[A case of palatal polymorphous low grade adenocarcinoma]

We present a 58-year-old male patient with bilateral cheek swelling and an extraorally protruding tumor who has had deaf mutism since birth. He underwent surgery of the right hard palate 11 years ago. Five years later biopsy was performed for a recurrent lesion diagnosed as pleomorphic adenoma. He refused additional treatment and the size of the tumor subsequently increased slowly. As rapid tumor-growth had been observed since autumn of 1992, he was referred to Tokyo University Hospital. We took meticulous care of this deaf-mute patient, especially from the psychological aspect, which caused him to place great reliance upon us. We performed bilateral maxillectomy with partial resection of the right cheek skin and reconstructed his face and palate successfully using both latissmus dorsi and serratus anterior musculocutaneous free flaps with a rib. Histopathological diagnosis of the tumor was polymorphous low grade adenocarcinoma, which was registered as a definite entity in the WHO Classification in 1991. There was no evidence of local recurrence or metastasis one year postoperatively.

Free vascularized double muscle transplantation for the treatment of facial paralysis

Two cases of free neurovascular double muscle transplantation for facial paralysis are reported, with detailed descriptions of the operative technique and follow-up study. The latissimus dorsi muscle segment is placed between the nasolabial fold and the zygoma to substitute for the zygomatic and levator labii muscles, while the serratus anterior muscle segment is placed between the lower lip and the mandibular margin to substitute for the depressor labii muscles. The thoracodorsal nerve is sutured to the stump of the cross-face nerve graft, and the lateral thoracic nerve is sutured to a part of the hypoglossal nerve. The procedure is able to restore a relatively symmetrical smile, especially in patients with a full denture smile. The satisfactory results of this procedure are expected to lead to new prospects in the treatment of facial paralysis.

[A case of mitochondrial encephalomyopathy with peripheral neuropathy and autonomic symptoms]

We report a 28-year-old man with mitochondrial encephalomyopathy with peripheral neuropathy and autonomic symptoms. Muscle biopsy from the quadriceps femoris muscle showed myopathic changes with ragged-red fibers and abnormal mitochondria. He experienced recurrent and acute weakness in his bilateral lower limbs. Needle electromyogram revealed neurogenic changes, and the amplitude of muscle action potential was low in the right posterior tibial nerve. Sural nerve biopsy showed a marked loss of both large and small myelinated fibers, and moderate to severe axonal degeneration was diagnosed. He experienced autonomic symptoms (nausea, constipation, hypoidosis and urinary retention) along with the weakness in his lower limbs which is considered to be a very rare situation. We hypothesized that autonomic symptoms in this case were due to the axonal degeneration that included unmyelinated fibers.

Versatility of a cross-leg free rectus abdominis flap for leg reconstruction under difficult and unfavorable conditions

A cross-leg free rectus abdominis flap, anastomosing to utilized "carrier" vessels of the contralateral noninjured leg, was used for reconstruction in six cases of extensive traumatic defects and deformities of a lower extremity. This method provides great advantages in free-flap reconstruction of complicated and unfavorable cases in which utilization of what would be suitable recipient vessels in the injured leg is most difficult, but there is good blood circulation of the leg.

Characterization of biphenyl catabolic genes of gram-positive polychlorinated biphenyl degrader Rhodococcus sp. strain RHA1

Rhodococcus sp. strain RHA1 is a gram-positive polychlorinated biphenyl (PCB) degrader which can degrade 10 ppm of PCB48 (equivalent to Aroclor1248), including tri-, tetra-, and pentachlorobiphenyls, in a few days. We isolated the 7.6-kb EcoRI-BamHI fragment carrying the biphenyl catabolic genes of RHA1 and determined their nucleotide sequence. On the basis of deduced amino acid sequence homology, we identified six bph genes, bphA1A2A3A4, bphB, and bphC, that are responsible for the initial three steps of biphenyl degradation. The order of bph genes in RHA1 is bphA1A2A3A4-bphC-bphB. This gene order differs from that of other PCB degraders reported previously. The amino acid sequences deduced from the RHA1 bph genes have a higher degree of homology with the tod genes from Pseudomonas putida F1 (49 to 79%) than with the bph genes of Pseudomonas sp. strains KF707 and KKS102 (30 to 65%). In Escherichia coli, bphA gene activity was not observed even when expression vectors were used. The activities of bphB and bphC, however, were confirmed by observing the transformation of biphenyl to a meta-cleavage compound with the aid of benzene dioxygenase activity that complemented the bphA gene activity (S. Irie, S. Doi, T. Yorifuji, M. Takagi, and K. Yano, J. Bacteriol. 169:5174-5179, 1987). The expected products of the cloned bph genes, except bphA3, were observed in E. coli in an in vitro transcription-translation system. Insertion mutations of bphA1 and bphC of Rhodococcus sp. strain RHA1 were constructed by gene replacement with cloned gene fragments.(ABSTRACT TRUNCATED AT 250 WORDS)

