2005 Japanese Society for Dialysis Therapy guidelines for vascular access construction and repair for chronic hemodialysis

The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Dr Ohira, has published an original Japanese guideline, 'Guidelines for Vascular Access Construction and Repair for Chronic Hemodialysis'. The guideline was created mainly because of the existence of numerous factors characteristic of Japanese hemodialysis therapy, which are described in this report, and because we recognized the necessity for standardization in vascular access-related surgeries. This guideline consists of 10 chapters, each of which includes guidelines, explanations or comments and references. The first chapter discusses informed consent of vascular access (VA)-related surgeries, which often resulted in trouble between dialysis staff and patients. The second chapter describes the fundamentals of VA construction and timing of the introduction of hemodialysis with emphasis on the avoidance of catheter indwelling if at all possible. In the third chapter, arteriovenous fistula (AVF) construction and management are discussed from the viewpoint of the most preferable type of VA. The fourth chapter deals with arteriovenous grafts (AVG) which has recently increased in clinical applications. The factors which improve the AVG patency rate are discussed and postoperative management methods are emphasized to avoid possible complications. The fifth chapter deals with short and long-term vascular catheters. It is emphasized that these methods are definitely effective but, at the same time, are apt to be associated with several serious complications and might result in vascular damage. In the sixth chapter, superficialization of an artery is explained. This was originally for emergency use or backup but has been used permanently in 2-3% of Japanese hemodialysis patients. In the seventh chapter, methods for the use of VA are described and the buttonhole method is referred to as one of the options for patients who complain of intense pain at every cannulation. In the eighth chapter, the importance of continuous monitoring is stressed for maintaining appropriate function of VA. As a rule, the internal shunt type VA (AVF, AVG) places a burden on cardiac function. Thus, in the ninth chapter, it is stressed that VA construction, maintenance and repair should always be carried out with consideration of cardiac function which is not constant but variable. The 10th chapter forms one of the cores of this guideline and deals with repair and timing of VA. It is shown how to select a surgical or interventional repair method. In the final 11th chapter, VA types and resultant morbidity and mortality of hemodialysis patients are reviewed.

In Preparation for a Treatment Guideline for Suitable Vascular Access Repair in Japan

In cases of vascular access (VA) for hemodialysis including arteriovenous fistula and arteriovenous graft, venipuncture and hemostasis are usually repeated three times a week. Accordingly, it is assumed that VA vascular disorders are worsened following long-term hemodialysis. In particular, angiostenosis frequently occurs and results in insufficient blood flow or increased venous pressure. Additionally, stenosis is a major cause of VA occlusion. While VA intervention treatment is mainstream for VA stenosis, its major advantage lies in its less invasiveness because it is a percutaneous treatment. A further advantage of this treatment procedure is that the existing VA can be preserved intact. For practical use of VA intervention treatment, however, compliance with the therapeutic indication guideline is required. In K/DOQI of the United States, such a guideline has already been formulated based on evidence and specialist opinion, while the guideline of the European Vascular Access Society is presented in the form of a flowchart. The Japanese Society for Dialysis Therapy is currently preparing a guideline for the construction and maintenance of VA, which introduces the timing and principles of repair of VA in the following six categories: (i) stenosis; (ii) occlusion; (iii) venous hypertension; (iv) steal syndrome; (v) excess blood flow; and (vi) infection. Except for infection, most of the treatments for these events involve VA intervention, thus the need for the guideline for VA intervention treatment is becoming widely recognized.

Evaluation of primary failure in native AV-fistulae (early fistula failure)

The most preferable method of vascular access (VA) in maintenance hemodialysis is a native arteriovenous fistula (AVF). Advanced age as well as the rapid increase in underlying diseases such as diabetic nephropathy and nephrosclerosis in these patients also means that the veins and arteries used to establish the AVF have undergone vascular damage, making construction of an AVF more difficult compared with earlier construction. Although there are various conditions under which arterial superficialization or AV graft must be chosen, it remains the rule that the first choice for VA should be AVF whenever possible. To improve postoperative results, it is necessary to reduce malfunctions immediately following surgery. We conducted a survey of 23 dialysis facilities throughout Japan and analyzed data from the past 3 years regarding the functionality of the AVF at initial puncture following construction of 5007 examples of newly constructed AVFs. Upon initial puncture, primary failure (PF) is defined as those cases in which thrombosis or inadequate blood flow occur. Primary failure occurred in 7.6% of the cases in this series, but there was a wide distribution of PF, 0.8% to 23.6%, because of differences in quality among facilities. This difference in PF is probably affected by technical aspects, the main factor being the characteristics of the patient. Survey responses included: (1) vascular damage of the veins and arteries used in creating the AVF and (2) the suitability of the location chosen for construction. In the data collected, many methods were used to repair those primary AFVs in which PF occurred. The salvage rate was 70%. Currently, the most preferable form of VA is AVF adhering to the principle that the proper timing of the choice and construction of AVF should consider the maturation period. To accomplish this, it is vital that vascular mapping be performed preoperatively to construct the AVF. If PF does occur, the cause should be thoroughly investigated and repairs made effectively.

