Interobserver agreement in endoscopic evaluation of reflux esophagitis using a modified Los Angeles classification incorporating grades N and M: a validation study in a cohort of Japanese endoscopists

The Los Angeles classification system is the most widely employed criteria associated with the greatest interobserver agreement among endoscopists. In Japan, the Los Angeles classification system has been modified (modified LA system) to include minimal changes as a distinct grade of reflux esophagitis, rather than as auxiliary findings. This adds a further grading M defined as minimal changes to the mucosa, such as erythema and/or whitish turbidity. The modified LA system has come to be used widely in Japan. However, there have been few reports to date that have evaluated the interobserver agreement in diagnosis when using the modified LA classification system incorporating these minimal changes as an additional grade. A total of 100 endoscopists from university hospitals and community hospitals, as well as private practices in the Osaka-Kobe area participated in the study. A total of 30 video clips of 30-40 seconds duration, mostly showing the esophagocardiac junction, were created and shown to 100 endoscopists using a video projector. The participating endoscopists completed a questionnaire regarding their clinical experience and rated the reflux esophagitis as shown in the video clips using the modified LA classification system. Agreement was assessed employing kappa (kappa) statistics for multiple raters. The kappa-value for all 91 endoscopists was 0.094, with a standard error of 0.002, indicating poor interobserver agreement. The endoscopists showed the best agreement on diagnosing grade A esophagitis (0.167), and the poorest agreement when diagnosing grade M esophagitis (0.033). The kappa-values for the diagnoses of grades N, M, and A esophagitis on identical video pairs were 0.275-0.315, with a standard error of 0.083-0.091, indicating fair intraobserver reproducibility among the endoscopists. The study results consistently indicate poor agreement regarding diagnoses as well as fair reproducibility of these diagnoses by endoscopists using the modified LA classification system, regardless of age, type of practice, past endoscopic experience, or current workload. However, grade M reflux esophagitis may not necessarily be irrelevant, as it may suggest an early form of reflux disease or an entirely new form of reflux esophagitis. Further research is required to elucidate the pathophysiological basis of minimal change esophagitis.

[Case of fulminant mixed cryoglobulinemia developing after atrial myxoma resection]

A 63-year-old man, with a 13-year history of asymptomatic proteinuria, was diagnosed with left atrial myxoma at the onset of heart failure. After resection of the tumor by hypothermal surgery, the patient developed fever, renal failure and skin rash. The diagnosis was type II mixed cryoglobulinemia accompanied by an IgMlambda clone with high titers of rheumatoid factor activity and polyclonal IgG. Treatment with high doses of steroids and plasmapheresis was ineffective, and the patient died of colon necrosis due to thrombotic occlusion in the supra-mesenteric arteries. Although the patient had suffered from sporadic Raynaud's phenomenon and purpura of the lower extremities from the age of 60 years, cryoglobulinemia was not suspected before surgery because of the atrial myxoma. Thus, we suggest that it is important to perform laboratory tests for cryoproteins before hypothermal surgery.

Hemodynamic infarction of the spinal cord: involvement of the gray matter plus the border-zone between the central and peripheral arteries

OBJECTIVE

Hemodynamic infarction of the spinal cord that affected an 81-year-old female having a dissecting aortic aneurysm is presented. During the graft replacement operation, systemic hypotension occurred and the patient was subsequently complicated with paraplegia of the lower limbs. The patient died 2 weeks after the surgery due to gastrointestinal bleeding. An autopsy, which did not include the brain, was performed and the spinal cord was sampled. The aim of this report is to describe the pathologic profile of the spinal cord of the patient, and to gain insight into the pathogenesis of the lesion.

METHODS

Histochemical and immunohistochemical methods were employed to study the spinal cord ranging from the lower thoracic to sacral segments.

RESULTS

The whole central areas of the spinal cord showed coagulation and/or liquefaction necroses, while the white matter on the circumference of the cord remained unaffected, thus exhibiting a 'ring-like' appearance.

