Successful late management of spontaneous esophageal rupture using T-tube mediastinoabdominal drainage

BACKGROUND

Spontaneous esophageal rupture is extremely rare, and early symptoms of the disease are similar to those of emergency diseases of the chest and abdomen. The diagnosis and treatments are often delayed, resulting in an unfavorable outcome in some cases.

METHODS

We performed improved T-tube drainage for spontaneous esophageal rupture in 5 patients between 1995 and 1999. Our improved method was a modified procedure of the reported method of Abbott et al, as follows: a T-tube was inserted into the esophagus. A separate stab incision was made in the abdominal wall, and the long limb of the T-tube was brought out through this incision ensuring that the course of the T-tube intra-abdominally was short and straight, with some slack to allow for postoperative abdominal distension. An advantage of this method was that it facilitated healing of the fistula after removal of the T-tube.

RESULTS

All patients were treated with a satisfactory outcome.

CONCLUSION

This improved T-tube drainage was technically very easy and safe method for spontaneous esophageal rupture in severe cases.

Colonization with Schizophyllum commune of localized honeycomb lung with mucus

We report a surgical case involving localized honeycomb lung with mucus, caused by colonization of a Schizophyllum commune, which displayed a tumorous shadow in the right upper mediastinum. A 74-year-old male with a history of tuberculosis in the 1970s was referred to Chiba University Hospital (Chiba, Japan) with an abnormal shadow evident in the chest roentgenogram. A transbronchial biopsy failed to yield a definite diagnosis. We resected the right upper lobe, which was found to contain a consolidative lesion filled with viscous mucus in the right upper lobe adjacent to the right upper mediastinum. Microscopic examination revealed a honeycomb lung formation with mucus in the destroyed space. Culture of the mucus yielded a whitish filamentous fungus, positively identified as S. commune. This is the first report of S. commune leading to a deposit of mucus and the formation of a consolidative lesion in the destroyed lung.

Oral tolerance induction by type V collagen downregulates lung allograft rejection

Immunization with specific proteins or peptides has been used to induce immunologic tolerance to allografts other than the lung. Recently, we have reported that the immune response to lung alloantigen also involves an immune response to type V collagen [col(V)]. The purpose of the current study was to determine if oral administration of col(V) to lung allograft recipients before transplantation downregulates acute rejection episodes. The data show that, compared with controls, col(V)-fed recipients had fewer polymorphonuclear cells and lymphocytes in allograft bronchoalveolar lavage fluid, and reduced rejection pathology. Data showing that col(V)- fed allograft recipients had diminished delayed-type hypersensitivity (DTH) responses to donor alloantigens suggest that feeding col(V) prevented allograft rejection by inducing tolerance to donor antigens. Systemic production of transforming growth factor (TGF)-beta, interleukin (IL)-4, or IL-10 has been reported to be a mechanism for oral tolerance-induced suppression of immune responses. Feeding col(V) induced upregulated production of TGF-beta, but not IL-4 or IL-10 in serum. Neutralizing TGF-beta recovered the DTH response to donor antigen in tolerant allograft recipients. Collectively, these data show that oral administration of col(V) is a novel approach to induce immunologic tolerance to lung allografts, and that TGF-beta contributed to suppression of the rejection response.

[Surgery for non-small cell lung cancer based on the T factor]

We review the indications of surgery in patients with non-small cell lung cancer (NSCLC) based on the T factor, focusing on peripheral small tumors, invasion to other organs, and the presence of malignant pleural effusion or intrapulmonary metastasis. While limited surgery in patients with peripheral, small-sized NSCLC preserves postoperative pulmonary function, the prospects for long-term survival are reduced due to the likelihood of recurrence, Novel prospective studies are being conducted to determine the indications for limited surgery in such patients which focus on histology, tumor size, and pulmonary function. In some patients with locally advanced disease, especially with invasion of the chest wall (T3), pericardium (T3), left atrium (T4), great vessel (T4), and carina (T4) and with malignant pleural effusion found intraoperatively and ipsilateral intrapulmonary metastasis, complete resection results in long-term survival. Thus surgery should be considered in patients without N2 disease.