Correlation between MRI and histopathologic findings in stage I cervical carcinomas: influence of stromal desmoplastic reaction

Although the effectiveness of magnetic resonance imaging (MRI) in depicting cervical carcinoma has been reported, whether MRI can detect early-stage or stage IB "occult"-type cervical carcinoma remained undetermined. We examined the correlation between MRI and pathologic findings in 38 stage I (IB 28 cases, IA 10 cases) cervical carcinoma patients, with special reference to the influence of desmoplastic stromal reaction around the tumor. The results demonstrated that the tumor was detected by MRI in none of stage IA patients but in 21 (75%) stage IB patients. The image was clearly demonstrated in 15 of 18 (83%) tumors of more than 2 cm in diameter and in 6 of 10 (60%) tumors of 2 cm or less. The tumor image was evident in 21 of 22 (95%) tumors with prominent (>200 micron) stromal reaction but in none of 6 tumors with minimal (</= 200 micron) stromal reaction. These findings suggest that MRI is not useful for the detection of stage IA tumors. In stage IB tumors, however, the stromal reaction rather than the size of the tumor may influence the tumor's image in MRI.

Encapsulating peritoneal sclerosis in Japan: a prospective, controlled, multicenter study

BACKGROUND

Encapsulating peritoneal sclerosis (EPS) is recognized as a rare but serious complication of peritoneal dialysis (PD). The aim of this study was to determine the incidence, clinical features, and mortality rate of EPS.

METHODS

The authors requested the registration of all PD patients in facilities across Japan where more than 10 patients were treated with PD in this prospective multicenter study. During the 4-year study, the incidence of EPS was observed in the enrolled patients.

RESULTS

A total of 1,958 patients who were treated with PD in 57 facilities were followed up from April 1999 through March 2003. EPS occurred in 48 patients, corresponding to an overall incidence of 2.5%. In 33 of the 48 (68.8%) patients, EPS was found after discontinuation of PD. The incidence (and mortality rate) of EPS was 0%, 0.7% (0%), 2.1% (8.3%), 5.9% (28.6%), 5.8% (61.5%), and 17.2% (100%) in patients who had undergone PD for 3, 5, 8, 10, 15, and more than 15 years, respectively. The recovery ratio with total parenteral nutrition, corticosteroids and surgical treatment were 0%, 38.5%, and 58.3%, respectively. Eighteen patients (37.5%) died, 22 (45.8%) recovered, and the status of the other 8 (16.7%) remained unchanged.

CONCLUSION

The results of this prospective multicenter study showed that the incidence of EPS was 2.5% within a 4-year observation period and that two thirds of the cases were diagnosed after discontinuation of PD. Because of the current progress in diagnostic technology and therapeutic methodology, it appears that PD can be continued successfully with an acceptable, low risk for EPS for at least 8 years, whereas stricter caution is required for patients receiving PD for longer periods.

Vulvar Paget's disease with underlying adenocarcinoma simulating breast carcinoma: case report and review of the literature

We report a case of extramammary Paget's disease with underlying adenocarcinoma simulating breast carcinoma of the vulva. An 82-year-old woman was found to have a 5 x 3-cm bulky tumor located in the left labium major, infiltrating to the clitoris, left labium minor, and left lateral tissue of the vulva. Small biopsy of the vulva showed intraepidermal proliferation of Paget cells. The patient underwent wide local excision of the vulvar tumor and dissection of left inguinal lymph nodes. Histopathological examination of the resected specimens revealed that Paget cells were distributed singly or tended to form small nests in the epidermis, and that association of these cells with the underlying carcinoma invading to the subcutis could be seen. The underlying carcinoma was composed of squamoid solid nests with central necrotic debris, mimicking 'comedocarcinoma' of the breast. In other areas, the tumor cells were present in tubular formations and solid cords reminiscent of invasive ductal carcinoma of the breast. Immunohistochemically, the Paget cells and the underlying carcinoma cells were positive for carcinoembryonic antigen, epithelial membrane antigen, estrogen receptors, and glandular keratins except for CK 20. We speculate that our case is vulvar Paget's disease presenting as a manifestation of underlying breast carcinoma of the vulva, which might have arisen from either the ectopic breast tissue or anogenital mammary-like glands.

Encapsulating peritoneal sclerosis in Japan: a prospective, controlled, multicenter study

BACKGROUND

Encapsulating peritoneal sclerosis (EPS) is recognized as a rare but serious complication of peritoneal dialysis (PD). The aim of this study was to determine the incidence, clinical features, and mortality rate of EPS.

METHODS

The authors requested the registration of all PD patients in facilities across Japan where more than 10 patients were treated with PD in this prospective multicenter study. During the 4-year study, the incidence of EPS was observed in the enrolled patients.

RESULTS

A total of 1,958 patients who were treated with PD in 57 facilities were followed up from April 1999 through March 2003. EPS occurred in 48 patients, corresponding to an overall incidence of 2.5%. In 33 of the 48 (68.8%) patients, EPS was found after discontinuation of PD. The incidence (and mortality rate) of EPS was 0%, 0.7% (0%), 2.1% (8.3%), 5.9% (28.6%), 5.8% (61.5%), and 17.2% (100%) in patients who had undergone PD for 3, 5, 8, 10, 15, and more than 15 years, respectively. The recovery ratio with total parenteral nutrition, corticosteroids and surgical treatment were 0%, 38.5%, and 58.3%, respectively. Eighteen patients (37.5%) died, 22 (45.8%) recovered, and the status of the other 8 (16.7%) remained unchanged.

