Development of cystic malacia after high-dose cranial irradiation of pediatric CNS tumors in long-term follow-up

PURPOSE

The purpose of this study is to investigate the incidence of cystic malacia in long-term survivors of pediatric brain tumors treated with high-dose cranial irradiation.

MATERIALS AND METHODS

Between 1997 and 2015, we treated 41 pediatric patients (26 males, 15 females; age ranging from 3.3 to 15.7 years, median 9-year-old) of pediatric brain tumors [17 medulloblastomas, 7 primitive neuroectodermal tumors (PNET), 3 pineoblastomas, 6 non-germinomatous germ cell tumors (NGGCT), 8 gliomas (including 4 ependymomas, 1 anaplastic astrocytoma, 1 oligodendroglioma, 1 pilocytic astrocytoma, 1 astroblastoma)] with high-dose craniospinal irradiation. Follow-up ranged from 14.0 to 189.2 months (median 86.0 months, mean 81.5 months), the irradiation dose to the whole neural axis ranged from 18 to 41.4 Gy, and the total local dose from 43.2 to 60.4 Gy. All patients underwent follow-up magnetic resonance imaging (MRI) studies at least once a year. Diagnosis of cystic malacia was based solely on MRI findings. Of the 41 patients, 31 were censored during their follow-up due to recurrence of the primary disease (n = 5), detection of secondary leukemia after development of cystic malacia (n = 1), or the absence of cystic malacia on the last follow-up MRI study (n = 25). We also evaluated the development of post-irradiation cavernous angioma and white matter changes.

RESULTS

Following irradiation treatment, 11 patients developed 19 cystic malacia during a median course of 30.8 months (range 14.9 to 59.3 months). The site of predilection for cystic malacia was white matter around trigone of lateral ventricles with an incidence of 47.4% (9 of 19 lesions, 7 in 11 patients). Patients with supratentorial tumors developed cystic malacia statistically earlier than the patients with infratentorial tumors (P = 0.0178, log-rank test). Among the same patient group, incidence of post-irradiation cavernous angioma increased progressively, while the incidence of post-irradiation cystic malacia did not increase after 5 years. White matter degeneration developed earlier than cystic malacia or cavernous angioma, and these three clinical entities developed mutually exclusive of each other.

CONCLUSION

We attribute the higher incidence of post-irradiation cystic malacia, in our long-term follow-up study, to the cranial irradiation for pediatric brain tumors, particularly supratentorial brain tumors, and recommend a regular, long-term follow-up of brain tumor patients treated with cranial irradiation.

Prognostic implications of the subcellular localization of survivin in glioblastomas treated with radiotherapy plus concomitant and adjuvant temozolomide

OBJECTIVE Currently, the standard treatment protocol for patients with newly diagnosed glioblastoma (GBM) includes surgery, radiotherapy, and concomitant and adjuvant temozolomide (TMZ). Various prognostic biomarkers for GBM have been described, including survivin expression. The aim of this study was to determine whether the subcellular localization of survivin correlates with GBM prognosis in patients who received the standard treatment protocol. METHODS The authors retrospectively examined the subcellular localization of survivin (nuclear, cytoplasmic, or both) using immunohistochemistry in 50 patients with GBM who had received the standard treatment. The relationship between survivin localization and overall survival (OS) was assessed with uni- and multivariate analyses including other clinicopathological factors (age, sex, Karnofsky Performance Scale [KPS] score, extent of resection, the use of second-line bevacizumab, O⁶-methylguanine-DNA methyltransferase [MGMT] status, and MIB-1 labeling index). RESULTS Log-rank tests revealed that patient age, KPS score, extent of resection, MGMT status, and survivin localization (p < 0.0001) significantly correlated with OS. Multivariate analysis indicated that patient age, MGMT status, and survivin localization significantly correlated with OS. Patients with nuclear localization of survivin had a significantly shorter OS than those in whom survivin expression was exclusively cytoplasmic (median OS 19.5 vs 31.7 months, respectively, HR 5.690, 95% CI 2.068-17.612, p = 0.0006). There was no significant difference in OS between patents whose survivin expression was exclusively nuclear or nuclear/cytoplasmic. CONCLUSIONS Nuclear expression of survivin is a factor for a poor prognosis in GBM patients. Subcellular localization of survivin can help to predict OS in GBM patients treated with the standard protocol.

Nonenhancing peritumoral hyperintense lesion on diffusion-weighted imaging in glioblastoma: a novel diagnostic and specific prognostic indicator

OBJECTIVE Glioblastoma differentials include intracranial tumors, like malignant lymphomas and metastatic brain tumors with indiscernible radiological characteristics. The purpose of this study was to identify a distinct radiological feature for the preoperative differentiation of glioblastoma from its differentials, which include malignant lymphomas and metastatic brain tumors. METHODS Preoperative MR images, including diffusion-weighted imaging (DWI) studies (b = 1000 and 4000 sec/mm²), obtained in patients with newly diagnosed malignant tumor, were analyzed retrospectively after receiving approval from the institutional review board. Sixty-four patients with histologically confirmed glioblastoma, 32 patients with malignant lymphoma, and 46 patients with brain metastases were included. The presence of a nonenhancing peritumoral DWI high lesion (NePDHL, i.e., hyperintense lesion in a nonenhancing peritumoral area on DWI) was confirmed in both DWI sequences. Gray matter lesions were excluded. Lesions were termed "definite" if present within 3 cm of the hyperintense tumor border with a signal intensity ratio ≥ 30% when compared with the contralateral normal white matter in both sequences. Discriminant analysis between the histological diagnosis and the presence of Definite-NePDHL was performed, as well as Kaplan-Meier survival analysis incorporating the existence of Definite-NePDHL. RESULTS In 25% of glioblastoma patients, Definite-NePDHL was present, while it was conspicuously absent in patients with malignant lymphoma and metastatic brain tumors. The specificity and positive predictive value were 100%. In the glioblastoma subset, a higher preoperative Karnofsky Performance Scale score (p = 0.0028), high recursive partitioning analysis class (p = 0.0006), and total surgical removal (p = 0.0012) were associated with better median overall survival. Patients with Definite-NePDHL had significantly early local (p = 0.0467) and distant/dissemination recurrence (p < 0.0001) and poor prognosis (p = 0.0007). CONCLUSIONS The presence of Definite-NePDHL is very specific for glioblastoma and indicates poor prognosis. Definite-NePDHL is a significant indicator of early local and distant/dissemination recurrence in patients with glioblastoma. Studying peritumoral DWI and high-b-value DWI is useful for tumor differentiation.