Microsatellite alterations in patients with thoracic sarcoma

Few studies on sarcomas have examined the relationships between microsatellite alterations in particular loci, tumor prognosis and tumorigenesis, because sarcomas are uncommon and those prognoses can be confounded by coexisting factors, such as tumor site. We studied the relationship between microsatellite alterations and prognosis in 31 patients with thoracic sarcoma. The frequency of loss of heterozygosity (LOH) at 17p13 in stage IV sarcomas was significantly higher than that in stage I and III sarcomas (p<0.05). The 5-year survival for patients with LOH at 17p13 was significantly lower than that for patients without LOH (p<0.05). Six of 31 cases (19.4%) revealed replication error. These results suggest that p53 abnormality occurs during advanced stages of sarcoma and are related to patient prognosis, and it is possible that aberrations in mismatch repair activity are related to sarcoma tumorigenesis.

Obstruction due to persimmon bezoars: computed tomography detection

BACKGROUND/AIMS

Small-bowel obstructions caused by persimmon bezoars are uncommon, and the diagnosis is difficult before operation. The aim of this study was to present computed tomography findings of persimmon bezoars in the small bowel.

METHODOLOGY

We reviewed 3 cases diagnosed with small-bowel obstruction caused by persimmon bezoars between April 1997 and March 1999 at Chikamori Hospital.

RESULTS

The cause of the small-bowel obstruction was bezoars in the 3 patients. Abdominal computed tomography performed before operation revealed a well-defined, intraluminal inhomogeneous mottled mass containing gas bubbles.

CONCLUSIONS

Computed tomography is useful for diagnosing obstructed small-bowel persimmon bezoars.

Long-term survival achieved by resection of metastases in the liver and lung in a patient with recurrent colonic cancer: report of a case

A 58-year-old man who underwent a potentially curative resection of cancer of the sigmoid colon at another hospital was subsequently followed up at our hospital. A lateral segmentectomy was performed for a solitary hepatic metastasis, and partial resection of right S1 was later carried out for a pulmonary metastasis. Another pulmonary metastasis was found 6 years after his third operation and to minimize the area to be resected, bronchial arterial infusion chemotherapy was performed twice. A 51% reduction in the size of the tumor was achieved, so a right upper lobectomy and wedge resection of the bronchus were performed. The patient remains alive 14 years after the initial resection of colonic cancer. This case is considered noteworthy because it demonstrates the potential effectiveness of local adjuvant chemotherapy and the possibility of extended survival in a patient who has undergone resection of both hepatic and pulmonary metastases from colonic cancer.

Urine-based enzyme-linked immunosorbent assay for the detection of Helicobacter pylori infection in children

OBJECTIVE

Serology and (13)C-urea breath test have been widely used as noninvasive tests to detect Helicobacter pylori infection. However, easier collection of samples and lower costs are desirable for diagnosis of the individual patient or for use in epidemiologic studies. Our aim was to study the diagnostic accuracy of a recently developed urine-based enzyme-linked immunosorbent assay (ELISA) kit for the detection of H pylori-specific immunoglobulin G (IgG) antibodies in children.

STUDY DESIGN

Specimens of serum and randomly voided urine were collected from 816 children (0-15 years old) and were analyzed using 2 serum-based ELISA kits and a urine-based ELISA kit, respectively. Based on results of serology, the sensitivity, specificity, and accuracy of the urine-based ELISA kit were evaluated. With regard to false-positive and false-negative results, urinary IgG concentrations and IgG/creatinine levels were studied.

RESULTS

Both serum-based ELISAs were positive in 41 children and were negative in 666, who were enrolled in this study. The remaining 109 children were excluded because of disagreement between the results of the 2 serum-based ELISAs, including indeterminate values. Overall sensitivity, specificity, and accuracy of urine-based ELISA test compared with serology were 85.4%, 95.5%, and 94.9%, respectively. On positivity rates, the urine-based ELISA was closely coincident with the serum-based ELISA in each age group. There was no correlation between antibody levels detected by urine-based ELISA and each serum-based ELISA. Urinary IgG concentrations and IgG/creatinine levels were significantly higher in false-positives and were lower in false-negatives than in true-positives plus true-negatives for serology. Most of those with false-positive results had trace to moderate proteinuria.

