Renal carcinoma in a solitary kidney

We studied the clinical and pathological features of 26 patients with renal carcinoma of a solitary kidney, including 6 treated at this hospital. Four patients had a contracted kidney and 22 had previously undergone nephrectomy. Partial nephrectomy was performed in 16 patients, enucleation of the tumour in 5 and radical nephrectomy in 5 because of the size of the tumour. Ex vivo surgery was carried out in 4 patients. The duration of ischaemia ranged from 15 to 365 min but was longer in those who underwent ex vivo surgery (149 to 365 min). Of the 21 patients who underwent partial nephrectomy or enucleation, the serum creatinine level increased (greater than or equal to 2.0 mg/dl) post-operatively in 16 patients, of whom 9 required temporary haemodialysis. No recurrence has been noted in those who underwent partial nephrectomy, but 1 patient who underwent enucleation of the tumour developed a solitary pancreatic metastasis 2 years 6 months after surgery and was treated by a partial pancreatectomy. Kidney-preserving surgical procedures are considered to improve the quality of life, but careful follow-up is necessary.

Molecular and functional identification and purification of complement component factor D from urine of patients with chronic renal failure

Urine proteins of normal subject and patients with impaired renal function were analyzed by two-dimensional polyacrylamide gel electrophoresis. As a result, a clear spot was detected specifically in urine from patients with obvious renal dysfunction. The isoelectrical point of this unique spot was pH 7.1-7.2 and the flow-rate (Rf) was 0.50-0.55 as that of albumin was 1.0. Partial amino acid sequence analysis revealed that the NH2-terminal to 22nd amino acid sequence was identical with that of complement factor D. We purified 22 mg of this protein (factor D) from 5000 ml of urine from a patient on hemodialysis by three chromatographic steps using DEAE-Sephadex A-50 and Sephacryl S-200. The purified urine factor D gave a single band in sodium dodecyl sulfate polyacrylamide gel electrophoresis at the position of 23 kD, and displayed normal factor D hemolytic activity. The concentrations of factor D estimated by hemolytic assay were 1.9 micrograms/ml of normal serum, less than 0.1 microgram/ml of normal urine, 15 micrograms/ml of patient serum and 50 micrograms/ml of patient urine.

[A case of urachal abscess]

A 26-year-old male with urachal abscess was demonstrated. Ultrasonography, CT and MRI revealed that there was a mass at the supravesical region, which was connected to the umbilicus. However, a differential diagnosis as to whether the mass was a tumor or an abscess was difficult from these examinations. Thus we performed an open biopsy. A pathological examination revealed no malignant change in the biopsy specimen. On the other hand, the pathological diagnosis of a follicular tumor located at the roof of the urinary bladder was TCC G2, but we considered that, this change was a reactive hyperplasia with dysplasia resulting from chronic inflammation of urachal abscess. Thus, the complete excision of urachal abscess and partial cystectomy were performed. The serial sections of the bladder wall revealed no malignant changes. We reviewed similar cases reported in our country and discussed various factors causing urachal abscess, especially related to the infectious root.

[Danazol therapy of endometriosis of the bladder and ureter: a case report]

Endometriosis of the urinary tract is uncommon. A thirty-year-old woman was referred to our hospital, complaining of macrohematuria. Intravenous pyelography (IVP) showed bilateral hydro nephrosis. Cystoscopic examination revealed a mass around the bilateral ureteral orifice. Danazol therapy was commenced. After 6 months of therapy, IVP showed the improvement of hydronephrosis of left kidney and cystoscopy revealed the resolution of most of the mass in the bladder. For definite diagnosis and treatment, danazol therapy is considered to be effective for endometriosis, but if secondary fibrosis has occurred, surgical treatment may be necessary.

