reduces the blood supply to the bronchial stump to a very low level and causes development of BPF. Therefore, we suggest that control of preoperative infection, wrapping of the bronchial stump, and preservation of the bronchial arteries during mediastinal lymph node dissection are important to prevent development of BPF.

[Prevalence of coexisting diabetes mellitus among patients with active pulmonary tuberculosis]

We investigated the prevalence of coexisting diabetes mellitus among patients with active pulmonary tuberculosis by the time of admission, sex and age among 2659 active pulmonary tuberculosis patients admitted to National Chiba Higashi Hospital during the 8 years period from 1987 to 1994. Out of total patients, 352 patients were diagnosed as having coexisting diabetes mellitus and the rate was 13.2%. Prevalence of coexisting diabetes mellitus among active pulmonary tuberculosis during the period from 1991 to 1994 was significantly higher than that from 1987 to 1990. The prevalence in male was higher than that in female significantly. The prevalence was particularly higher in male of 40s (22.0%), and 50s (21.3%), than that in the other age groups.