[Gene cloning and expression of CTLA-4 in E. coli]

OBJECTIVE

To express hsCTLA-4 in E. coli.

METHODS

The hsCTLA-4 gene was obtained by PCR amplification from pE plasmid which contains CTLA-4 gene and was inserted into the expression vector pGEX-2T. The recombination strain was induced by IPTG with different concentrations and time.

RESULTS

The sequence of PCR amplified DNA fragments was identical with the reported CTLA-4 gene. SDS-PAGE and Western blot showed that 0.10 mmol/L IPTG can induce higher production of the fusion protein with molecular weight 40,000 after addition of IPTG 4 hours and GST-CTLA4 had immunological activity.

CONCLUSIONS

hsCTLA-4 can be expressed in soluble form high efficiency.

Induction of apoptosis by esculetin in human leukemia cells

Esculetin, a coumarin compound, has been shown to exhibit antioxidant and anti-inflammatory effects. In the present study, esculetin was found to inhibit the survival of human promyelocytic leukemia HL-60 cells in a concentration-dependent and time-dependent manner. HL-60 cells underwent internucleosomal DNA fragmentation and morphological changes characteristic of apoptosis after a 24-h treatment with esculetin (100 microM). Flow cytometric analysis showed that the hypodiploid nuclei of HL-60 cells were increased to 40.93% after a 36-h treatment with esculetin (100 microM). Further investigation showed that esculetin induced the release of cytochrome c from mitochondria into cytosol in a time-dependent and concentration-dependent manner. Moreover, esculetin application reduced Bcl-2 protein expression to 58% after 9 h as compared with that time at 0. Cysteine protease 32 kDa proenzyme (CPP32), a caspase 3, was activated and its substrate, poly (adenosine diphosphate-ribose) polymerase, was cleaved after a 24-h treatment of HL-60 cells with esculetin. These data suggest that esculetin induces apoptosis in human leukemia cells by increasing cytosolic translocation of cytochrome c and activation of CPP32.

Posterior cruciate ligament and coupled posterolateral instability of the knee

We wanted to investigate the role of the posterior cruciate ligament (PCL) in the knee's posterolateral stability and the magnitude of the coupled posterolateral instability with the knee examined at 90 degrees of flexion. The coupled posterolateral instability of the knee was studied by selective ligament cutting in cadaver knees set at 90 degrees. The coupled posterolateral displacement after cutting the PCL was 173% of the intact knee. With an intact PCL, the coupled posterolateral displacement after cutting the popliteus tendon and lateral collateral ligament with the knee at 90 degrees of flexion was 299% of the intact knee. When the PCL was cut together with the popliteus tendon and lateral collateral ligament, the coupled posterolateral displacement was 367%. The PCL plays an important role in the posterolateral stability of the knee, and its injury may cause mild (< 5 mm) to moderate (5-10 mm) posterolateral instability. Thus, in a knee with posterolateral instability, injury of the PCL must be considered. With an intact PCL, the posterolateral instability was very recognizable with the knee at 90 degrees of flexion, and injury to the PCL further increased the posterolateral instability and caused posterior translation of the knee. Therefore, examination for posterolateral instability of the knee should also be performed with the knee at 90 degrees of flexion, which is much easier to perform in a clinical setting. A positive posterior translation rather than posterolateral instability at different knee positions differentiates knees with combined PCL and posterolateral instability from knees with isolated posterolateral instability.

Diagnosis and results of treatment with radiation therapy in gliomatosis cerebri patient: case report

Gliomatosis cerebri (GC) is a rare disease loosely defined as a diffusely infiltrating glioma involving extensive areas of the brain. The prognosis is poor and no definite treatment has proven effective for GC. Little information exists regarding the role of radiation therapy (RT) for GC, but some researchers have suggested that it is a good choice of treatment from their limited experience. In this report, we present a case with imaging and histological diagnosis of GC and demonstrate the treatment results of RT. The patient was a 39-year-old woman with progressive symptoms of dizziness, unsteady gait, headache, vomiting, and consciousness disturbance for 6 months. She received a series of radiographic examinations and surgical interventions for diagnosis. The definite diagnosis of GC was made by a combination of magnetic resonance imaging (MRI) findings and histological examinations. Forty Gray (Gy) of whole brain irradiation followed by 14 Gy reduced-field boosts were given to her. The MRI, following treatment, showed regressive changes, and clinical symptoms were slightly improved. The patient survived 19 months after the diagnosis, which is longer than the average survival time of patients without treatment.

Clinical characteristics of outpatients at a psycho-oncology clinic in a radiation oncology department

BACKGROUND

Psychosocial care in cancer medicine has become increasingly important. The first psychiatric consultation-liaison (C-L) outpatient clinic in Taiwan was established in a department of radiation oncology in a medical center in Oct. 1998.

METHODS

From October 1998 through January 2000, 121 patients were referred for psychosocial evaluation. Six referred patients were excluded because of cerebral complications of malignant disease or coincidental psychiatric disorder. The remaining 115 patients were referred because of psychological problems related to their malignant disease. These patients were divided into 'depression related disorder' and 'anxiety related disorder' groups according to psychiatric standard diagnoses. The records of these referred patients were retrospectively analyzed based on the psychiatric diagnoses.

RESULTS

The outpatient utilization rate for psychiatric consultation escalated from 0% to 5.92% after the C-L clinic was established. Patients with nasopharynx, breast, and head and neck cancer had higher referral, rates (over 10%) than patients with other types of cancer. There were significant differences in major subjective psychiatric problems and psychological reactions between patients with psychiatric diagnosis and those without psychiatric diagnosis. Cancer patients who were diagnosed with 'depression related disorder' visited this clinic more times than those with 'anxiety related disorder'. The former received antidepressant drugs more frequently than the latter. There were also more multiple visits in the former group than the latter group.

CONCLUSION

Locating a C-L clinic in a radiation oncology department improves access to psychiatric evaluation, early detection and continuous intervention can then be offered to cancer patients with anxiety or depression, especially those with 'depression related disorder'.

Increased expression of iNOS and c-fos via regulation of protein tyrosine phosphorylation and MEK1/ERK2 proteins in terminal bronchiole lesions in the lungs of rats exposed to cigarette smoke

Epidemiological evidence suggests that smoking is a major cause of human lung cancer. However, the mechanism by which cigarette smoke induces the cancer remains unestablished. To evaluate the effects of cigarette smoke on the expression of inducible nitric oxide synthase (iNOS), nuclear protooncogenes and related mitogen-activated protein kinases (MAPKs) in rat lung tissue, a histopathological study of the effects of gas-phase cigarette smoke on rat lung tissue were carried out. The terminal bronchioles were found to be infiltrated predominantly by lymphocytes in the peribronchiolar region and a mild to moderate degree of emphysema was noted in the alveolar spaces. The terminal bronchioles also showed marked lipid peroxidation, dilatation, and peribronchiolar fibrosis. Immunohistochemical evaluation showed that the expression of iNOS, NF-kappa B, MAPKs (MEK1, ERK2), phosphotyrosine protein and c-fos was increased in the terminal bronchioles but protein kinase C (PKC), MEKK-1, c-jun, p38 and c-myc showed no change. These results provide evidence to suggest that exposure to cigarette smoke results in oxidant stress which leads to the stimulation of iNOS and c-fos together with the induction of protein tyrosine phosphorylation and MEK1/ERK2 which in turn may promote lung pathogenesis.