[Histopathological assessment of renal biopsy specimens of subjects with urine abnormality]

Between April 1985 and April 1992, 25,672 men (age 47 +/- 9 years, mean +/- SD) and 9,791 women (48 +/- 9 years) underwent mass urinalysis in the Center for Adult Complete Physical Examination in our hospital. The results revealed proteinuria in 6.3% of the men and 4.4% of the women and hematuria in 17.4% of the men and 37.8% of the women. Thirty-five subjects with asymptomatic persistent proteinuria and/or hematuria identified as a result of follow-up testing by the nephrologists at our hospital underwent renal biopsy. All of the biopsy specimens obtained were examined by light microscopy, fluorescence microscopy and electron microscopy. Histopathological findings in the biopsy specimens from these 35 subjects were as follows: One case (3%) of chronic pyelonephritis, 11 cases (31%) of IgA nephropathy, 4 cases (11%) of IgA nephropathy (severe type), 5 cases (14%) of membranous nephropathy, 4 cases (11%) of thin basement membrane disease (TMD), 7 cases (28%) of benign nephrosclerosis and 3 cases (9%) of minor glomerular abnormality. Light microscopy, fluorescence microscopy and electron microscopy for histopathological assessment of renal specimens, especially for the diagnosis of TDM, which was not uncommon, were indispensable tools in our study. Moreover, it is essential for proteinuria and hematuria to be tested simultaneously using the same standard method in all the urine specimens collected.

[A case of spinal astrocytoma presenting spinal transverse sign due to hematomyelia]

An unusual case of cervical astrocytoma due to hematomyelia was reported. A 68-year-old man was admitted to our institute because of sudden onset of paraplegia and urinary and bowel disturbance. CT and plain X ray on admission showed no abnormal findings, but emergency MRI revealed a high signal intensity area in Th 8-9 level on T1 weighted image. Preoperative diagnosis was idiopathic hematomyelia and emergency laminectomy was performed. After the dural incision from Th 8-10, the intramedullary hematoma was totally removed, but at the cephalic portion within the hematoma cavity an abnormal tumorous tissue was detected. It was noticed with the bleeding sauce of hematomyelia, and it, too, was totally removed. The microscopic finding concerning the surgical specimen was fibrillary astrocytoma (grade 2), and its vascular component was relatively rich.

A comparison of temporal muscle transfer and lid loading in the treatment of paralytic lagophthalmos

Temporal muscle transfer (n = 78) and lid loading with a gold plate (n = 52) were compared in the treatment of paralytic lagophthalmos. Three sizes of gold plate (1.0, 1.2 and 1.4 g) were used. Lid loading was inferior to temporal muscle transfer in improving functional ability to close the eye, but it did protect the cornea from irritation. There were no significant differences among the sizes of plate, but there was most relief from corneal irritation when the 1.4 g gold plate was used. The plate had to be removed in 25% of the patients, but this did not make the condition worse than before lid loading. Lid loading has the advantage that patients can close their eyes without conscious effort. We therefore recommend lid loading as the first choice for correction of paralytic lagophthalmos, and that temporal muscle transfer should be undertaken after plate removal in only those patients for whom lid loading has not given a satisfactory result.

