[Anti-neutrophil cytoplasmic anti body (ANCA)-negative limited form of Wegener's granulomatosis; report of a case]

A 54-year-old man, who was suspected to suffer from multi-drug resistant lung abcess, was admitted to our hospital. Chest computed tomography (CT) scan showed large cavitary mass in right S6 and nodules in left S1+2 and S10. No abnormal findings were detected without raised immunoglobulin E (IgE) and C-reactive protein (CRP). Anti-neutrophil cytoplasmic antibody (ANCA) was repeatedly negative. We couldn't make a diagnosis by percutaneous biopsy. Finally we performed open lung biopsy of left lung, and Wegener's granulomatosis was diagnosed at last He improved immediately after treatment with prednisolone, cyclophosphamide and sulfamethoxazole-trimethoprim. ANCA-negative Wegener's granulomatosis should be considered when we diagnose multiple pulmonary nodules.

Progressive expression of vascular endothelial growth factor (VEGF) and angiogenesis after chronic ischemic hypoperfusion in rat

Cerebrovascular stenosis caused by arteriosclerosis induces failure of the cerebral circulation. Even if chronic cerebral hypoperfusion does not induce acute neuronal cell death, cerebral hypoperfusion may be a risk factor for neurodegenerative diseases. The purpose of this study was to determine if vasodilation, expression of VEGF, and neovascularization are homeostatic signs of cerebral circulation failure after permanent common carotid artery occlusion (CCAO) in the rat. Neuronal cell death in neocortex was observed 2 weeks after CCAO and gradually increased in a time-dependent manner. The diameter of capillaries and expression of VEGF also increased progressively after CCAO. Moreover, we observed unusual irregular angiogenic vasculature at 4 weeks. In conclusion, chronic hypoperfusion results in mechanisms to compensate for insufficiency in blood flow including vasodilation, VEGF expression, and neovascularization in the ischemic region. These results suggest that angiogenesis might be induced in adult brain through the support of growth factors and transplantation of vascular progenitor cells, and that neovascularization might be a therapeutic strategy for children and adults with diseases such as vascular dementia.

Nano-sized domains related to dielectric anomaly in YFe2O4-delta

We examined microstructures related to the charge ordering in YFe2O4-delta, by transmission electron microscopy. It is found that two types of characteristic diffuse scatterings appear at room temperature. One is characteristic diffuse streaks elongated along the [0001] direction through the (1/3 1/3 2/3 0)-type reciprocal positions and the other is diffuse spots at (1/3 - eta 1/3 - eta 2/3 + 2eta 0)-type incommensurate positions (eta approximately 0.066). Real-space images revealed that the former diffuse scattering is related to nano-domains due to the charge ordering and the latter one is related to those due to vacancy ordering. The presence of the nano-sized domains should be strongly related to the dielectric anomalies found in YFe2O4-delta.

Thoracoscopic enucleation of esophageal stromal tumor

Gastrointestinal stromal tumor is a rare entity, especially in the esophagus. We report a patient with a stromal tumor of the esophagus who underwent a thoracoscopic enucleation of the tumor. The patient was a 61-year-old man complaining of slight dysphagia. A submucosal tumor of the middle thoracic esophagus was found endoscopically. The tumor was approximately 4.0 cm in diameter measured by endoscopic ultrasonography. On 17 May 2001, thoracoscopic enucleation of the esophageal tumor was performed using a Kodama Di-suction. The Kodama Di-suction was useful for the thoracoscopic enucleation of the submucosal tumor of the esophagus, acting as both a dissector and a sucker. The patient's course was uneventful after surgery. Histopathologically the esophageal tumor revealed a high cellularity, consisting of spindle cells, and the tumor cells were immunohistochemically positive for CD34 and c-kit protein, but not for a-smooth muscle actin or S-100 protein. From these findings, the esophageal submucosal tumor was diagnosed as gastrointestinal stromal tumor, distinguished from leiomyoma.

Paraovarian cyst: MR imaging features

BACKGROUND

Paraovarian cysts are common intrapelvic neoplasms, but the magnetic resonance (MR) findings of paraovarian cyst have never been reported. We investigated the spectrum of MR imaging features of paraovarian cyst.

METHODS

MR images of 18 paraovarian cysts in 16 patients were reviewed retrospectively. MR images were evaluated for the size and location of paraovarian cysts, single or multicystic, signal intensity on T1- and T2-weighted images, and visualization of the normal ovary on the affected side.

RESULTS

The normal ovary of the affected side was recognized in 13 lesions. Four of these 13 cysts were separated from the ipsilateral ovary. In seven cysts, the normal ovary was abutted by cysts but maintained its shape. In two cysts, the beak sign was recognized at the interface between the cyst and the ovary. Most other MR features were nonspecific.

CONCLUSION

Most paraovarian cysts were homogeneous cystic masses near the ipsilateral round ligament and the uterus. Demonstration of a normal ipsilateral ovary close to, but separated from, the adnexal cyst may be an important MR finding for the diagnosis of paraovarian cysts.