Advantage of High b Value Diffusion-Weighted Imaging for Differentiation of Hemangioblastoma from Brain Metastases in Posterior Fossa

OBJECTIVE

It is sometimes difficult to make a differential diagnosis between brain metastases and hemangioblastomas in the posterior fossa. We assessed whether high b value diffusion-weighted image (DWI) at b = 4000 could differentiate these tumors.

METHODS

We acquired DWI at 3-T magnetic resonance imaging with b = 1000 and b = 4000 seconds/mm² in histologically confirmed 12 patients of hemangioblastoma without von Hippel-Lindau disease and 16 patients with brain metastases originating at the posterior fossa. Apparent diffusion coefficient (ADC) values were measured by manually placing regions of interest on ADC maps at the site of enhanced tumor confirmed on contrast-enhanced T1- weighed image. ADC was expressed as the minimum (ADC_MIN), mean (ADC_MEAN), and maximum (ADC_MAX) values.

RESULTS

All the ADC values of hemangioblastomas were statistically higher than those of metastatic tumor in both b = 1000 and b = 4000 (P < 0.0001 in ADC_MIN, ADC_MEAN, and ADC_MAX; Mann-Whitney U test). With the cutoff value at 0.6 × 10^-3 mm²/second, the positive predictive value of ADC_MIN at b = 4000 was higher than that of ADC_MIN at b = 1000 (100% vs. 89.3%, logistic analysis) to differentiate hemangioblastomas from brain metastases. Moreover, we studied the pathologic subtype of hemangioblastoma and confirmed that ADCs (b = 4000_MIN) of cellular subtype were statistically lower than those of reticular subtype (P = 0.03; Mann-Whitney U test).

CONCLUSIONS

High b value DWI reflects diffusion more accurately than does regular b value. Our results showed that ADC calculation by high b value (b = 4000) DWI at 3-T magnetic resonance imaging is clinically useful for differentiating hemangioblastomas from brain metastases.

Permeability Surface Area Product Using Perfusion Computed Tomography Is a Valuable Prognostic Factor in Glioblastomas Treated with Radiotherapy Plus Concomitant and Adjuvant Temozolomide

OBJECTIVE

The current standard treatment protocol for patients with newly diagnosed glioblastoma (GBM) includes surgery, radiotherapy, and concomitant and adjuvant temozolomide (TMZ). We hypothesized that the permeability surface area product (PS) from a perfusion computed tomography (PCT) study is associated with sensitivity to TMZ. The aim of this study was to determine whether PS values were correlated with prognosis of GBM patients who received the standard treatment protocol.

METHODS

This study included 36 patients with GBM that were newly diagnosed between October 2005 and September 2014 and who underwent preoperative PCT study and the standard treatment protocol. We measured the maximum value of relative cerebral blood volume (rCBVmax) and the maximum PS value (PSmax). We statistically examined the relationship between PSmax and prognosis using survival analysis, including other clinicopathologic factors (age, Karnofsky performance status [KPS], extent of resection, O6-methylguanine-DNA methyltransferase [MGMT] status, second-line use of bevacizumab, and rCBVmax).

RESULTS

Log-rank tests revealed that age, KPS, MGMT status, and PSmax were significantly correlated with overall survival. Multivariate analysis using the Cox regression model showed that PSmax was the most significant prognostic factor. Receiver operating characteristic curve analysis showed that PSmax had the highest accuracy in differentiating longtime survivors (LTSs) (surviving more than 2 years) from non-LTSs. At a cutoff point of 8.26 mL/100 g/min, sensitivity and specificity were 90% and 70%, respectively.

CONCLUSIONS

PSmax from PCT study can help predict survival time in patients with GBM receiving the standard treatment protocol. Survival may be related to sensitivity to TMZ.

Multicentric Glioma Develops via a Mutant IDH1-Independent Pathway: Immunohistochemical Study of Multicentric Glioma

Multicentric gliomas are very rare. Due to differences in their tumor types they remain enigmatic. We focused on the pathogenesis of multicentric gliomas and compared their immunoprofile with that of solitary gliomas. This retrospective study included 6 males and 8 females with multicentric glioma (8 glioblastomas, 2 anaplastic astrocytomas, 4 diffuse astrocytomas). Their age ranged from 27 to 75 years and all were treated between 2004 and June 2015. The expression of mutant isocitrate dehydrogenase 1 (IDH1), α-thalassemia X-linked intellectual disability (ATRX), p53, phosphatase and tensin homolog (PTEN), and epidermal growth factor receptor (EGFR) was examined immunohistochemically; for 1p19q analysis we used fluorescence in situ hybridization (FISH). In all patients, immunohistochemical staining was negative for mutant IDH1 and cytoplasmic PTEN; only 1 patient (7.1%) manifested nuclear PTEN positivity. FISH for 1p19q codeletion was negative in all 9 examined samples; 5 of 14 specimens (35.7%) were p53-positive, 9 (64.3%) were EGFR-positive, and 4 (28.6%) were ATRX-negative. The MIB-1 labeling index was 0.9-15.6% for grades II and III, and ranged between 17.3 and 52.4% for glioblastoma. Our results suggest that the pathogenesis of multicentric gliomas is different from the mutant IDH1-R132H pathogenesis of lower-grade glioma and secondary glioblastomas. More studies are needed to confirm the molecular mechanisms underlying the pathogenesis of multicentric glioma.

Post-traumatic Unilateral Avulsion of the Abducens Nerve with Damage to Cranial Nerves VII and VIII: Case Report

Traumatic injuries of the abducens nerve as a consequence of facial and/or head trauma occur with or without associated cervical or skull base fracture. This is the first report on unilateral avulsion of the abducens nerve in a 29-year-old man with severe right facial trauma. In addition, he exhibited mild left facial palsy, and moderate left hearing disturbance. Magnetic resonance imaging (MRI) using fast imaging employing steady-state acquisition (FIESTA) revealed avulsion of left sixth cranial nerve. We recommend thin-slice MR examination in patients with abducens palsy after severe facial and/or head trauma.