CONCLUSION

The results of this prospective multicenter study showed that the incidence of EPS was 2.5% within a 4-year observation period and that two thirds of the cases were diagnosed after discontinuation of PD. Because of the current progress in diagnostic technology and therapeutic methodology, it appears that PD can be continued successfully with an acceptable, low risk for EPS for at least 8 years, whereas stricter caution is required for patients receiving PD for longer periods.

Vulvar Paget's disease with underlying adenocarcinoma simulating breast carcinoma: case report and review of the literature

We report a case of extramammary Paget's disease with underlying adenocarcinoma simulating breast carcinoma of the vulva. An 82-year-old woman was found to have a 5 × 3-cm bulky tumor located in the left labium major, infiltrating to the clitoris, left labium minor, and left lateral tissue of the vulva. Small biopsy of the vulva showed intraepidermal proliferation of Paget cells. The patient underwent wide local excision of the vulvar tumor and dissection of left inguinal lymph nodes. Histopathological examination of the resected specimens revealed that Paget cells were distributed singly or tended to form small nests in the epidermis, and that association of these cells with the underlying carcinoma invading to the subcutis could be seen. The underlying carcinoma was composed of squamoid solid nests with central necrotic debris, mimicking ‘comedocarcinoma’ of the breast. In other areas, the tumor cells were present in tubular formations and solid cords reminiscent of invasive ductal carcinoma of the breast. Immunohistochemically, the Paget cells and the underlying carcinoma cells were positive for carcinoembryonic antigen, epithelial membrane antigen, estrogen receptors, and glandular keratins except for CK 20. We speculate that our case is vulvar Paget's disease presenting as a manifestation of underlying breast carcinoma of the vulva, which might have arisen from either the ectopic breast tissue or anogenital mammary-like glands.

Management of Refractory Ascites by Using a Peritoneal Dialysis System with Extracorporeal Ultrafiltration by Hemodialysis Dialyzer

Background

The treatment of refractory ascites remains a challenge in cirrhosis with ascites and end-stage renal disease (ESRD). Successful experiences with continuous ambulatory peritoneal dialysis (CAPD) for treatment of ESRD patients with ascites secondary to liver cirrhosis have been reported, but the CAPD modality has the drawback of protein loss and was observed to cause patients to become severely malnourished. We devised a CAPD method for treatment of ascites without protein loss. We use a peritoneal dialysis (PD) system to drain ascitic fluid and to reinject concentrated ascites into the abdomen after extracorporeal ultrafiltration of the ascitic fluid using a hemodialysis dialyzer and pump. Here, we report our experience with 2 cirrhotic patients with ascites treated by this method.

Patients and Method

Ascites are collected by gravity through a Y transfer set into a 3-L plastic bag for intravenous hyperalimentation. The ascitic fluid drained is removed by a pump at a rate of 200 mL/min (AK-90: Gambro Lundia, Lund, Sweden) and passed through a hollow-fiber dialyzer with triacetate membrane (FB-210G: Nipro, Osaka, Japan). Heparin (5 000 U) is infused into the inflow line at the start of the session only. At the end of treatment, about 500 mL concentrated ascitic fluid is returned to the peritoneal cavity by gravity through the Y transfer set. Case 1: A 77-year-old female was referred to us because of massive ascites from hepatic cirrhosis associated with hepatitis B infection and renal insufficiency. Abdominal paracentesis was required once weekly for recurrence of massive ascites. As a result, the patient was obliged to stay in the bed almost all day, and her nutritional condition deteriorated because of poor appetite and respiratory compromise. Using the Y transfer set, we commenced using our method, and performed it thrice or twice weekly. After 9 months of treatment, the patient's body weight was being maintained at 52 kg, and her serum albumin level had risen from 2.4 g/dL to 3.4 g/dL without albumin administration. Case 2: A 61-year-old male with diabetes from the age of 51 was diagnosed with hepatitis C at age 53. At age 60, his renal function deteriorated, requiring hemodialysis (HD). After 3 months, abdominal distention was noted, and HD was frequently complicated by low blood pressure, large weight gains between HD treatments, and interruption of HD sessions. Albumin administration was required to treat the low blood pressure. Ascites was poorly controlled using HD, and tense ascites developed, requiring repeated paracentesis for comfort. At first during application of our method, ascitic fluid volume was 6 L per thrice-weekly HD session. After 5 months, ascitic fluid volume had diminished to about 2 – 3 L per HD session, and we decreased the frequency of our method to once weekly. Protein levels in the ascitic fluid were 6 g/dL at the start of treatment and decreased to 2 – 3 g/dL after 6 months. Hemodynamic instability during HD was reduced.

Conclusion

We conclude that management of refractory ascites by using a PD system with extracorporeal ultrafiltration by an HD dialyzer is useful. The technique compensates for the drawbacks of PD management of ESRD patients with ascites, although further experience with the technique is necessary.

Management of refractory ascites by using a peritoneal dialysis system with extracorporeal ultrafiltration by hemodialysis dialyzer

BACKGROUND

The treatment of refractory ascites remains a challenge in cirrhosis with ascites and end-stage renal disease (ESRD). Successful experiences with continuous ambulatory peritoneal dialysis (CAPD) for treatment of ESRD patients with ascites secondary to liver cirrhosis have been reported, but the CAPD modality has the drawback of protein loss and was observed to cause patients to become severely malnourished. We devised a CAPD method for treatment of ascites without protein loss. We use a peritoneal dialysis (PD) system to drain ascitic fluid and to reinject concentrated ascites into the abdomen after extracorporeal ultrafiltration of the ascitic fluid using a hemodialysis dialyzer and pump. Here, we report our experience with 2 cirrhotic patients with ascites treated by this method.