Long-term follow-up of patients with aplastic anemia and refractory anemia responding to combination therapy with recombinant human granulocyte colony-stimulating factor and erythropoietin

In our previous study, approximately 60% of aplastic anemia (AA) and refractory anemia (RA) patients treated with recombinant human granulocyte colony-stimulating factor (rhG-CSF) and recombinant human erythropoietin (rhEpo) showed a multilineage response. In this study, we analyzed the long-term follow-up of the multilineage responders (multi-R). In the follow-up analysis of 11 multi-R (6 AA and 5 RA), 10 patients (5 AA and 5 RA) were evaluable. The range of time from the start of treatment to the final contact was 50 to 125 months. Analysis of survival times revealed a significant difference between multi-R and non-multi-R among AA patients given this treatment (P = .016). One AA and 1 RA patient among the multi-R developed acute leukemia. Of 7 living multi-R, 3 AA and 2 RA patients did not need transfusion at final contact. Four of them maintained the target hemoglobin concentration of more than 11 g/dL for quality-of-life benefit. The findings suggested that this result is an important advantage of this treatment.

[De novo CD5-positive diffuse large B-cell lymphoma with leukemic dissemination diagnosed by immunohistochemical examinations of bone marrow clot sections]

A 61-year-old male visited his doctor in October 2000 because of a high fever. Laboratory examination revealed leukocytosis with blast-like cells and thrombocytopenia. He was referred and admitted to our hospital in November 2000. Although he had mild splenomegaly, he had no lymphadenopathy on the first admission. The white blood cell count was 10,520/microliter with 45% blast-like cells and the platelet count was 51 x 10(3)/microliters. Bone marrow aspiration revealed 82% blast-like cells, which were positive for CD5, CD10, CD13, CD19, and CD20. Immunohistochemistry of the bone marrow clot sections revealed blast-like cells were positive for CD5, but negative for TdT, CD23 and cyclin D1. We diagnosed the patient as having de novo CD5-positive diffuse large B-cell lymphoma (DLBCL) with leukemic dissemination. He obtained a complete remission after two courses of CHOP therapy. The third chemotherapy was postponed because of strangulation of the intestine. He relapsed and died in spite of the third chemotherapy. CD5-positive DLBCL is one of the established disease entities that requires an appropriate therapy regimen because it is characterized by elderly onset, extranodal involvement, and a poorer prognosis.

Differences and relationships of thymidine phosphorylase expression in tumor-associated macrophages and cancer cells in squamous cell carcinoma of the esophagus

Thymidine phosphorylase (TP), which has been shown to be identical to platelet-derived endothelial cell growth factor, is expressed in tumor-associated macrophages (TAMs) as well as cancer cells. The aim of this study was to clarify the differences or relationships of TP expression in TAMs and cancer cells in esophageal squamous cell carcinoma (SCC). Tissues samples were taken from 56 patients with esophageal SCC after curative surgery. The expression of TP in TAMs or SCC cells was examined using a monoclonal antibody to TP (clone 654-1). Microvessels in SCC that stained positively for Factor VIII-related antigen were counted (microvessel density, MVD). Macrophages in SCC that stained positively for CD68 antigen were counted (monocytic count). Ki-67 antigen was immunostained with MIB-1, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate biotin nick end labeling was performed, and Ki-67 labeling index (LI) and apoptotic index were calculated. The expression of TP in stromal cells and cancer cells was observed in 43 (76.8%) and 33 patients (58.9%), respectively. There were significant correlations between TP expression in stromal cells (TAMs) as well as in cancer cells and venous invasion, distant metastasis, or MVD. There was a correlation between TP expression in cancer cells and lymph node metastasis, and there were correlations between TP expression in TAMs and monocytic count or Ki-67 LI; however, there was no correlation between TP expression in TAMs and lymph node metastasis. On the other hand, in SCCs with TP expression in both TAMs and cancer cells, higher frequencies of venous invasion and distant metastasis, higher MVD and lower apoptotic index were observed than in other SCCs. The 5-year survival rate in patients with TP expression in both TAMs and cancer cells was poorer than that in patients with TP expression in neither TAMs and cancer cell. In conclusion, these results suggest that co-expression of TP in TAMs and cancer cells is strongly associated with angiogenic promotion and distant metastasis. However, other effects of TP, such as promotion of tumor growth and lymph node metastasis, may be different depending on whether these are expressed in TAMs or cancer cells in esophageal SCCs. Patients with coexpression of TP in TAMs and cancer cells may be associated with a poor prognosis.