Concomitant closure of patent canal of Nuck during laparoscopic surgery: case report

Indirect inguinal hernia is neglected by many female patients. When women undergo laparoscopy for infertility work-up or other gynaecological conditions, the hernia appears pressurized by the pneumoperitoneum. A large opening on the peritoneum followed by the patent canal of Nuck-as seen in the patient in this case report-is accompanied by a bulge above the labia major. This situation was treated with simple ligation of the canal of Nuck from the internal inguinal ring, and the vulvar bulging mass quickly disappeared, even while under pneumoperitoneal pressure. Laparoscopic hernia repair is currently performed with a mesh prosthesis to cover the defect; however, in female patients it seems unnecessary to use such an invasive method designed largely for males. According to our experience, the concomitant simple closure method for female indirect inguinal hernia is a quick and simple procedure, and deals with the problem during the same laparoscopy. In addition, disappearance of the bulging mass under the pneumoperitoneum offers a useful diagnostic test to secure hernia management.

Uterovaginal canalization and endometrial ablation of the obstructed uterine horn with hypoplastic cervix in the didelphic uterus

Maldevelopment of the mullerian duct system may result in various urogenital anomalies including didelphic uterus with a hypoplastic cervix. Two women with this anomaly experienced symptoms including recurrent lower abdominal pain off and on of 1 to 2 years' duration. Magnetic resonance imaging revealed a double uterus with right hematometrium both patients. After hysteroscopic identification of hypoplasia of right uterine cervix, laparoscopic resection of the hematosalpinx, followed by uterovaginal canalization and prophylactic endometrial ablation of the right uterus was successfully performed by resectoscope. Normal menstruation ensued during follow-up of 18 and 24 months, respectively. Our experience suggests that uterovaginal canalization with prophylactic endometrial ablation may be an efficacious alternative to hysterectomy for management of didelphic uterus with a hypoplastic cervix. (J Am Assoc Gynecol Laparosc 8(1):151-153, 2001)

Laparoscopic closure of patent canal of Nuck for female indirect inguinal hernia

STUDY OBJECTIVE

To determine the efficacy of concomitant laparoscopic closure of the patent canal of Nuck in treatment of indirect inguinal hernias in women.

DESIGN

Prospective clinical trial (Canadian Task Force classification II-2).

SETTING

University-associated tertiary care referral center.

PATIENTS

Six women scheduled for laparoscopy for gynecologic indications. Intervention. Concomitant simple closure of the patent canal of Nuck from the peritoneal cavity during laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Inguinal hernias were repaired in all six patients, with no recurrence.

CONCLUSION

l Laparoscopic closure of the patent canal of Nuck is an easy, safe, and effective treatment of indirect inguinal hernias in women. (J Am Assoc Gynecol Laparosc 8(1):143-146, 2001)

A new portal for gynecologic laparoscopy

We used the middle upper abdomen as a primary port insertion as an alternative portal for laparoscopy and multiport operative pelviscopy in 188 women who were at high risk for subumbilical adhesions because of previous abdominal surgeries or history of gynecologic cancer. Primary cannula insertion was in the middle upper abdomen between xyphoid process and umbilicus (Lee-Huang point). This was the single entry site for the Veress needle and primary laparoscopy port. In 184 (98.4%) of 188 women surgery was performed without complications. No procedure was converted to laparotomy due to visceral or vascular injuries. Two omentum injuries from primary port insertion were repaired with bipolar electrocoagulation; a colon injury was repaired with laparoscopic sutures. In our experience, this laparoscopic port is effective in women who have had abdominal surgery or gynecologic malignancy. (J Am Assoc Gynecol Laparosc 8(1):147-150, 2001)

Attenuation of radiation dose by the skull base bone in patients with nasopharyngeal carcinoma: clinical importance

PURPOSE

To measure the degree of attenuation of radiation dose by the skull base bone in patients with nasopharyngeal carcinoma (NPC) and to study its clinical importance.

MATERIALS AND METHODS

Isodose distribution in 11 patients with NPC who received bilaterally opposed large-field irradiation (1.8 Gy per fraction) was studied with a three-dimensional treatment planning system with tissue inhomogeneity correction. Also studied were the sites of local tumor recurrence in 37 patients with NPC and skull base destruction (>/=0.5 cm) or intracranial invasion treated with radiation therapy from January 1989 to December 1992. Regression analyses were performed.

RESULTS

In the dosimetric study, the low-dose areas (<1.65 Gy) were located at the level of the skull base in all 11 patients. A significantly positive correlation between the maximum width of the skull base bone and the low-dose volume (<1.65 Gy) was demonstrated (P =.003, linear regression). In the clinical study, local tumor recurrence was noted in 18 patients (49%). The sites of local recurrence included skull base in 16 patients (43%) and nasopharynx in six patients (16%). Wider skull base bone was a significant predictor of skull base recurrence after radiation therapy (P =.03, logistic regression).

CONCLUSION

Herein demonstrated is the inadequacy of the radiation dose over the skull base due to attenuation by the skull base bone. The relationship between width of skull base bone and skull base tumor recurrence also is established.

Intraoperative stroke under epidural anesthesia for bipolar hemiarthroplasty in a patient with multiple myeloma: a case report

A 56-yr-old, 58-kg woman with right femoral neck fracture underwent right bipolar hemiarthroplasty. Her medical problems included diabetes mellitus and multiple myeloma. Epidural anesthesia was performed uneventfully. No other drug except for local anesthetic (2% lidocaine) was administered during the procedure. Unfortunately, we "witnessed" the dramatically hemodynamic change of an intraoperative stroke, which was preceded by a hypotensive episode and followed by sustained hypertension. The stroke was presented with decreased level of consciousness initially and confirmed by the brain CT, which revealed acute infarction at the right middle cerebral artery territory, four days after the procedure. Multiple mechanisms such as intraoperative hypotensive episode and vascular atherosclerotic change due to poor controlled diabetes mellitus might be involved in the event. In the meanwhile, hyperviscosity (3.7 centipoise units of the patient v.s. 1.4-1.8 centipoise units of normal range) caused by multiple myeloma might also have contributed to the intraoperative stroke. Clinical presentation of this case will be discussed.

Effect of isoflurane versus nicardipine on blood flow of lumbar paraspinal muscles during controlled hypotension for spinal surgery

STUDY DESIGN

This study compared the effects of isoflurane and nicardipine on regional blood flow of the lumbar paraspinal muscles.

OBJECTIVES

The purpose of this study was to determine whether treatment with hypotensive agents result in ischemia of the lumbar paraspinal muscles, thereby facilitating surgical procedures.

SUMMARY OF BACKGROUND DATA

Despite the general acceptance of controlled hypotension as effective in reducing blood loss during spinal surgery, the changes of blood flow that occur at the lumbar paraspinal muscles when this technique is applied remain unclear. The use of laser Doppler flowmetry allows changes of muscle blood flow to be easily detected in real time with minimal invasion, thereby allowing differences among distinct pharmacological approaches for induction and maintenance of controlled hypotension to be evaluated.

METHODS

The prehypotensive and hypotensive (reduction of mean arterial pressure by 20 mm Hg) blood flow of the lumbar paraspinal muscles were assessed with a laser Doppler flowmeter in 40 patients undergoing lumbar spinal surgery. The first half of the patients (n = 20) received isoflurane, whereas the second half received nicardipine to achieve arterial hypotension.

RESULTS

Compared with the prehypotensive state, during the hypotensive state, patients in the isoflurane group exhibited a 17% to 46% (mean, 33.7%) decrease in lumbar paraspinal muscle blood flow, whereas patients in the nicardipine group exhibited a 24% to 177% (mean, 82.5%) increase in lumbar paraspinal muscle blood flow. Statistical analysis showed a significant difference in the changes of flux after induced hypotension between the isoflurane and nicardipine group (P < 0.001).