PATIENTS AND METHOD

Ascites are collected by gravity through a Y transfer set into a 3-L plastic bag for intravenous hyperalimentation. The ascitic fluid drained is removed by a pump at a rate of 200 mL/min (AK-90: Gambro Lundia, Lund, Sweden) and passed through a hollow-fiber dialyzer with triacetate membrane (FB-210G: Nipro, Osaka, Japan). Heparin (5,000 U) is infused into the inflow line at the start of the session only. At the end of treatment, about 500 mL concentrated ascitic fluid is returned to the peritoneal cavity by gravity through the Y transfer set. Case 1: A 77-year-old female was referred to us because of massive ascites from hepatic cirrhosis associated with hepatitis B infection and renal insufficiency. Abdominal paracentesis was required once weekly for recurrence of massive ascites. As a result, the patient was obliged to stay in the bed almost all day, and her nutritional condition deteriorated because of poor appetite and respiratory compromise. Using the Y transfer set, we commenced using our method, and performed it thrice or twice weekly. After 9 months of treatment, the patient's body weight was being maintained at 52 kg, and her serum albumin level had risen from 2.4 g/dL to 3.4 g/dL without albumin administration. Case 2: A 61-year-old male with diabetes from the age of 51 was diagnosed with hepatitis C at age 53. At age 60, his renal function deteriorated, requiring hemodialysis (HD). After 3 months, abdominal distention was noted, and HD was frequently complicated by low blood pressure, large weight gains between HD treatments, and interruption of HD sessions. Albumin administration was required to treat the low blood pressure. Ascites was poorly controlled using HD, and tense ascites developed, requiring repeated paracentesis for comfort. At first during application of our method, ascitic fluid volume was 6 L per thrice-weekly HD session. After 5 months, ascitic fluid volume had diminished to about 2 - 3 L per HD session, and we decreased the frequency of our method to once weekly. Protein levels in the ascitic fluid were 6 g/dL at the start of treatment and decreased to 2 - 3 g/dL after 6 months. Hemodynamic instability during HD was reduced.

CONCLUSION

We conclude that management of refractory ascites by using a PD system with extracorporeal ultrafiltration by an HD dialyzer is useful. The technique compensates for the drawbacks of PD management of ESRD patients with ascites, although further experience with the technique is necessary.

Expression and activation of MAP kinases, ERK1/2, in the human villous trophoblasts

Mitogen-activated protein kinase (MAP kinase) plays a central role in the signal transduction for diverse cellular responses, such as proliferation, differentiation, stress response and cell death, via activation after binding of growth factors to the respective receptors on the cell membrane. In the human placental tissues, however, little is known about the expression and activation of the classical MAP kinases, extracellular signal-regulated kinase1/2 (ERK1/2). We therefore examined the expression of ERK1/2 in the human chorionic and placental tissues between 5 and 41 weeks of gestation, using Western blotting, immunohistochemistry and in situ hybridization. To explore the activation of ERK1/2 protein, we used an antibody that reacts with both phosphorylated and non-phosphorylated ERK1/2 (total ERK1/2), as well as antibodies that react only with phosphorylated ERK1/2. The expression pattern of phosphorylated ERK1/2 in the trophoblasts was compared with that of various growth factor receptors, such as c-met, IGF-1R, flt-1, EGFR, PDGFR, Bek, and flg. Total ERK1/2 was immunolocalized in the villous cytotrophoblasts (CTs), but not in the syncytiotrophoblasts (STs), throughout pregnancy. In situ hybridization also showed the localization of ERK1 mRNA in the villous CTs. Interestingly, however, phosphorylated ERK1/2 was immunolocalized in the villous CTs only up to 12 weeks of gestation. Western blot also showed the stronger bands of phosphorylated ERK1/2 in the tissues of the first trimester. Among the growth factor receptors, c-met was strongly expressed in the villous CTs during the first trimester, and resembled the expression pattern of phosphorylated ERK1/2. These findings suggest that the MAP kinase pathway is activated in the villous CTs during the first trimester in the human placenta.