Efficacy of carboplatin with an MEP (mitoxantrone, etoposide and prednisone) regimen for relapsed and CHOP-resistant diffuse large B-cell lymphomas

Mitoxantrone, etoposide and prednisone (MEP)-based regimens using granulocyte colony-stimulating factor (G-CSF) were designed for relapsed and CHOP-resistant diffuse large B-cell lymphomas in a single institution, and the therapeutic effects and adverse reactions were studied. In a total of 49 patients, the MEP regimen had a 41% (9/22) overall response rate compared with 48% (13/27) for the MEP plus carboplatin (C-MEP) regimen (Chi-squared test, P=0.602). Among 38 CHOP-resistant patients, however, the overall response rate to C-MEP [42% (10/24)] was significantly superior compared with MEP [7% (1/14)] (P=0.023), and the overall survival to C-MEP was superior compared with MEP (P=0.088). Taken together, our results, although non-randomized, suggest that a combination of MEP with carboplatin is better than MEP alone in CHOP-resistant diffuse large B-cell lymphomas.

Differential response to stem cell factor and Flt3 ligand by the FAB subtype in acute myeloid leukemia clonogenic cells

Proliferative response of blast clonogenic cells to various hematopoietic growth factors (HGF), including stem cell factor (SCF) and flt3 ligand (FL) was investigated in 100 patients with acute myeloid leukemia (AML) and chronic myelogenous leukemia (CML) in myeloid crisis (MC). The frequency of spontaneous colony formation was significantly high in CML in MC (55%) and AML French-American-British (FAB) subtype M4 (48%) compared with M2 (16%). No spontaneous colony was formed in any of the patients with M1 and M3. The frequency of proliferative response to various HGF alone and in combination according to FAB subtype and CML in MC was as follows: that to granulocyte colony-stimulating factor (G-CSF) was lowest in M1 and CML in MC (50%) compared with other FAB subtypes (>or=86%), that to granulocyte-macrophage CSF (GM-CSF) was lowest in CML in MC (44%) compared with FAB subtypes (>or=74%), and that to interleukin-3 (IL-3) was lowest in CML in MC (30%) compared with FAB subtypes (>or=78%). SCF and FL stimulated blast colony formation in 11% and 17% of patients with M3, respectively, but there was no response to both, and in 60% and 57% of patients with CML in MC, respectively, with 14% showing a response to both. The frequency of proliferative response to both SCF and FL increased in the order of M1 (33%), M2 (63%), M4-5 (95%), and M6 (100%). The results are summarized as follows: absence of spontaneous colony formation and response to HGF other than SCF and FL, designated as HGF-dependent growth (M3); spontaneous colony formation and lowest response to HGF, designated as autonomous growth (CML in MC); and spontaneous colony formation and highest response to HGF including SCF and FL, designated as autocrine growth (M4-6). M1 and M2 were intermediate between CML in MC and M4-6. The relation between in vitro growth pattern of blast clonogenic cells and prognosis in AML FAB subtype and CML in MC is discussed.

Serum thymidine kinase and soluble interleukin-2 receptor predict recurrence of malignant lymphoma

Before and after therapy, serum thymidine kinase (TK) and soluble interleukin-2 receptor (sIL-2R) were serially determined in 28 patients with malignant lymphoma (ML). In 15 patients achieving and maintaining complete remission (CR) for more than 2 years, serum TK and sIL-2R were unchanged or decreased gradually. In contrast, logarithmic linear increases of TK and sIL-2R were observed in 13 relapsed patients. The increments of the serum markers occurred more than 10 months before the relapse. A significant positive correlation between the slope of the line for TK and that for sIL-2R was noted. The doubling time for TK estimated from the slope also showed a positive correlation with that for sIL-2R. Taken together, serum TK and sIL-2R were shown to be quite sensitive and interrelated serum markers for the recurrence of ML. Slopes of logarithmic linear increase, which are proper and specific for the individual patients, are inversely correlated with the doubling time and reflect proliferation of ML. We conclude that serum TK and sIL-2R are better predictors of relapse than LDH and the international prognostic index (IPI).

[Systemic capillary leak syndrome presenting remarkable erythrocytosis]

Systemic capillary leak syndrome (SCLS) is a disorder characterized by hypotension, edema, and an increased hematocrit (Ht) due to sudden leakage of plasma into the extravascular space through some unknown mechanism, in which monoclonal gammopathy is observed. A 30-year-old man visited our emergency department because of abdominal pain, and was admitted to our hematology department because of a markedly increased hemoglobin concentration reaching 26.2 g/dl. The polycythemia was thought to be pseudo-polycythemia due to hemoconcentration, and we diagnosed the patient as having SCLS based on the triad of increased hematocrit, whole-body edema which was especially marked in the lower extremities, and monoclonal gammopathy. The patient recovered after administration of extracellular fluids and albumin, but the attacks recurred. Prophylaxis with terbutaline sulfate, theophylline and corticosteroid reduced the frequency of severe attacks. Because there is possibility that patients with SCLS may be admitted to hematology departments due to severe erythrocytosis, we report this case to increase the awareness of hematologists that SCLS is one of the important differential diagnoses of erythrocytosis.

Immature teratoma with gliomatosis peritonei associated with pregnancy

Immature teratoma, which contains variable quantities of immature tissues that resemble those of the embryo, is one of the primitive germ cell tumors. It occurs most frequently in young women but it is rarely reported in association with pregnancy. We report a case of immature teratoma associated with pregnancy exhibiting unique MR findings with pathologic correlation.