CONCLUSIONS

Depending on the pharmacological treatment used to achieve arterial hypotension in spine surgery, there will be either a reduction in paraspinal muscle blood flow (ischemia) or an enhancement of this blood flow (hyperemia).

High external parametrial dose can increase the probability of radiation proctitis in patients with uterine cervix cancer

OBJECTIVE

The aim of this study was to evaluate the relationship between external parametrial dose and radiation proctitis after external irradiation and high-dose-rate intracavitary (HDR-IC) brachytherapy among patients with cervical cancer.

METHODS

From May 1993 through December 1996, 191 patients with stage IB-IVA cervical cancer were managed by curative-intent radiotherapy. External irradiation to the whole pelvis (44-45 Gy/ 22-25 fractions) was delivered to all patients initially. One hundred twenty-seven patients received additional bilateral parametrial and sidewall boost (5.4-14.4 Gy/ 3-8 fractions) with 4-cm midline shielding. HDR-IC brachytherapy, 19.2-24 Gy/ 5 fractions to Point A, was given after external irradiation. Patients receiving an external dose of 44-45, 50-54, and >54 Gy were categorized as no parametrial boost (NPMB), low parametrial boost (LPMB), and high parametrial boost (HPMB) group, respectively. The actuarial proctitis rate was compared among the three groups.

RESULTS

Three-year overall and Grade 2-4 proctitis rates were 30 and 15%, respectively. Overall proctitis rates were 12, 34, and 51% in the NPMB, LPMB, and HPMB groups (P < 0.0001), respectively. Grade 2-4 proctitis rates were 5, 17, and 27% in the NPMB, LPMB, and HPMB groups (P = 0.0022), respectively. In multivariate analysis of overall and Grade 2-4 radiation proctitis, external parametrial dose was the only independent prognostic factor (P = 0.0002 and 0.0030, respectively).

CONCLUSION

Regardless of central shielding after 44-45 Gy whole pelvis irradiation, more patients with high external parametrial dose developed radiation proctitis. Incomplete midline shielding of the upper rectum may be the cause. Diminishing the external beam doses further may decrease rectal complications.

Two-stage operation for treatment of a large dissecting popliteal cyst after failed total knee arthroplasty

A symptomatic popliteal cyst after total knee arthroplasty (TKA) is rare, occurring most frequently as a result of intra-articular knee pathology. We present a case of a large dissecting popliteal cyst 7 years after TKA with symptoms of severe calf pain and functional disability. The symptomatic cyst was excised completely in a first-stage operation, and the severely worn TKA was corrected by a second-stage surgical procedure. The patient in this report was pain free and had satisfactory range of knee motion 5 years after the index revision TKA, without recurrence of effusion or popliteal cyst formation.

Intramedullary femoral nails: one or two lag screws? A preliminary study

Failures of proximal femoral nails that treat unstable femoral fractures have been reported. In this communication, a finite element model to include a proximal femoral nail within a fractured femur was used to carry out preliminary investigations into configurations of single or double lag screws. The effects of the different types of fracture were investigated. The results show that in order to share the load evenly between two lag screws, a good configuration seems to be to have a slightly larger screw above the lower screw. This also ameliorates stresses in the nail at the lag screw insertion holes. However, using two screws in this way can lead to large stresses in the cancellous bone in the femoral head, and these stresses may be significant in the initiation of cut-out.

Deep vein thrombosis after total knee arthroplasty

BACKGROUND AND PURPOSE

The incidence of deep vein thrombosis (DVT) after total knee arthroplasty (TKA) in the Asian population is probably higher than is commonly assumed by clinicians. The purpose of this study was to investigate the incidence of DVT after TKA in a southern Taiwanese population and to determine whether routine prophylaxis against DVT is indicated.

MATERIALS AND METHODS

The incidence of DVT was investigated in 107 ascending venograms performed in 105 knees in 102 patients after TKA. Observations were made and interpreted by orthopedic radiologists blinded to the clinical condition of the patients. The correlation of DVT with the medical conditions, anesthesia type, and local physical findings were analyzed.

RESULTS

The overall incidence of DVT after TKA was 63.6% (68/107); 95.6% (63/68) of cases involved the distal veins in the calf and only 4.4% (3/68) involved the proximal vein at the popliteal level. There was no higher incidence of thrombosis in the femoral and iliac veins, and no pulmonary embolism. Approximately 70% of patients with DVT were symptomatic and required treatment. There was no statistically significant correlation of DVT with medical condition, including diabetes mellitus, hypertension, body weight, varicosity, history of thromboembolic disorder and congestive heart failure, or the type of anesthesia or bone cement used. There was a positive correlation of DVT with local physical findings including calf girth enlargement, leg edema, and skin discoloration, and a negative correlation with findings including Homans' sign, cord induration, venous engorgement, and knee effusion.

CONCLUSION

The incidence of DVT after TKA in this southern Taiwanese cohort was similar to that in Western populations, and higher than is commonly assumed by clinicians at this facility. However, the rate of proximal thrombosis and pulmonary embolism was much lower than in previous studies from Western populations. The majority of cases of DVT involved the veins in the calf; approximately 70% of patients were symptomatic and required treatment.

Laparoscopic-assisted vaginal myomectomy

STUDY OBJECTIVE

To evaluate the safety and efficacy of combined laparoscopic and vaginal approach in dealing with uterine myomas.

DESIGN

Retrospective case study (Canadian Task Force classification II-2).

SETTING

Tertiary care major teaching hospital.

PATIENTS

Thirty-one women with symptomatic fundal and/or posterior wall uterine myomas.

INTERVENTION

Laparoscopic-assisted vaginal myomectomy performed by one of the authors from July 1996 to December 1998.

MEASUREMENTS AND MAIN RESULTS

Mean +/- SD operating time, blood loss, and length of hospital stay were 79.19+/-18.31 minutes, 150.00+/- 103.28 ml, and 3.10+/-0.75 days, respectively. No patients developed serious complications, and only two minor complications occurred.

CONCLUSION

After laparoscopic inspection and location of uterine myomas, dealing with posterior and fundal uterine myomas by the vaginal route makes hemostasis and uterine repair easier than by purely laparoscopic approach.

Dermatofibrosarcoma protuberans: treatment results of 35 cases

BACKGROUND AND PURPOSE

This study evaluates the treatment results of patients with dermatofibrosarcoma protuberans.

PATIENTS AND METHODS

Between August 1987 and July 1998, 35 consecutive patients with pathologically proved dermatofibrosarcoma protuberans received surgery with or without radiation therapy. Their treatment results were analyzed retrospectively.

RESULTS

The patient ages ranged from 5 to 67 years (median 37 years). There were 24 males and 11 females. The anatomic sites of tumor were: trunk in 21, extremity in eight, and head and neck region in six. The maximal dimension of tumor ranged from 1.5 to 25 cm. Surgery techniques included local excision and wide excision with or without graft or flap. Adjuvant radiation therapy was given to 11 patients, with a dose ranging from 46 to 68 Gy (one pre-operative, ten post-operative). At a median follow-up of 50 months (range 11-131 months), there were 11 patients (nine patients without radiation therapy) who developed local failure. Salvage therapy (excision with or without radiation therapy) was given to all of them, and ten achieved disease control. Some patients had treatment-related moderate cosmetic or functional problems.

CONCLUSIONS

Dermatofibrosarcoma protuberans is a malignancy of a high cure rate, and adjuvant radiation therapy can reliably decrease the local recurrence rate and prevent mutilation and functional deficit caused by repeated surgery.

