Completion pneumonectomy of the residual left lung to treat lung cancer in a patient with hemophilia A: report of a case

Hemophilia A is a sex-linked recessive hereditary disease that is relatively rare and the number of patients with this disorder who undergo major surgery is limited. Although replenishing coagulation factors can allow hemophiliac patients to undergo similar surgery to that performed for patients without hemophilia, there have been few reports on major surgery and none on the resection of lung cancer in patients with hemophilia A. We recently performed completion pneumonectomy of the left lung in a 70-year-old man with hemophilia A, for squamous cell carcinoma in the residual left lung. The administration of a recombinant DNA coagulation factor VIII preparation allowed this operation to be successfully carried out. This case serves to demonstrate that the recombinant DNA coagulation factor VIII preparation described may enable us to safely perform major surgery on hemophiliac patients, since there is no risk of viral infection or any other adverse effects, such as deterioration of immunocompetence or hemolysis, which are occasionally encountered with human plasma-derived preparations.

Pathologic significance of Staphylococcus saprophyticus in complicated urinary tract infections

OBJECTIVES

To determine the pathologic significance of Staphylococcus saprophyticus in complicated urinary tract infections.

METHODS

We performed a retrospective analysis of specimens demonstrating this organism based on a survey of 9980 urine specimens cultured in our clinic during an 11-year period. Forty-two specimens from 34 patients were positive for S. saprophyticus.

RESULTS

S. saprophyticus was isolated in 13 women without underlying urologic disease, and their symptoms were compatible with acute cystitis or acute pyelonephritis. S. saprophyticus was isolated from 7 men and 14 women with underlying urologic disease. In most of these 21 patients, S. saprophyticus was thought not to be a true uropathogen but rather a colonizer, because the isolated organism was usually low in numbers and found with a low degree of pyuria, and the hosts were usually asymptomatic. However, 2 patients demonstrating S. saprophyticus colonization developed sepsis after urologic surgery.

CONCLUSIONS

Although this organism is pathogenic in certain circumstances, suggesting the necessity of preoperative antimicrobial elimination, it is usually a colonizer in complicated urinary tract infections.

Development of small hepatocellular carcinoma 80 months after clearance of hepatitis C virus with interferon therapy

We describe a patient who had a complete and sustained response to interferon (IFN) therapy for chronic hepatitis C but developed small hepatocellular carcinoma (HCC) 80 months later. A 55-year-old Japanese man with hepatitis C virus (HCV) infection and histological features of chronic active hepatitis was treated with recombinant IFN alpha-2a, 9,000,000 U daily for 2 weeks followed by three times a week for 22 weeks. He successfully responded to IFN therapy with a normalization of serum alanine aminotransferase and continuous disappearance of serum HCV-RNA. However, 80 months after the cessation of IFN therapy, the patient's alpha-fetoprotein (AFP) level became elevated for the first time and HCC, 12 mm in diameter, was detected by routine ultrasonographic screening. Laparotomy revealed a small HCC with no metastasis, and the nontumorous liver demonstrated chronic inactive hepatitis. This case indicates the need for careful follow-up using ultrasonography and AFP testing for at least 7 years after completing IFN therapy in all patients with chronic hepatitis C, even if the patients have a complete response to the therapy.

In vitro selection of fluoroquinolone-resistant Neisseria gonorrhoeae harboring alterations in DNA gyrase and topoisomerase IV

PURPOSE

We attempted to select increasingly fluoroquinolone-resistant strains of Neisseria gonorrhoeae in vitro and to assess whether selected mutants harbored alterations in the GyrA subunit of DNA gyrase and the ParC subunit of DNA topoisomerase IV, which were analogous to those in fluoroquinolone-resistant clinical isolates.