Midpeliq reduces glucose load

The rate of technique failure is still high in Japan for peritoneal dialysis (PD) patients. Of the dropouts who have been treated with PD for more than 6 years, about half suffer from ultrafiltration failure. That condition is supposedly related to the bioincompatible aspects of conventional acidic PD solutions. In 2001, a neutral-pH, lactate-buffered PD solution with low glucose degradation products (GDPs), Midpeliq (Terumo Corporation, Tokyo, Japan), was developed and began to be used in Japan. After switching 3 patients from conventional acidic PD solution to Midpeliq, we observed that 2 patients could then use lower-glucose PD solutions. Case 1 was a 42-year-old woman with a 10-year history of PD. In February 2001, she was switched from Peritoliq (Terumo) to Midpeliq. One month later, she complained of dizziness, and her blood pressure was found to be down to 96/60 mmHg. Post-change fluid removal increased to 1,481 mL from 1,238 mL (p < 0.02). Before the solution switch, this patient exchanged 4 times daily, using 2 L of 2.5% Peritoliq each time. From 3 months after the solution switch, she exchanged 3 times daily using 2 L of 2.5% Midpeliq and 1 time daily using 2 L of 1.35% Midpeliq. Fluid volume removal stayed almost the same. Case 2 was a 52-year-old man with a 9-year history of PD. In June 2002, he was switched from Dianeal 4 (Baxter Healthcare, Tokyo, Japan) to Midpeliq. After the change, his daily drainage volume increased from approximately 1,500 mL to 2,000 mL. He began to use 2 L of 1.35% Midpeliq 4 times daily instead of 2 L of 1.5% Dianeal 3 times daily and 2 L of 2.5% Dianeal 1 time daily. At 1 month after the solution switch, his drainage volume was still approximately 1,500 mL daily. Our observations suggest that new, neutral-pH PD solutions such as Midpeliq might reduce the glucose load in addition to having low GDPs and fewer toxic effects on the peritoneum.

Central bronchopleural fistulas closed by bronchoscopic injection of absolute ethanol

Five consecutive bronchopleural fistulas (BPFs) were successfully treated by injecting absolute ethanol directly into the submucosal layer of the fistula under flexible bronchoscopic observation. No complications occurred as a result of this treatment. Our nonsurgical treatment may be very useful to reduce the costs of and duration of hospitalization and to improve the patient's quality of life. This is the first report of the bronchoscopic closure of BPFs by injecting absolute ethanol, and we would recommend this treatment as a first-line therapy for patients with a postoperative central BPF with an orifice that is < 3 mm in diameter.

Case report. Phaeohyphomycosis caused by Phialophora verrucosa developed in a patient with non-HIV acquired immunodeficiency syndrome

A 53-year-old woman had asymptomatic multiple nodules on her gluteal region for 6 months. She had a history of systemic corticosteroid treatment for Evans' syndrome. Recently she had developed an immunodeficiency condition with CD4+ cell depletion without an HIV infection and a normal serum gamma globulin level. A smear from the purulent exudate of the nodules revealed many brown-coloured hyphae, spores and few large dark-brown cells. A short, hairy, dark-brown coloured colony was cultivated on Sabouraud glucose agar. Slide culturing revealed only a Phialophora-type conidia formation, and the fungus was diagnosed as Phialophora verrucosa. Severe immunosuppressive condition (non-HIV acquired immunodeficiency syndrome) of this patients after systemic corticosteroid treatment for Evans' syndrome predisposed an opportunistic cutaneous fungal infection due to P. verrucosa. Cases with cutaneous infection due to P. verrucosa reported in Japan are summarized and discussed.

Non-Fermi-liquid spin dynamics in CeCoGe3-xSi(x) for x = 1.2 and 1.5

Muon spin relaxation has been measured in CeCoGe3-xSi(x) at the magnetic/nonmagnetic boundary compositions of x = 1.2 and x = 1.5. Both the alloys are found to exhibit an ordered region and a disordered region. At x = 1.2, short-range magnetic ordering is observed below 0.86 K in the ordered region. The disordered region is paramagnetic and the muon spin-lattice relaxation rate lambda2 in this region displays non-Fermi-liquid (NFL) spin dynamics, i.e., the power law lambda2 proportional to T0.72 which shows the formation of Griffiths phase. lambda2 in the x = 1.5 alloy displays logarithmic (NFL) scaling below 1 K, in agreement with the theory of a T = 0 K magnetic transition.

[Consideration of surgical treatment for recurrence after the resection of hepatic metastases from colorectal cancer]

We considered treatment for recurrence following the resection of hepatic metastases from colorectal cancer. The subjects of this study were 15 of 29 patients who had undergone WHF arterial infusion following resection of hepatic metastases from colorectal cancer, in whom there was a recurrence. Of these 15 cases, 6 involved recurrence in a single organ (residual liver, 4; lung, 1; local area, 1), 7 involved two organs (residual liver and lung, 2; residual liver and local area, 2; residual liver and bone, 1; spleen and intra-abdominal lymph node, 1; intra-abdominal lymph node and peritoneum, 1) and 2 involved three organs (lung, bone and abdominal wall, 1; lung, peritoneum and distal lymph node, 1). Reresection was performed in all cases in which recurrence occurred in a single organ. For those cases in which recurrence occurred in two or more organs, reresection and infusion were performed in the 4 cases of recurrence in the residual liver and reresection was performed in the case of recurrence in the spleen and intra-abdominal lymph node (No. 16), the case of local recurrence and the case involving the abdominal wall. The 5-year survival rate of the 29 cases who underwent initial hepatic resection was 61.9%. Five years following resection, the recurrence rate in the residual liver was 38.3%. The survival rates following treatment for recurrence were 76.9, 51.3 and 25.6% for 1, 3 and 5 years, respectively. Of the 8 deaths which have occurred to date, only one was directly related to an increase in hepatic metastases. Following resection of hepatic metastases from colorectal cancer, WHF provides a high rate of prevention as well as a high survival rate. Furthermore, with regard to recurrence following WHF treatment, if the recurrence is in only one organ, there is the possibility of achieving effective treatment by reresection (WHF = 5-FU 1,000 mg/m2 5 hrs qw).