Suppressive effect of penta-acetyl geniposide on the development of gamma-glutamyl transpeptidase foci-induced by aflatoxin B(1) in rats

The suppressive effects of penta-acetyl geniposide, (Ac)(5)-GP, on the hepatotoxic lesions-induced by aflatoxin B(1) (AFB(1)) were investigated in male Wistar rats. Rats were divided into six groups: groups I and II served as normal and solvent control, respectively; group III was given AFB(1) (2 mg/kg body weight) alone; group IV was given (Ac)(5)-GP (2 mg/kg) alone; and groups V and VI received both AFB(1) (2 mg/kg body weight) and (Ac)(5)-GP (1 mg and 2 mg/kg body weight, respectively). Rats received treatments for 8 weeks, then were maintained on basal diet for 32 weeks. At the end of the experiment (week 40), the liver lesions (e.g. fatty change, eosinophilic and bile duct dilation) and preneoplastic changes in rats of groups V and VI were reduced when they were compared with group III. There were no liver lesions and preneoplastic changes in rats treated with (Ac)(5)-GP alone. Although no differences in the total number of gamma-glutamyl transpeptidase (GGT)-positive foci was observed between the groups treated with AFB(1) along with or without (Ac)(5)-GP, the treatment of (Ac)(5)-GP significantly reduced the number of AFB(1)-induced GGT positive foci (with diameter larger than 0.3 mm). These results indicated that the protective effect of (Ac)(5)-GP on early hepatocarcinogenesis-induced by AFB(1) was associated with the inhibition of GGT foci development.

Multivariate analysis of pulmonary fibrosis after electron beam irradiation for postmastectomy chest wall and regional lymphatics: evidence for non-dosimetric factors

BACKGROUND AND PURPOSE

To evaluate the factors associated with pulmonary fibrosis after postmastectomy electron beam irradiation of chest wall and regional lymphatics in patients with breast cancer.

MATERIALS AND METHODS

From July 1987 through July 1994, 109 women with stage II and III breast cancer receiving modified radical mastectomies were managed by postoperative electron beam irradiation. Doses of 46 to 50.4 Gy were delivered to the chest wall covered with bolus, internal mammary nodes, supraclavicular nodes and axillary lymph nodes via 12 or 15 MeV single portal electron beam. Seventeen patients received additional 10-16 Gy surgical scar boost via 9 MeV electron beam. Comparison of pre-treatment and post-treatment chest X-ray films were used to monitor the development of pulmonary fibrosis.

RESULTS

Only Grade 1 radiation-induced late pulmonary toxicity was noted in 33 patients (29%). Twenty-six patients (24%) developed pulmonary fibrosis under unbolused chest wall. Lung fibrosis under bolused chest wall was noted in 11 patients (10%). Statistical difference (P<0.01) was noted between the incidence of fibrosis in these two sites. In multivariate analysis of lung fibrosis under unbolus-covered chest wall, the independent prognostic factors are low body mass index (BMI) (P<0.01), tamoxifen taking (P=0.03), and no treatment interruption (P=0.03). No independent factor was associated with lung fibrosis under bolus-covered chest wall in multivariate analysis.

CONCLUSIONS

In the analysis of pulmonary fibrosis induced by unbolused electron beam, BMI rather than body weight and body height is a strong prognostic factor. Tamoxifen and short overall time can predispose the development of lung fibrosis.

Inhibitory effect of esculetin on oxidative damage induced by t-butyl hydroperoxide in rat liver

Increasing evidence regarding free radical-generating agents and inflammatory processes suggests that accumulation of reactive oxygen species can cause hepatotoxicity. A short-chain analog of lipid hydroperoxide, t-butyl hydroperoxide (t-BHP), can be metabolized to free radical intermediates by cytochrome P-450 in hepatocytes, which in turn can initiate lipid peroxidation, affect cell integrity and result in cell injury. In this study, we used t-BHP to induce hepatotoxicity in vitro and in vivo and determined the antioxidative bioactivity of esculetin, a coumarin compound. Our investigations showed that pretreatment with esculetin (5-20 microg/ml) significantly decreased the leakage of lactate dehydrogenase (LDH) and alanine transaminase (ALT), and also decreased the formation of malondialdehyde (MDA) in primary cultured rat hepatocytes induced by a 30-min treatment with t-BHP. An in vivo study in rats showed that pretreatment with esculetin (i.p.) at concentrations of 0.5 and 5 mg/kg for 5 days before a single i.p. dose of t-BHP (0.1 mmol/kg) significantly lowered the serum levels of the hepatic enzyme markers (ALT and AST) and reduced oxidative stress in the liver. Histopathological evaluation of the rat livers revealed that esculetin reduced the incidence of liver lesions induced by t-BHP, including hepatocyte swelling, leukocyte infiltration, and necrosis. Based on the results described above, we speculate that esculetin may play a chemopreventive role via reducing oxidative stress in living systems.

Intracortical osteosarcoma: report of a case

Intracortical osteosarcoma is the rarest anatomic variation of osteosarcoma. There have been only 12 cases reported in the English-language literature. We present a case of osteosarcoma in an 18-year-old Taiwanese man that originated within the cortex of the tibial diaphysis. The initial radiograph revealed a lytic mass confined to the cortex, mimicking a benign bone lesion. Histopathologic examination of the biopsy specimen showed an osteoblastic osteosarcoma mingled with some fibroblastic foci. He underwent en bloc resection, and a metallic prosthetic intercalary stem was used to replace the larger bone defect. Adjuvant chemotherapy was administered before and after the operation. He was free of disease during 40 months of follow-up. A review of all reported cases of intracortical osteosarcoma revealed that the initial method of treatment plays an important role in local recurrence and distant metastasis. Local excision and curettage leads to the worst results. The outcomes of more recently reported cases have improved because of early awareness of the possibility of malignancy and advances in chemotherapy. However, whether patients with intracortical osteosarcoma have a different prognosis from those with conventional osteosarcoma cannot be determined, because of the small number of intracortical osteosarcoma cases available for analysis.

Serial analysis of gene expression: from gene discovery to target identification

Serial Analysis of Gene Expression (SAGE) is a sequence-based genomics tool that features comprehensive gene discovery and quantitative gene expression capabilities. As an 'open' system, SAGE can reveal which genes are expressed and their level of expression rather than merely quantifying the expression level of a predetermined, and presently incomplete, set of genes as carried out by 'closed' system gene expression profiling platforms such as microarrays. These distinguishing attributes enable SAGE to be used as a primary discovery engine that can characterize human disease at the molecular level while illuminating potential targets and markers for therapeutic and diagnostic development, respectively.

Specific induction of glutathione S-transferase GSTM2 subunit expression by epigallocatechin gallate in rat liver

The antitumor effect of green tea polyphenols has been well characterized in numerous papers. However, the mechanism of their action is still poorly defined. In this study, epigallocatechin gallate (EGCG), the main ingredient of green tea extract, was studied for its effect on the expression of glutathione S-transferases (GSTs) in rat liver to examine the mechanism of action. Liver samples were collected from Sprague-Dawley rats treated with EGCG in H(2)O by portal vein perfusion and examined for total GST activity and GST expression. The results showed that the induction of GST activity by EGCG was dose- and time-dependent. GST activity was increased about 28-fold at 12 hr after treatment. Three GST subunits (GSTA1/2, GSTM1, and GSTM2) were examined by Western blot for changes in protein level affected by EGCG (1 mg/kg weight). Only GSTM2 revealed a significant time-dependent increase, with a maximal induction of approximately 2.0-fold. The differential effect of EGCG on GST subunit expression was also verified by immunocytochemical examination and showed strong induction of the GSTM2 (but not the GSTA1/2 and GSTM1) level in liver section. This induction occurred as early as 3 hr after treatment and extended gradually outward from the hepatic veins as treatment time increased. The change in the GSTM2 protein level was accompanied by a corresponding alteration in mRNA quantity ( approximately 2.0-fold of control). Our report is the first to demonstrate a specific induction of the GSTM2 subunit by a chemopreventor and suggests a primary influence of EGCG on GSTM2 gene expression.

