Factors regulating SCC antigen expression in squamous cell carcinoma of the uterine cervix

Expression of squamous cell carcinoma (SCC) antigen emerged concurrently with squamous formation of the uterine cervix and increased during the neoplastic transformation of the cervical squamous epithelium. SCC antigen expression differed considerably among the histomorphologic cell types of cervical carcinoma. Large cell nonkeratinizing carcinoma contained high levels of the antigen. In contrast, no appreciable expression of SCC antigen was observed in small cell nonkeratinizing carcinoma. The pattern of SCC antigen expression closely coincided with EGF receptor (EGF-R) expression in cervical squamous neoplasia. This suggests that the expression of SCC and EGF-R in cervical carcinoma is related to the differentiation or dedifferentiation processes of the tumor cells. SCC production by CaSki cervical epidermoid carcinoma cells was stimulated by EGF. It seems likely that an autocrine system, in which EGF serves as the signal, may exist in cervical squamous carcinoma. 17beta-estradiol and L-triiodothyronine were found to upregulate EGF-R expression, proliferative potential and SCC production in the CaSki cervical carcinoma cells.

Antenatal use of ambroxol for the prevention of infant respiratory distress syndrome

OBJECTIVE

Our purpose was to evaluate the efficacy and safety of ambroxol for the prenatal prophylaxis of infant respiratory distress syndrome (IRDS).

STUDY DESIGN

This was a prospective study with 2 groups of pregnant patients with premature labor or with premature rupture of membranes at an estimated gestation between 27 to 34 completed weeks. Ambroxol treatment group consisted of 39 subjects in whom 1,000 mg of ambroxol diluted in 500 ml of 5% glucose solution was given intravenously for 4 hours once a day for 3 days, while the control group consisted of 41 subjects in whom ambroxol was not administered. Main measures included Apgar scores, clinical signs of one or more of the following: respiratory rate of > 60/min, intercostal retraction, alar flaring, expiratory grunting, cyanosis on room air and radiological evidence of IRDS. Chi-square test was used to determine the statistical significance of the results.

RESULTS

Tolerable maternal side effects were noted. Profile of newborns delivered were similar in both groups. Incidence of IRDS was significantly less in the treatment group (p < 0.01).

CONCLUSIONS

Antenatal administration of ambroxol resulted in a significant decrease in the incidence of IRDS as well as perinatal morbidity and mortality. Due to the efficacy and safety of this drug, it might be useful for the prevention of IRDS.

[Binocular function of intermittent exotropia before and after surgery]

PURPOSE

We examined the binocular function of intermittent exotropia before and after surgery, and studied the effect of the surgery and the factor that might be involved in its result.

MATERIALS AND METHODS

402 intermittent exotropic patients, who underwent their first surgical correction for the strabismus at Teikyo University Hospital, were examined for retinal correspondence and stereo acuity before and after surgery.

RESULTS

367 patients (91.3%) had already had good stereo acuity before surgery when their eyes were straight. Regarding retinal correspondence, though 192 patients (47.8%) were abnormal (dual) before surgery, 301 patients (74.9%) were normal after surgery. The eye deviation of 101 patients who could not get normal retinal correspondence after surgery was significantly larger than normal (p < 0.001), and 77.2% of them had also vertical strabismus which was mainly composed of dissociated vertical deviation.

CONCLUSION

Normal binocular function could be recovered by surgical treatment in most intermittent exotropic patients. When patients could not get normal retinal correspondence after surgery, we supposed that dissociated vertical deviation might exert an important effect upon their binocular function.

Skew transposition of vertical rectus muscles for excyclovertical deviation

PURPOSE

The authors established a surgical treatment for excyclovertical strabismus in which either the inferior rectus muscle or the superior rectus muscle was transposed diagonally. The effects and the safety of the procedure, called skew transposition, were studied.

METHODS

Eighteen operations using local anesthesia with eye drops were performed on 17 cases, including 10 with superior oblique palsy. Diplopia was checked during the operation with the cooperation of each patient. Both the clinical findings and eye deviation were examined during observation periods.

RESULTS

After the first operation, the diplopia in the primary position had disappeared in 10 cases and had improved in the other 7. The average effect of all operations on excyclodeviation was a correction of 6.2 degrees in the primary position. In the 7 cases of superior oblique palsy that received nasal recession of the inferior rectus muscle, the average correction of excyclodeviation was 6.4 degrees, and vertical deviation improved 1.8 degrees per 1 mm of recession. In no case did the diplopia worsen, nor were there any complications.

CONCLUSIONS

This safe procedure facilitates the simultaneous improvement of both excyclo- and vertical deviations. It may become the treatment of choice for excyclovertical strabismus.

Expression of adrenomedullin by human granulosa lutein cells and its effect on progesterone production

OBJECTIVE

Adrenomedullin (AM) has diverse functions and is expressed in a variety of tissues. This study was conducted to investigate the expression of AM in the human ovary and its effect on progesterone production by human granulosa lutein cells.