[A clinicopathological analysis of renal cell carcinoma in solitary kidney]

Seven patients with renal cell carcinoma, who had undergone uninephrectomy or who had only one functioning kidney were clinicopathologically studied. They were 5 males and 2 females, with ages ranging from 51 to 74 years (mean: 61 years). Of these cases, 4 had undergone uninephrectomy for renal cell carcinoma, and 1 had received uninephrectomy because of renal calculus. In the remaining 2 cases, one kidney did not function (hypoplastic kidney). Renal cell carcinoma was discovered by macroscopic hematuria in 2 cases, during the follow-up observation after a previous surgical treatment of renal cell carcinoma in 4 cases and by abdominal computed tomography during treatment of abdominal aneurysm in 1 case. Excluding one case with multiple metastases, all cases were surgically treated (3 with partial nephrectomy and 3 with enucleation). During surgery, renal blood vessels were clamped for 24-60 minutes (mean: 38 minutes). After operation, 5 cases showed an elevation in serum creatinine (greater than or equal to 2.0 mg/ml), which, however, was normalized rapidly by conservative treatment. They have been followed up for 6 months to 7 years and 8 months after operation (mean: 2 years and 11 months). The case which had undergone before and recently received enucleation (2 pieces) showed metastasis of cancer to the pancreas 2.5 years after the recent operation. Therefore, this case additionally received partial pancreatectomy. The results of this study suggest that conservative surgical treatments are appropriate for the treatment of renal cell carcinoma in patients with solitary kidney from viewpoint of the quality of life, so long as postoperative management is sufficiently made.

[Rethymectomy for intractable myasthenia gravis with thymus remnants]

Nine myasthenia gravis patients (including 6 thymomas) with partial or no recovery were studied from 2 to 13 years after previous thymectomy, which had been carried out by the transsternal simple thymectomy in three, transretrothoratic simple thymectomy in three and extended thymectomy in three. X-ray CT and MRI of the mediastinum showed images compatible with residual thymic tissue in 8 of 9 patients. All patients underwent reoperation by extended thymectomy, and thymic tissue was found in 7 of 9 patients. There is no patients with recurrent thymoma localized to the mediastinum. After repeated thymectomy, 7 of 9 patients improved clinical including one patient without remnant and 2 patients were unchanged. Persistence of symptoms in patients with myasthenia gravis who have undergone the first surgery has been attributed to remnant thymic tissue. There is no correlation in the improvement and corticosteroid hormone therapy before the re-exploration. Therefore, it is quite reasonable to infer that incomplete removal of the thymus was responsible, at least partly, for failure of the first procedure.

Prognostic factors after hepatectomy for hepatocellular carcinomas. A univariate and multivariate analysis

The current study determines the prognostic factors after hepatectomy for hepatocellular carcinomas. The 295 patients who underwent hepatectomy from 1973 through 1987 were included for a univariate and a Cox multivariate analysis. The favoring conditions were determined as follows. The essential requirements are (1) the absence of tumor thrombi; (2) no intrahepatic metastasis, but even when present, it should be close to the main tumor and removed with a massive resection; and (3) retention rate of indocyanine green dye (ICG) at 15 minutes should be within 14 +/- 4.2% (M +/- SD) to allow that resection. The desired requirement is that the tumor size should preferably be less than 5 cm; a wider free margin from tumors (greater than or equal to 1 cm) is recommended, but not determining factor. The eligible patients, having no thrombi, no intrahepatic metastasis, a tumor size of 5 cm or less, negative surgical margin (greater than or equal to 1 cm), had achieved a 5-year survival of 78%. In conclusion, resection therapy is the first option for patients with those requirements.

Prognostic factors after hepatectomy for hepatocellular carcinomas. A univariate and multivariate analysis

The current study determines the prognostic factors after hepatectomy for hepatocellular carcinomas. The 295 patients who underwent hepatectomy from 1973 through 1987 were included for a univariate and a Cox multivariate analysis. The favoring conditions were determined as follows. The essential requirements are (1) the absence of tumor thrombi; (2) no intrahepatic metastasis, but even when present, it should be close to the main tumor and removed with a massive resection; and (3) retention rate of indocyanine green dye (ICG) at 15 minutes should be within 14 +/- 4.2% (M +/- SD) to allow that resection. The desired requirement is that the tumor size should preferably be less than 5 cm; a wider free margin from tumors (greater than or equal to 1 cm) is recommended, but not determining factor. The eligible patients, having no thrombi, no intrahepatic metastasis, a tumor size of 5 cm or less, negative surgical margin (greater than or equal to 1 cm), had achieved a 5-year survival of 78%. In conclusion, resection therapy is the first option for patients with those requirements.