Effect of N-(biphenylyl-methyl)imidazole, a type 1 angiotensin II receptor inhibitor, on the contractile function of the rat corpus cavernosum

The effect of N-(biphenylyl-methyl)imidazole, losartan potassium, a newly developed antihypertensive type 1 angiotensin II receptor antagonist on the rat erectile function, was studied. Sexually active 9-week-old male spontaneously hypertensive rats (SHR) and normotensive Wistar-Kyoto (WKY) rats were given losartan 60 mg/kg intraperitoneal injections. Mean blood pressure (MBP) dropped significantly in both SHR and WKY rats (for SHR: from 140 +/- 8 to 114 +/- 5 mm Hg, p < 0.05, n = 8; for WKY: from 113 +/- 7 to 79 +/- 9 mm Hg, p < 0.05, n = 8). On the contrary, the intracavernous pressure (ICP) of SHR and WKY rats did not differ significantly from that of the corresponding controls receiving saline injections (p > 0.05, n = 8 for each group). For the chronic study, the rats were fed with losartan 30 mg/kg/day for 30 days. MBP decreased significantly in SHR but not in WKY rats (for SHR: from 137 +/- 7 to 113 +/- 5 mm Hg, p < 0.05, n = 8; for WKY: from 110 +/- 6 to 107 +/- 5 mm Hg, p > 0.05, n = 8). The ICP of the losartan-treated rats was not significantly different from that of control rats (p > 0.05, n = 8 for each group). In contrast, WKY rats receiving guanethidine 1 mg/kg/day for 30 days showed significantly decreased ICP. Angiotensin II (10(-9)-10(-5) M) and losartan (10(-9)- 10(-5) M) did not induce significant contractile responses of the cavernosal strip when tested in vitro. On the other hand, methoxamine 10(-4) M induced good contractile responses. In conclusion, the present study demonstrated that angiotensin II did not cause significant change in the contractile status of rat corpus cavernosum. Correspondingly, the type 1 angiotensin II inhibitor effectively lowered blood pressure but did not affect cavernosal contractile function, thus is useful clinically in the treatment of hypertensive disorders without significant detrimental effects on male sexual function.

Improved PCR-based subtractive hybridization strategy for cloning differentially expressed genes

An improved PCR-based subtractive hybridization strategy was used to clone apoptosis-related genes induced by all-trans retinoic acid (ATRA) from human promyelocytic leukemia cell line HL-60 cells. The protocol used the cap-finder method, long-distance PCR, streptavidin magnetic bead-mediated subtraction and spin column chromatography. Twenty-seven clones related to apoptosis were identified by reverse dot blot assay. Seventeen were known genes, of which seven have been reported to be apoptosis related. The remaining 10 were unknown genes, five of which were sequenced and named apr-1 to apr-5. apr-1, apr-2, apr-3 and TNF were reidentified by reverse dot blot, and it is suggested that they might be related to apoptosis. The results suggest that this strategy might be efficient for large-scale cloning of differentially expressed genes in target cells.

Induction of apoptosis by hibiscus protocatechuic acid in human leukemia cells via reduction of retinoblastoma (RB) phosphorylation and Bcl-2 expression

Hibiscus protocatechuic acid (PCA), a phenolic compound isolated from the dried flower of Hibiscus sabdariffa L. (Malvaceae), demonstrated antioxidant and antitumor promotion effects in our previous study. In the present study, Hibiscus PCA was found to inhibit the survival of human promyelocytic leukemia HL-60 cells in a concentration- and time-dependent manner. The study revealed that HL-60 cells underwent internucleosomal DNA fragmentation and morphological changes characteristic of apoptosis after a 9-hr treatment with Hibiscus PCA (2 mM). Flow cytometric analysis of the DNA content of cells treated with PCA for 12 hr showed that the cells were distributed mainly in the hypodiploid phase (apoptotic peak, 46.7%), less in the G(1) (34.2%) and S phase (14.0%), and few in the G(2)/M phase (5.1%). Moreover, PCA treatment caused an increase in the level of hypophosphorylated retinoblastoma (RB; 180% of control at the 6-hr time point) and, on the contrary, a decline in hyperphosphorylated RB. A rapid loss of RB was observed when the treatment period was extended. Further studies showed that Hibiscus PCA application reduced Bcl-2 protein expression to 47%, and increased Bax protein expression to 181% after 1.5 hr as compared with time 0. Overexpression of Bcl-2 in HL-60 cells delayed the occurrence of Hibiscus PCA-induced apoptosis. These data suggest that Hibiscus PCA is an apoptosis inducer in human leukemia cells, and that RB phosphorylation and Bcl-2 protein may play a crucial role in the early stage.

Healing of superior vena cava defect in mediastinal seminoma with invasion

We present an unusual case of mediastinal seminoma with direct intraluminal invasion into the superior vena cava (SVC) and extension to the right atrium. Magnetic resonance imaging demonstration of the SVC defect due to tumor invasion was important for determining treatment strategy because rapid posttherapeutic tumor regression may increase the risk of SVC rupture. Gradual healing of the SVC defect at the tumor entrance site was attained using a tailored treatment plan with radiotherapy and chemotherapy.

Development of brain injury in mice by Angiostrongylus cantonensis infection is associated with the induction of transcription factor NF-kappaB, nuclear protooncogenes, and protein tyrosine phosphorylation

Eosinophilic meningitis or meningoencephalitis caused by Angiostrongylus cantonensis is endemic to the Pacific area of Asia, especially Taiwan, Thailand, and Japan. Although eosinophilia is an important clinical manifestation of A. cantonensis infection, the role of eosinophils in the progress of the infection remains to be elucidated. In this experiment, we showed that A. cantonensis-caused eosinoplia and inflammation might lead to the induction of NF-kappaB and protooncogene expression via activation of the tyrosine phosphorylation signal pathway. After mice were infected daily with 30 third-stage larvae of A. cantonensis by oral adminstration for 6 weeks, no significant differences PKC-alpha, MEK-1, ERK-2, JNK, and p38 protein expression were found between the control and infected mice. However, the protein tyrosine phosphorylation levels, NF-kappaB, and iNOS protein products were significantly increased by 3.5-, 3.3-, and 6.3-fold, respectively, after 3 weeks of A. cantonensis infection. The same pattern was found for c-Myc, c-Jun, and c-Fos proteins, which were elevated by 3.2-, 2.3-, and 3.4-fold, respectively, compared to control animals after 3 weeks. The expression potency of these proteins started increasing in week 1, reaching maximal induction in week 3, and then declining in week 5 after A. cantonensis infection. Another consistent result was noted in the pathological observations, including eosinophilia, leukocyte infiltration, granulomatous reactions, and time responses in brain tissues of infected mice. These data suggest that the development of brain injury by eosinophlia of A. cantonensis infection is associated with NF-kappaB and/or nuclear protooncogenes expression, which is activated by the tyrosine phosphorylation pathway.