Epithelioid trophoblastic tumor metastatic to the vagina: an immunohistochemical and ultrastructural study

We describe an epithelioid trophoblastic tumor (ETT) metastatic to the vagina in a 30-year-old Japanese woman. A polypoid tumor in the vaginal orifice was composed of nests of intermediate trophoblastic cells that showed a striking epithelioid appearance. In the hysterectomy specimen, a tumor infiltrated through the myometrium and showed histologic findings similar to those of the vaginal tumor. The tumor cells were positive for cytokeratin, inhibin-alpha, and melanoma cell adhesion molecule (Mel-CAM, CD146) but were only focally positive for human placental lactogen. Electron microscopic examination revealed bundles of well-developed, intermediate-type filaments surrounding the nuclei.

[Three cases in which CR was obtained in residual metastatic lesions by intrahepatic arterial infusion after resection of hepatic metastases from colorectal carcinoma]

We report three cases in which CR was maintained after infusion (WHF) was performed for residual metastatic lesions following resection of hepatic metastases from colorectal cancer. (Case 1) A 55-year-old female with sigmoidal cancer and hepatic metastases, H2 (4 lesions). Right lobectomy and partial resection of the left lobe were performed. On the third month following surgery, CT showed two lesions in the lateral segment of the left lobe, and WHF was then begun. One month after the start of infusion, the lesions calcified and following that, disappeared. Infusion was performed for 12 months and the total amount of 5-FU was 52.8 g. Eight years and nine months following surgery, the patient is currently alive and without recurrence. (Case 2) A 65-year-old male with rectal cancer and hepatic metastases, H3 (6 lesions). Four lesions were removed by hepatic resection; however, 2 deep lesions in S4 and S5 were left unresected. WHF was begun one month following surgery, following which the lesions were undetectable by either CT or US. Infusion was performed for 18 months and the total amount of 5-FU was 81 g. Two years and ten months after surgery an isolated lung metastasis was discovered in the right lung and a thoracoscopic partial resection was performed. Eight years and four months following the original surgery and five years and four months following the lung operation the patient is alive and without recurrence. (Case 3) A 55-year-old male with rectal cancer and subsequently discovered hepatic metastases, H3 (5 lesions). Resection of the lateral segment and a partial resection of the right lobe were performed; however, one deep lesion in S7 was left unresected. WHF was begun on the 10th day following surgery. At about eight months there was a change in shape and shrinkage of the lesion. Infusion was performed for 11 months and the total amount of 5-FU was 48 g. Ten months following surgery, CT showed a new lesion in S7 and a partial resection was performed. Intraoperative US confirmed the disappearance of the previous residual lesion in S7. One year and one month following the original surgery, the patient is alive and without recurrence. From these results, it is suggested that with postoperative WHF it is possible to obtain a complete cure in cases of colorectal cancer with hepatic metastases without the resection of all lesions. (*WHF: 5-FU 1,000 mg/m2/5 hrs/week).

High fat feeding of lactating mice causing a drastic reduction in fat and energy content in milk without affecting the apparent growth of their pups and the production of major milk fat globule membrane components MFG-E8 and butyrophilin

Lactating mice were fed either a low fat or a high fat diet. Milk samples were collected and the composition was examined. Triglyceride and free fatty acid contents were greatly reduced in the milks of high fat diet group, while protein and lactose contents were almost the same between both diet groups. Although the energy content of each component was also lower in milk of high fat diet group, there was apparently no significant difference in the growth of the pups raised by either diet group. This discrepancy might be in part explained by a hypothesis that the pups might monitor calorie content in milk and keep suckling until the energy intake reaches their satisfaction. Moreover, nearly the same amounts of major milk fat globule membrane proteins MFG-E8 and butyrophilin were shown to be present in the milks from both diet groups and gene expression of both proteins in the mammary glands were also indistinguishable, suggesting that production of major MFGM components is not simply related to fat production and secretion.

[Evaluation of 18F-FDG positron emission tomography (PET) in the detection of unknown primary tumors]

18F-fluorodeoxyglucose positron emission tomography was able to identify previously unknown primary tumors in 2 of 4 patients after an unsuccessful conventional diagnostic workup such as chest radiography, ultrasound, computed tomography, MRI and various endoscopies. The 2 patients in which the primary tumors were detected proved to have a carcinoma of the lung, one of the patients received radiotherapy and chemotherapy after the detection of the primary tumor by FDG PET. The primary tumor of the lung demonstrated no focal FDG uptake after the successive treatment. On the other hand, in one patient with prostatic carcinoma and another in which the primary tumor has yet to be detected, FDG PET was unable to identify the primary tumor. This suggests a limitation of PET studies in detecting cancers. Because of increased glycolysis in cancer cells, FDG PET can be used to detect cancers with its high sensitivity, surveying the entire body non-invasively in one session. PET has the advantage of detecting primary tumors of an unknown origin when compared to conventional diagnostic studies.

Down-regulation of protein tyrosine phosphatase gene expression in lactating mouse mammary gland

Detailed analysis of protein tyrosine phosphatase (PTP) expression in mouse mammary gland and mammary epithelial cells using a set of degenerate primers corresponding to the PTP core domain sequence revealed the presence of 16 different receptor-type and intracellular PTPs. Northern blot and RT-PCR analyses revealed that some PTPs were up-regulated during gestation, suggesting that these enzymes are involved in development of mammary gland. However, expression of most PTPs dramatically decreased during lactation, whereas the beta-casein gene expression was increased and remained at a high level. At the involution stage after weaning, most PTPs were up-regulated and their expression returned almost to the virgin level. Such up-regulation was also induced by forced weaning in lactating mother mice. These results suggest the possible contribution of PTPs to the development, involution, and remodeling of mammary gland and their possible inhibitory action on maintaining high expression of milk genes during lactation.