[The present status and problems of phase III clinical trials of the new anti tumor drug-pharmaceutical company's view]

Daiichi Pharmaceutical Co., Ltd. obtained the Japanese manufacturing approval of irinotecan hydrochloride (CPT.-11) in January 1994, which was developed through the collaboration with Yakult Honsha Co., Ltd. Prior to the approval, the manufacturer submitted to the Japanese MHW the draft protocols for phase III studies of the drug required to be conducted after its approval under the Guidelines for the Clinical Evaluation of Anti-tumor Drugs, which was promulgated in February 1991. As these studies were to be conducted as part of post-marketing surveillance, the manufacturer encountered various types of questions and complicated problems in designing the studies. Thus, the present report describes the pharmaceutical company's view on the present status and problems of phase III studies of novel anti-tumor drugs in Japan.

Electromyographic study of functional recovery of free vascularized muscles grafted to the face

The functional recovery of gracilis muscles grafted for treatment of facial paralysis in combination with a cross-face nerve graft was evaluated on the basis of electromyography in 98 cases. Initial action potentials were recorded, on average, 8 months after transplantation. There was a tendency for such potentials to appear earlier in the case of patients who finally attained good muscle activity. Action potentials were polyphasic in the early stage and of short duration and low amplitude. An increase in the amplitude and duration of potentials and a shortening of the distal latency were observed with increase in the numbers of reinnervated muscle fibers. Thereafter, there was a tendency toward decreases in the duration and number of spikes due to the increasing similarity in the distal latency of each neuromuscular unit. The grafted gracilis muscles attained a stable state about 1 year after the initial recording of action potentials. It was expected that spontaneous action potentials during rest might serve to indicate the condition of reinnervation. Their absence during the first few months after transplantation may suggest necrosis of the grafted muscle, while those of long duration and high amplitude observed after 1 postoperative year may be suggestive of disturbance in the reinnervation process. In this study, we could not find any significant difference in the reinnervation process between that of a gracilis muscle grafted following a cross-face nerve graft and a muscle reinnervated following nerve transection and repair. We therefore believe that free gracilis muscle transplantation combining a cross-face nerve graft is appropriate for the reconstruction of muscle function.

[Observation of retinal vasculature in experimental renal hypertension rat using bis-benzimide]

The retinal vessels of experimental renal hypertensive rats (RHRS), spontaneously hypertensive rats (SHRS), and normotensive Wistar-Kyoto rats (WKYS) were studied using bis-benzimide vital staining. In the bis-benzimide stained flat retinal preparations (B-FRP) of SHRS, it was only observed that the endothelial nuclei were elongated and their arrangement was irregular. In B-FRPS of RHRS, the arrangement was more irregular and the nuclei disappeared at the point where the caliber irregularity was marked. The nuclei of smooth muscle cells, which were arranged circumferentially, and the perivascular tissues were clearly identified. This finding suggests that hyperpermeability or disruption of the blood-retinal barrier did not occur in the mild hypertension but in the severe hypertension. The retinal vessels of RHRS in the regressive stage also showed seved the same kinds of findings in electron microscopy.

Chloramine-T in radiolabeling techniques. II. A nondestructive method for radiolabeling biomolecules by halogenation

Chloramine-T (CAT) is commonly used in the radiolabeling of bioactive molecules by halogenation. CAT may be used either as a solution or in an immobilized form (Iodobeads) to release radioactive elemental iodine or other halogens by oxidation of their salts. CAT has a very high chlorine potential, and it causes oxidative damage to sensitive substrate molecules, such as peptides and proteins. In some cases, the substrates are completely destroyed. To reduce the chlorine potential of CAT, morpholine was mixed with CAT prior to exposure to the substrates. This formed N-chloromorpholine, in situ, which readily reacted with KI to form I2. The kinetics of the formation of N-chloromorpholine from CAT and morpholine were studied spectrophotometrically by following the disappearance of CAT at 250 nm. The reaction was found to be rapid at all pH's from 5 to 11. 1-Aminocyclohexanecarboxylic acid (a model amino acid) decomposed rapidly in the presence of CAT, but there was no decomposition in the presence of N-chloromorpholine. N-Chloromorpholine was compared to CAT solution and Iodobeads for the iodination of L-tyrosine. The formation of mono- and diiodotyrosine were followed by HPLC. On an equimolar basis (0.55 microM), N-chloromorpholine produced a much greater yield of the mono- and diiodinated tyrosine than Iodobeads. Furthermore, decomposition products were observed when tyrosine was exposed to Iodobeads for 15 min. When a CAT solution was used at a higher concentration (5.5 microM), a substantial amount of decomposition occurred, and the yields of the two iodinated species were very small.(ABSTRACT TRUNCATED AT 250 WORDS)