CONCLUSION

This case is an example of hemodynamic infarction of the spinal cord involving the gray matter that is supplied by the central artery, plus the border-zone that is supplied by both the central and peripheral arteries. The former is probably associated with selective vulnerability of the gray matter to ischemia, while the latter is probably associated with intrinsic vulnerability of the border-zone to systemic hypotension or low blood-flow states.

Distribution of amylose, nitrogen, and minerals in rice kernels with various characters

The distribution of chemical constituents is known not to be even within a rice kernel. To improve the eating quality of rice or to give it some special traits by adjusting the milling intensity, we investigated the distribution of amylose, nitrogen (N), and specific minerals (P, K, Mg, Ca, and Mn) in rice kernels of 11 cultivars with various characteristics cultivated under similar conditions. The distributions of these constituents were determined using flour samples prepared consecutively by abrasive milling from the outer to the inner portions of hulled rice. In all the cultivars tested, N and the minerals were found to be more abundant in the outer than in the inner portion, but amylose was rich in the inner portion. P, Mg, K, and Mn were extremely rich in the outer portion, while N and Ca were only relatively rich there. Koshihikari, which is the most popular cultivar in Japan because of its excellent eating quality, showed the highest Mg/K ratio in the outermost portion of polished rice. The color of flour samples became pure white going from outside portions toward the center of the kernel, even if the sample was from red rice or purple-black rice because only the surface of hulled rice contains pigments. These findings suggest that the outer portion contains various compounds other than starch and the inner portion contains relatively pure starch. Rice palatability and other characteristics can be improved through controlling the degree of milling using the biased distribution of chemical constituents within a rice kernel.

A case of chronic expanding hematoma in the tensor fascia lata

We describe a patient in whom a chronic expanding hematoma was pathologically confirmed by examination of the resected specimen. It developed gradually in the left lateral thigh, which had been bruised 8 months before, but had produced no mass-related symptoms initially. Computed tomography (CT) showed the mass to be homogeneous with capsule formation, whereas ultrasonography showed it to resemble a multilocular cyst. The lesion was treated by complete excision of a perifascial mass. Grossly, a well-circumscribed, fusiform mass with a soft cystic center and a fibrous pseudocapsule was observed. Histologically, the mass was composed of necrotic debris, fibrin and blood clots. This was surrounded by a rim of hyalinized fibrous tissue with a chronic inflammatory infiltrate and granulation tissue with sprouting new capillaries. CT was unable to discriminate the chronic expanding hematoma from other soft tissue masses, ultrasonography being needed to reveal its characteristics in this case.

Intramolecular 1,3-dipolar cycloaddition strategy for enantioselective synthesis of FR-900482 analogues

[reaction: see text] Enantioselective synthesis of FR-900482 analogues is described. The key reaction of the synthesis is intramolecular 1,3-dipolar cycloaddition of a highly functionalized nitrile oxide with complete stereo- and regioselectivities to construct the eight-membered benzazocine ring.

Pseudolymphomatous folliculitis: a clinicopathologic study of 15 cases of cutaneous pseudolymphoma with follicular invasion