Cavernous angioma after chemotherapy for desmoplastic/nodular medulloblastoma associated with anhidrotic ectodermal dysplasia

PURPOSE

While cavernous angioma (CVA) after cranial irradiation has been documented, its development after high-dose chemotherapy with autologous peripheral blood stem cell transplantation (PBSCT) has not. We present a patient with desmoplastic/nodular medulloblastoma (DNMB) associated with anhidrotic ectodermal dysplasia (AED) who developed CVA 2 years after high-dose chemotherapy and PBSCT.

METHODS

A 1-year-old boy with ingravescent vomiting was admitted to our institute. He presented with a large head, a depressed nasal bridge, low-set ears, thick lips with peg-shaped teeth, hypohidrosis, sparse hair, thin atrophic skin, scaly dermatitis with frontal bossing, and a bulging anterior fontanel. Neuroradiological examination revealed multiple cerebellar masses with heterogeneous enhancement and speckled calcifications and severe obstructive hydrocephalus. The histological diagnosis of surgical specimens was DNMB, and he underwent postoperative multiple-drug chemotherapy with autologous PBSCT. The outcome was favorable and he did not undergo radiotherapy.

RESULTS

After 2 years, intracranial hemorrhage was detected at his regular radiological check-up and he again underwent surgery. The histological diagnosis was CVA.

CONCLUSIONS

To our knowledge, this is the first report of AED-associated DNMB and CVA.

Magnetic resonance spectroscopy detection of high lipid levels in intraaxial tumors without central necrosis: a characteristic of malignant lymphoma

OBJECT

The differentiation of malignant lymphomas from gliomas or malignant gliomas by conventional MRI can be difficult. The authors studied Gd-enhanced MR images to obtain a differential diagnosis between malignant lymphomas and gliomas without central necrosis or cystic changes and investigated the diagnostic value of single-voxel proton MR spectroscopy ((1)H-MRS) using different parameters, including lipid levels.

METHODS

This was a retrospective study of patients with primary malignant CNS lymphoma (n = 17) and glioma (n = 122 [Grades I, II, III, and IV in 10, 30, 33, and 49 patients, respectively]) who were treated between 2007 and 2013. The authors focused on 15 patients with homogeneously enhanced primary malignant CNS lymphomas and 7 homogeneously enhanced gliomas. Images of all the included tumors were acquired with (1)H-MRS at 3 T, and the diagnoses were histologically confirmed.

RESULTS

Using a short echo time (1)H-MRS, large lipid peaks were observed in all 17 patients with a malignant lymphoma, in 39 patients (79.6%) with a Grade IV glioma, and in 10 patients (30.3%) with a Grade III glioma. A focus on homogeneously enhanced tumors revealed large lipid peaks in 15 malignant lymphomas that were free of central necrosis on Gd-enhanced T1-weighted images. Conversely, in the 7 homogeneously enhanced gliomas (glioblastoma and anaplastic astrocytoma, n = 2 each; anaplastic oligodendroglioma, diffuse astrocytoma, and pilomyxoid astrocytoma, n = 1 each), lipid peaks were small or absent.

CONCLUSIONS

Large lipid peaks on (1)H-MRS images of tumors without central necrosis were characteristic of malignant lymphomas. Conversely, small or absent lipid peaks in intraaxial tumors without central necrosis were strongly suggestive of glioma.

p16 Gene Transfer Induces Centrosome Amplification and Abnormal Nucleation Associated with Survivin Downregulation in Glioma Cells

OBJECTIVE

In human glioma cells, p16 gene transfer induced G1/S arrest, increased radiosensitivity and abnormal nucleation (especially bi- and multinucleation). Survivin suppression caused G2/M arrest, radiosensitization and an increase in aneuploidy accompanied by centrosome amplification. Abnormal nucleation and aneuploidy represent chromosome instability (CIN), and it is well known that centrosome amplification leads to CIN. However, little has been reported that suggests that transferring p16 causes centrosome overduplication during the G1/S phase.

METHODS

The p16 gene was transferred into p16-null human glioma cell lines (U251MG and D54MG) using adenovirus with or without irradiation. Centrosome amplification was evaluated by immunofluorescence. We also investigated the DNA replication licensing factor CDT1, its inhibitor geminin and survivin expression as regulators of chromosomal segregation.

RESULTS

p16 gene transfer with radiation initiated the greatest degree of centrosome overduplication. CDT1 showed low levels, geminin was unchanged and survivin decreased in Ax-hp16-infected cells with radiation. Those changes of factors affecting DNA licensing or chromosomal segregation might contribute to CIN.

CONCLUSION

p16 transfer caused centrosome amplification even in G1/S phase-arrested cells. This suggests that p16 is involved in abnormal nucleation and radiosensitization in human glioma cells. © 2015 S. Karger AG, Basel.

[Anti-emetic effect of granisetron in patients undergoing cranial and craniospinal radiotherapy]

PURPOSE

Approximately 30-59% of patients undergoing cranial or craniospinal radiotherapy experience nausea and/or vomiting. Here, we evaluated the effectiveness of granisetron for controlling emesis in patients treated with cranial or craniospinal radiotherapy.

PATIENTS AND METHODS

Between December 2011 and January 2013, 34 patients(19 males, 15 females;age range, 3-80 years)received cranial or craniospinal radiotherapy at our department. All but one male patient, who developed meningitis during the irradiation period were enrolled in this retrospective study. Patients who experienced irradiation-induced vomiting(grade 1)or nausea(grade 2)were treated with granisetron as a rescue anti-emetic. Episodes were graded as(1)no vomiting, no nausea, no anti-emetic;(2)no vomiting, nausea, no anti-emetic;(3)no vomiting, nausea with anti-emetic;and(4)vomiting.

RESULTS

Of the 9 patients who underwent whole-brain or whole neural-axis irradiation, 5(55.6%)experienced grade 2 nausea or vomiting. Two of 6 patients(33.3%)treated with whole ventricle irradiation experienced grade 2 nausea or vomiting. Three of 18 patients(16.7%)who underwent local-field irradiation experienced grade 2 nausea or vomiting. Patients who underwent wide-field irradiation experienced nausea, vomiting, and anorexia(p<0.05). Complete response(no vomiting, no additional rescue anti-emetic, and no nausea)was observed in 5 of 9 patients treated with granisetron. Four of 9 patients(44.4%)treated with granisetron experienced constipation(grade 1 or 2);its administration had no major adverse effects in our study population.