MATERIALS AND METHODS

A fluoroquinolone-susceptible strain was exposed to norfloxacin in vitro. Selected mutants were sequentially exposed to norfloxacin, and this procedure was repeated. For 11 mutants, minimum inhibitory concentrations (MICs) of antimicrobial agents were determined, and mutations in the region corresponding to the quinolone resistance-determining region (QRDR) of the Escherichia coli gyrA gene and the analogous region of the parC gene were analyzed.

RESULTS

Mutants obtained in one step exhibited significantly increased MICs of norfloxacin, ofloxacin and ciprofloxacin and had a single amino acid change in GyrA. Two-step mutants exhibited significantly higher norfloxacin MICs. Three of four two-step selected strains had single amino acid changes in both GyrA and ParC. Three-step mutants exhibited further increases in fluoroquinolone MICs and were assigned to the ciprofloxacin-resistant category. Two had a double amino acid change in GyrA, and one had a double GyrA change and a single amino acid change in ParC.

CONCLUSION

We selected fluoroquinolone-resistant strains that carried GyrA and ParC alterations analogous to those in clinical isolates. The serial accumulation of changes in the QRDR of GyrA and the analogous region of ParC was associated with a stepwise increase in fluoroquinolone resistance, although the development of additional alterations in other regions of GyrA and ParC or other mechanisms of fluoroquinolone resistance also might contribute to the enhancement in fluoroquinolone resistance. The clinical emergence of fluoroquinolone-resistant strains may be due to in-vivo stepwise selection of strains with genetic alterations in GyrA and ParC, as observed here in the in-vitro selection of fluoroquinolone-resistant mutants.

Case report. Localized pulmonary zygomycosis without pre-existing immunocompromised status

Pulmonary zygomycosis rarely occurs without pre-existing immunocompromised disease. A 72-year-old male was found to have a nodular shadow (3 cm x 4 cm) in the right S8 and S9 on a chest X-ray. Right lower lobectomy was performed and histological examination of the resected material demonstrated pulmonary zygomycosis. Hyphae stained positively not only with Grocott-Gomori methenamine silver staining, but also with an anti-Rhizopus oryzae polyclonal antibody.

[A case of preoperatively diagnosed primary pulmonary leiomyosarcoma]

A 29-year-old woman had been suffering from right back pain for 3 months. Chronic pulmonary thromboembolism was suspected and she was referred to our hospital. She presented with no risk factors for thromboembolism, and during the previous 6 months had lost 4 kg in body weight. Chest radiography showed nodular shadows in the lower field of the right lung. Contrast-enhanced computed tomography demonstrated a filling defect in the right pulmonary artery and nodular lesions in the lower field of the right lung, which were considered to be signs of pulmonary infarction. Absence of perfusion into the right lung was demonstrated by a perfusion scan. Right heart catheterization showed normal pressure in the pulmonary arteries, and pulmonary angiography showed an abrupt cutoff of the right pulmonary artery, which was similar to the finding of pulmonary thromboembolism. A transvenous catheter suction biopsy was performed in the right pulmonary artery and the histopathologic findings yielded a diagnosis of leiomyosarcoma. The patient underwent surgical resection under total cardiopulmonary bypass. A large tumor completely filled the right main pulmonary artery and invaded the posterior wall of the pulmonary trunk close to the left main pulmonary artery. Primary pulmonary leiomyosarcoma is a rare tumor and its prognosis is very poor. Radical surgical resection is the only effective treatment, but early diagnosis is very difficult. Transvenous catheter suction biopsy is a useful procedure for the early diagnosis of pulmonary artery sarcoma.