Prognostic factors after hepatectomy for hepatocellular carcinomas. A univariate and multivariate analysis

The current study determines the prognostic factors after hepatectomy for hepatocellular carcinomas. The 295 patients who underwent hepatectomy from 1973 through 1987 were included for a univariate and a Cox multivariate analysis. The favoring conditions were determined as follows. The essential requirements are (1) the absence of tumor thrombi; (2) no intrahepatic metastasis, but even when present, it should be close to the main tumor and removed with a massive resection; and (3) retention rate of indocyanine green dye (ICG) at 15 minutes should be within 14 +/- 4.2% (M +/- SD) to allow that resection. The desired requirement is that the tumor size should preferably be less than 5 cm; a wider free margin from tumors (greater than or equal to 1 cm) is recommended, but not determining factor. The eligible patients, having no thrombi, no intrahepatic metastasis, a tumor size of 5 cm or less, negative surgical margin (greater than or equal to 1 cm), had achieved a 5-year survival of 78%. In conclusion, resection therapy is the first option for patients with those requirements.

[Clinical experience with three cases of haemorrhagic tendency--bladder carcinoma with hemophilia A, a bladder carcinoma with von Willebrand disease and a benign prostatic hypertrophy with idiopathic thrombocytopenic purpura (ITP)]

Recent understanding of the pathogenicity of haemorrhagic tendency as well as advance of management of patients with this disease makes its surgical treatment possible. Since 1979 we have experienced three male patients with haemorrhagic tendency. The first case was a bladder carcinoma with hemophilia A. He had been given 2500 unit of Conco-eight (coagulation factor VIII) before transurethral resection of bladder tumor (TUR-Bt) and was given 1000 unit of Conco-eight every eight to twelve hours for seven days postoperatively. The second case was a bladder carcinoma with von Willebrand disease. This case was also pretreated by Conco-eight before operation and we had difficulty in controlling his coagulopathy for one month postoperatively. The third case was a benign prostatic hypertrophy with idiopathic thrombocytopenic purpura (ITP). He had been given a huge dose of gamma globulin for six days before operation and on the operation day his platelet count was normalized. Since his prostate was estimated to weight over 70 g, suprapubic prostatectomy was selected. All these three cases were operated uneventfully. From this experience we believe that with proper preoperative and postoperative management, patients with haemorrhagic tendency can be operated safely.

[Renal cell carcinoma and angiomyolipoma in tuberous sclerosis. Case report]

The association of angiomyolipoma with renal cell carcinoma in tuberous sclerosis is extremely rare, although the relation between tuberous sclerosis and angiomyolipoma of the kidney is widely recognized. We report here a case of bilateral angiomyolipoma and renal cell carcinoma of the right kidney with tuberous sclerosis and demonstrate the diagnostic difficulties in distinguishing between these tumors.

Epstein-Barr virus in nasal T-cell lymphomas in patients with lethal midline granuloma

Five cases of lethal midline granuloma were identified histologically and phenotypically as peripheral T-cell lymphomas. Epstein-Barr virus (EBV) DNA was detected in the nasal tumour biopsy specimens by Southern blotting and in-vitro hybridisation with simultaneous detection of EBV-determined nuclear antigen (EBNA) and T-cell surface markers by two-colour immunofluorescence. Further immunofluorescence and northern blotting revealed that EBNA2 gene and also latent membrane protein gene were expressed in the nasal tumour cells. The patients had high titres of antibodies to EBV. These findings suggest that lethal midline granuloma is causally associated with EBV.

[Immunohistological study on human palatine tonsils in cases with pustulosis palmaris et plantaris--the quantitative study by image analyzer]