Tumor promotion of N-nitroso-N-(3-keto-1, 2-butanediol)-3'-nitrotyramine derived from nitrosation of Maillard reaction product in CD-1 mice

N-Nitroso-N-(3-keto-1,2-butanediol)-3'-nitrotyramine (NO-NTA) is a product of a model browning system generated in the presence of sodium nitrite. Our previous study showed that NO-NTA had genotoxicity and proved to be an initiator and promoter on mouse C3H10T1/2 cells. In this study, a two-stage skin carcinogenesis protocol was used to promote CD-1 mouse skin carcinogenesis using NO-NTA. Twice weekly, for 38 weeks, topical application of NO-NTA at the concentration of 250 nmol to mice previously initiated with benzo(a)pyrene (BaP) caused 90% tumor incidence. However, no tumors were observed in mice treated with BaP or treated with NO-NTA alone. The NO-NTA-promoted tumors that were observed histologically in mice showed well-differentiated squamous cell carcinoma with invasion into the subcutaneous region. Application of the same amount of NO-NTA not only caused significant induction of hyperplasia but also epidermal ornithine decarboxylase (ODC) activity. Treatment of mouse skin (1 cm(2)) with various amounts of NO-NTA (10, 50, or 250 nmol) caused production of hydrogen peroxide by 1.63-, 1.91-, and 2. 38-fold, respectively, and marked induction of myeloperoxidase (MPO) by 21-, 39-, and 61-fold. These results indicate that NO-NTA is a new tumor promoter and may induce tumor promotion by oxidant stress in CD-1 mouse skin.

Elective neck irradiation for nasopharyngeal carcinoma

BACKGROUND

This study was conducted to evaluate the effectiveness of elective neck irradiation (ENI) for nasopharyngeal carcinoma (NPC), and to analyze factors associated with ENI failure.

METHODS

A radiation port covering the side of a neck without gross nodal metastasis was qualified for evaluation of the effectiveness of ENI. From 1988 through 1992, a total of 261 patients with N0 (130 cases), N1 (91 cases), and N3 (40 cases) NPCs were studied. All patients were irradiated with 60Co teletherapy or 10 MV x-ray to a total dose of 46.8 Gy/26 fractions, followed by a boost treatment to the primary site to a total dose of 64.8 to 75.6 Gy/36-42 fractions. All ENI ports received irradiation to a dose of 46.8 to 60.8 Gy. The duration of follow-up was 6 to 10 years, with a median of 8.1 years. Factors associated with to the risk of ENI failure were analyzed.

RESULTS

(1) The overall 5-year actuarial local control rate and actuarial survival rate were 74% and 63%, respectively. (2) Among the 261 cases in which ENI treatment was used, the treatment failed in 12 cases, accounting for a crude ENI failure rate of 5%. The overall 5- and 10-year cumulative risk of ENI failure was 5% and 7%, respectively. (3) Time from the start of treatment to ENI failure ranged from 9 to 66 months, with a median of 17 months. (4) Of the 12 patients for whom EMI failed, 11 (92%) had recurrence in the upper neck, and one in the lower neck. (5) Existence of prior failure at the primary site was the only factor significantly correlated with the risk of ENI failure (p < 0.001). The 5-year cumulative risk of ENI failure for patients with local failure vs. those without was 16% vs. 1% (p < 0.0001).

CONCLUSION

Moderate-dose ENI was highly effective in the control of subclinical disease in the neck for NPC. ENI failure was closely associated with prior failure at the primary site, implying that local primary tumor failure may lead to an increased potential for metastasis to the neck.

Treatment of painful heels using extracorporeal shock wave

BACKGROUND AND PURPOSE

Shock wave therapy has been shown to improve many tendinopathies at the tendon-bone junction. The purpose of this study was to investigate the safety and effectiveness of extracorporeal shock wave therapy for the treatment of painful heels.

METHODS

Sixty-six patients, including 45 women and 21 men with an average age of 47.70 years (range, 19-75 years), were included in the study. Each patient received 1,000 impulses of shock waves at a 14-kV generator voltage at the affected site under local anesthesia. Twelve patients received a second treatment, and two patients received a third treatment.

RESULTS

Of 58 patients with 6 weeks' follow-up, five (9%) were complaint-free, 21 (37%) were significantly better, 27 (47%) were slightly better, and five (9%) were unchanged. Of 41 patients with 12 weeks' follow-up, 11 (27%) were complaint-free, 22 (54%) were significantly better, seven (17%) were slightly better, and one (2%) was unchanged. The results at 12 weeks were much better than those at 6 weeks. The effect of shock waves on painful heels continued between 6 and 12 weeks. Twelve patients who did not respond favorably to the first treatment showed significantly better results after a second treatment. Two patients who had a third treatment also achieved satisfactory results. There were no device-related problems or systemic or local complications.

CONCLUSIONS

Extracorporeal shock wave therapy is a new modality that is safe and effective in the treatment of painful heel spurs.

Concomitant boost radiation therapy for inoperable non-small-cell lung cancer: preliminary report of a prospective randomized study

PURPOSE

The radiation therapy results for patients with inoperable non-small-cell lung cancer (NSCLC) have been disappointing. Tumor dose escalation using concomitant boost technique (CBT) has been shown to improve local control in a few prospective studies. This trial was carried out to prospectively assess the radiation response and acute toxicity of CBT in comparison to the conventional treatment technique (CTT).

METHODS AND MATERIALS

Ninety-seven consecutive eligible patients were entered in this prospective clinical trial between November 1994 and February 1998. Patients were randomized to receive either CBT (43 patients) or CTT (54 patients) radiation therapy. These patients either refused chemotherapy or were judged as unsuitable for chemotherapy. Patients in the CBT group received 46.8 Gy in 26 fractions using large fields that encompassed the gross and occult disease. A concomitant boost of 18.2 Gy (0.7 Gy per fraction) was delivered to the gross disease using small fields with 1.5-cm margins. The small fields were treated concurrently with the large fields and the total dose to the tumor area was 65 Gy in 26 fractions. Patients in the CTT group received 70.8 Gy in 38 fractions. The acute toxicity between each group was compared. The response rate was analyzed and compared by treatment group, gender, age, stage, histology, initial Karnofsky performance score (KPS), severity of acute toxicity, and maximum body weight loss (MBWL) during treatment course.

RESULTS

The demographic parameters such as sex, age, and stage were evenly distributed in each treatment group. The majority of these patients had Stage IIIA and IIIB disease. Overall median treatment times were 39 days for the CBT group of patients and 62 days for the CTT group. No treatment-related mortality was found. There were 2 patients in the CTT group with acute RTOG Grade 3 lung toxicity, and no Grade 3 lung or esophageal toxicity was observed in CBT group. The response rates, assessed by radiographic images, were 69.8% and 48.1% for the CBT and CTT patients, respectively. Univariate and multivariate analysis revealed that patients in the CBT group, patients with better KPS, and patients with more severe acute toxicity had a higher response rate.

CONCLUSION

This study demonstrates that concomitant boost radiation therapy is tolerable, and produces a superior response rate than conventional radiation therapy for patients with inoperable NSCLC. The length of treatment was reduced from 38 to 26 treatment days, almost a 30% reduction.

Protective effect of Hibiscus anthocyanins against tert-butyl hydroperoxide-induced hepatic toxicity in rats

Hibiscus anthocyanins (HAs), a group of natural pigments occurring in the dried flowers of Hibiscus sabdariffa L., which is a local soft drink material and medical herb, were studied for antioxidant bioactivity. The preliminary study showed that HAs were able to quench the free radicals of 1,1-diphenyl-2-picrylhydrazyl. This antioxidant bioactivitiy was further evaluated using the model of tert-butyl hydroperoxide (t-BHP)-induced cytotoxicity in rat primary hepatocytes and hepatotoxicity in rats. The results demonstrated that HAs, at the concentrations of 0.10 and 0.20 mg/ml, significantly decreased the leakage of lactate dehydrogenase and the formation of malondialdehyde induced by a 30-min treatment of t-BHP (1.5 mM). The in vivo investigation showed that the oral pretreatment of HAs (100 and 200 mg/kg) for 5 days before a single dose of t-BHP (0.2 mmol/kg, ip) significantly lowered the serum levels of hepatic enzyme markers (alanine and aspartate aminotransferase) and reduced oxidative liver damage. The histopathological evaluation of the liver revealed that Hibiscus pigments reduced the incidence of liver lesions including inflammatory, leucocyte infiltration, and necrosis induced by t-BHP in rats. Based on the results described above, we speculate that Hibiscus pigments may play a role in the prevention of oxidative damage in living systems.

