Use of miniature ultrasonic probe system for intravesical ultrasonography for transitional cell cancer of the urinary tract

OBJECTIVE

We describe the use of a miniature ultrasonic probe (MUP) system for intravesical ultrasonography for staging of urinary bladder and/or ureteral tumors.

MATERIAL AND METHODS

Seventeen patients with bladder tumors were enrolled in this study. Probes (8 F; 15 and 20 MHz) were inserted through a channel in a 22 F rigid cystoscopy sheath.

RESULTS

Using the MUP, each tumor could be scanned under simultaneous cystoscopic observation to choose the optimal probe position. However, in 4 of 17 patients optimal scanning could not be obtained because of large tumors and poor ultrasound penetration or because of tumor localization at the anterior dome which did not allow an appropriate scanning plane for staging. Of 13 evaluable patients, 5 with no interruption or folding of the low-echoic muscle layer were diagnosed as having a superficial tumor, and this was confirmed histopathologically in all but one case. All 8 cases evaluated as having invasive tumors demonstrated muscle invasion histologically.

CONCLUSION

The MUP can be more easily manipulated than a conventional probe.

Recurrence of IgA nephropathy 17 months after renal transplantation in the allograft transmitted thin basement membrane disease (TBMD) from donor

Recurrence of IgA nephropathy (IgAN) following renal transplantation has been described in 40-50% of such patients and it usually has a good outcome. We present the case of a 20-yr-old woman with IgAN who developed end-stage renal failure in 1995. In November 1996, she received a kidney from a living-related donor and was treated with tacrolimus, azathioprine and steroids. Zero- and one-hour biopsies were performed, which revealed minor glomerular abnormalities in light microscopy, thin basement membrane disease (TBMD) in electron microscopy. Eight months later she developed microscopic hematuria and proteinuria; however, the graft function was normal. Renal biopsy revealed an IgAN that is thought to be due to recurrence of the original disease.

Significance of serum-soluble CD95 (Fas/APO-1) on prognosis in renal cell cancer patients

Serum-soluble CD95 (sCD95) levels for 72 renal cell cancer patients were significantly higher than those of 17 healthy donors. Twenty-one of 72 patients had elevated (defined as more than mean of healthy donors + 2 s.d.) sCD95. The disease-specific survival rate was significantly lower in the elevated sCD95 group. Serum sCD95 level was shown to be an independent prognostic factor by univariate and multivariate analysis, indicating a possible significant role in determining treatment strategies.

Volumegraph (overlaid three-dimensional image-guided navigation). Clinical application of augmented reality in neurosurgery

OBJECTIVE

We have developed an overlaid three-dimensional image (Volumegraph)-guided navigation system that allows navigation during operative procedures. The three-dimensional image is superimposed on the patient's head and body via a semi-transparent mirror. The Volumegraph can display three-dimensional images in the air by a light beam which is based on CT/MRI.

METHOD

The system consists of a Volumegraph (thin plate of three-dimensional recorded medium), a Volumegraphscope and an original designed triangular-shaped marker system for registration. The three-dimensional data obtained from CT and MRI before the operation were processed by a computer. Such image data are applied for preoperative investigation to recognize the three-dimensional structure of organs and tumor. These reconstructed three-dimensional images were superimposed and registered at the patient's head according to a fiducial marker (registration). Then the operator can operate with this three-dimensional-image-guided navigation system.

RESULTS

Based on clinical application in 7 cases, the system was found to be advantageous because the surgical procedures could be navigated easily by augmented reality in the surgical field. Invisible parts of the surgical field were supplemented with the overlaid three-dimensional images (Volumegraph) as if it were the virtual operative field. At another time, spatial positioning and overlaid visualization by the Volumegraph was useful for identifying anatomical structures and functional location in the image.

CONCLUSION

This preliminary study of overlaid three-dimensional-image-guided navigation demonstrated its clinical usefulness. The application of augmented reality in the surgical field makes it possible to do a neurosurgical intervention easily and accurately.

Adoptive immunotherapy of patients with metastatic renal cell cancer using lymphokine-activated killer cells, interleukin-2 and cyclophosphamide: long-term results

BACKGROUND

Initial results of adoptive immunotherapy using lymphokine-activated killer (LAK) cells and interleukin-2 (IL-2) appeared to offer promise for treating renal cell cancer (RCC). However, lower response rates were seen in subsequent trials, and the long-term results of this treatment method have not been fully reported. In this study, we examine long-term results of adoptive immunotherapy using LAK cells, IL-2, and cyclophosphamide (LAK/IL-2/CPM therapy).

METHODS

We administered 10 courses of therapy to 9 patients with advanced RCC. One patient had liver and para-aortic lymph node metastases; the others had only lung metastases. The clinical effects were initially evaluated 4 weeks after therapy and follow-up was continued for periods of 43 to 76 months.

RESULTS

The 4-week evaluation revealed 3 complete responses (CR), 3 partial responses (PR), 1 minor response (MR), 1 patient with no change in disease status (NC), and 2 patients whose disease progressed (PD). One CR patient remained apparently free of disease for 43 months. After tumors recurred in the lung of another CR patient further disease progression was suppressed by IL-2 administration until the patient died from other causes at 46 months. The third CR patient showed tumor recurrence in the lung and was re-treated with the same LAK/CPM/IL-2 therapy. Lung tumors decreased in size (PR), but the patient died due to brain metastasis 2 months after the second round of treatment. The 2 initial PR patients, as well as the MR and NC patients, developed regrowth or new metastatic lesions within 2 to 15 months following therapy. The 2 PD patients died 2 and 9 months after therapy.