Renal lesion of type Ia glycogen storage disease: the glomerular size and renal localization of apolipoprotein

In order to investigate the glomerular size and renal localization of apolipoprotein in type Ia glycogen storage disease, a renal biopsy was performed in two proteinuric patients. Histopathological examination of the biopsy specimens revealed focal sclerotic glomerular sclerosis in both patients. The mean glomerular area was 21.6 +/- 11.6 x 10(3) microns 2, indicating enlargement of the glomeruli. Immunohistochemical staining of the specimens for apolipoprotein showed localization of apolipoprotein AI on the inner side of the glomerular capillary wall, and in proximal tubular epithelial cells. In one patient with a history of several episodes of hypoglycemia, treatment with corn starch improved the carbohydrate and lipid metabolic profile and reduced the daily urinary protein excretion from 2.23 to 0.5 g. These results suggest that focal sclerotic glomerular lesions associated with type Ia glycogen storage disease may be related to disorders of carbohydrate and lipid metabolism.

[A case of facial diplegia in associated with reactivation of herpes simplex virus type I]

A 27-year-old Japanese man developed right peripheral facial palsy after suffering from a cold and low-grade fever for 7 days. Left peripheral palsy developed 4 days later. When he visited our hospital 3 days after that, neurological examination revealed no abnormalities except peripheral facial diplegia. Cerebrospinal fluid (CSF) was normal on admission and on hospital day 12. On admission, the patient had a transient increase of serum titers of HSV type I IgM (fluorescence assay). Then, serum titers of HSV type I IgG (ELISA) continuously increased. A diagnosis of peripheral facial diplegia due to reactivation of HSV type I was made clinically and serologically. Steroid pulse therapy was performed and his facial diplegia disappeared completely after 2 weeks. This case may support the hypothesis of virus etiology of Bell's palsy, and HSV type I should be considered as one of the possible causes of facial diplegia.

Tissue expansion in facial reconstruction

The tissue expansion technique is advantageous in facial reconstruction because it makes it possible to resurface even wider defects with neighboring skin similar in color and texture and superior to skin obtained elsewhere, thereby surpassing conventional methods. However, there still remain some problems relating to procedural details, such as the selection of tissue expanders and sites of their insertion; the design, elevation, suturing, and fixation of the expanded flap; and the management of free margins such as the lower lip and lower eyelid. In each case, some modification is required with respect to the status of the defect. The experiences encountered in a series of 23 patients are described, with illustration of several representative cases, and advantages and problems are discussed.

Radiotherapy for superficial esophageal cancer

PURPOSE

The results of definitive radiotherapy for superficial esophageal cancer is presented.

METHODS AND MATERIALS

Twenty-one patients with superficial squamous cell carcinoma of the esophagus were treated by definitive radiotherapy with megavoltage x-rays in Tokyo Women's Medical College from 1975 to December 1990. Eight patients refused surgery and 13 patients were considered to be unsuitable for surgery due to advanced age or morbid conditions such as severe pulmonary dysfunction, myocardial infarction, liver cirrhosis, and other cancer. Radiotherapy was performed using 1.8-2.2 Gy fraction dose, 5 times a week and with a total dose of 50-76 Gy/5-7 weeks (median; 70 Gy). Three patients received intraluminal radiotherapy in addition. Combined chemotherapy was performed in four cases, and three cases received it before radiotherapy and one case after radiotherapy.

RESULTS

Overall survival rate was 40.8%, and the cause-specific 5-year survival rate was 61.7%. The 5-year survival rate of the group with morbid conditions was 17.5%, but that of the group without morbid conditions was 60.6%. Seven patients developed recurrence (primary site: 3, lymph nodes: 3, lung: 1) and one patient revealed multicentric cancer of the hypopharynx with wide submucosal spread of the esophagus at 28 months after radiotherapy. No patient developed severe side effect due to radiotherapy.