We report the clinical, histopathologic, and immunohistologic features of 15 cases of pseudolymphomatous folliculitis (PLF). The patients comprised seven males and eight females (mean age, 38.6 years; age range, 2-67 years). All patients had dome-shaped or flat-elevated nodules suggestive of cutaneous lymphoid hyperplasias (CLHs). The lesions were solitary in all 15 cases, except in one case with duplex lesions. All lesions were located on the face and measured less than 1.5 cm. In 14 cases with one lesion each, five lesions showed rapid regression after incisional biopsy, whereas the remaining nine underwent excisional biopsy. In the case with duplex lesions, one regressed spontaneously after excisional biopsy of the other. Histopathologically, all PLFs showed dense lymphocytic infiltrates from the dermis to the subcutis simulating cutaneous lymphomas. The walls of hair follicles in all cases were enlarged and irregularly deformed with their epithelium blurred by lymphocytic infiltrates; we called this change "activation" of hair follicles. In nine cases, many atypical lymphocytes were intermingled; three of these cases had been misdiagnosed as cutaneous T-cell lymphoma at other institutions. Immunohistologically, 10 and 5 cases showed predominantly B cells and predominantly T cells, respectively. Remarkably, all lesions showed increased numbers of perifollicular histiocytes expressing anti-S-100 protein and CD1a, and seven lesions showed histiocytes in aggregates. We conclude that PLF is a subset of CLH with characteristic clinical and pathologic features showing perifollicular clustering of T-cell-associated dendritic cells with activation of pilosebaceous units. PLF is an entity to be differentiated from malignant lymphomas and other cutaneous pseudolymphomas.

[Small cell neuroendocrine carcinoma of the urinary bladder: a case report]

A 60-year-old male was referred to our hospital with a complaint of asymptomatic gross hematuria. Cystoscopic examination revealed a non-papillary broad-based tumor on the posterior wall of the urinary bladder. Computed tomography revealed no evidence of metastases. Transurethral resection of bladder tumor (TUR-BT) was performed and muscle invasion was detected by histological examination of the specimen. Total cystectomy and ileal conduit formation were performed at the preoperative diagnosis of T2-3N0M0. Hematoxylin-eosin staining of the specimen revealed small cancer cells with hyperchromatic nucleus and scanty cytoplasm growing in the muscle layer of the urinary bladder and in the left obturator lymph nodes. Immunohistochemistry for neurospecific enolase showed diffuse staining in the cytoplasm of cancer cells, and ultrastructural study showed dense core granules. From these findings, the patient was diagnosed with small cell neuroendocrine carcinoma of the urinary bladder at the stage of pT3bpN1M0. Three courses of adjuvant chemotherapies with cis-platinum (CDDP) and etoposide were administered. The patient is still alive with no evidence of any recurrence at 22 months after the operation. This case suggests that treatment with combined total cystectomy and adjuvant CDDP and etoposide chemotherapies is effective against neuroendocrine carcinoma of the urinary bladder with regional lymph node metastases.

[A case of genital Paget's disease with severe dermal invasion and early dissemination]

A 65-year-old man was referred to our hospital with a complaint of a scrotal mass which he first noticed 8 months ago. The mass was resected saving genital organs. Pathological diagnosis was extramammary Paget's disease with severe dermal invasion and many nuclear mitoses. The tumor was 15 mm in diameter, and 18 mm in thickness. The bilateral inguinal lymph nodes were dissected and multiple metastases were revealed in the right specimen. Since paraaortic lymph node metastases were detected later 5 cycles of chemotherapy consisting of cyclophosphamide, adriamycin and cisplatin (CAP) followed by radiation therapy were performed. However, only a partial response could be obtained, and multiple brain metastases were revealed on computed tomographic scan. He died 22 months after discovery of this disease. Since extramammary Paget's disease tends to grow slowly and horizontally, cases with such severe dermal invasion and early dissemination as in our case are unusual.

Molecular cloning of a novel receptor-type protein tyrosine phosphatase from murine fetal liver

A cDNA fragment encoding a novel tyrosine phosphatase (PTPase), termed ptpf, was isolated from day 11.5 mouse fetal liver using reverse transcription-polymerase chain reaction (RT-PCR) with degenerate primers. The 5.5-kb cDNA encoding the complete coding region was isolated from an adult mouse kidney cDNA library. This cDNA contained a single open reading frame (ORF) encoding a predicted 1436-amino-acid protein with a molecular mass of 161,150 Da. Sequence analysis revealed that PTPf was homologous to PTPmu and PTPkappa, and a putative receptor-type PTPase. Northern blotting analysis of adult mouse mRNA indicated the existence of four major ptpf transcripts of approximately 10, 6, 3 and 2.7 kb, and these transcripts were expressed in a tissue-specific manner. During embryogenesis, only the 6-kb transcript was detected.