CONCLUSION

Long-term effects of LAK/IL-2/CPM therapy were not correlated with the maximal response observed 4 weeks after therapy. Although LAK/IL-2/CPM therapy appears suitable for use as induction therapy in RCC, our data suggest that long-term suppression will require surgical removal of remnant tumors or more intensive maintenance therapy.

[Objective evaluation of selective peripheral denervation for spasmodic torticollis]

The authors evaluated the results of selective peripheral denervation (SPD) of posterior rami of the cervical spinal nerves and/or the accessory nerve for spasmodic torticollis. Five patients underwent seven operations in total and the results were evaluated with the modified Tsui's score which was used in the clinical trial of botulinum toxin (BTX) for torticollis in Japan. The preoperative score was 10.8 +/- 2.2 (mean +/- S.D.) and the postoperative score was 1.4 +/- 1.7. The score changes indicated the effects of the operation as "excellent" in four cases and "good" in one case. These results indicate that SPD is superior to BTX in terms of control of symptoms in spasmodic torticollis. After the initial operation, however, two patients showed the so-called "mole-hitting game phenomenon" in which normal muscles develop abnormal contraction after denervation of abnormal muscles. This forced us to perform the second operations. Although this phenomenon was first described in botulinum toxin treatment, this is probably the first report in surgically denervated cases.

Split cannula method for accurate placement of an electrode for deep brain stimulation: technical note

OBJECTIVE

We describe a "split cannula method" for accurate placement of a deep brain stimulation electrode. This method eliminates the risk of displacement of the electrode when withdrawing the outer guide cannula.

METHOD

A separate short guide cannula is covered over the distal part of a long cannula for microrecording or macrostimulation. After confirmation of the stimulation point, the short cannula is fixed with an accessory-holding device and the long cannula is pulled out. The electrode for deep brain stimulation is inserted through the short cannula. Because this cannula is much shorter than the electrode, securing the stimulation electrode at any withdrawal stage of the outer guide cannula is always possible.

RESULTS AND CONCLUSION

With this simple method, we experienced no displacement of the stimulation point during stereotactic insertion of a deep brain stimulation electrode. This method can be easily adapted to any stereotactic frame.

Ex vivo partial nephrectomy and partial kidney autotransplantation for renal pelvic carcinoma in a functionally solitary kidney: case report

A 46-year-old Japanese man was diagnosed with a left renal pelvic carcinoma and a contralateral hypoplastic kidney. The tumor was adjacent to the renal pelvis and was considered too difficult to completely resect in situ. The patient was treated by ex vivo partial nephrectomy of the left kidney followed by autotransplantation of the remaining renal segment. A pathologic evaluation revealed a transitional cell carcinoma, G2, pT3. Graft function recovered satisfactorily postautotransplantation and no significant complications developed during the postoperative period. The patient is alive and doing well 12 months postoperatively with no evidence of tumor recurrence.

Superior sagittal sinus thrombosis treated with combined local thrombolytic and systemic anticoagulation therapy

We recently encountered a patient with thrombosis of the superior sagittal sinus of an idiopathic cause. The patient was treated initially with combined local thrombolytic therapy through the burr hole over the superior sagittal sinus and systemic anticoagulant therapy. Continuous ventricular drainage and hyperbaric oxygenation therapy were used to control the increased intracranial pressure. The superior sagittal sinus was successfully recanalized. Whereas the patient suffered a complication with subacute subdural haematoma, he was successfully treated with the combination of these therapies. The rationale and approach are discussed.

Mechanisms of coronary microvascular dilation induced by the activation of pertussis toxin-sensitive G proteins are vessel-size dependent. Heterogeneous involvement of nitric oxide pathway and ATP-sensitive K+ channels

G proteins are critically important mediators of many signal transduction systems. In the present study, we investigated the effect of direct activation of pertussis toxin (PTX)-sensitive G protein (GPTX) on coronary arterial microvascular tone in 37 open-chest anesthetized dogs in vivo. Coronary arterial microvessels on the surface of the beating left ventricle were visualized by performing fluorescence coronary microangiography using an intravital microscope with a floating objective system. Microvessels were divided into two groups, small microvessels (inner diameter, < or = 130 microns) and large microvessels (inner diameter, > 130 microns). Topically applied mastoparan (G protein activator, 10, 30, and 100 mumol/L) produced homogeneous microvascular dilation in a concentration-dependent manner (10 mumol/L, 7.9 +/- 2.0%; 30 mumol/L, 10.3 +/- 2.4%; and 100 mumol/L, 16.7 +/- 4.5% in small microvessels; 10 mumol/L, 5.3 +/- 1.2%; 30 mumol/L, 9.8 +/- 2.5%; and 100 mumol/L, 15.5 +/- 3.9% in large microvessels). These dilations were reversed to constriction by pretreatment with PTX (300 ng/mL, 2 hours) in both microvessel groups. Blockade of nitric oxide production by NG-nitro-L-arginine (LNNA, 300 mumol/L) offset the mastoparan-induced dilation in large microvessels but not in small microvessels. Cosuperfusion of glibenclamide (10 mumol/L) with LNNA produced constriction of all sizes of microvessels in response to mastoparan, whereas charybdotoxin (10 nmol/L) did not affect the mastoparan effect. Pretreatment with glibenclamide alone reversed mastoparan dilation to constriction in small microvessels, whereas it only offset the dilation without producing constriction in large microvessels. We conclude that the activation of GPTX produces homogeneous coronary arterial microvascular dilation and that the underlining mechanisms of the dilation are vessel size dependent. The L-arginine-nitric oxide pathway mediates the dilation only in large microvessels, whereas ATP-sensitive K+ channel activation plays a central role in the dilation of small microvessels when GPTX is directly activated. ATP-sensitive K+ channels are also involved in the dilation of large microvessels in a synergistic fashion with nitric oxide production.