DESIGN AND METHODS

Follicular fluid and blood samples were obtained at the time of oocyte retrieval from patients undergoing in vitro-fertilization cycles. Concentrations of AM in follicular fluid and plasma were measured by RIA. Granulosa cells were isolated from follicular fluid and expression of AM mRNA was examined by RT-PCR. Granulosa lutein cells were cultured in vitro and secretion of AM by those cells was determined by immunoprecipitation followed by PAGE. Immunohistochemical staining with human ovaries was carried out, using a specific antibody to AM. Furthermore, the effect of AM on progesterone production by cultured granulosa lutein cells was studied.

RESULTS

Concentrations of AM in follicular fluid collected just before ovulation were significantly higher than those in the plasma (P<0.01). AM mRNA was expressed in granulosa cells at the preovulatory stage. Cultured granulosa lutein cells secreted immunoreactive AM. With immunohistochemical staining, it was revealed that AM was most abundantly expressed in granulosa lutein cells at the midluteal phase. No appreciable staining for AM was observed in granulosa cells in primordial and preantral follicles, whereas immunolocalization of AM was noted in granulosa cells of dominant follicles although it was not as prominent as in granulosa lutein cells at the midluteal phase. Furthermore, addition of AM to cultured granulosa lutein cells augmented progesterone secretion in a dose-dependent manner.

CONCLUSIONS

These results suggest that AM is transcribed and secreted in human granulosa lutein cells as a local factor to enhance progesterone production by those cells.

Changes in proliferative potential, apoptosis and Bcl-2 protein expression in cytotrophoblasts and syncytiotrophoblast in human placenta over the course of pregnancy

In order to evaluate placental trophoblast proliferation and apoptosis during pregnancy, we investigated proliferating cell nuclear antigen (PCNA) expression, apoptosis and Bcl-2 protein expression in the human placenta using avidin/biotin immunoperoxidase method to examine PCNA and Bcl-2 protein expression, and TUNEL method to assess apoptosis. The appearance of apoptotic cells in very early term placental trophoblasts was also examined by transmission electron microscopy. PCNA was immunolocalized in the nuclei of cytotrophoblasts (C-cells). Determination of the mean percentage of PCNA-positive nuclei of C-cells revealed that PCNA expression in C-cells was highest in very early term (4th to 5th wk) placentas and significantly decreased with the advance of pregnancy. Bcl-2 protein was immunolocalized in the cytoplasm of syncytiotrophoblast (S-cell), being least abundant in very early term placentas, less abundant in early term and midterm placentas, and most abundant in term placentas. On the basis of TUNEL method, apoptosis was apparent in the nuclei of both C-cells and S-cell. The apoptosis positive rate of C-cell nuclei was highest in very early term 4th to 5th wk placentas, and significantly decreased in early term 7th to 9th wk and midterm placentas, but somewhat increased in term placentas compared to that in midterm placentas. On the other hand, apoptosis positive rate of S-cell nuclei was remarkably higher only in very early term 4th to 5th wk placentas compared to that in early term, midterm and term placentas. Transmission electron microscopy revealed the appearance of apoptotic nucleus in very early term placental trophoblasts. These results demonstrate for the first time that apoptosis in the human normal placenta predominates in both C-cells and S-cell in very early term 4th to 5th wk pregnancy and drastically diminished after 7th wk of pregnancy. An apparent increase in apoptosis in C-cells in term placentas compared to that in midterm placentas may reflect aging of the placenta or parturition-associated biological change. The abundant expression of Bcl-2 protein in S-cell in term placentas may be responsible for the diminished occurrence of apoptosis in S-cell in term placentas.

Screening of BRCA1 mutation using immunohistochemical staining with C-terminal and N-terminal antibodies in familial ovarian cancers

We examined the subcellular localization of BRCA1 proteins using immunohistochemical staining with C-terminal (GLK-2 antibody) and N-terminal (Ab-2 antibody) monoclonal antibodies in 44 familial ovarian cancers. Among these, 24 cases were associated with 13 independent germ-line mutations of BRCA1, and loss of heterozygosity (LOH) at one or more BRCA1 microsatellite markers was found in all 21 informative tumors tested. With GLK-2 antibody, cytoplasmic staining was observed in 15 of 16 tumors (93.8%) with mutation in exon 11, and BRCA1 staining was absent in 8 of 8 tumors (100%) with mutation in exons other than exon 11. When immunohistochemical staining was performed with Ab-2 antibody, both nuclear and cytoplasmic staining were observed in 14 of 16 tumors (87.5%) with mutation in exon 11. Interestingly, nuclear staining was observed in 3 of 3 tumors (100%) with mutation downstream of exon 11, even though no staining was detected in 5 of 5 tumors (100%) with mutation upstream of exon 11. On the other hand, in familial ovarian cancers without BRCA1 mutations, nuclear staining or both nuclear and cytoplasmic staining was observed in 18 of 20 specimens (90%) and 20 of 20 specimens (100%) with GLK-2 antibody and with Ab-2 antibody, respectively. These results suggest that an immunohistochemical assay in combination with employing the C-terminal and the N-terminal antibodies appears to have potential as a reliable and useful technique for the screening of BRCA1 mutations, at least to predict the status of mutation, upstream or downstream of exon 11.