[Bacillus Calmette-Guerin intravesical instillation treatment for carcinoma in situ of the bladder. Gifu BCG Instillation Therapy Research Group]

We performed a retrospective long-term study to evaluate the efficacy of intravesical instillation of Tokyo 172 strain Bacillus Calmette-Guerin (BCG) on carcinoma in situ (CIS) of the bladder. Between 1989 and 1998, 42 patients with CIS of bladder underwent intravesical instillation of BCG. In the follow-up period from 6 to 116 months (mean: 37.3 months), the efficacy rate of intravesical BCG instillation for CIS of the bladder was 81.0%. Two patients died from the bladder cancer. The non-recurrence rate in patients with grade 2 carcinoma (19 cases) was not significantly different from that in those with grade 3 carcinoma (23 cases). However, the recurrence rate in patients with secondary CIS (15 cases) was significantly higher than in those with primary CIS (27 cases). The recurrence of CIS was observed in 7 of 42 cases. In 6 of 7 patients, CIS recurred within one year after treatment. Total cystectomy was performed in 10 of 42 patients, and pathological findings of muscle layer invasion were detected in 8 patients. Although side effects occurred in 33 patients (77.5%), no clinically significant side effects were observed. Our results suggest that intravesical BCG therapy may be useful for the treatment of CIS of the bladder.

[The current status of molecular detection of micrometastatic prostate cancer cells]

We summarized and reviewed published reports, including our studies, on the reverse transcription-polymerase chain reaction (RT-PCR) detection of micrometastatic prostate cancer cells in lymph nodes, bone marrow and peripheral blood. Some published data preliminarily suggest that the RT-PCR assay of micrometastatic prostate cancer cells may allow a more accurate assessment of lymph node and bone metastases of prostate cancer, and offer a presurgical prediction of the pathological stage of clinically localized disease. In addition, the RT-PCR assay may have a unique prognostic value in prostate cancer. However, controversy remains over the clinical significance of the RT-PCR assay. This assay could potentially develop into a diagnostic procedure for the clinical decision making in patients with prostate cancer. To establish the clinical significance of the RT-PCR assay, further optimized and standardized RT-PCR assay studies are needed, investigating large populations and involving long-term follow-up for the determination of any association between the results of the RT-PCR assay and specific clinical outcome.

[Treatment of recurrent cancer after surgery for biliary malignancies]

Our strategy for recurrent tumor after surgical resection for biliary malignancies, especially for hilar cholangiocarcinoma, is described. One hundred and thirty-three patients with hilar cholangiocarcinoma underwent curative resection in our department until November, 1998, and recurrent carcinomas have been pointed out in 73 patients (54.9%). The site of recurrence was peritoneum (21 cases), liver (16 cases), pre-caval and retro-duodenal space (15 cases), hepatic hilum (11 cases), lymph node (9 cases), bone (6 cases), sinus tract of percutaneous transhepatic biliary drainage (PTBD) (5 cases) and so on. Surgical resection was applied to recurrent carcinomas after careful evaluation, and 9 patients underwent surgical resection of the recurrent tumor: sinus tract of PTBD in the abdominal and/or chest wall (4 cases), lymph node (2 cases), liver (1 case), hepaticojejunostomy (1 case) and duodenum (1 case). There were three hospital death patients. Other six patients survived for 16 months on an average (11-20 months) after surgery for recurrent tumor. PTBD for recurrent cancer at the hepatic hilum and gastrojejunostomy for local recurrence around the duodenum improved quality of life of patients. Radiation therapy for bone metastasis or local recurrence at the hepatic hilum was sometimes very effective. Effect of systemic or transarterial chemotherapy is still unknown.

Using minimum deviation of a secondary rainbow and its application to water analysis in a high-precision, refractive-index comparator for liquids

A new method for measuring the refractive-index difference of a liquid has been developed. The liquid to be measured is contained in a 60-mm-diameter, cylindrical glass cell, and a He-Ne laser light is passed into the cell so that the laser light incidence fulfills the condition of minimum deviation. In this condition, the beam emerging from the cell has a fine interference fringe. The position of the interference fringe is read out as a marker to measure the deflection of the laser light. Directly reading the peak shift of the interference fringe makes it easy to obtain the refractive index difference of the liquid with a fairly high precision of at least 6 x 10(-6). Further high precision is potentially expected to be realized by use of an improved data analysis treatment of the overall interference fringe pattern.