The purpose of this study was to clarify the mechanism of tonsillar focal infections such as pustulosis palmaris et plantaris (PPP), especially the role of tonsil on it. In 88 cases of various tonsillar diseases, i.e., PPP, chronic tonsillitis, and sleep apnea syndrome, distribution of immunocompetent cells, i.e., B cells having various immunoglobulin isotypes (IgG, IgM, IgA, IgD, IgE, IgA1, and IgA2) on their surfaces and T cell subsets, helper/inducer (CD4+) T cell and suppressor/cytotoxic (CD8+) T cell were investigated immunohistologically using monoclonal antibodies and ABC method. The proportion of the immunocompetent cells in four anatomical sites in tonsil (germinal center, mantle zone, interfollicular area, and subepithelial area) were quantitatively studied by the image analyzer (CUE-2, Olympus, USA) and compared among various age groups and among three groups of tonsillar diseases. The difference of immunocompetent cells in tonsils between the effective group (showing marked improvement of skin lesions of PPP after tonsillectomy) and the not-effective group (showing no improvement of skin lesions after tonsillectomy) was also investigated. The results were summarized as follows. 1) Every type of Ig-positive cells in tonsils was decreased in proportion to age, especially the changes of IgG-, IgM-, and IgD-positive cells were inversely proportional to age with statistical significance. On the other hand, changes to T cell subsets with age were smaller in comparison with those of Ig-positive cells, especially the proportion of CD4-positive cells showed almost no changes in accordance with age. 2) Eighty percent of cases with PPP were classified into the effective group, whereas only 20% of them into the not-effective group. 3) IgG-, IgM-, and IgD-positive cells in tonsils of PPP were found to be significantly increased in the effective group compared to the not-effective group. In addition, in the effective group, CD4-positive cells were significantly increased in the interfollicular area and the subepithelial area of the tonsil. These results indicate that the image analysis will be a breakthrough in quantitative study on the immunohistology of the tonsil and give us useful informations in terms of the mechanism of tonsillar focal infections, i.e., immunological abnormalities in tonsils may play one of the important roles in the pathogenesis of PPP.

[Immunohistological study on immunocompetent cells in palatine tonsil and pharyngeal tonsil--the quantitative study by image analyzer]

Distribution of various immunocompetent cells, i.e., IgG-, IgM-, IgA-, IgD-, IgE-, CD4-, and CD8-positive cells in palatine tonsils (tonsils) and pharyngeal tonsils (adenoids) of same patients were investigated immunohistologically by using monoclonal antibodies. The proportion of Ig-positive cells and T cell subsets in both tonsils were quantitatively studied by the image analyzer (CUE-2, Olympus, USA). The results were summarized as follows: 1) There was no significant difference in proportions of Ig-positive cells and T cell subsets between tonsils and adenoids. 2) IgG- and IgD-positive cells in the tonsils were significantly increased in cases with recurrent tonsillitis than in those with simple tonsillar hypertrophy. 3) Number of IgA2-positive cells were significantly changed, i.e., decreased in the subepithelial area of tonsils and increased in the interfollicular area of adenoids in cases complicated with otitis media with effusion. 4) In cases complicated with nasal allergy, IgE-positive cells were significantly increased in the interfollicular area in both of those tonsils and adenoids. These results indicate that the image analyzer will be a breakthrough in quantitative study on the immunohistology of tonsils and adenoids and give us useful informations about roles of the tonsil and the adenoid on the local immunity of the upper respiratory airway.

The N.I.F. classification of ossicular disorders

The authors present their classification of ossicular disorders. It is felt to be easy to use, and self-explanatory, and it lends itself conveniently to analysis of data by computer. Examples are shown of its use in analyzing data in relationship to the ossicular status, in quantifying the effects of different ossicular situations, and in comparing our results with those of other authors. Using the N.I.F. classification, these factors are surprisingly easy to manipulate. It is hoped that this classification will be of use to others engaged in the same type of studies.

[A case of reexpansion pulmonary edema during fenestration of a giant hepatic cyst]

We experienced a case of reexpansion pulmonary edema during the fenestration of giant hepatic cyst. The patient was a 56 year-old female who had been suffering from dyspnea due to a large abdominal mass for 3 months. The preoperative chest X-ray revealed remarkable elevation of diaphragm (right third and left fifth intercostal spaces). The result of blood gas analysis showed hypoxemia and respiratory compensation for metabolic acidosis. By the drainage of 12L of the cyst fluid for 30 minutes during operation, bloody and foamy bronchial secretion spurted out. Vigorous respiratory management using PEEP was promptly started and continued postoperatively in ICU. The endotrachial tube was withdrawn on the 2nd postoperative day. The ratio of protein in airway secretion in to plasma protein was 0.78, and it appeared that the pulmonary edema was mainly caused by increased permeability of pulmonary capillary vessels.