CONCLUSIONS

The urine-based ELISA is an alternative to serum-based ELISA for diagnosis of H pylori infection in children and should be suitable for large-scale epidemiologic studies concerning the organism. In children with proteinuria, results of the test should be interpreted with caution. It is possible that the urine-based ELISA method would be applicable to diagnosis of other infectious diseases.

The shapes and sizes of two domains of tropomodulin, the P-end-capping protein of actin-tropomyosin

Tropomodulin, the P-end (slow-growing end)-capping protein of the actin-tropomyosin filament, and its fragment (C20) of the C-terminal half were studied by synchrotron small-angle X-ray scattering, restoring low-resolution shapes using an ab initio shape-determining procedure. Tropomodulin is elongated (115 A long) and consists of two domains, one of 65 A in length and the other being similar to C20 in shape and size if the long axes of the two are tilted by about 40 degrees relative to each other. We propose a model for tropomodulin in association with tropomyosin and actin: the N-terminal half of tropomodulin, a rod, binds to the N-terminus of tropomyosin and the C-terminal triangle domain protrudes from the P-end being slightly bent towards the actin subunit at the end, thereby blocking the P-end.

Universal occurrence of the vasa-related genes among metazoans and their germline expression in Hydra

The vasa (vas)-related genes are members of the DEAD box protein family and are involved in germ cell formation in higher metazoans. In the present study, we cloned the vas-related genes as well as the PL10-related genes, other members of the DEAD box protein family, from lower metazoans: sponge, Hydra and planaria. The phylogenetic analysis suggested that the vas-related genes arose by duplication of a PL10-related gene before the appearance of sponges but after the diversion of fungi and plants. The vas-related genes in Hydra, Cnvas1 and Cnvas2 were strongly expressed in germline cells and less strongly expressed in multipotent interstitial stem cells and ectodermal epithelial cells. These results suggest that the vas-related genes occur universally among metazoans and that their expression in germline cells was established at least before cnidarian evolution.

Prognostic implication of Ki-67 immunostaining in treating subclinical pleural cancer found at thoracotomy in lung cancer patients

BACKGROUND

Therapeutic principles for managing subclinical pleural cancer found unexpectedly during intraoperative examination are unclear. We analyzed prognostic factors including the tumor proliferative marker Ki-67 in these circumstances.

METHODS

The cases of 65 surgically treated patients with lung cancer and subclinical T4 pleural cancer, microscopic in 25 and macroscopic in 40, were reviewed.

RESULTS

The overall 5-year survival rate of patients undergoing lobectomy was 14.3%. For patients with T4 NO disease, the 5-year survival rate was 46.7%. In patients with a low Ki-67 labeling index, the 5-year survival rate was 28.6%. The Ki-67 labeling index was a significant (p < 0.05) indicator of survival. Multivariate analysis demonstrated Ki-67 labeling index, lymph node involvement, and tumor differentiation to be the most influential prognostic factors for postoperative survival (p < 0.01).

CONCLUSIONS

In the treatment of lung cancer patients with subclinical pleural cancer found at thoracotomy, tumor resection is not necessarily contraindicated. Resection appears to be beneficial in patients with no nodal involvement or a low tumor Ki-67 labeling index. This index is a good therapeutic indicator for lung cancer patients.