[Kinetics of peripheral blood CD34-positive cells and optimal timing of blood stem cell harvest after urological anticancer chemotherapy]

PURPOSE

We evaluated the changes in stem cells in peripheral blood and the optimal timing for harvesting peripheral blood stem cells (PBSCs) following the administration of conventional cancer chemotherapy in patients with urological malignancies.

PATIENTS AND METHODS

We evaluated the changes in PBSCs after the administration of cancer chemotherapy in 12 patients with urological malignancies (6 testis cancer, 3 bladder cancer, 3 prostate cancer) using flowcytometry analysis of CD34, a marker of blood stem cell. We evaluated the optimal timing for PBSCs harvesting following the administration of conventional cancer chemotherapy in 6 patients with urological malignancies (2 patients with testis cancer, 3 patients with prostate cancer, 1 patient with bladder cancer) using flowcytometry analysis of CD34 and granulocyte-macrophage colony-forming units (CFU-GM) counts. PBSC samples from 2 patients with prostate cancer were analyzed by the reverse transcriptase-polymerase chain reaction (RT-PCR) method to detect prostate cancer cells.

RESULTS

The percentages of CD34-positive cells tended to increase in the peripheral blood during the period of convalescence that followed the induction of marked myelosuppression produced by the cancer chemotherapy. The peak in CD34-positive cells occurred between days 15 and 31 after beginning of cancer chemotherapy. The percentage of CD34-positive cells was increased in the mononuclear cells in harvested PBSCs. The percentages of CD34-positive cells in peripheral blood and in mononuclear cells harvested from PBSCs was correlated with the CFU-GM counts in harvested PBSCs. The CFU-GM counts peaked between days 16 to 31 following cancer chemotherapy. RT-PCR detected prostate-specific antigen (PSA) mRNA expression in PBSCs obtained from 1 of the 2 patients with prostate cancer. An amount of contamination with PSA mRNA reduced as chemotherapy was repeated.

CONCLUSION

A sufficient number of PBSCs can be harvested after conventional cancer chemotherapy without the need for special cytotoxic mobilization that may be delayed the patient's treatment. RT-PCR results suggested that the harvested PBSCs should be examined for tumor cell contamination in patients with metastasis in bone marrow. If a sufficient amount of PBSCs will be harvested, the PBSC samples from the patient with bone marrow metastasis after repeated chemotherapy should be used by priority for PBSC transplantation as of today.

[Nephron sparing surgery for synchronous and asynchronous bilateral renal cell cancer. A procedure using intraoperative ultrasonography, argon beam coagulator and fibrin glue]

BACKGROUND

Bilateral renal cell cancer (RCC) is an imperative indication of nephron sparing surgery (NSS). In the present study, we examined a new modality for NSS; intraoperative ultrasonography, argon beam coagulator (ABC) and fibrin glue.

PATIENTS AND METHODS

We performed NSS against 7 kidneys in 5 patients, including 3 with synchronous and 2 with asynchronous tumors. Radical nephrectomy was performed on the contralateral kidney in 2 patients including one with asynchronous and the other with synchronous RCC.

RESULTS

To examine satellite lesions and exact tumor extent within the kidney, intraoperative ultrasound scan was performed for all cases. Intraoperative ultrasound scan was shown to be useful for the above mentioned purposes because of its high resolving power. After clamping of the renal artery and surface cooling, dissection of the kidney was done by knife holder or by ultrasonic aspirator. Hemostasis was made by figure eight sutures with chromic catgut or poliglecaprone 25 monofilament, followed by coagulation using ABC, and with fibrin glue. Duration of arterial clamp ranged 20 approximately 78 min under surface cooling. Major complication did not occur except urinary fistula in one case caused by inadequate placement of a double J ureteral catheter. Postoperative renal functions were well preserved and any additional therapy for daily life was not needed in each patient.

CONCLUSION

For performing NSS, the use of intraoperative ultrasound scan, ultrasonic aspirator, ABC and fibrin glue seemed to be useful, encouraging us to widespread its indication.

[A clinico-pathological study of cystic spinal Schwannomas]

It is not rare for a spinal Schwannoma to have cystic formations, but there are various opinions about the mechanism. Since the installation of MRI in our institution in 1989, we have experienced 4 cases of cystic spinal Schwannoma. The diagnosis of such lesions was based on identifying cystic formations histopathologically. Among these cases, tiny hemorrhages were noted microscopically in three of them along with hemosiderin depositions and phagocytes containing hemosiderin. Besides, there are also a lot of sinusoidal vessels with thin endothelium. Perhaps in these three cases, it is the tiny hemorrhages that resulted in degenerative changes which in turn caused the formation of microcysts. But in addition to the above findings, a lot of hyalinized vessels were also demonstrated in the angiomatous components of two cases. Therefore, it is also possible that the microcyst formation is secondary to the degenerative changes caused by ischemia within the tumors. On the other hand, in the only case without hemorrhage, neither phagocytes containing hemosiderin nor abnormal sinusoidal vessels could be found. In stead, a lot of clear foamy cells with positive lipid staining were seen. There may be some factors underlying the xanthomatous change of these tumors that cause their vacuolar formation from degenerated of the foamy cells. It is possible that all three factors mentioned above may act alone or in combination to contribute to the formation of cysts. At its late stage, a spinal Schwannoma may have various findings which can not be classified into either Antoni A or Antoni B type. In conclusion, a spinal Schwannoma can occasionally have cystic formations. Its mechanisms can be a hemorrhagic or an ischemic process occurring within the tumor.