Tapetum-specific expression of theOsg6B promoter-β-glucuronidase gene in transgenic rice

The promoter of an anther tapetum-specific gene,Osg6B, was fused to aβ-glucuronidase (GUS) gene and introduced into rice byAgrobacterium-mediated gene transfer. Fluorometric and histochemical GUS assay showed that GUS was expressed exclusively within the tapetum of anthers from the uninucleate microspore stage (7 days before anthesis) to the tricellular pollen stage (3 days before anthesis). This is the first demonstration of an anther-specific promoter directing tapetum-specific expression in rice.

Myofibroblastoma of the breast: report of a case

We report herein the case of a 36-year-old woman in whom a breast mass was diagnosed histologically and immunohistochemically as myofibroblastoma (MFB). The patient initially presented with a breast mass measuring 1.0 x 1.5 cm which was demonstrated by mammography as a well-circumscribed, round tumor with two coarse calcifications. On ultrasonography, the tumor showed slight shadowy internal echoes. Histological examination of an excisional biopsy specimen demonstrated a tumor consisting of spindle-shaped cells and broad bands of hyalinized collagen with cartilaginous and osseous components, but no epithelial components were observed. Immunohistochemically, the tumor cells were diffusely positive for alpha smooth muscle actin, and a diagnosis of MFB was made. A wide excision of the breast was performed as a secondary procedure, and the patient is well and free from recurrence 1 year after her operation. We present this case to stress the need for breast surgeons to be aware of the existence of MFB when considering the differential diagnosis of stromal lesions of the breast to avoid performing unnecessarily extensive procedures.

Transgenic plant production mediated by Agrobacterium in Indica rice

A reproducible system has been developed for the production of transgenic plants in indica rice using Agrobacterium-mediated gene transfer. Three-week-old scutella calli served as an excellent starting material. These were infected with an Agrobacterium tumefaciens strain EHA101 carrying a plasmid pIG121Hm containing genes for β-glucuronidase (GUS) and hygromycin resistnace (HygR). Hygromycin (50 mg/l) was used as a selectable agent. Inclusion of acetosyringone (50μM) in the Agrobacterium suspension and co-culture media proved to be indispensable for successful transformation. Transformation efficiency of Basmati 370 was 22% which was as high as reported in japonica rice and dicots. A large number of morphologically normal, fertile transgenic plants were obtained. Integration of foreign genes into the genome of transgenic plants was confirmed by Southern blot analysis. GUS and HygR genes were inherited and expressed in R1 progeny. Mendelian segregation was observed in some R1 progeny.

Determination of growth fraction index in mammary carcinoma using MIB-1 monoclonal antibody: estimation of whole tumor proliferative potential using biopsy specimens

We labeled the Ki-67 antigen in mammary carcinomas, using a MIB-1 monoclonal antibody, to evaluate the usefulness of MIB-1 Ki-67 Growth Fraction Indices (GFI; number of Ki-67 positive cells/total number of cells) of biopsy specimens in estimating the proliferative potential of the carcinomas. Formalin-fixed paraffin sections prepared from biopsy material, primary tumors, and axillary lymph nodes of ten invasive mammary carcinomas were chosen for immunohistochemical study. Bound antibody was detected using the avidin-biotin-complex peroxidase method. The GFI of the resected mammary carcinomas was similar to the estimated values based on the GFI of the biopsy specimens. The GFIs of the metastatic nodes in seven of the carcinomas were similar to those of the primary carcinomas, whereas two carcinomas yielded significantly different GFIs in the metastatic foci. These results suggest that the GFI of a mammary carcinoma biopsy specimen may reflect the proliferative ability of the whole carcinoma.