[Nuclear DNA analysis of hepatocellular carcinoma]

Retrospective DNA ploidy studies of paraffin-embedded blocks were performed by flow cytometry on 212 surgically resected hepatocellular carcinoma. One hundred and sixty-four of 212 specimens yielded evaluable DNA histograms. Eighty-three cases showed a DNA diploid pattern and 81 a DNA non-diploid pattern. The incidence of non-diploid pattern increased with the tumor size. (2cm; 15.4%, 2-5; 42.3%, 5-10; 70.8% greater than 10; 73.3%). The DNA pattern correlated with the backgrounds, the degree of vascular invasion, intrahepatic metastasis and serum AFP levels. Survival of patients with non-diploid pattern was significantly less than those with diploid patients in any different stage. Of thirty who survived three years with disease free condition, 20 patients showed diploid patterns. Though remaining 10 patients were non-diploid patterns, 9 were high DNA index more than 1.5. It is concluded that flow cytometric DNA ploidy study had prognostic value for patients with surgically resected hepatocellular carcinoma.

[Criteria of curability in the resection therapy for hepatocellular carcinoma]

The present study was aimed at determining a criteria for curability of hepatic resection in the treatment of hepatocellular carcinomas. The 239 patients hepatectomized from 1973 through 1987 were included for analysis. The patients with the tumor thrombi(V) or intrahepatic metastasis(IM) scattered over the unilateral lobe(IM2) showed very poor prognosis in spite of macroscopically complete resections. Consequently, these conditions were categorized into non-curative group(NC). The 5-year survival rate of the tumors less than 2 cm was 42%, which was much better than that of 5 cm or more group but no better than that of 2 to 5 cm group. When the prognosis was compared by an extent of resection among the patients with the tumors of less than 5 cm in size and V(-), the patients with lobectomy showed a 5-year survival rate of 84%, much better than 45% of those with segmentectomy or less range. The surgical margin (SM) negative patients showed a better prognosis than the SM positive patients with a slight difference. The tumor backgrounds of the 39 patients who survived three years with disease free condition were as follows: V(-) in all, no intrahepatic metastasis(IM0) in 79%, no IM2, massive resection for all IM1 in whom IM was confined to the area close to the main tumors, a tumor size of 5 cm or less in 82%, SM(-) in 62%. From the findings described above, we defined a complete resection for V(-) and IM0-1 as a curative condition, of which absolute curative resections(AC) corresponded to the patients with the tumors of 5 cm or less and SM(-), and relative curative ones(RC) to the remainders.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of renal leiomyoma with extensive cystic degeneration]

An extremely rare case of renal leiomyoma presenting as a cystic mass, involving the upper pole of the right kidney in a 59-year-old woman, complaining of right flank pain is reported. Some discussion regarding pathogenesis of leiomyoma with cystic change, diagnostic feature, malignant potential of leiomyoma and others was done. Since 1948, 19 cases including our own case of renal leiomyoma have been reported in the Japanese literature.

[A case of motor and sensory neuropathy with elevated serum lactate and pyruvate which responded to large dose of coenzyme Q10 therapy]

A 16-year-old high school male student was admitted to our hospital with complaints of difficulty in walking and muscle atrophy of the lower legs. He noticed his gait disturbance when he was about 12 years old and his symptoms had gradually increased. On examination, he was unable to walk on his heels and on his toes. He had mild pes cavus and marked muscle wastes of the lower legs. The weakness was limited to the feet, lower legs, and hands. Mild sensory losses were demonstrated inside of the feet. Autonomic dysfunction was not present. The deep tendon reflexes were diminished. Nerves were not enlarged or excessively firm. On laboratory examinations, pyruvate and lactate were elevated in both serum and cerebrospinal fluid. The serum level of coenzyme Q10 (CoQ10) was low (0.57 micrograms/ml). Nerve conduction velocities were normal or just below normal except sural nerves and amplitudes of M waves were decreased. The sural nerve finding revealed marked reduction in number of large myelinated fibers and no onion bulb formation. The teased myelinated fiber analysis suggested ongoing axonal degeneration. Electron microscopy showed no mitochondrial abnormalities in muscle and nerve. The therapeutic trial of large dose of CoQ10 (120 mg/day) was dramatically effective to muscle weakness and atrophy at about third week after therapy. His gait disturbance disappeared after about 16 months. These findings may indicate an alteration of mitochondrial function in this case.