Clinical characterization of pulmonary large cell neuroendocrine carcinoma and large cell carcinoma with neuroendocrine morphology

BACKGROUND

Large cell carcinoma has been classified as four potential types based on its neuroendocrine morphology and evidence of neuroendocrine differentiation discernible by immunohistochemistry or electron microscopy. However, the clinical relation among these four categories has not been clearly defined. In 1999, the World Health Organization (WHO) categorized large cell neuroendocrine carcinoma as a variant of large cell carcinoma. MATERIAL AND METHODS The authors analyzed 119 cases of large cell carcinoma from a total of 2070 primary lung carcinoma cases resected surgically between 1969-1999. Using light microscopy, electron microscopy, and immunohistochemical staining, the authors reclassified these cases into large cell neuroendocrine carcinoma (LCNEC), large cell carcinoma with neuroendocrine differentiation (LCCND), large cell carcinoma with neuroendocrine morphology (LCCNM), and classic large cell carcinoma (CLCC).

RESULTS

In multivariate analyses, the authors found that large cell carcinoma with neuroendocrine features, which combined LCNEC, LCCND, and LCCNM, impacted both the overall survival and disease-free survival of patients. The clinical behavior of LCCNM was similar to that of LCNEC.

CONCLUSIONS

Large cell carcinomas with neuroendocrine features appear to be more clinically aggressive than CLCCs. The authors' findings suggest that the histologic identification of neuroendocrine features in tumor tissue from patients diagnosed with large cell carcinoma of the lung may have clinical relevance.

Polyps, peptides and patterning

Peptides serve as important signalling molecules in development and differentiation in the simple metazoan Hydra. A systematic approach (The Hydra Peptide Project) has revealed that Hydra contains several hundreds of peptide signalling molecules, some of which are neuropeptides and others emanate from epithelial cells. These peptides control biological processes as diverse as muscle contraction, neuron differentiation, and the positional value gradient. Signal peptides cause changes in cell behaviour by controlling target genes such as matrix metalloproteases. The abundance of peptides in Hydra raises the question of whether, in early metazoan evolution, cell-cell communication was based mainly on these small molecules rather than on the growth-factor-like cytokines that control differentiation and development in higher animals.

Two hyperandrogenic adolescent girls with congenital portosystemic shunt

We describe two adolescent girls with a congenital portosystemic shunt who exhibited hyperandrogenism in addition to insulin resistant hyperinsulinaemia. Case 1 was referred to our clinic to undergo a routine clinical work-up prior to tonsillectomy at 14 years of age. Mild liver dysfunction was identified and hypogenesis of the portal vein with a congenital portosystemic shunt diagnosed. Primary amenorrhoea and virilization were evident and an endocrinological evaluation revealed hyperandrogenism and insulin resistant hyperinsulinaemia. Case 2 was referred at 15 years of age because of cardiomegaly. Mild liver dysfunction and hyperbilirubinaemia led to a diagnosis of agenesis of the portal vein with a congenital portosystemic shunt. Virilization was evident and an endocrinological evaluation revealed hyperandrogenism and insulin resistant hyperinsulinaemia. The haemodynamics of these patients were similar to those of secondary portosystemic shunt due to liver cirrhosis, which is often associated with hyperinsulinaemia and/or non-insulin dependent diabetes mellitus. On the other hand, hyperandrogenism is associated with certain insulin-resistant conditions with hyperinsulinaemia, including the polycystic ovary syndrome (PCO). Hyperinsulinaemia is believed to cause hyperandrogenism in patients with PCO by stimulating androgen production in both the ovary and adrenal gland. Therefore, in congenital portosystemic shunts, hyperinsulinaemia is also thought to cause hyperandrogenism due to the same mechanism.

CONCLUSION

A certain percentage of female patients with hyperandrogenism, likely including those with polycystic ovary syndrome may also have congenital portosystemic shunts. Our results indicate that serum levels of total bile acids and ammonia are prognostic indicators of this hepatic vascular anomaly.