CONCLUSION

Definitive radiotherapy with or without chemotherapy can be applied as an alternative therapy to surgery for superficial esophageal cancer, even for the operable patients under good general condition.

[A successful surgical treatment for type IA cor triatriatum with an unroofed coronary sinus]

The combination of type IA cor triatriatum (Lucas-Schmidt's classification) and unroofed coronary sinus is very rare in congenital heart diseases. We have presented the first successful surgical treatment for an infant who had this combination. The patient was 10-month-old infant who admitted with cardiac murmur and short stature. Echocardiography revealed that an abnormal septum in the left atrium and dilated coronary sinus. Under cardiopulmonary bypass she underwent surgical treatment which consisted of a resection of the intra-left-atrial diaphragma, closure of ASD with an equine pericardial patch. During operation, unroofed coronary sinus (partially unroofed terminal portion of the coronary sinus) was revealed. Her postoperative course was uneventful.

Tacrolimus (FK506)-induced nephrotoxicity in spontaneous hypertensive rats

To clarify the profile of the tacrolimus (FK506)-induced nephrotoxicity and its mechanism, 1, 2 and 4 mg/kg/day of tacrolimus was administered intramuscularly (i.m.) to spontaneous hypertensive rats (SHR) for 2 weeks, and biochemical and pathological parameters were studied in the animals. The acute nephrotoxicity of tacrolimus was characterized as increase of blood urea nitrogen (BUN) and plasma creatinine (P-Cr) levels in the groups of 1 mg/kg/day and more, decrease of creatinine clearance (CCr) value in the groups of 2 mg/kg/day and more, and histopathologically luminal narrowing of the arteriole adjacent the glomerulus in the groups of 1 mg/kg/day and more. These changes were associated with an increase of plasma renin activity (PRA) and urinary thromboxane B2 content and decrease of 6-keto-prostagrandinF1 alpha (6-keto-PGF1 alpha) content. Nilvadipine, which is one of the Ca2+ antagonist and is known to have renal vasodilating activity, prevented both biochemical and histopathological changes due to tacrolimus. The results indicated that the acute nephrotoxicity of tacrolimus was derived from impairment of glomerular function associated with the constriction of the renal arteriole brought about by the drug. All of these renal disorders induced by tacrolimus recovered completely or partially when the drug was withdrawn for 2 or 4 weeks. Consequently, the acute nephrotoxicity of tacrolimus in SHR was considered to be reversible.

Effects of ONO-1078, a peptide leukotriene antagonist, on endotoxin-induced acute lung injury

The role of lipoxygenase metabolites in the pathogenesis of endotoxin (LPS)-induced lung injury remains to be clarified. We investigated the contribution of peptide leukotrienes to LPS-induced acute lung injury using a potent antagonist, ONO-1078 (ONO). Experimental groups consisted of a saline group (n = 10), an LPS group (n = 9) injected intravenously with 2 mg E. coli LPS, an ONO group (n = 8) receiving 30 mg/kg of intraperitoneal ONO, and an LPS+ONO group (n = 6) receiving 30 mg/kg of ONO intraperitoneally 10 min before the LPS injection. The [125I]albumin lung plasma ratio, which is a parameter of acute lung injury, was significantly increased (p < 0.01) in the LPS group compared with the saline, ONO, and LPS+ONO groups. The [125I]albumin BAL fluid plasma ratio was also increased (p < 0.01) in the LPS group compared with the other groups. ONO pretreatment attenuated the LPS-induced increases in neutrophil counts in the BAL fluid. In vitro studies showed that ONO suppresses the neutrophil chemotaxis induced by LTB4, zymosan-activated serum, and FMLP. We conclude that (1) ONO-1078 attenuates LPS-induced acute lung injury; and (2) this effect appears mainly a result of its potent antagonistic actions against peptide leukotrienes and also, in part, the suppression of neutrophil chemotaxis.