[Intra-arterial preventive chemotherapy for residual liver after resection of hepatic metastasis from colorectal cancer]

We treated 18 cases with intra-hepatic arterial infusion chemotherapy after resection of hepatic metastasis from colorectal cancer (June 1991-September 1997). Eight cases were H1, 7 were H2, and 3 were H3. Hepatic lobectomy was done in 3 cases, lobectomy + partial resection in 2 cases, and partial resection in 13 cases. All cases received high-dose intermittent 5-FU infusion (WHF = 5-FU 1,000 mg/m2/5 hrs/w) on an outpatient basis. The total frequency of WHF was 4-54 times (average 29), and total 5-FU doses ranged from 6.0 to 81.0 g (average 40 g). The 1- and 5-year cumulative survival rates were 100% and 77.5% in all patients 100% and 87.5% in H1 group and 100% and 64.3% in H2 + H3 group, respectively. There was no significant difference of survival between the H1 and H1 + H3 groups. The 1- and 5-year recurrence rates in residual liver were 5.9% and 14.4%, respectively. One of 2 cases with residual liver recurrence was resected for metastasis again, and the patient is now in a disease-free state. WHF after resection of hepatic metastasis from colorectal cancer has a preventive effect for their survival, not only in H1 group but also in H2 + H3 group.

[Correlation between the age-dependent changes in caloric response and in pure tone hearing]

Previous reports have examined the age-dependent changes of the auditory system or the caloric response, but results have been inconsistent. No study to date has correlated the age-dependent changes in caloric response with those in pure tone hearing in the same subjects. In this study a caloric test and a pure tone audiometry test were performed in 86 subjects (172 ears), age range 24 to 84 years of age, including 12 otoneurologically healthy volunteers (24 ears), and 74 tinnitus patients without subjective hearing loss (148 ears). The maximal slow phase eye velocity (SPEV) of caloric nystagmus response and the mean hearing level at high frequencies were measured and the age-dependent changes in these scores were compared. The following results were obtained. 1) The SPEV of caloric nystagmus, which remained unchanged until markedly advanced age, decreased significantly from 65 years of age in men and from 75 years in women; the change occurring earlier in men than in women. 2) The hearing level at high frequencies decreased abruptly from 50 years of age with a more gradual change from 75 years was significantly lower in men than in women over 65 years of age. 3) There was a weak but significant correlation between the age-dependent changes in SPEV and those in hearing level at high frequencies.

Stage specific expression of milk fat globule membrane glycoproteins in mouse mammary gland: comparison of MFG-E8, butyrophilin, and CD36 with a major milk protein, beta-casein

The expression of mouse milk fat globule membrane (MFGM) glycoproteins, MFG-E8, butyrophilin, CD36 was analyzed by Northern blot analyses. MFG-E8 and butyrophilin mRNAs were specifically detected in the mammary gland of lactating mice, whereas CD36 mRNA was detected in the heart and lung as well as in the mammary gland of lactating mice. The mRNAs of the three MFGM glycoproteins accumulated at mid-lactation were about 2-10-times as much as those of the early and late gestation stages, whereas beta-casein mRNA accumulation was dramatically increased; the mRNA at mid-lactation was no less than 40-times as much as that before lactation. In mouse mammary epithelial cell lines, HC11 and COMMA-1D, only a slight or almost no enhancement for the expression of MFG-E8, butyrophilin and CD36 mRNAs was induced simply by the treatment with the lactogenic hormones such as prolactin, insulin and dexamethasone, whereas the beta-casein mRNA expression was remarkably enhanced only by that treatment. Furthermore, while the beta-casein protein was constantly detected in milk throughout the lactation stage, the content of MFG-E8 and butyrophilin proteins increased during the lactation with an increase in the milk fat content. These results suggest that the stage-specific expression of milk fat globule membrane glycoproteins in mammary epithelial cells is regulated in a similar but not necessarily identical mechanism to that of a major milk protein, beta-casein.

[A case of giant hepatocellular carcinoma successfully treated by arterial administration of SMANCS]

A 68-year-old male was referred to our hospital for the precise examination of a giant hepatic tumor detected in a mass survey. The lesion occupied most of the right hepatic lobe, further advancing to the medial segment of the left lobe. However, hepatic functions were well preserved (ICG K = 0.141). Considering the characteristic images of the lesion with positive anti-HCV and high titer of PIVKA II (0.860 AU/ml), the diagnosis was hepatocellular carcinoma. First arterial administration of SMANCS was performed on May in 1994, followed by 6 successive procedures with an interval of about 2 months (total dosage 36 mg), resulting in remarkable tumor shrinkage and tumor marker normalization. On January in 1995, a metastatic lesion to the right rib was controlled by 2 mg of SMANCS administered to the intercostal artery combined with radiation therapy (60 Gray). Frequent administrations of SMANCS caused no serious complications, and tumor feeders were well preserved. Therefore, arterial administration of SMANCS is thought to be one choice for the therapy of giant HCC with good functional reserve.