[Lessons from experience of bertrand's selective peripheral denervation for splenius type torticollis]

A 23-year-old male with splenius type torticollis underwent selective denervation of C1 and C2 roots and C3-C6 spinal posterior rami, with excellent results. Based on this experience, we stress the importance of dynamic EMG and thorough review of video recording for identifying the involved neck muscles. In the operative procedures, the nerve rami are identified under the semispinalis muscle. To dissect the correct plane under the semispinalis muscle, the key point to keep in mind is to follow the great occipital nerve to the proximal part. An ultrasonic blood flow meter is useful to locate the vertebral artery in the spaces between the occiput and the C1 lamina and between C1-C2 laminae. Because fine nerve branches run in the soft tissues over the laminae, to avoid transient neuroapraxia, dissection around the C1, C2 arches should not be carried out under the periosteum, as is usually done in case of laminectomy. Dissection of C1 and C2 rami as far as the very medial part is rather difficult because of bleeding from the venous plexus and the presence of the vertebral artery. Therefore, the intradural approach might be easier for sectioning the C1 and C2 roots. We would like to add these points to the original description by Bertrand.

A new approach to control central deafferentation pain: spinal intrathecal baclofen

Baclofen, an agonist of the gamma-aminobutyric acid (GABA) receptor, has antinociceptive effects, and its intrathecal administration reduces allodynic responses in animal models of neurogenic central pain. Such experimental studies lead to the hypothesis that neurogenic pain may be induced in part by functional abnormalities in spinal GABAergic systems. However, whether a GABAergic system is actually involved in human central pain is unknown. The authors investigated the effect of an intrathecal bolus injection of baclofen in 14 patients with central pain due to a stroke or spinal cord injury. Nine reported substantial pain relief they had never experienced previously. The effect appeared 1-2 h after the injection and persisted for 10-24 h. Allodynia and hyperalgesia, if present, were relieved as well. Pinprick and light touch sensations did not change in nonaffected regions. The results indicate that dysfunction of spinal GABAergic systems plays a role in the clinical expression of central pain. In clinical situations, continuous intrathecal infusion of baclofen seems feasible for relief of central pain.

A new approach to the control of central deafferentation pain--spinal intrathecal baclofen

We investigated the short-term effects of an intrathecal bolus injection of baclofen on central pain due to stroke or spinal cord injury. Pain relief was obtained in 64% of the patients. The effects developed 1-2 hours after the injection and continued for 10-24 hours. Both spinal segmental and supraspinal mechanisms may be involved in the production of baclofen-analgesia.

Indonesian medicinal plants. X. Chemical structures of four new triterpene-glycosides, gongganosides D, E, F, and G, and two secoiridoid-glucosides from the bark of Bhesa paniculata (Celastraceae)

Four new triterpene-glycosides, named gongganosides D (4), E (5), F (6), and G (7), and two new secoiridoid-glucosides, (7R)-7-caffeoyloxysweroside (8) and (7S)-7-caffeoyloxysweroside (9), were isolated from the bark of the Indonesian medicinal plant Bhesa paniculata (Celastraceae). The chemical structures have been elucidated on the bases of their chemical and physiocochemical properties.

Indonesian medicinal plants. IX. Chemical structures of gongganosides A, B, and C, three new quinovic acid glycosides from the bark of Bhesa paniculata (Celastraceae)

Three new quinovic acid glycosides, named gongganosides A (1), B (2), and C (3), were isolated from the bark of Bhesa paniculata (Celastraceae), an Indonesian medicinal plant collected in Sumatra Island. The chemical structures have been elucidated on the basis of chemical and physicochemical evidence as quinovic acid 3-O-beta-D-xylopyranosyl(1-->3)-alpha-L- rhamnopyranoside for 1,28-O-beta-D-glucopyranosylquinovic acid 3-O-alpha-L-rhamnopyranoside for 2, and 28-O-beta-D-glucopyranosyl-quinovic acid 3-O-beta-D-xylopyranosyl(1-->3)-alpha-L-rhamnopyranoside for 3.

mRNA and protein expression of p53 mutations in human bladder cancer cell lines

We investigated mRNA and protein expression in p53 gene mutations in four human bladder cancer cell lines using polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) and Northern blot and Western blot analyses. The following mutations were identified in three of the four cell lines: a missense transversion at codon 110, a missense transition at codon 250 and a non-sense transversion at codon 126. These mutations were located outside previously identified hot spot codons and have rarely been reported in bladder cancer tissues or other neoplasms. Positive intranuclear p53 immunostaining in neoplastic cells in the two missense mutations and the premature stop codon in the non-sense mutation suggested the presence of structural and functional alterations in the p53 protein. Northern and Western blot analyses revealed either an intense or a weak p53 mRNA band together with an intense p53 protein band in the missense mutations, but no p53 mRNA or protein band in the non-sense mutation. A weak p53 mRNA band, but no distinct p53 protein band was observed in the cell line without a mutation and in normal control bladder cells. Our findings suggest that regulation of p53 expression in these cell lines differs at the post-transcriptional and/or post-translational level between the wildtype and the mutant p53 genes and also among different mutant p53 genes. The three cell lines with mutations were derived from high-grade carcinomas; the cell line without mutation was derived from a low-grade carcinoma.