Radical laparoscopic surgery for carcinoma of the cervical stump

Traditionally, most women with cervical stump cancer underwent radiation therapy, as radical surgery was considered difficult. Given our success performing laparoscopic-assisted radical vaginal hysterectomy, we modified that technique to treat two women with carcinoma of the cervical stump. At follow-up of 14 and 17 months, respectively, both patients were free of recurrence.

Early catastrophic failure of rotating hinge total knee prosthesis

The mechanical failure of a prosthesis component is usually observed as a late complication of total knee arthroplasty (TKA). In knees with severe ligament instability and bone deficiency, either a true hinge prosthesis or a rotating hinge implant is commonly used. Failure of the polyethylene bearing bush in a hinge-type prosthesis is a complication that has not been reported to date. We report the cases of 2 rotating hinge TKA prostheses that dislocated as a result of mechanical failure of the prosthetic component within 5 months of initial implantation. Clinicians should be aware of this potential complication when selecting rotating hinge prostheses for certain patients.

Cartilage repair by free periosteal grafts in the knees of pigs: a histologic study

BACKGROUND AND PURPOSE

Periosteal grafts may result in cartilage formation and, therefore, have the potential to repair cartilage defects. We evaluated the histologic results of free periosteal grafts for the repair of full-thickness cartilage defects in pigs.

METHODS

A free autogenous periosteal flap from the proximal tibia was grafted to a size-matched, full-thickness articular defect on the lateral femoral condyle of the knees of 12 pigs. The same defect on the medial femoral condyle was used as a control lesion. Biopsies were performed at 4, 8, and 12 weeks after grafting.

RESULTS

The control lesions showed dense fibrous tissue with no evidence of cartilage-like tissues. The predominant tissues after grafting were mixtures of fibrous tissue, fibrocartilage, mesenchyme tissue, and occasional bone islands, but no cartilage tissue was identified. The tissue distribution did not change in the same knee from the week 4 to the week 8 biopsy; nonetheless, there were interindividual variations in tissue distribution.

CONCLUSIONS

The results of this study do not support the use of free periosteal transplantation for full-thickness cartilage defects of the knee.

Antibiotic-impregnated autogenic cancellous bone grafting is an effective and safe method for the management of small infected tibial defects: a comparison study

OBJECTIVE

Bone grafting plays an important role in reconstructing infected tibial nonunions. The effects of antibiotic-impregnated bone grafting in infection elimination and bone incorporation was reported in this retrospective study.

METHODS

Ninety-six patients treated for infected tibial nonunions were evaluated. These patients were managed with local antibiotic bead therapy and staged antibiotic-impregnated autogenous cancellous bone graft or pure autogenous cancellous bone graft. Patients were randomized to antibiotic-impregnated bone grafting or bone grafting-only groups on the basis of whether the admission date was odd or even. Patients were divided into two groups (antibiotic-impregnated bone grafting group and pure cancellous bone grafting group), according to the procedure used in preparing the bone grafts. The antibiotic-impregnated bone grafting group included 37 men and 9 women whose average age was 36 years (range, 17 to 72 years). The average follow-up period was 4.8 years. By using the Cierny-Mader staging classification of chronic osteomyelitis, 32 of 46 patients (70%) were stage 4A, and 14 of 36 patients (30%) were stage 4B. The pure cancellous bone grafting group included 39 men and 11 women whose average age was 37 years (range, 18 to 72 years). The average follow-up period was 4.5 years (range, 4 to 6 years). Thirty-nine of 50 patients (78%) were stage 4A, and 11 of 50 patients (22%) were stage 4B. The bone defects in both groups ranged from 2 to 4 cm.

RESULTS

Wound healing and bony union were achieved in the antibiotic-impregnated bone grafting group. Only two patients had recurrent infections. The infection arrest rate was 95.6%. However, 9 of 50 patients in the pure cancellous bone grafting group had recurrent infections. The infection arrest rate was 82%. The antibiotic-impregnated bone grafting group had significantly superior results (95.6% vs. 82% chi2 test, p < 0.05) in infection elimination than the pure cancellous bone grafting group.

CONCLUSION

After 4 to 6 years of follow-up, our results suggest that the use of impregnating antibiotics have no adverse effects on autogenic cancellous bone graft incorporation and could help to eliminate infection effectively.

Nasopharyngeal carcinoma with leptomeningeal dissemination: case report

Nasopharyngeal carcinoma (NPC) is a highly prevalent malignancy in southeast China, Hong Kong, and Taiwan. Spread of this tumor is known to occur via three main routes, i.e., local invasion of adjacent structures, regional metastasis to neck nodes, and hematogenous metastasis to distant organs. In this report, we describe a rare case of NPC disseminated via the leptomeninges, so called meningeal carcinomatosis (MC). The patient was a 62 year-old man who presented with multiple cranial nerve palsies and a headache, and was diagnosed with NPC in August 1988. The primary tumor regressed completely after induction chemotherapy and radiation therapy. Computerized tomography (CT) 17 months after radiation therapy showed multiple enhanced nodules scattered along the temporal meninges. The nodules increased in number and size in the subsequent CT scan 4 months later. The patient declined further invasive procedures and oncologic treatments, and he expired at home 9 months after the development of MC. It is speculated that perineural invasion and access to the subarachnoid space was the major cause of MC in this case. The case, although rare, possibly highlights a rare route of tumor dissemination in NPC.

Oral glutamine to alleviate radiation-induced oral mucositis: a pilot randomized trial

PURPOSE

To evaluate the influence of oral glutamine on radiation-induced oral mucositis in the radiotherapy of head and neck cancer.

METHODS AND MATERIALS

From July 1997 through June 1998, 17 patients with head and neck cancer receiving primary or adjuvant irradiation were randomized to either glutamine suspension (16 g in 240 ml normal saline) (n = 8) or placebo (normal saline) (n = 9) arm. Patients were instructed to swish the test solutions (30 ml) four times per day. All patients received half-mouth irradiation at least. Patients were treated 1.8 Gy per fraction daily, 5 days a week. We evaluated the grading of oral mucositis daily fraction at each day of treatment until 45 Gy/25 fractions. World Health Organization (WHO) step analgesic medication and body weight change were compared between the two arms.

RESULTS

The duration of objective oral mucositis > or = Grade 1 (p = 0.0097), Grade 2 (p = 0.0232), and Grade 3 (p = 0.0168) was shorter in the glutamine arm. Mean maximum grade of objective oral mucositis was less severe in the glutamine arm (1.6 vs. 2.6) (p = 0.0058). Glutamine did not reduce the duration and severity of subjective oral mucositis except for duration > or = Grade 3 (p = 0.0386). In the analysis of mean maximum WHO step of analgesic medication, there was no statistical difference (p = 0.5374) between the two arms. Mean body weight change was also not significantly different (p = 0.8070).

CONCLUSIONS

Oral glutamine may significantly reduce the duration and severity of objective oral mucositis during radiotherapy. It may shorten the duration of > or = Grade 3 subjective mucositis.

Laparoscopic extraperitoneal sacrospinous suspension for vaginal vault prolapse

BACKGROUND

A new laparoscopic sacrospinous suspension procedure is described for the correction of vaginal vault prolapse using an extraperitoneal approach. This is the first report in the literature of the extraperitoneal approach.