Polymorphism in gene for islet autoantigen, IA-2, and type 1 diabetes in Japanese subjects

Autoantibodies against IA-2 have been detected in up to 86% of newly diagnosed patients with type 1 diabetes and appear to identify a subgroup of prediabetic subjects who rapidly progress to type 1 diabetes. We examined the association of IA-2 gene polymorphism with type 1 diabetes in Japanese subjects. A total of 276 Japanese subjects were studied for disease association and, in addition, another 53 patients were studied for association with the autoantibody status to IA-2. A microsatellite marker D2S1753E, located in the intron of the IA-2 gene, was used as a genetic marker in this study. In Japanese, two alleles (161mu and 165mu) were more frequent, and the 163mu allele was less frequent than in Caucasians (p = 0.0001). There was no significant difference in frequencies of alleles between diabetic patients and control subjects. The frequency of IA-2 gene polymorphism was not significantly different between patients stratified by age-at-onset, or between patients with and without susceptible HLA, DRB1*0405, DRB1*0802 and DRB1*0901. There was no significant difference in allele frequency of the IA-2 gene polymorphism between patients with and without autoantibody to IA-2. In conclusion, IA-2 gene polymorphism is not associated with either susceptibility to, or heterogeneity in type 1 diabetes in Japanese subjects.

Expression of vascular endothelial growth factor in thoracic sarcomas

BACKGROUND

A body of data indicates that vascular endothelial growth factor (VEGF) expression by carcinomas is closely related to the prognosis of carcinomas. However, the relationship between VEGF expression and the prognosis of sarcomas is contradictory.

METHODS

Tissue from 27 cases of thoracic sarcoma was analyzed immunohistochemically for VEGF expression while tumor vascularity was quantified using an antibody directed against endothelial CD34. The relationship between VEGF expression and the prognosis of patients with sarcomas was then evaluated semiquantitatively.

RESULTS

The microvessel count in sarcomas with strong VEGF expression was significantly higher than that in sarcomas with absent or faint VEGF expression. The disease-free survival rates of sarcomas with strong VEGF expression were significantly lower than those of sarcomas with absent or faint VEGF expression. We found that strong VEGF expression impacted on the disease-free survival in multivariate analyses.

CONCLUSIONS

VEGF expression of thoracic sarcomas is directly related to angiogenesis and tumor vascularity, and our findings suggest that strong VEGF expression is an independent prognostic factor in patients with thoracic sarcomas.

Matrix metalloproteinases and tissue inhibitors of metalloproteinases in synovial fluids of patients with temporomandibular joint osteoarthritis

AIMS

Imbalance between matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) may be involved in the breakdown of articular cartilage matrix of the temporomandibular joint (TMJ). In this study, MMPs, TIMPs, and MMP-1/TIMP-1 complex levels were examined in TMJ synovial fluid samples aspirated from TMJ osteoarthritis (OA) patients (2 males, 8 females; mean age, 29.7 years) and asymptomatic control subjects (2 males, 8 females; mean age, 23.6 years) to determine the likelihood of increased proteolytic activity in the OA joints.

METHODS

The various types of MMPs and TIMPs were detected by Western blotting with monoclonal antibodies and gelatin zymography. The MMP-1/TIMP-1 complex level was measured by an enzyme-linked immunosorbent assay kit. All aspirates were first analyzed for total protein content and then individually diluted to make the total protein levels equivalent.

RESULTS

The mean MMP-1/TIMP-1 complex concentration in the synovial fluids of the OA patients was 3.92 +/- 1.39 ng/mL; this value was significantly lower (P < 0.05) than the value from control subjects (5.46 +/- 1.32 ng/mL). Matrix metalloproteinase-1 (52 kDa), MMP-3 (57 kDa), TIMP-1 (28 kDa), and TIMP-2 (26 kDa) were detected in all of the normal and the OA samples. However, MMP-1 (28 kDa), MMP-2 (72 kDa), MMP-3 (45 kDa), and MMP-9 (83 kDa) were detected in higher concentration in the OA samples.

CONCLUSION

These findings suggest a strong association between the OA-active joints and the presence of biologically active forms of known tissue degradation enzymes (MMP-1, MMP-3, and MMP-9).