Changes in urinary excretion of endothelin-1-like immunoreactivity in patients with testicular cancer receiving high-dose cisplatin therapy

To assess the value of endothelin-1 (ET-1) in estimating renal injury in patients receiving high doses of cisplatin, urinary excretion of ET-1-like immunoreactivity (U-ET-1), beta 2-microglobulin (U-beta 2-MG), and N-acetyl-beta-d-glucosaminidase (NAG) were measured before, 1 week after, and 2 weeks after the administration of cisplatin in eight patients with testicular cancer (mean age, 33.3 years). Levels of U-ET-1/creatinine (Cr) during and 1 week after cisplatin treatment were significantly higher than before cisplatin treatment. There were no differences in U-ET-1/Cr levels during, 1 week after, and 2 weeks after cisplatin treatment. The level of U-beta 2-MG/Cr during cisplatin treatment was significantly higher than levels before, 1 week after, and 2 weeks after treatment. However, there were no differences in U-beta 2-MG/Cr levels before, 1 week after, and 2 weeks after cisplatin treatment. The level of U-NAG/Cr during cisplatin treatment was higher than levels before, 1 week after, and 2 weeks after treatment; U-NAG/Cr during cisplatin treatment was higher than levels before, 1 week after, and 2 weeks after treatment; U-NAG/Cr gradually decreased after cisplatin treatment. Among the three parameters, only U-ET-1/Cr maintained a higher level after cisplatin treatment. The U-beta 2-MG/Cr level returned most rapidly to normal after cisplatin treatment. Although U-ET-1/Cr did not show any significant correlation with U-NAG/Cr (r = 0.282, P = NS), it showed a significant correlation with U-beta 2-MG/Cr (r = 0.454, P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary endothelin-1-like immunoreactivity in young male patients with testicular cancer treated by cis-platinum: comparison with other urinary parameters

1. Urinary excretion of endothelin-1-like immunoreactivity and urinary excretion of other parameters (beta 2-microglobulin, N-acetyl-beta-D-glucosaminidase and microalbumin) were measured before, within 1 week after and 2 weeks after the administration of cis-platinum in five young male patients with testicular cancer (mean age 33.0 years) and were compared. 2. Urinary endothelin-1-like immunoreactivity/creatinine during, 1 week after, and 2 weeks after cis-platinum treatment was significantly higher than before cis-platinum. There was no difference in urinary endothelin-1-like immunoreactivity/creatinine during, 1 week after and 2 weeks after cis-platinum. 3. Among the four parameters, urinary endothelin-1-like immunoreactivity/creatinine showed the highest level after cis-platinum treatment. Urinary beta 2-microglobulin/creatinine most rapidly returned to normal levels after cis-platinum. 4. Although urinary endothelin-1-like immunoreactivity/creatinine did not show any significant correlations with urinary N-acetyl-beta-D-glucosaminidase (r = 0.291, not significant) or urinary microalbumin/creatinine (r = 0.076, not significant), it showed a significant correlation with urinary beta 2-microglobulin/creatinine (r = 0.475, P < 0.05). 5. These results suggest that endothelin-1 may be a sensitive urinary parameter in detecting cis-platinum-induced renal tubular injury.

Origin of lymphocytic-choriomeningitis-virus-bearing mice in Japan

Mice found in the port areas in Japan, where antibody to lymphocytic choriomeningitis virus (LCMV) was detected, may have originated or partially originated from a southern Asian subspecies, Mus musculus castaneus.

Rebleeding of intracranial dissecting aneurysm in the vertebral artery following proximal clipping

We describe a case of rebleeding from an intracranial vertebral dissecting aneurysm following proximal clipping. This case suggests that proximal clipping alone may not be an adequate surgical procedure to prevent rebleeding. Surgical treatment of intracranial dissecting aneurysms in the vertebral artery presenting as subarachnoid haemorrhage. (SAH) is discussed.

Correlation of p53 protein expression in human urothelial transitional cell cancers with malignant potential and patient survival

The p53 gene product has been detected frequently in various human malignancies. We have studied the expression of p53 protein in urothelial transitional cell cancers (TCCs) and examined its correlation with pathologic grade, stage(pT) and patient survival. Specimens from 69 surgically-resected TCCs (38 cases of urinary bladder cancer, 17 cases of ureteral cancer and 14 cases of renal pelvic cancer) were examined by immunohistochemical staining, using two anti-p53 monoclonal antibodies, PAb1801 and PAb240, and a polyclonal antibody, CM-1. Twenty-six TCCs (37.6%) were positively stained by at least one of the three antibodies. Statistical analysis showed a significant correlation between p53 expression and high pathologic grade (p < 0.05, p < 0.001) or progressive pathologic stage (p < 0.01). In addition, in 51 of the patients who were available for follow-up (23 cases of urinary bladder cancer, 13 cases of ureteral cancer, and 15 cases of renal pelvic cancer), the correlation between p53 protein expression and prognosis was examined. The survival of patients exhibiting positive p53 protein expression was significantly worse than those with p53-negative tumors (p < 0.05). These results suggest that an immunohistochemical test for p53 protein may be a useful method of evaluating the malignant potential of TCCs. Additionally, expression of p53 protein in TCCs is an indicator of a poor prognosis which should be considered in drawing up treatment strategies.