Report of a case of benign cystic mesothelioma

A 32-yr-old man was admitted to Anjo Kosei Hospital for the examination of a cystic peritoneal lesion. This patient had a past medical history significant for an appendectomy. Ultrasonography and computed tomography revealed multiple cysts in the abdominal and pelvic cavities. An exploratory laparotomy was performed on July 1, 1993, revealing numerous thin-walled and translucent cysts in the serosal tissues of the parietal and visceral abdominal peritoneum. These cysts were excised surgically because of clinical suspicion of pseudo-myxoma peritonei. Microscopic examination revealed cysts within the thin cyst wall that were composed of fibrous connective tissue and lined by a single layer of cuboidal or flattened epithelium. Immunohistochemical and ultrastructural studies demonstrated that the lining cells were of mesothelial origin, and the diagnosis was benign cystic mesothelioma. In this paper, we present appropriate diagnostic and treatment procedures for benign cystic mesothelioma and discuss the particular usefulness of using immunohistochemical methods to achieve a histological diagnosis.

Frantz's tumor (solid and cystic tumor of the pancreas) with liver metastasis: successful treatment and long-term follow-up

A rare case of Frantz's tumor with liver metastasis is reported. An 11-year-old girl had local resection of a Frantz's tumor in the head of the pancreas. Ten years later, she had a recurrence in the pancreatic head, and two liver metastases were also disclosed at reoperation. Pancreaticoduodenectomy and enucleation of metastatic lesions in the liver were performed. Six years after the second operation, she is well and free of disease. A review of 174 cases of Frantz's tumor disclosed that metastatic disease in the pediatric age group is extremely rare and yet the prognosis is favorable. On the other hand, the outcome in older patients, especially those over 40 years old, is very poor.

[The thalamic changes in progressive supranuclear palsy]

This report is to investigate neuropathological changes of the thalamus observed in progressive supranuclear palsy. Six autopsy cases were examined. They were 5 males and a female, whose age was between 57 and 72 years old. They developed dementia in various degrees and three of the cases showed periodic stuporous state and akinetic mutism in the last stage. The paraffined thin-sections were stained with hematoxylin-eosin, luxol-fast-blue, Holzer, modified Bielschowsky, Gallyas and anti-tau stainings. The histological changes were evaluated in the aspects of neuronal loss, fibrillary gliosis and neurofibrillary tangles. In conclusion, there were three types in six cases. The first was seen in two cases and that there appeared many Alzheimer's neurofibrillary tangles (NFTs) in medial nuclei, lateral and ventral nuclei as well as zona incerta and reticular nucleus. The second was observed in two cases and that the loss of nerve cells was severe, especially in medial nuclei and the dorsal part of lateral and ventral nuclei and fibrillary gliosis was observed beyond the lesions of neuronal loss. The third was that the appearance of NFTs was moderate in number and neuronal loss was minimal. Moreover, neuronal loss and NFTs of zona incerta were common in these cases. Argentophilic fibrillary inclusions were observed in the neuropil and astrocytes in all cases. It is important to investigate the correlations between neuropathological changes and clinical manifestations, especially in the peculiar type of dementia observed in PSP. The thalamic changes of PSP may play an important role in causing stuporous state and akinetic mutism as well as subcortical dementia.

Gerstmann-Sträussler syndrome--a variant type: amyloid plaques and Alzheimer's neurofibrillary tangles in cerebral cortex

This report presents a variant of Gerstmann-Sträussler syndrome (GSS). A 53-year-old female had developed slowly progressive dementia and atactic gait since the age of 45. No myoclonic jerks and periodic synchronous discharges were observed throughout the illness. The neuropathological study revealed that many amyloid plaques and widespread Alzheimer's neurofibrillary tangles (NFTs) appeared in the cerebral cortex. Characteristically, the plaques reacted with anti-prion protein and none of them reacted with anti-beta protein, and they were made of many components, including amyloid cores, macrophages laden with lipid granules and/or degenerated neurites. Neuropil threads were seen mainly in amyloid plaques. Moreover, plaques appeared which were confluent and laminar in arrangement in the fifth and sixth cortical layers and had a close relationship to the neuronal loss. There was no spongiform change in the cerebral cortex or cerebellum. The cerebellum was almost intact except for a few amyloid plaques. Ultrastructurally, some of the plaques simulated kuru plaques and others had many degenerated neurites possessing paired helical filaments and other accumulated organelles. GSS has been proposed to include cases with progressive ataxia, dementia and massive multifocal plaques in the brain with or without cerebral spongiform changes. The case presented here is a very peculiar case of GSS. Recently, similar cases have been reported in some large families, diagnosed as familial Alzheimer's disease. These cases may be a telencephalic form with numerous NFTs of GSS.