CONCLUSION

Rescue therapy with granisetron is safe and effective to treat nausea and vomiting in patients subjected to cranial or craniospinal irradiation.

Postoperative fever specific to neuroendoscopic procedures

The most common complication of neuroendoscopic surgery is postoperative fever without infection, although the details have not been discussed. The objective of this study was to clarify the clinical features and predicting factors of the postoperative fever following neuroendoscopic procedures. Between March 1998 and March 2013, 83 patients (46 males, 37 females; median age, 14.0 years) who had undergone surgery via the transventricular approach under a neuroendoscopic view were included in this study. A total of 86 neuroendoscopic procedures were performed in 83 patients. The incidence and duration of postoperative fever (≥38.0 and ≥39.0 °C) over the 7 days after surgery were examined. Moreover, the following variables predictive of fever were investigated: age, sex, neuroendoscopic procedure, operative time, and intraoperative irrigation fluid. The incidence of postoperative fever was 65.1 % (≥38.0 °C) and 15.1 % (≥39.0 °C). The median level of the highest fever was 38.6 °C. The fevers developed immediately after surgery and spontaneously disappeared within four postoperative days. Only age was related to postoperative fever (p = 0.032). The postoperative body temperature was negatively correlated with age in all 86 surgeries (p < 0.001, Spearman r = -0.396). In particular, patients under 10 years of age tended to have postoperative fever (p = 0.005). The result of this study demonstrated a peculiar pattern of fever following neuroendoscopic procedures. This type of fever did not cause serious problems; however, special attention should be paid to the high incidence of postoperative fever in patients under 10 years of age.

Preoperative histological grading of meningiomas using apparent diffusion coefficient at 3T MRI

PURPOSE

We assessed whether a high b-value DWI at b=4000s/mm(2) would discriminate the histopathological differentiation of the tumor grade of meningiomas, and also focused on the relationship between radiologic features and the tumor grade.

MATERIALS AND METHODS

We acquired DWI at 3T with b=1000 and b=4000s/mm(2) in 77 patients (42, 31 and 4 patients were WHO grades I (G1), II (G2), and III (G3), respectively). The apparent diffusion coefficient (ADC) was measured by placing multiple regions of interest (ROIs) on ADC maps. The ADC values of each tumor were determined preoperatively from several ROIs, and expressed as the minimum (ADCMIN), mean (ADCMEAN), and maximum absolute values (ADCMAX). We evaluated the relationship between ADCs and histological findings, and assessed the radiologic features such as tumor location, tumor size, presence/absence of peritumoral edema, shape of the tumor, presence/absence of bone destruction or hyperplasia, status of contrast enhancement, presence/absence of calcification and cyst.

RESULTS

ADCs of the meningiomas were inversely correlated with the histological grade of meningiomas. According to results of the discriminant analysis, the apparent log likelihood value was greatest for ADCMIN at b=4000. Furthermore, only the ADCMIN value at b=4000 was significantly correlated with the histological grade of meningiomas when we performed a multiple logistic regression analysis to identify the significant independent factors such as shape of tumor, presence/absence of bone destruction, status of contrast enhancement, presence/absence of cyst and ADCMIN at b=4000.

CONCLUSION

A meningioma with a low ADCMIN at a high b-value might imply a high-grade meningioma.

Magnetic resonance spectroscopic detection of lactate is predictive of a poor prognosis in patients with diffuse intrinsic pontine glioma

Diffuse brainstem glioma has a poor prognosis, and there are few long-term survivors. We looked for clinical, conventional magnetic resonance (MR), and MR spectroscopic (MRS) findings predictive of the prognosis of patients with brainstem glioma. Our institutional review board approved this retrospective study of 23 patients with diffuse intrinsic pontine or diffuse medullary brainstem glioma treated during the period 2000-2009. To evaluate prognostic values, we performed a Kaplan-Meier survival analysis (log-rank test) that incorporated the patients' age and sex, symptom duration, the presence or absence of cranial nerve palsy, long tract sign, ataxia, and cysts, the chemotherapeutic regimen, Gd enhancement, longitudinal and cerebellar extension, basilar artery encasement, and MRS parameters. Of the 23 diffuse brainstem gliomas, 19 were located at the pons (ratio of male to female patients, 1.1:1). The mean age of the 23 patients was 15.9 years (range, 4-50 years); 16 were aged <20 years. The duration of overall survival was 19.7 months; in patients with diffuse intrinsic pontine glioma, it was 16.6 months, and in patients aged <20 years, it was 11.8 months. Clinical and conventional MR findings at presentation were not predictive of the prognosis in children with diffuse intrinsic pontine glioma. In addition, a patient age <20 years and the detection of lactate by MRS were poor prognostic factors. The MRS detection of lactate is a prognostic factor in patients with diffuse intrinsic pontine glioma. Additional studies of larger patient populations using other imaging modalities are needed.

[Vertebral arteriovenous fistula as a complication of atlantoaxial transarticular screw fixation--case report]

We report a rare case of a vertebral arteriovenous fistula that developed as a complication of atlantoaxial transarticular screw fixation. The patient was a 44-year-old male with a history of juvenile rheumatoid arthritis. He had undergone an atlantoaxial transarticular screw fixation for an atlantoaxial dislocation. At 2 months after the surgery, he complained of right-side tinnitus. A selective left vertebral angiography showed a high-flow arteriovenous fistula of the right V2 segment and occulusion of the right vertebral artery at the level of the C3 vertebral body. Endovascular embolization of the arteriovenous fistula was successfully performed using detachable coils. No deficits were observed after the treatment, and the tinnitus disappeared completely. Endovascular coil embolization is currently an effective and safe treatment for the vertebral arteriovenous fistula.

Determination of formoterol in rat plasma by liquid chromatography-electrospray ionisation mass spectrometry

A sensitive method for the determination of formoterol in rat plasma is described, using high performance liquid chromatographic separation with tandem mass spectrometry. Samples were purified using liquid-liquid extraction and separated on CAPCELL PAK C18 UG120 (2.0 x 150 mm) with a mobile phase consisting of a mixture of methanol- 50 mM ammonium hydrogen carbonate (1:1 v/v). Detection was performed with a TSQ 7000 mass spectrometer using positive ion electrospray ionisation, monitoring the shift from precursor ions for formoterol at m/z 344.9 to product ions of m/z 121.0. The limit of quantitation of the method was found to be 0.1 ng/ml, when using 0.1 ml plasma. Plasma concentrations of formoterol could be quantified from 0.15 to 7.01 ng/ml, allowing the analysis of samples up to 32 h after a single oral dose of formoterol fumarate (0.25 mg) to rats.