Incidence of pouch stones and risk factors for urolithiasis in patients with continent urinary diversion or neobladder using intestine

Urinary risk factors and inhibiting factors for urolithiasis, such as oxalate, calcium, phosphate, uric acid, citrate, and magnesium, were examined in 12 patients receiving continent urinary diversion, neobladder, or augmentation cystoplasty using intestine. These data were compared with the incidence of pouch stone formation. Ten (83.3%) of 12 patients had at least one risk factor, and 5 (41.7%) of 12 had two or more risk factors. Pouch stone developed in 4 (80%) of 5 patients with two or more risk factors, and in none of 7 patients with one or zero risk factors. The incidence of pouch stone in the former group was significantly higher than in the latter group. These results suggest that urinary reservoir operations should not be performed in patients with two or more risk factors for urolithiasis.

[Intracavernous internal carotid artery aneurysm associated with persistent trigeminal artery variant: case report]

The authors report a case of an intracavernous internal carotid artery aneurysm associated with a persistent trigeminal artery variant (PTAV). A 47-year-old-woman developed a subarachnoid hemorrhage due to the rupture of aneurysm and underwent direct clipping operation. PTAV is basically an anomalous anastomosis between the internal carotid artery and the anterior inferior cerebellar artery. In this patient, the PTAV originated from the C4 portion of the right internal carotid artery and distributed in the territory of the hemispheric branch of the posterior inferior cerebellar artery. There have been only three reported cases of the internal carotid artery aneurysms arising from the crotch of PTAV. It is also unusual that rupture of such a small aneurysm in the cavernous sinus causes subarachnoid hemorrhage. Embryological development of PTAV and possible mechanism of subarachnoid hemorrhage from the intracavernous aneurysm are discussed.

An image-guided stereotactic system for neurosurgical operations

A new simulation system utilizing digital images (CT/MRI/SPECT) and an ultrasound/laser navigation system has been developed for image-guided surgery. Preoperative CT/MRI imaging does not always indicate the actual location of the lesion during intracranial operation, because the lesion may be displaced or distorted by operative procedures or CSF flowout. The authors developed an image integration system including an intraoperative ultrasonogram, which provides accurate information not only on the location of the deep-seated lesions but also surrounding anatomical structures during operation. The rationale of the system is to coordinate the three-dimensional axes of each image with the aid of a stereotactic subframe. Our simulation system has two ways. One simulation system works on a SUN workstation. At the preoperative simulation study: the entry point on the brain surface and the access route to the lesion are decided on from the three-dimensional CT/MRI images on the computer display. Then the configuration of the lesion from the operative view is displayed as an expected ultrasound image by reconstructing the CT and/or SPECT image. Another simulation system (HyperCAS) works on the HyperCard of a MacIntosh. The target point, the entry point and the trajectory are decided on and the three-dimensional location of these points is measured from serial CT images on the LCD display. At the time of operation, stereotactic craniotomy is performed using the laser navigator. The extent of the lesion at every depth in the surgical process is predicted from these images, and the access route to the lesion is easily corrected with the intraoperative ultrasound navigator.(ABSTRACT TRUNCATED AT 250 WORDS)

Concentration of gadolinium-diethylene triamine pentaacetic acid in human kidney--study on proper time for dynamic magnetic resonance imaging of the human kidney on low and high magnetic fields

Although Gadolinium diethylene triamine pentaacetic acid (Gd-DTPA) has been used as a contrast material in magnetic resonance imaging, it is known that contrast enhancement effect disappears if the concentration of Gd-DPTA increases beyond some levels. In this study, to evaluate the proper pulse sequences for dynamic magnetic resonance imaging (MRI) in the human kidney, the concentration of Gd-DTPA was quantitatively measured by inductively coupled plasma (ICP) emission spectrometry in human biological samples after administration of Gd-DTPA, and the signal intensity of MRI is the solutions of several concentrations of Gd-DTPA was measured. The results were; 1. In using a low magnetic field apparatus, signal intensity linearly correlated with the concentration of Gd-DTPA between 0 and 2.0 mumol/g under saturation recovery sequences (flip angle was 60 degrees or 90 degrees). Using a high magnetic field apparatus, signal intensity linearly correlated with the concentration of Gd-DTPA between 0 and 2.0 or 3.0 mumol/g under spin echo or gradient-echo sequences. 2. Gd-DTPA concentration of the renal cortex ranged from 0.132 to 0.152 mumol/g tissue at 5 min after intravenous injection of Gd-DTPA 0.05 mmol/kg body weight in 7 patients with adrenal tumor or renal cell cancer, and 1 patient with both urinary bladder cancer and prostatic cancer. Seven of them showed normal renal function and the other had renal insufficiency (GFR 25 ml/min/1.48 m2). Gd-DTPA concentrations of renal medulla and renal cell cancer tissue were 0.123 and 0.108 mumol/g tissue, respectively, at 5 min after intravenous injection of Gd-DTPA 0.05 mmol/kg body weight. These results suggest that the signal intensity of renal cortex, renal medulla, and renal cell cancer tissue may linearly correlate with Gd-DTPA concentration of tissues at 5 min after intravenous injection of Gd-DTPA 0.5 mmol/kg body weight.

Mixed gonadal dysgenesis: endogenous hormonal effects in the endometrium and histogenesis of germinoma

The clinicopathologic features of two patients with mixed gonadal dysgenesis are presented, with specific reference to the relationship between endogenous sex hormones and the endometrium and the development of neoplastic disease. One patient, whose immature gonad contained granulosa cells and theca cells, had elevated serum estrogen levels and an endometrium with frequent ciliated metaplasia and squamous metaplasia. Another patient had elevated serum testosterone levels and atrophic endometrium. Both had gonadal tumors, more specifically, germinomas, which contained many calcified nodules within the tumor. These findings suggest that these germinomas arose from a gonadoblastoma.