METHODS

We reviewed 12 women who had been treated in our hospital using this technique because of vaginal vault prolapse. These women had undergone hysterectomies (10 abdominal; 2 vaginal) between 5 and 22 years previously (mean, 12 years). After pre-laparoscopic preparation, a 10-mm trocar with a 10-mm zero-degree telescope was placed into the Retzius space. Using a direct air-distended method with a 20 mmHg insufflation pressure, Retzius and para-rectal spaces were created. The sacrospinous ligament could be easily identified and confirmed. A permanent suture was then inserted from the sacrospinous ligament to the vaginal vault to ensure that there was no space in between.

RESULTS

This procedure was followed for all 12 patients. There were no major complications during surgery. Eleven women had no recurrence of vaginal vault prolapse during a follow-up period of 1 to 3 years (mean, 2.2 years). One patient developed recurrent vaginal vault prolapse; however, she subsequently underwent a successful colposacropexy by laparoscopy 23 months after the initial surgery.

CONCLUSION

We modified the traditional sacrospinous fixation laparoscopically, following principles to restore the correct anatomic position of the vault. Laparoscopic extraperitoneal sacrospinous suspension can eliminate the procedure of opening and closing the peritoneum and avoid interference with the intestine during surgery. It can be used as an alternative to traditional genital suspension surgeries.

Comparison the efficacy of laparosonic coagulating shears and electrosurgery in laparoscopically assisted vaginal hysterectomy: preliminary results

OBJECTIVE

To compare the safety and effectiveness of laparosonic coagulating shears (LCS) and electrosurgery for use in laparoscopically assisted vaginal hysterectomy (LAVH).

STUDY DESIGN

In this prospective study, patients undergoing LAVH performed by one of the authors from October 1997 to January 1998 were assigned at random to the electrosurgery group (n = 20) or the LCS group (n = 20). Procedures performed with LCS or electrosurgery included coagulation and separation of infundibulopelvic or utero-ovarian round ligaments, vesico-uterine-visceral peritoneal fold dissection, and anterior and posterior colpotomy. Outcome measures were operative time, blood loss, decrease in hemoglobin values, and length of hospitalization.

RESULTS

The mean operative time (90+/-22.9 min versus 80.3+/-17.1 min, P = 0.391), blood loss (308+/-167 ml versus 250+/-104 ml, P = 0.11), and hemoglobin decrease (1.57+/-0.769 mg/dl versus 1.36+/-0.886 mg/dl, P = 0.55) were slightly greater in the LCS group than in the electrosurgery group, although these differences were not statistically significant. The length of hospital stay was similar in the two groups (5 days). No patients developed serious complications related to electrosurgery or LCS.

CONCLUSION

Our findings indicate that LCS is as safe and effective as electrosurgery, and may offer an alternative option for patients undergoing LAVH.

Inhibitory effect of 12-O-tetradecanoylphorbol-13-acetate-caused tumor promotion in benzo[a]pyrene-initiated CD-1 mouse skin by baicalein

The effects of topical application of baicalein on 12-O-tetradecanoylphorbol-13-acetate (TPA)-induced promotion of skin tumors, hyperplasia, ornithine decarboxylase activity, and inflammation were evaluated in female CD-1 mice. Topical application of baicalein (0.08, 0.16, or 0.2 mumol) with TPA (5 nmol) twice weekly for 24 weeks to mice previously initiated with benzo[a]pyrene inhibited the number of TPA-induced tumors per mouse significantly. Preapplication of the same amount of baicalein also afforded significant protection against TPA-induced hyperplasia in the ear skin. Topical application of baicalein inhibited tumor promoter-caused induction of epidermal ornithine decarboxylase activity by TPA (5 nmol). The topical application of baicalein (0.008, 0.016, or 0.02 mumol) inhibited TPA-induced edema of mouse ears by 88%, 96%, or 97%, respectively. Pretreatment of mouse skin with various amounts of baicalein caused inhibition of H2O2 and myeloperoxidase formation by TPA. These results indicate that baicalein can be a potential cancer-chemopreventive agent against tumor promotion.

Pituitary adenomas in adolescence--ten-year experience and literature review

Pituitary adenomas account for less than 6% of all intracranial tumors in adolescence. Between November 1987 and October 1996, 8 patients were treated by transsphenoidal resection at Kaohsiung Medical College Hospital. This series included 4 girls and 4 boys with ages ranging from 14 to 19 years. Symptoms reflecting endocrine dysfunction such as scanty pubic hairs in males and amenorrhea in females, were more often found than neurological problems in all adolescents at presentation. Macroadenoma occurred in five of our eight cases (62%) of adolescent pituitary adenoma. In one case (12%), the tumor was plurihormonal tumor. Long-term follow-up (mean 4.5 +/- 2.7 years) revealed the majority of patients had good endocrine function. Significant operative morbidity included steroid-induced psychosis in one patient and transient diabetes insipidus in three, which resolved in all three within two weeks. Our study showed that 1) pituitary tumors in children were uncommon, and when they occurred they were frequently large and invasive; 2) the endocrine disturbance caused by pituitary adenomas alerted the patients to seek medical help more often than neurological deficit; 3) in adolescence, almost all pituitary adenomas were functioning; nonfunctioning pituitary adenomas were rare in adolescence; and 4) transsphenoidal surgery was feasible and safe in adolescence, even with poor pneumatization of the sphenoid sinus, which remains controversial in the literature.

A huge 6.2 kilogram uterine myoma coinciding with omental leiomyosarcoma: case report

Surgery for massive abdominal tumors is both interesting and challenging. We present a case involving a multiple uterine myoma weighing 6.2 Kg which coincided with omental leiomyosarcoma. To our knowledge, this is the first report of this type of condition in the English literature. A 44-year-old nulliparous woman had suffered from abdominal pain for a long time. A huge abdominal mass was palpated on physical examination. Computed tomography scanning revealed a huge pelvic-abdominal mass with the possibility of small bowel loops invaded by the mass. A 6-cm omental mass was incidentally found during the subsequent hysterectomy procedure. Perforation of the urinary bladder occurred during the dissection of adhesion. Resection of the omental mass, wide wedge resection of the invaded small bowel, primary repair of the bladder, and hysterectomy were performed. The final pathologic diagnosis was uterine leiomyomata with omental leiomyosarcoma. The patient returned home on postoperative day 14 and was well at the 18-month follow-up examination. The challenge of these tumors lies in their proper diagnosis and surgical management. More case reports and follow-up studies are needed to confirm the efficacy of their management.

Endoscopic management of injured bowel using the automatic stapler

Bowel injury is a rare but potentially fatal complication of laparoscopy if it is unrecognized at the time of the procedure. Once a bowel injury is identified, it must be repaired by either laparoscopy or laparotomy. The Endo GIA 30 stapler is effective for achieving large-vessel hemostasis and facilitating laparoscopic procedures, and is reported safe for laparoscopic hysterectomy. It was used successfully in two women to repair extensive bowel injuries.

Paeoniflorin reverses guanethidine-induced hypotension via activation of central adenosine A1 receptors in Wistar rats

1. Intravenous injection of paeoniflorin, a glycoside purified from the root of Paeonia lactiflora, reversed guanethidine-induced hypotension in Wistar rats. 2. Pretreatment with the adenosine A1 receptor antagonist 8-cyclopentyl-1,3-dipropylxanthine inhibited this effect of paeoniflorin in a dose-dependent manner. 3. The action of paeoniflorin was not modified by 8-(p-sulfophenyl)theophylline, the polar antagonist of the adenosine A1 receptor, which is not able to enter the central nervous system. 4. We conclude that paeoniflorin can reverse guanethidine-induced hypotension via activation of adenosine A1 receptors in the brain of Wistar rats.