Effect on fusion induction of point mutations introduced into the F protein of mumps virus

We have tested the effect of substitution of an amino acid at position 195 of the F protein of mumps virus on cell-to-cell fusion caused by the virus. Introduction of amino acids with aromatic side chains into this position resulted in reduction of fusion induction. Furthermore the F protein was not cleaved when the amino acid at this position was substituted by several amino acids, suggesting that the amino acid at this position was essential to keep the tertiary structure of the protein that might be required not only for proper folding of the protein but also for induction of membrane fusion.

Free neurovascular muscle transplantation for the treatment of facial paralysis using the hypoglossal nerve as a recipient motor source

Seventeen cases of free-muscle transplantation using the hypoglossal nerve as a recipient motor nerve for the treatment of long-standing or irreversible facial paralysis are reported with details of a follow-up study. The muscle, usually the latissimus dorsi muscle, is transferred to the cheek with microvascular anastomoses. The muscle's motor nerve is sutured to the hypoglossal nerve. There are three classifications of hypoglossal nerve sectioning: total section, central section, and lower section. The results were compared on the basis of these three methods, leading to the recommendation that branches of the hypoglossal nerve diverging inferiorly to innervate the suprahyoid muscles be utilized as a recipient motor source. This method permits acceptably natural movement of the grafted muscle without functional disability of the tongue. Good candidates for this procedure are considered to be those patients for whom muscle transplantation combined with a cross-face nerve graft cannot be adopted because of bilateral paralysis or surgical intervention on the healthy side of the face or who are so old that the long two-stage operation holds no hope for them.

[A case of pulmonary hypertensive crisis (PHC) treated with prostaglandin E1 and tolazolin after surgery of ventricular septal defect in an adult]

A 32-year-old woman was diagnosed with ventricular septal defect (VSD) with severe pulmonary hypertension (PH). Though Pp/Ps was 0.98, an operation was carried out because the index of pulmonary vascular disease (IPVD) was 1.73. Pp/Ps on the operation day was 0.51 and extubation was carried out on the next day. Five days after the operation, she suffered shock, convulsions and loss of consciousness, but these were relieved by endotracheal intubation. On the 7th day, because Pp/Ps was 0.97, we confirmed the diagnosis of PHC. PHC was treated by intravenous continuous infusion of a high dose of PGE1 (220 ng/kg/min) and tolazolin (Tz) (7-18 micrograms/kg/min) in combination with norepinephrine (0.07 microgram/kg/min) via a catheter in the descending aorta. Pp/Ps soon decreased and was 0.60 at 15 hours after administration of PGE1 and Tz. To prevent recurrent PHC, she was administered with PGE1 (20-60 ng/kg/min) intravenously for 3 weeks after improvement of PHC. As side effects of PGE1, she showed swelling and arthralgia of the hands and feet after 2 weeks. Those side effects improved after discontinuing of administration of PGE1.

Development of a sensitive two-site immunoradiometric assay for parathyroid hormone-related peptide: evidence for elevated levels in plasma from patients with adult T-cell leukemia/lymphoma and B-cell lymphoma

We have developed a sensitive immunoradiometric assay for PTH-related peptide (PTHrP) using a monoclonal antibody against PTHrP(1-34) and a polyclonal antibody against PTHrP(50-83), with recombinant human PTHrP(1-87) as the standard. The detection limit of the immunoradiometric assay was 0.5 pmol/L, and plasma PTHrP(1-87) concentrations in 110 healthy subjects were 0.8 +/- 0.01 pmol/L, with the upper limit of the normal range being 1.1 pmol/L. Increased circulating PTHrP(1-87) concentrations were demonstrated in all 46 cancer patients with hypercalcemia, but not in patients with primary hyperparathyroidism, chronic renal failure, or hypoparathyroidism. Normalization of serum calcium levels after resection of tumors was shown to correlate well with that of plasma PTHrP(1-87) concentrations in 2 cancer patients. High circulating PTHrP(1-87) levels were also demonstrated in 12 out of 13 hypercalcemic patients with adult T-cell leukemia/lymphoma and in 7 out of 8 hypercalcemic patients with non-Hodgkin's lymphoma especially of B-cell type. These results suggest that PTHrP is a major humoral factor responsible for the hypercalcemia frequently associated with adult T-cell leukemia/lymphoma and also with B-cell lymphoma.