A pituitary abscess showing high signal intensity on diffusion-weighted imaging

The utility of diffusion-weighted imaging (DWI) for the diagnosis of intracranial abscesses has already been established. However, the use of DWI for pituitary abscesses has not been previously reported. We present a case of postoperative pituitary abscess in which T1-weighted and T2-weighted magnetic resonance imaging (MRI) revealed a supra-sellar cystic mass, with the cyst contents showing high intensity on DWI. This case suggests that DWI is useful for the diagnosis of pituitary abscesses.

Screening and determination of methamphetamine and amphetamine in the blood, urine and stomach contents in emergency medical care and autopsy cases

Methamphetamine (MA) and amphetamine (AMP) were screened and their levels were determined using the Toxi-Lab thin-layer chromatography system and gas chromatography-mass spectrometry, respectively, in the blood, urine and stomach contents from 211 emergency medical care and 417 autopsy cases. MA and AMP were detected in 5 emergency medical cases, and the blood MA and AMP concentrations ranged from 0.697-0.041 micromol/100 g and from 0.0944-0.0003 micromol/100 g, respectively. MA and AMP were detected in 19 autopsy cases, in which blood MA and AMP concentration ranged from 14.3-0.123 micromol/100 g and from 0.256-0.0017 micromol/100 g, respectively. The autopsy cases included 5 cases of sudden death with blood MA concentration of less than 3 micromol/100 g. MA and AMP screening and determination in emergency medical care and autopsy cases provide useful information and are indispenable in clarifying the dimensions of MA abuse in Japan.

Allylnitrile: generation from cruciferous vegetables and behavioral effects on mice of repeated exposure

The objective of the present study was to examine the possible generation of allylnitrile from commonly consumed cruciferous vegetables, and to determine the long-term behavioral effects of its oral administration at levels comparable to or greater than human dietary exposures. On the basis of gaschromatographic and mass spectrometric analyses, allylnitrile generation was observed in eight out of twelve vegetables, broccoli, broccoli (young stems and leaves), brussels sprouts, cabbage, cauliflower, chinese cabbage, komatsuna and kaiware-daikon (young stems and leaves). The daily dietary intake of allylnitrile was estimated to be at least 0.12 micromol/kg body weight for Japanese, based on its generation from the vegetables, broccoli, cabbage, cauliflower and Chinese cabbage and their daily dietary consumption. Mice received oral doses of 2, 20, 200, 500 and 1,100 micromol/kg allylnitrile once a day, 5 days per week for 13 weeks. Mice in the lower dosage groups of 2, 20 and 200 micromol/kg exhibited no behavioral changes. Mice dosed at the level of 500 micromol/kg showed restlessness, and one of them displayed alteration in tail hanging. These abnormalities were seen around seven days following the beginning of the treatment period. Animals in the highest dosage group elicited behavioral abnormalities, and their degree increased with increasing dosage. These results suggest that allylnitrile intake levels through daily vegetable consumption is below the level producing behavioral abnormalities.

Ubiquitin expression in skin wounds and its application to forensic wound age determination

The time-dependent expression of ubiquitin (Ub) was examined in murine skin wounds and 55 human skin wounds with different wound ages (groups I: 0-12 h, II: 1-5 days, III: 7-14 days and IV: 17-21 days). In murine skin wound specimens, neutrophils, macrophages and fibroblasts showed intensive Ub-positive reactions in the nuclei. In the human wound specimens with wound ages between 4 h and 1 day, neutrophils with strong intranuclear positive reactions for Ub were observed. With increasing wound ages, the nuclei of macrophages and fibroblasts were more intensively stained with anti-Ub antibody. Morphometrically, the intranuclear Ub-positive ratios were very low in group I. The skin wound specimens in groups II and IV showed Ub-positive ratios of >10%, and all samples in group III had Ub-positive ratios of >20%. These results suggest that a ratio of >10% for Ub indicates a wound age of at least 1 day. In contrast, Ub-positive ratios of less than 10% indicate a wound age of <1 day. Moreover, there was a significant difference in the Ub-positive ratio between group III and the other three groups. Thus, Ub-positive ratios considerably exceeding 30%, possibly indicate a wound age of 7-14 days. From the viewpoint of a forensic pathology application, the present study showed that Ub is suitable as a marker of wound age determination.

Complete transection of the pancreas due to a single stamping injury: a case report

Complete transection of the pancreas due to a single stamping injury is reported. A 47-year-old female was stamped on in the epigastric region by her common-law husband when lying on her back. Immediately after the stamping, she complained of severe abdominal pain. In an emergency hospital, the abdominal CT (computed tomography) scan showed a large haematoma around the pancreas head. In the surgical operation that followed, a complete transection of the pancreas between the head and body was unexpectedly discovered. Furthermore, severe traumatic changes were found in the liver, mesentery, splenic artery and vein. The medico-legal autopsy revealed marked haemorrhaging in the abdominal subcutaneous adipose tissue and rectus muscle in the epigastric region. The external blunt force that acted on the abdomen had forcibly compressed the pancreas against the spinal column. Blunt pancreatic injury is relatively uncommon, but pancreatic injuries should always be considered in patients or autopsy cases after external blunt force to the abdomen.

Rapid analysis of pesticide components, xylene, o-dichlorbenzene, cresol and dichlorvos, in blood and urine by pulse heating-gas chromatography-mass spectrometry

Analysis of the pesticide components, xylene, o-dichlorbenzene (DCB), cresol and dichlorvos (DDVP, an organophosphate), was attempted using 3 microl of biological samples by pulse heating (Py)-gas chromatography-mass spectrometry (GC-MS) without pretreatment. Xylene, DCB, cresol and DDVP were separately detected by Py-GC-MS. The regression lines for these four substances in the blood were shown to be linear between the peak height and their concentrations, 0.1/0.2-20 microg/ml. Recoveries of DDVP, cresol, DCB and xylene at the concentration of 1.0 microg/ml by Py-GC-MS ranged from 78.8 to 89.0% in blood, and from 84.2 to 91.2% in urine. For within-run precision, the coefficient of variation values at the concentration of 1.0 microg/ml ranged from 7.9 to 10.6% in blood, and from 5.8 to 9.4% in urine. The lower detection limits of xylene, DCB, cresol and DDVP in blood were 50, 50, 50 and 150 ng/ml, respectively. In comparison with the measured value in blood that was added to these four substances, Py-GC-MS showed good accuracy similar to GC-MS after the extraction method. DDVP and xylene could be successfully determined by Py-GC-MS in blood and urine in emergency medical and autopsy cases. From these results, Py-GC-MS can be performed in a short analytical time (15 min) and is a useful method to determine pesticide components in forensic medicine and emergency medical practice.