Degeneration of the corticopontine tract in olivopontocerebellar atrophy

Nine cases of sporadic olivopontocerebellar atrophy [Déjérine-Thomas type, multisystemic atrophy (MSA)] were examined histologically and electron microscopically with special reference to the corticopontine tract. Five of nine cases showed degeneration of the myelinated nerve fibres in this tract. More severe degeneration of the fibres at the level of the pons than the crus cerebri indicates that degeneration of the fibres may start axodistally. Electron microscopy revealed selective involvement of large fibres in olivopontocerebellar atrophy, in contrast to unselective axonal atrophy in dentatorubropallidoluysian atrophy. The problem whether the degeneration of the tract is primary or secondary due to the loss of the pontine neurons remains open. We believe the former to be most likely. Degeneration of the corticopontine fibres should be added to the list of neuropathological findings in sporadic olivopontocerebellar atrophy.

A nuclear magnetic resonance spectroscopic and conformational study of eight pseudo-trehaloses (D-glucopyranosyl 5a-carba-D- and -L-glucopyranosides)

N.m.r. data (1H and 13C) are presented for eight pseudo-trehalose derivatives in which the D-glucopyranosyl moiety is alpha or beta and the 5a-carbaglucopyranoside moiety is alpha-D, beta-D, alpha-L, or beta-L. The differences in the chemical shifts and then n.O.e. effects have been correlated with the preferred conformations estimated from empirical force-field calculations (HSEA), which have been used to calculate the average parameters over the whole energy surface. Of the four alpha-D-glucopyranosyl derivatives, only that with a 5a-carba-beta-D-glucopyranoside moiety (3) was a substrate for glucoamylase.

[An autopsy case of complicated form of spastic paraplegia with amyotrophy, mental deficiency, sensory impairment, and parkinsonism]

An autopsied case of complicated form of spastic paraplegia with many unusual clinical and pathological features is reported. Present case: a 31-year-old male. His parents are first cousins. Pregnancy and delivery had been unremarkable. Though he was mentally retarded, his physical development was normal. He was considered normal until age 10. He suffered from progressive disturbance in gait at the age of 11. He could not walk without assistance at the age of 22. Neurological examination revealed the following findings. He was obese and mentally deteriorated. Spastic paraplegia with increased tendon reflexes and pathological reflexes was prominent. Though slight sensory disturbance was present in the lower extremities, neither involuntary movement nor cerebellar ataxia was observed. In the age of late 20's, dementia, general muscular atrophy, and Parkinsonism developed. At the age of 30, he could not move by himself. He was apathic and indifferent, and showed forced laughing. Muscle tonus was flaccid because of general muscular atrophy and peripheral neuropathy. He died of acute gastric enlargement. Neuropathological findings were characterized by mal-development of the central nervous system (CNS) and the multisystem degeneration. There existed cerebral white matter hypoplasia with hypogenesis of the corpus callosum and ectopia of neurons of the cerebral and cerebellar cortex. Hypoplasia of melanin pigment was also observed in the remaining neurons of the substantia nigra and the locus ceruleus. Many neurons in the CNS included lipofuscin granules of variable shapes. Some of them showed clusters of several block-like inclusions which were green with luxol fast blue and cresyl violet stain.(ABSTRACT TRUNCATED AT 250 WORDS)