[Two cases of giant aneurysms arising from the distal segment of the anterior cerebral circulation]

Giant aneurysm arising from the distal segment of the anterior cerebral circulation is extremely rare, and only 14 cases of anterior cerebral circulation aneurysms have been reported in the literature. This report describes two cases of giant intracranial aneurysms, one arising from the distal segment of the middle cerebral artery, and the other from the azygos anterior cerebral artery. Although both of the patients started with intracranial hemorrhage, their surgical outcomes were good. The growth mechanisms of each aneurysm are discussed based on the clinical and pathological findings. Since the wall of the middle cerebral artery aneurysm showed granulomatous changes with infiltration of many inflammatory cells, the aneurysmal enlargement is considered to have resulted from chronic inflammation of the wall. In the case of anterior cerebral artery aneurysm, hemodynamic stress through the azygos artery may have caused the giant aneurysm. Operative indication for giant intracranial aneurysm is controversial. Since the surgical outcomes of reported cases are definitely better than those of the patients with proximal giant aneurysm, we conclude that giant aneurysm arising from the distal segment of the cerebral artery should be treated surgically.

Epizootiological study of hantavirus infection among Rattus norvegicus in Tokyo Bay area, Japan

The prevalence of antibodies against hantavirus in 413 rats (Rattus norvegicus) captured in eight regions of the Tokyo Bay area from 1983 to 1992 were examined by the indirect fluorescent antibody test. Antibody-positive rats were found in Tokyo Port in 1983 (34.8%), 1984 (25.9%), 1985 (22.0%) and 1986 (15.6%), in Kasai Seaside Park in 1989 (3.2%) and 1990 (4.2%) and in Chiba Port in 1990 (6.7%). In Tokyo Port, antibody-positive rats were found in any season in 1984 and 1985, and seroprevalences among two age groups, i. e., less than six months and six or more months of age were 18.1% and 28.4%, respectively. Three virus strains were isolated from rats captured on reclaimed land No. 13 in Tokyo Port in 1985 and named TQR-23, TQR-48 and TQR-50. These strains were antigenically identical with other rat strains, e. g., strain SR-11 and TR-352 but were discriminated from 76-118 strain by the neutralization test. Until 1990, persistence of hantavirus among rats inhabiting the Tokyo Bay area was demonstrated and hantavirus may be continuously prevalent in rats in this area.

Immunohistochemical detection of intercellular adhesion molecule-1 (ICAM-1) and major histocompatibility complex class I antigens in seminoma

Expression of intercellular adhesion molecule-1 (ICAM-1) and major histocompatibility complex (MHC) antigens, and characterization of tumor-infiltrating mononuclear cells (TIM) were examined immunohistologically in 10 specimens of seminoma. ICAM-1 and MHC antigens were not detected on normal spermatogenic cells. ICAM-1 and MHC class I antigens were variably expressed in 7 and 9 seminomas, respectively, whereas class II antigens were not detected. Although the degree of expression of ICAM-1 and MHC antigens was not correlated with any clinical or histopathological factors, neither of the antigens was detected on an anaplastic seminoma. Various numbers of TIM were detected in all of the seminoma, and comprised mainly T cells bearing the lymphocyte function-associated antigen (LFA)-1. No significant correlation was noticed between the degree of lymphocyte infiltration and ICAM-1 or MHC antigen expression. Although ICAM-1 and MHC class I antigens were expressed in seminoma, possibly facilitating an anti-tumor reaction of host, their expression remained low in several cases, despite marked lymphocyte infiltration within the tumor.

An autopsied case of Williams syndrome complicated by moyamoya disease

An 18 year old girl with typical clinical features of Williams syndrome suddenly died of intracerebral hemorrhage due to moyamoya disease. Autopsy revealed vascular abnormalities, such as supravalvular aortic stenosis (SAS) and an abnormal complicated cerebrovascular network in the cerebral arteries. The arterial wall of the SAS lesion consisted of thickened medial tissue showing elastic disorganization with prominence of the smooth muscle cells. The narrowed vessels of the circle of Willis showed intimal thickening with an extremely wavy internal elastic lamina and marked thinning of the media. To our knowledge, this is the first report of moyamoya disease associated with Williams syndrome.

A simple system for stereotactic volumetric resection

Stereotactic volumetric resection of deep-seated intracerebral lesions is generally believed to require expensive and complex facilities. The authors report a simple system for stereotactic craniotomy, in which the software in the computed tomographic scanner and a personal computer are used for preoperative planning and intraoperative orientation.

Evaluation of upper urinary tract dynamics by diuresis renography in patients receiving urinary reservoir operation. Comparison of full and empty reservoir

Upper urinary tract dynamics was evaluated using diuresis renography during full and empty reservoir in 14 patients (11 men, 3 women, 13-70 years old) with intestinal urinary reservoir or intestinal bladder augmentation. Types of operation were Mainz pouch urinary diversion 5, Mainz neobladder to urethra, 5, Kock pouch urinary diversion 2, and Mainz bladder augmentation 2. Diuresis renography was performed using 99mTc-DTPA and furosemide during full and empty reservoir, and several parameters (Tmax, T75, T50, GFR) in addition to the patterns of renogram were evaluated. In the normal control, none of the parameters of the diuresis renogram with full bladder differed from those with empty bladder. In 5 of 14 patients, abnormal waves on cystometry (CMG) were found, and in 4 of these 5 patients, the patterns of diuresis renogram of full reservoir were worse than those of empty reservoir. However, the patterns of diuresis renogram of full reservoir were not different from those of empty reservoir in 9 patients without abnormal waves on CMG. In conclusion, renal injury may easily occur in patients with intestinal reservoir and abnormal waves on CMG.