Intratracheal gas analysis for volatile substances by gas chromatography/mass spectrometry--application to forensic autopsies

Intratracheal gas analysis was carried out by gas chromatography/mass spectrometry (GC/MS) in 20 burned body cases (13 males and 7 females). Volatile aromatic and aliphatic hydrocarbons were detected by GC/MS using a GS-Q column with the intratracheal gas as well as the blood in 19 cases. The characteristic patterns of mass chromatograms for gasoline, kerosene (gas oil), and liquid petroleum gas could be differentiated from each other using the intratracheal gas. The burned body in one case showed no presence of volatile substances in the intratracheal gas, nor intratracheal soot, although high concentrations (1 microg/g and more) of volatile substances were detected on the clothes. The victim also had normal CO-Hb concentrations (0.1 to 0.2%) in the heart blood. The results of intratracheal gas analysis were consistent with signs of the vital reaction. In conclusion, intratracheal gas analysis provides a supportive method for diagnosing the cause of death in burned bodies, and yields for at least 48 hours valuable information on volatile hydrocarbons (being detected in deliberate or accidental fire cases) to which the body had been exposed just before death.

Determination of triazolam by GC-MS in two autopsy cases: distribution in body fluids and organs

A detailed procedure for analysis of triazolam by GC-MS was constructed in our laboratory. At the concentration of 100 ng/ml, recoveries of triazolam in plasma and urine were 84.9 and 91.0%, respectively. The coefficients of variation in terms of its recovery were 11.5 (plasma) and 10.2% (urine). The detection limit for quantitation by the method was approximately 5 ng/g. This method was applied to two autopsy cases, giving triazolam distribution in body fluids and organs. In one case (33-year-old woman), concentrations of triazolam in the heart blood, urine, brain, lung, liver, kidney, skeletal muscles and stomach contents were 83.9, 741, 106, 165, 507, 293, 125 and 343 ng/g, respectively. From these toxicological data together with autopsy findings, her cause of death was diagnosed as triazolam poisoning. In the other case (45-year-old man), triazolam concentrations in the urine and stomach contents were 7.81 and 41.1 ng/g, respectively, but it could not be detected in the pleural blood; his cause of death was judged to be a traumatic shock, based on autopsy findings.

[Detection of methamphetamine in a severely burned cadaver--a case report]

We report an autopsy case of a severely burned cadaver in which methamphetamine (MA) and amphetamine (A) were detected. A severely burned cadaver was found in a burned-out car on the seashore. At the autopsy, the drug screening test in the urine using Triage system gave positive result for MA and/or A. Qualitative analysis by gas chromatography/mass spectrometry (GC/MS) confirmed the presence of MA and A. The concentrations of MA and A (mumol/100 g) were 1.66 in the thermo-coagulated blood, 16.3 in the urine, 4.60 in the cerebrum, 4.11 in the lung, 7.84 in the liver, 0.94 in the skeletal muscle and 0.54 in the bone marrow. From these results, we concluded that the man had been under the moderate MA and A intoxication. The cause of death was diagnosed as the death of fire on the basis of autopsy findings, and the cadaver was identified as the owner of the car by the DNA typing. This case indicated the importance of drug screening tests in autopsy cases. Furthermore, the qualitative and quantitative analysis of MA and A should be successfully performed by GC/MS even in the case of severely burned cadaver.

Genetic variation and relationships at five STR loci in five distinct ethnic groups in China

Five short tandem repeat (STR) systems of TH01, vWA, LPL, F13B and FES/FPS were investigated in five ethnic groups living in China (Tujia, Miao, Bai, Chaoxian and Han). All five loci did not deviate from the Hardy-Weinberg equilibrium (P>0.05). At the five loci of each ethnic group, the observed heterozygosity, the mean exclusion chance (MEC), and the power of discrimination (PD) ranged from 0.42 to 0.86, from 0.20 to 0.66 and from 0.61 to 0.95, respectively. For the five ethnic groups, the combined MEC and combined PD were >0. 9360 and >0.9998, respectively, suggesting that combinations of these five systems are feasible for DNA typing in forensic investigations such as personal identification or paternity testing. Furthermore, the allelic frequencies at the five loci suggested that these five ethnic groups were distinctly different communities. Judging from the phylogenetic tree constructed based on the genetic distance among the five ethnic groups, Han, Chaoxian and Tujia were involved in an identical cluster, and Miao and Bai in another. These findings indicate that each of the five groups examined is not only a distinct community, but also has a relationship with each of the others.

Simultaneous determination of local anesthetics including ester-type anesthetics in human plasma and urine by gas chromatography-mass spectrometry with solid-phase extraction

The present study describes the simultaneous determination of seven different kinds of local anesthetics and one metabolite by GC-MS with solid-state extraction: Mepivacaine, propitocaine, lidocaine, procaine (an ester-type local anesthetics), cocaine, tetracaine (an ester-type local anesthetics), dibucaine (Dib) and monoethylglycinexylidide (a metabolite of lidocaine) were clearly separated from each other and simultaneously determined by GC-MS using a DB-1 open tubular column. Their recoveries ranged from 73-95% at the target concentrations of 1.00, 10.0 and 100 microg/ml in plasma, urine and water. Coefficients of variation of the recoveries ranged from 2.3-13.1% at these concentrations. The quantitation limits of the method were approximately 100 ng/ml for monoethylglycinexylidide, propitocaine, procaine, cocaine, tetracaine and dibucaine, and 50 ng/ml for lidocaine and mepivacaine. This method was applied to specimens of patients who had been treated with drip infusion of lidocaine, and revealed that simultaneous determination of lidocaine and monoethylglycinexylidide in the blood and urine was possible.