Evidence of delayed mesangial transport of human IgA in glomeruli of ddY mice pretreated with sheep anti-type IV collagen serum

In order to investigate whether mesangial transport by glomeruli is delayed in ddY mice pretreated with sheep anti-type IV collagen serum, the mice were administered an overload of human IgA myeloma serum. Non-pretreated ddY mice used as controls and both experimental and control BALB/c mice were also processed in a similar manner. The intensities of mesangial deposition of human IgA were examined periodically and were found to correlate well with deposition of mouse IgA. Both mouse and human IgAs showed a gradual increase for up to 8 experimental weeks. In the control young ddY mice, however, the overloaded mesangial human IgA quickly disappeared, presenting no appreciable mesangial deposition of autologous IgA. In sharp contrast, both the experimental and control BALB/c mice showed an initially prolonged and rather heavy mesangial deposition of human IgA, followed by a gradual decrease and somewhat light mesangial deposition of autologous mouse IgA. These results obtained using experimental ddY mice appear to confirm the possibility that non-immunological local trapping, due to retardation of mesangial transport function, causes mesangial deposition of autologous mouse IgA in this particular strain.

[Colon bladder replacement after total cystectomy]

Although ileal conduit diversion is widely accepted in the treatment of the patients undergoing radical cystectomy, many patients would prefer other alternatives which allow continence. and urination through the urethra. We describe a new procedure in which a segment of detuburalized right colon is used as a continent reservoir. Eight patients, 7 after radical cystectomy for bladder cancer and one after total exenteration for rectal cancer, have undergone colon bladder replacement. New created bladder had a capacity of 300 to 600 ml. All patients could pass urine through the urethra but one is on self-catheterization. Five of the 8 patients had no residual urine. Three months after operations 4 were totally continent and 3 were satisfactorily dry during daytime but slightly enuretic. Excretory urography showed no abnormalities in their upper urinary tract. Considering the "quality of life' of a patient, this procedure can be an ideal option for selected patients.

Tonsillectomy-induced changes in anti-keratin antibodies in patients with pustulosis palmaris et plantaris: a clinical correlation

Titers of anti-keratin antibodies (AKA) involving IgG and IgM fractions were determined by a solid-phase enzyme-linked immunsorbent assay (ELISA) and were found to be significantly higher on average in patients with pustulosis palmaris et plantaris (PPP) than in normal controls. Positive rates of IgG-AKA and IgM-AKA in sera of PPP patients were 50% and 66%, respectively. Following tonsillectomies, patients with high IgM-AKA titers that decreased after surgery were found to benefit by a marked improvement in their skin lesions. There was a close relationship between the degree of this improvement in the skin lesions and the changes in IgM-AKA titers after the operation. These results suggest that PPP may be a tonsil-related immunological skin disease.

[Fundamental studies of targeting cancer chemotherapy against choriocarcinoma--application of liposome]

For the fundamental study of the targeting cancer chemotherapy against choriocarcinoma using the anti-human chorionic gonadotropin beta subunit (hCG beta) antibody-conjugated-liposome containing anticancer drugs, we evaluated the specific accumulation of the antibody to the choriocarcinoma tissue and the uptake of liposome by choriocarcinoma cells. In vivo, the mice bearing human choriocarcinoma were injected anti-hCG beta antibody (30 micrograms/body) and the localization of the antibody in the tumor and other mouse organs were investigated by the PAP method. The antibody specifically accumulated to the choriocarcinoma tissue within 4 hours after the injection of the antibody, and gradually increased. In vitro, cultured BeWo cells were exposed to the liposome containing adriamycin, the antibody conjugated liposome containing adriamycin or the adriamycin alone, respectively, for 2 hours. Then the uptake of the adriamycin by the tumor cells was studied under fluorescent microscopy. The nuclear accumulation of adriamycin was clearly observed in the tumor cells exposed to the liposome containing adriamycin or the antibody conjugated liposome containing adriamycin, whereas only faint cytoplasmic accumulation of the adriamycin without any nuclear accumulation was observed in the cells exposed to the adriamycin alone. These results indicate that the liposome is a good carrier of anticancer drugs for immunotargeting chemotherapy.