Regulation of surface FcepsilonRI expression on human eosinophils by IL-4 and IgE

BACKGROUND

Recent studies have demonstrated that eosinophils from allergic patients express low levels of FcepsilonRI on their surface, but the regulatory mechanisms of eosinophil surface FcepsilonRI expression are not fully understood. We investigated whether IL-4 and IgE, which are reported to regulate surface FcepsilonRI expression on human mast cells, are able to affect surface FcepsilonRI expression in normal human eosinophils.

METHODS

Eosinophils purified from peripheral blood were cultured with IL-5 and with or without IL-4 and/or IgE, and surface FcepsilonRI expression was analyzed by flow cytometry using an anti-FcepsilonRI mAb, CRA-1.

RESULTS

Apparent FcepsilonRI expression (approximately 1% of mast cell FcepsilonRI levels) was observed in eosinophils cultured with both IL-4 and IgE. A combination of IL-4 (>or=1 ng/ml) and IgE (>or= 0.5 microg/ml) was necessary for the maximal induction of surface FcepsilonRI expression. In the presence of IL-4 and IgE, eosinophils cultured for 2 days demonstrated low but statistically significant levels of surface FcepsilonRI, which reached a plateau after 7 days of culture. However, cross-linkage of surface FcepsilonRI molecules by CRA-1 or anti-IgE did not induce any eosinophil activation.

CONCLUSIONS

IL-4 and IgE can affect the levels of surface FcepsilonRI on normal human eosinophils. FcepsilonRI expression on eosinophils may be regulated by a mechanism similar to that in mast cells.

Fluorescence bronchoscopy in the detection of preinvasive bronchial lesions in patients with sputum cytology suspicious or positive for malignancy

BACKGROUND

A new strategy in the treatment of squamous cell carcinoma of the tracheobronchial tree is the detection and eradication of preinvasive bronchial lesions before they become invasive cancers. It is, however, difficult to detect preinvasive lesions by conventional white-light bronchoscopy alone.

PURPOSE

we conducted a detailed investigation on the use of fluorescence bronchoscopy in the detection of preinvasive bronchial lesions in patients with sputum cytology suspicious or positive for malignancy.

METHODS

64 participants with sputum cytology suspicious or positive for malignancy were examined with both white light and fluorescence bronchoscopy (LIFE group). Earlier to this study, before fluorescence bronchoscopy became available in our institute, 48 participants having sputum cytology suspicious or positive for malignancy were examined with white light bronchoscopy alone (control group). Biopsy specimens for pathological examinations were taken of all abnormal areas discovered by white light or fluorescence bronchoscopy examination.

RESULTS

In sputum cytology suspicious or positive for malignancy, the diagnosis of preinvasive bronchial lesions was greatly enhanced in the LIFE group as compared with the control group (45 vs. 7 lesions). The percentage of participants with preinvasive bronchial lesions was also significantly higher in the LIFE group than in the control group (40.6 vs. 12.5%, P = 0.00087, respectively).

CONCLUSIONS

Our study suggests that the use of fluorescence bronchoscopy in addition to conventional white-light examination could greatly enhance the detection and localization of preinvasive bronchial lesions in patients with sputum cytology suspicious or positive for malignancy.

Identification of a new point mutation in the human xanthine dehydrogenase gene responsible for a case of classical type I xanthinuria

A 60-year-old Japanese man was diagnosed as having hypouricemia at an annual health check-up. The routine laboratory data was not remarkable except that the patient's hypouricemia and plasma levels of xanthine and hypoxanthine were much higher than those of normal subjects. Furthermore, the patient's daily urinary excretion of xanthine and hypoxanthine was markedly increased compared with reference values. The xanthine dehyrogenase activity of the duodenal mucosa was below the limits of detection. Nevertheless, allopurinol was metabolized to oxypurinol in vivo. Based on these findings, a subtype of classical xanthinuria (type I) was diagnosed. The xanthine dehyrogenase protein was detected by Western blotting analysis. Sequencing of the cDNA of the xanthine dehyrogenase obtained from the duodenal mucosa revealed that a point mutation of C to T had occurred in nucleotide 445. This changed codon 149 from CGC (Arg) to TGC (Cys), a finding that has not been previously reported in patients with classical xanthinuria type I.