Role of apoptosis in spontaneous regression of peripheral T-cell lymphoma arising in the skin or subcutis

Apoptosis was suspected to play a significant role in spontaneous regression of skin lesions in four cases of peripheral T-cell lymphoma arising in the skin or subcutis. All of the patients had skin tumors with ulcer formation, but no metastasis to the lymph nodes or viscera. Biopsy showed a sea of CD3-positive lymphoma cells involving the dermis to the subcutis with scattered foci of coagulative necrosis. In the zone of incipient necrosis surrounding the core of coagulative necrosis, frequent apoptotic bodies were identified by electron microscopy (EM), and DNA strand breaks were detected in 34% to 51% (mean, 42%) of lymphoma cells by the TdT-mediated deoxyuridine triphosphate (dUTP)-biotin nick end-labeling (TUNEL). As for the pathogenesis of coagulative necrosis, ischemic necrosis attributable to lymphocytic vasculitis appeared unlikely, because necrotic foci were devoid of neutrophils and had no relation to vascular distribution. Primary cataclysmic apoptosis appeared more likely, but its pathogenetic role could not be established, because EM and TUNEL could not be applied to the core of the debris-ridden coagulative necrosis. Although these cases had been classified as pseudolymphomas because they were histologically malignant but clinically benign, they were in fact true lymphomas characterized by extensive coagulative necrosis with a high rate of apoptosis demonstrable in the zone of incipient necrosis.

[Two cases of cavity formation in prostatic urethra after transurethral microwave thermotherapy (TUMT) with Prostatron]

The Prostatron device, developed by Dr. Devonec, provides microwave heating of the prostate and simultaneous conductive cooling of the urethra. Treatment with Prostatron (transurethral microwave thermotherapy: TUMT) of BPH can be performed in a single session, and the urethra, the rectum and the surrounding tissue are protected with the temperature monitoring system. TUMT with Prostatron may be more suitable for a small adenoma with mild symptoms than a large adenoma with severe symptoms, because objective improvement is rarely observed compared with subjective improvement. We have treated 40 cases of BPH with Prostatron (Prostasoft 2, max. energy: 50 watt, max. urethral temperature: 44.5 degrees C, max. rectal temperature: 42.5 degrees C) since March 1993. Among them, there were 2 cases of large cavity formation involving the prostatic urethra. With cavity formation, TUMT may have its place in the treatment of a large adenoma with severe urinary symptoms, but loses its advantage in the prevention of persistent urinary infection and retrograde ejaculation, especially in the treatment of a small adenoma in a younger patient with mild urinary symptoms. It is unknown why such cavity formation occurred only in 2 patients among 40 equally treated cases, but the causes of cavity formation and safety of TUMT should be evaluated again, even though no injury to the rectum and the external urethral sphincter were detected. We report these 2 cases, and causes of cavity formation and discuss the prospects of TUMT.

Neurofibromatosis 2 and neurilemmomatosis gene are identical

Neurofibromatosis 2 (NF2) is an autosomal dominant disorder characterized by the occurrence of bilateral acoustic neuromas, as well as meningiomas and schwannomas. The gene locus for NF2 resides on chromosome 22q12 and has been cloned recently. Neurilemmomatosis is characterized by multiple cutaneous and spinal neurilemmomas without other signs of NF1 or NF2. Many cases with this disorder include the diagnosis of neurofibromatosis or other rare diseases unexplained by current nosology. In this study, we analyzed the peripheral leukocytes and tissue from cutaneous neurilemmomas of seven patients with neurilemmomatosis using DNA markers for different regions of chromosome 22. We detected allelic losses in three of seven tumors from seven patients with a probe for the NF2 region of the long arm of chromosome 22 and the germ-line mutations in two of three tumors from the same three patients. Mutations in the NF2 gene were a deletion from at least codon 334 to 579 and G insertion at codon 42. We conclude that the neurilemmomatosis locus lies within the NF2 region and that these diseases might be identical.