[Endoscopic operation of congenital anterior urethral valve. Application of flexible renoureteroscope for antegrade urethroscopy]

4 children with anterior urethral valve were treated by TUR-Valve. Before TUR, valve anatomy could be easily seen by antegrade urethroscopy through cystostomy using a 10.8Fr caliber flexible renoureteroscope and destruction of the valve could be recognized after TUR. Antegrade urethroscopy with a flexible fiberscope was so helpful to TUR-Valve and the findings of voiding cystourethrography and micturition have remarkably improved. This technique is not so difficult to apply and thought to be one of the best methods to recognize valve anatomy and degree of resection. This technique is also applicable to other lower urinary tract lesions in children.

Aspergillotic aneurysm formation of cerebral artery following neurosurgical operation

A rare case of intracranial aspergillotic aneurysm following neurosurgical operation for facial spasm is presented. Severe meningitis had persisted several days prior to the subarachnoid hemorrhage which occurred on 70th postoperative day. Angiography demonstrated a fusiform aneurysm at the peduncular segment of the superior cerebellar artery on the other side of operation. As the repeated cultures of CSF were negative, the pathogenetic factor causing aneurysm formation could not be identified before second operation of aneurysmal resection. Pathological study of the specimen revealed the arterial wall being deeply invaded by aspergillotic hyphae.

Unexpected movement disorders in neurosurgical practice: report of three cases

Hyperkinetic movement disorders may develop as a complication of stereotactic thalamotomy or pallidotomy. However, such movement disorders are uncommon after nonsterotactic intracranial operations. The authors report three cases of involuntary movement disorders unexpectedly developing after intracranial operations. The patients had undergone clipping of an internal carotid aneurysm, removal of an intracerebral hematoma, and resection of a tentorial meningioma. Two patients developed choreic movements and a dystonic posture of the unilateral upper extremity. One patient showed a tremor that had features of both parkinsonism and essential tremor. The symptoms of these patients were medically uncontrollable, and they were successfully treated with stereotactic ventrolateral thalamotomy.

Prevalence of Listeria (spp.) in wild rats captured in the Kanto area of Japan

In the Kanto area a total of 245 wild rats were captured. All rats captured in Ikebukuro (110 rats) and 9 out of 41 rats in Yokohama were Rattus rattus, and all other 126 rats were Rattus norvegicus. In Kashima and Ikebukuro, listeria was isolated from 28 rats (77.8%) and 27 rats (24.5%), respectively, but in the other 4 areas listeria was isolated from 0-7% rats. Listeria monocytogenes was isolated from 12 rats (10.9%) captured in Ikebukuro and 2 rats in Kashima and Numazu. The frequent isolation of L. monocytogenes in buildings suggests the possibility of R. rattus as a reservoir of L. monocytogenes and the continual environmental contamination in buildings by L. monocytogenes.

[Sequential methotrexate and 5-fluorouracil, doxorubicin, and cisplatin for advanced urothelial cancer]

Twenty cases (fourteen males, six females, mean age 66.0) with locally advanced (T2-4 N0, M0, n = 9) or metastatic (N2-3 or M1, n = 11) urothelial cancer were treated sequentially with methotrexate (MTX) and 5-fluorouracil (5-FU), Doxorubicin (ADM), and cisplatin (CDDP) since August, 1988. Primary tumors were in the bladder in fifteen patients and in the renal pelvis or ureter in five cases. Histological findings were adenocarcinoma in one and transitional cell carcinoma in the other cases. Histological grades were grade 2 in four, grade 3 in fifteen, poorly differentiated adenocarcinoma in one. Seven patients were treated by neoadjuvant chemotherapy. Three were treated for recurrent lesions. Ten were treated for the unresectable disease. The patients received one to four cycles of this regimen (average: 2.8 cycles). Complete clinical response was observed in seven of twenty patients (35%) with measurable indicator lesions. Seven patients (35%) had a partial clinical response. Significant tumor regression was noted in fourteen of twenty patients (70%) in total, in eight of ten (80%) treated with full dose chemotherapy. The group of full dose chemotherapy showed an improved trend in survival rate as compared with the group treated by 80% and less dose chemotherapy. Toxicity was relatively mild, with anemia, leukopenia, thrombocytopenia, and no drug related death. The results suggest that the combined chemotherapy with sequential MTX and 5-FU, ADM, and CDDP is remarkably effective on advanced urothelial cancer.

[A case of advanced ureteral squamous cell carcinoma showing complete response to combination chemotherapy with cisplatinum, vindesine, and bleomycin]

A 56-year-old Japanese female was diagnosed as advanced squamous cell carcinoma of the left ureter, stage IV (T4N0M0), and treated with anti-cancer drugs using cis-platinum, vindesine, and bleomycin. The tumor vanished after the treatment. The specimen after left total nephroureterectomy and hysterectomy showed only granulomatous change with necrosis and foreign giant cells but not cancer cells.

Schwannoma of the Penile Shaft. Case Report

A case of Schwannoma arising from the penile shaft is reported. The patient ignored the tumor for about five years because he felt no pain. Cystourethrograms showed the tumor did not cause urethral compression. Histologically the tumor belonged to the Antoni A type category. Resection of the tumor, which included the tunica albuginea, did not cause bending of the penis during erection. The postoperative course was uneventful and he had no detectible recurrence as of July 1990.