Stability of tricyclic antidepressants in formalin solutions

We investigated the stability of the secondary amines, desipramine (DP) and nortriptyline (NRT), and the tertiary amines, imipramine (IP) and amitriptyline (AT), in formaldehyde (F) and paraformaldehyde (PF) aqueous solutions. NRT showed little instability in 0.37 to 37% F and PF solutions, but AT formation was detected and increased, up to 0.46 to 2.7%, in parallel with rising F and PF concentrations. DP was unstable and levels decreased to 74 to 96% with increasing F concentrations, and fell only to 96% in 10% PF solution. IP formation increased in the same manner as AT to 2.9 to 3.5% of the initial DP. When AT and IP were stored in F and PF solutions, concentrations of AT and IP did not change. DP in F pH 3 to 11 phosphate buffer (PB) solutions showed high recovery in the order: pH 5 > pH 7 > pH 9 > pH 3 and pH 11. DP in PF buffered solutions decreased slightly only at pH 3 (3.5%). By contrast, IP did not change at any pH (pH 3 to 11) of the F or PF solutions. During storage for 21 days at room temperature in 3.7% F and PF solutions, IP and DP degradation was accelerated when compared with the values in pH 3 and 7 PB solutions. However, IP detected in DP F or PF solution was only 0.2% of the initial DP 21 days after storage. Thus, AT, NRT, IP and DP degraded gradually in F and PF solutions during storage at room temperature. TCAs may first react nucleophilically with formaldehyde to form hemiaminals. DP in 3.7% formaldehyde aqueous solution formed little of its methylated product, IP, at room temperature.

A transferrin D variant (DHR5) identical with DSaga by polyacrylamide gel isoelectric focusing was found in a disputed paternity case

A transferrin (TF) variant was found in the child in a paternity case by polyacrylamide gel isoelectric focusing (PAGIF). Further analysis of serum TF disclosed that this rare TF variant was inherited from the alleged father. This TF variant was identified as TF DHR5, being identical with a variant TF DSaga, in a direct comparison with several known TF D variants by PAGIF. The isoelectric points (pIs) of holo-type (Fe(II) binding type) of TF DHR5 (= DSaga) and TF C were 5.6 and 5.4, respectively. After sialidase treatment, TF DHR5 (= DSaga) showed a single band migrating at a more basic position than TF C, thus suggesting that the pI difference between the two was due to amino acid substitution.

Effect of sequence of administration on the pharmacokinetic interaction between the anticholinergic drug biperiden and [3H]quinuclidinyl benzylate or [3H]N-methylscopolamine in rats

In rats the pharmacokinetic interactions between the anticholinergic drug biperiden and [3H]quinuclidinyl benzylate ([3H]QNB) or [3H]N-methylscopolamine ([3H]NMS) is affected by the sequence in which the drugs are administered. Drug concentrations in various tissues were determined after intravenous administration of [3H]QNB or [3H]NMS (325 ng kg(-1)). Biperiden (6.4 mg kg(-1)) was administered either 5 min before, concomitantly with or 20 min after injection of [3H]QNB or [3H]NMS. When biperiden was administered concomitantly with or before [3H]QNB, distribution of [3H]QNB among the regions of the brain and other tissues was reduced; at 4 h the ratio of the distribution of [3H]QNB for experimental animals to that for control animals ranged from 0.15 to 0.9. When biperiden was administered after [3H]QNB, the distribution of [3H]QNB in the brain and other tissues was significantly higher than for the other two treatments (P < 0.01). However, for [3H]NMS the sequence of administration had no effect on the distribution of the drug in the brain and other tissues except for the kidney. In-vitro, in crude synaptosomal membranes, the amount of [3H]QNB at 2 h relative to the control concentration at equilibrium was 87% when biperiden was added before [3H]QNB and 56% when biperiden was added after [3H]QNB. In both instances the concentration of [3H]NMS reached equilibrium within 30 min. These findings suggest that the difference between the rate constant of association and dissociation at the possible site of action gives rise to the effect of the sequence of administration on the pharmacokinetic interaction.

Muscarinic receptor-mediated dual regulation of ADP-ribosyl cyclase in NG108-15 neuronal cell membranes

Cyclic ADP-ribose (cADP-ribose) is an endogenous modulator of ryanodine-sensitive Ca2+ release channels. An unsolved question is whether or not cADP-ribose mediates intracellular signals from hormone or neurotransmitter receptors. The first step in this study was to develop a TLC method to measure ADP-ribosyl cyclase, by which conversion of [3H]NAD+ to [3H]cADP-ribose was confirmed in COS-7 cells overexpressing human CD38. A membrane fraction of NG108-15 neuroblastoma x glioma hybrid cells possessed ADP-ribosyl cyclase activity measured by TLC. Carbamylcholine increased this activity by 2.6-fold in NG108-15 cells overexpressing m1 or m3 muscarinic acetylcholine receptors (mAChRs), but inhibited it by 30-52% in cells expressing m2 and/or m4 mAChRs. Both of these effects were mimicked by GTP. Pretreatment of cells with cholera toxin blocked the activation, whereas pertussis toxin blocked the inhibition. Application of carbamylcholine caused significant decreases in NAD+ concentrations in untreated m1-transformed NG108-15 cells, but an increase in cholera toxin-treated cells. These results suggest that mAChRs couple to ADP-ribosyl cyclase within cell membranes via trimeric G proteins and can thereby control cellular function by regulating cADP-ribose formation.

Postmortem alcohol analysis of the synovial fluid and its availability in medico-legal practices

Alcohol analyses using the synovial fluid of the knee joint (synovial alcohol concentration, SAC) as well as blood (BAC) and urine (UAC) were performed by the pulse heating-gas chromatographic method in 12 medico-legal autopsy cases. In 11 of the 12 cases, the regression analysis showed that BAC and UAC had a fairly linear relationship with SAC, and the average ratios of the BAC/SAC and UAC/SAC were 0.76 +/- 0.12 (range 0.60-0.94) and 1.03 +/- 0.11 (range 0.90-1.21), respectively. The measured BACs showed a difference of 11.8 +/- 9.4% (0.9-27.1%) when compared with the calculated BACs by means of the average BAC/SAC ratio. Between the measured UACs and the calculated UACs, there was an average difference of 7.9 +/- 6.0% (0.3-17.8%). The present study demonstrates that the synovial fluid is one of the available biological specimens for the prediction of BAC or UAC within a range in autopsy cases in which suitable blood and/or urine specimens cannot be obtained.