Chromosome 1q terminal deletion resulting from de novo translocation with an acrocentric chromosome

Distal deletion of chromosome 1q has been reported in nearly 30 patients, all being associated with a deletion ranging from the 1q42 or q43 band to 1qter region. Here, we describe a girl with 1q terminal deletion resulting from an unbalanced de novo translocation t(1;D or G)(q44;p11), as revealed by the presence of a satellited feature and an NOR-stained region at the tip of 1q. We suggest that most of the phenotypic abnormalities seen in patients with 1q distal deletion are attributable to the monosomy for band 1q44.

Septum formation of the common hepatic duct associated with an anomalous junction of the pancreaticobiliary ductal system and gallbladder cancer: report of a case

We herein describe a 48-year-old woman who developed a septum formation of the bile duct combined with an anomalous arrangement of the pancreaticobiliary ductal system in conjunction with gallbladder cancer. A preoperative endoscopic retrograde cholangiogram demonstrated a filling defect in the common hepatic duct which was misdiagnosed to be an elevated lesion. Further exploration revealed a septum formation of the bile duct along with gallbladder cancer. A resection of the dilated bile duct and gallbladder along with a dissection of the regional lymph nodes was performed. A histological evaluation showed the septum to consist of a normal bile duct wall while the tumor in the gallbladder was poorly differentiated adenocarcinoma. The patient made an uneventful recovery. The septum formation was presumed to be congenital in origin.

Characterization of the translocation breakpoint on chromosome 22q12.2 in a patient with neurofibromatosis type 2 (NF2)

We previously described a patient with neurofibromatosis type 2 (NF2) who showed a constitutional balanced translocation, t(4;22). To characterize the breakpoint on chromosome 22 in this patient in relation to a candidate gene (NF2) responsible for NF2, we analyzed DNAs from this patient and her parents using parts of NF2 cDNA as probes. Southern analyses and DNA sequencing revealed that the chromosome 22 breakpoint in this patient lies within the intron between exons 14 and 15 of NF2. The results lend support to the conclusion that NF2 is the gene responsible for the CNS form of neurofibromatosis.

Differentiation between cutaneous form of adult T cell leukemia/lymphoma and cutaneous T cell lymphoma by in situ hybridization using a human T cell leukemia virus-1 DNA probe

Adult T cell leukemia/lymphoma (ATLL) shares overlapping clinicopathological features with cutaneous T cell lymphoma (CTCL), requiring detection of monoclonal integration of proviral DNA of type 1 human T cell leukemia virus for its differential diagnosis from the latter. We applied in situ hybridization (ISH) and polymerase chain reaction (PCR) to paraffin sections from 63 Japanese autopsy cases that had been diagnosed as CTCL in earlier years when ATLL was still not widely known. Eleven and two cases with confirmed diagnoses of ATLL and CTCL served as positive and negative controls, respectively. It was found that ISH was positive in 7 of 63 test cases and 10 of 11 positive controls, whereas PCR was positive in none of the test cases and eight of the positive control cases. Two negative controls were negative for both ISH and PCR. We conclude that ISH is superior to PCR for detecting type 1 human T cell leukemia virus proviral DNA on paraffin sections and that the ISH method is useful for differentiating CTCL from the cutaneous form of ATLL.

Primary cutaneous T-cell-rich B-cell lymphoma

A 61-year-old man presented with a skin tumour in the right axilla of 2 months' duration. An excision biopsy revealed a malignant lymphoma, of diffuse mixed small and large cell type, morphologically suggestive of T-cell lymphoma, but shown to be a T-cell-rich B-cell lymphoma by subsequent immunohistochemical staining. A review of the literature revealed 47 cases of T-cell-rich B-cell lymphoma with descriptions of primary sites, 35 nodal and 12 extranodal, of which only one was a cutaneous primary.