Calcium-free hemodialysis is useful for evaluating parathyroid function and bone disease in chronic hemodialysis patients

By serum concentration of c-PTH, 18 hemodialysis patients were divided into 3 groups: group I (< 2.0 ng/ml, n = 8), group II (2.0-10.0 ng/ml, n = 5), group III (> 10.0 ng/ml, n = 5). When patients were dialyzed with Ca-free dialysate during the first 2 hours intact PTH level in serum shows no or slight increase in 5 out of 8 in group I.

Carpal tunnel syndrome in patients undergoing CAPD: a collaborative study in 143 centers

Patients undergoing continuous ambulatory peritoneal dialysis (CAPD) who developed carpal tunnel syndrome (CTS) were retrospectively studied in 143 centers in Japan. Among the total 5,050 patients undergoing CAPD between 1980 and 1993 only 7 patients (0.14%) given CAPD developed CTS. Five of these 7 patients treated solely with CAPD developed CTS 12-108 months after starting CAPD. The remaining 2 patients who were initially treated with HD for 7-9 years and then switched to CAPD developed this complication 9 years after starting CAPD. All 7 patients were women, ranging in age from 32 to 70 (average 52) years. We detected the presence of amyloid deposits in 2 of 5 specimens and beta 2-microglobulin in 2 of 4 specimens from these patients. It was concluded that CAPD minimizes the emergence of CTS although constant surveillance is necessary to detect CTS in patients during CAPD.

[Combination therapy with low dose adriamycin for advanced or recurrent breast cancer. Hokkaido Breast Cancer Treatment Study Group]

Comparative clinical trials among 3 regimens for patients with advanced or recurrent breast cancer were performed as a multi-institutional joint study. Arm-I of 3 regimens consisted of a 3-day consecutive administration of adriamycin (ADM) at 10 mg/body every 4 weeks, a daily oral administration of cyclophosphamide (CPA), 5-FU and tamoxifen (TAM) at 100 mg, 200 mg, and 20 mg, respectively, and a once-a-week intramuscular or subcutaneous injection of OK-432 (OK) gradually increased from the initial dose of 1 KE to the maintenance dose of 5 KE. Arm-II contained methotrexate (MTX) at 10 mg/body for 3 consecutive days every 4 weeks in place of ADM in Arm-I. Arm-III contained neither ADM nor MTX. Of 69 cases registered, 52 were eligible, leaving 6 non-eligible and 11 incomplete cases. The results of the overall evaluation of 48 complete cases other than 4, in which the tumor was not exactly measured, were as follows. Arm-I resulted in 2 CR and 3 PR out of 19 cases, the response rate being 23.6% (5/19). Arm-II resulted in 1 CR out of 15, the response rate being 6.7% (1/15). In Arm-III, no response cases were found. No significant difference was observed among three treatment groups (p = 0.055), but in Arm-I, the response rate was higher than in the other treatment groups, suggesting that there is a probability of useful combined use of ADM.

Functioning oxyphil cell adenoma in a patient with secondary hyperparathyroidism

A 45-year-old Japanese woman who has been receiving haemodialysis for 13 years suffered from an ectopic calcifying nodule and deformity of the thorax. She was diagnosed as hyperparathyroidism secondary to chronic renal failure. Total parathyroidectomy was performed, and the excised parathyroid glands showed hyperplasia in four and an adenoma in the left upper gland. On the electron microscopic study, the adenoma was composed of oxyphil cells and transitional oxyphil cells, the latter predominating in number. It was revealed from immunohistochemical study that the oxyphil cells in adenoma were strongly stained for parathyroid hormone (PTH). Continuous stimuli to secrete PTH seemed to generate the functioning oxyphil cell adenoma with an ability of PTH production, as well as hyperplasia of parathyroid chief cells. It seems to be the first case of tertiary hyperparathyroidism caused by an oxyphil cell adenoma. Functions of oxyphil cells and transitional oxyphil cells are briefly discussed.

[Statistical analyses on over ten years survivals in Hokkaido under chronic dialysis therapy]

In Hokkaido, there were 305 chronic dialysis patients surviving more than ten years as of July 31, 1985. All patients except for one (CAPD) have been placed under hemodialysis. About 73% of them were introduced into a dialysis therapy in their thirties and chronic glomerulonephritis was extremely predominant as for the underlying disease. 93.2% of the cases possessed internal AV-fistulae using own vessels and other types of blood access remained only 6.8%. Hematocrit (Hct) was 27.5% on average of 305 cases. The value was fairly satisfactory but it must be noted that Hct of 33 patients (10.8% of all) was less than 20%. Severe anemia is still one of major complication in chronic dialysis patients. Characteristic complications, which have been increasing in frequency in parallel with prolonged dialysis length, became clarified: renal osteodystrophy, secondary hyperparathyroidism, carpal tunnel syndrome, persistent hypotension and so on. The former two are strongly related to Ca & P metabolism and some of the long-term survivals require parathyroidectomy. It is now estimated that carpal tunnel syndrome is induced by accumulation and deposition of beta 2-microglobulin, which increases in blood progressively if used Cuprophane membrane dialyser. Patients with CTS must be placed under surgical intervention, which relieves the symptoms effectively and the prophylaxis might require protein-permeating dialyser.