False identification of urinary ephedrine as methamphetamine by gas chromatography/mass spectrometry with a DB-17 column

A 17-year-old motorcyclist was killed in a traffic accident. The urine sample collected at autopsy was screened by the Toxi-Lab system; it showed a possible presence of either methamphetamine (MA) or ephedrine (Eph). Gas chromatography-mass spectrometry (GC-MS) was carried out for a trifluoroacetyl (TFA)-derivatized sample after extraction with an Extrelut column. A peak was detected at the same retention time as that of the authentic Eph by GC-MS with a DB-17 wide-bore column; the mass spectrum of the peak was, however, very similar to that of MA. The presence of Eph and absence of MA were proved by GC-MS using a DB-1 column. The Eph in the urine was further confirmed by high performance liquid chromatography (HPLC)-MS using an ODS column. By the REMEDi HS system, Eph and methylephedrine were determined in the urine, and their concentrations (hydrochloride salt) were 0.752 and 2.13 micrograms/ml, respectively. Ethanol was detected as well in the blood (1.55 mg/ml) and urine (2.01 mg/ml) by a pulse heating method. Nicotine, caffeine and dihydrocodeine were also qualitatively detected in the urine by Toxi-Lab, HPLC-MS and REMEDi HS systems. The present case warned that urinary Eph can be misidentified as MA by GC-MS with an intermediately polar column after TFA derivatization.

An autopsy case of suicidal strangulation with four looped rubber bands

A rare case of suicidal strangulation with four looped rubber bands is reported. A 57-year-old female was found dead in the vestibule of her house, with four looped rubber bands wrapped around her neck. Her face was markedly congestive, and lots of petechial hemorrhages were seen on the face and in the palpebral conjunctive. At the medico-legal autopsy, the ligature mark was 1.7 cm in maximum width at the anterior part of the neck and accompanied by such vital reactions as linear hemorrhage, but there were no other injuries to account for her death. Many petechial hemorrhages were also found in the visceral pleurae and epicardium. There was hemocoagulum in the cardiac blood, and the other organs were as well markedly congestive. Gas-chromatographic analysis revealed ethanol; 0.83 mg/ml in the heart blood and 1.37 mg/ml in the urine. No other drugs or poisons were found with Toxi-Lab and REMEDi-HS systems. In addition, police investigation denied the possibility of homicide and disclosed her living will stating that she had suffered from a chronic heart disease. This case was of suicidal strangulation with looped rubber bands.

Use of REMEDi HS in emergency toxicology for a rapid estimate of drug concentrations in urine, serum, and gastric samples

The REMEDi HS is a broad spectrum drug identification system, designed for emergency toxicology screening and forensic applications. The total analysis time is about 20 min. The current library has 555 drugs and metabolites. The system has a software routine that uses an internal standard (IS) to perform quantitative analysis for target compounds when calibrators are available; further, response factors (RF) are supplied for a rapid estimate of drug concentrations when calibrators are unavailable. In the present study, The concentrations of six drugs (bromisovalum, ephedrine, hydroxyzine, diphenhydramine, ranitidine, and lidocaine) and a metabolite of lidocaine (glycinexylidide) were determined using both methods. The slopes of the regression lines between the rapid estimate method and the IS method were generally within 20% of unity, in agreement with the manufacturer's claim. Semiquantitative estimates based on RF also showed good agreement with results obtained using multipoint calibration. These estimates were sufficient for clinical differentiation of routine and toxic levels. Our study demonstrated that the REMEDi HS is particularly useful for a rapid estimate of drug concentrations in the samples from emergency cases when calibrators are not readily available. Our study also showed that this system can be used for the therapeutic monitoring of ranitidine, bromisovalum, lidocaine, and diphenhydrmine.

[Death due to cold of a 63-year-old male associated with hepatocellular carcinoma--bibliographic consideration on alcohol metabolism of the patients with liver dysfunction]

In the early morning of late December, a 63-year-old man was found dead in front of his apartment house. At medico-legal autopsy, subcutaneous hemorrhages of the occipital region and linear fractures of the occipital bone was observed, but there was no cerebral contusion leading him to death. Many white tumors, ranging from 0.5 to 2.0 cm in diameter, were observed in the liver. On sections of the liver, hepatic parenchyma was found entirely occupied by the tumors, which were histopathologically diagnosed as moderately- or well-differentiated hepatocellular carcinoma. Alcohol concentrations of the mixed intracardiac blood and the urine were determined to be 1.9 and 3.6 mg/ml, respectively. Through the police investigation, it became clarified that the male had been sleeping in front of his apartment house about at 10:30 p.m. on the day before he was found dead. The cause of his death was, therefore, considered due to cold, and the authors gave a bibliographic consideration on blood and urine alcohol concentrations and alcohol metabolism of a patient with liver dysfunction due to hepatocellular carcinoma.

Determination of arsenic in blood and stomach contents by inductively coupled plasma/mass spectrometry (ICP/MS)

Inductively coupled plasma/mass spectrometry (ICP/MS) was used and evaluated for the practical analysis of the arsenic content of body fluid samples without ashing. The calibration curve for arsenic in blood solution was shown to have good sensitivity, linearity and reproducibility. Blood obtained from normal volunteers was determined by ICP/MS, and compared with that determined by atomic absorption spectrometry (AAS). The arsenic contents determined by ICP/MS showed a linear correlation with that determined by AAS. Furthermore, arsenic was determined in the blood and supernatant of stomach contents obtained from a suicide autopsy case resulting from ingestion of an arsenic compound. It was therefore concluded that ICP/MS could be used rapidly and conveniently in the field of forensic toxicology in acute metal poisoning cases.

Determination of timiperone in rat plasma by high-performance liquid chromatography with electrochemical detection

We report a sensitive new method for the determination of timiperone in rat plasma by using high-performance liquid chromatography with electrochemical detection. The method involves extraction of plasma samples with heptane-isoamyl alcohol at pH > 8, followed by back-extraction into dilute acetic acid. Separation was accomplished by reversed-phase high-performance liquid chromatography on an ODS column with the mobile phase consisting of 0.1 M phosphate buffer (pH 3.5)-acetonitrile-methanol (65:20:15, v/v). Recovery was greater than 80%. Calibration curve was linear over the concentration range 0.5-50.0 ng/ml. The limit of quantitation of timiperone was 0.5 ng/ml plasma.