Potential use of bioelectrical impedance analysis in the assessment of edema in pregnancy

OBJECTIVE

To evaluate the validity of Bioelectrical Impedance Analysis (BIA) in the assessment of edema in pregnancy.

METHODS

A prospective study of healthy women identified during the first trimester of pregnancy. From a pool of 200 eligible volunteers, BIA was conducted on 90 women during the rest of pregnancy and postpartum period.

RESULTS

The values for bioelectrical impedance in normal pregnant women decreased gradually in the course of pregnancy, whereas a more remarkable decrease in the values was noted in eight patients who developed edema. The bioelectrical impedance (BI) changes correlated closely with body weight changes. There was a strong relation between bioelectrical impedance values and the degree of edema. The precedent decrease of the values before the onset of edema was noted in seven of the eight patients with edema.

CONCLUSION

BIA can be a useful and practical method for the early detection and quantitative assessment of edema in pregnant women.

Adrenomedullin expression in the human endometrium

Immunohistochemical studies were performed using a specific antibody to human adrenomedullin (AM) to determine its presence and cellular localization in the human endometrium, in the different phases of the menstrual cycle, and in the postmenopausal period. Specimens were obtained from 21 patients who underwent abdominal hysterectomy for various reasons. The endometrium had no pathological lesion in all cases. In the early and mid proliferative phases of the menstrual cycle, no immunostaining for AM was noted in the endometrium. AM immunostaining in the endometrium became apparent in the late proliferative phase. The staining intensity of AM in the endometrium became more abundant in the secretory phase. No appreciable difference in the staining intensity of AM in the endometrium was noted among early, mid, and late secretory phases. Immunostaining for AM was evident in both the epithelial and stromal compartments of the endometrium. In the postmenopausal endometrium, there was intense immunostaining for AM only in the stromal compartment. This is the first study to demonstrate the expression of AM in the endometrium in relation to the menstrual cycle. The results obtained suggest the participation of AM in the growth and differentiation of the endometrium.

Comparative analysis of the effects of gonadotropin-releasing hormone agonist on the proliferative activity, apoptosis, and steroidogenesis in cultured porcine granulosa cells at varying stages of follicular growth

This study was conducted to analyze comparative effects of gonadropin-releasing hormone (GnRH) agonist on the proliferation, apoptosis, and differentiated function of cultured porcine granulosa cells from varying follicle stages. Comparative analyses of porcine granulosa cells from varying follicle stages to respond to GnRH agonist were performed in terms of proliferating cell nuclear antigen (PCNA) expression, occurrence of apoptosis, and 17beta-estradiol (E2) and progesterone (P) secretion. PCNA expression was examined by the avidin/biotin immunoperoxidase method with a monoclonal antibody to PCNA, and apoptosis was assessed by in situ DNA 3'-end labeling method and DNA fragmentation analysis. E2 and P were measured by radioimmunoassays. The PCNA positive rate of granulosa cells cultured in the presence of GnRH agonist (10(-9) M) was lower compared with that of cells cultured in the absence of GnRH agonist. However, the apoptosis positive rate was higher, and E2 and P secretion by cultured granulosa cells was lower in the presence of GnRH agonist (10(-9) M) compared with that in the absence of GnRH agonist. The inhibitory effect of GnRH agonist on PCNA positive rate of cultured cells was prominent in granulosa cells from small and medium but not from large follicles. By contrast, the inhibitory effect of GnRH agonist on E2 and P secretion by cultured cells was prominent in granulosa cells from large but not small and medium follicles. The stimulatory effect of GnRH agonist on apoptosis positive rate of cultured cells was, however, uniform regardless of the stages of follicular growth. These results demonstrate that GnRH agonist exerts diverse actions on granulosa cells over the course of follicular growth. One downregulates granulosa proliferation in immature follicles as well as steroidogenesis in mature follicles, and the other upregulates apoptosis of granulosa cells regardless of the stages of follicular growth.

Prenatal diagnosis of a Japanese family at risk for Tay-Sachs disease. Application of a fluorescent competitive allele-specific polymerase chain reaction (PCR) method

Tay-Sachs disease (TSD) is caused by mutation of the HEXA gene, which results in a deficiency of the alpha-subunit of hexosaminidase A. The major mutation in Japanese TSD is a G-to-T transversion at the 3'-splice site of intron 5. We established a fluorescent competitive allele-specific polymerase chain reaction (FCAS-PCR) method for detection of the mutation and applied it to prenatal diagnosis of a Japanese TSD family. FCAS-PCR distinguished the wild and mutant alleles clearly, with broad ranges in the amount of template DNA, the dNTP concentration, the MgCl2 concentration and the number of PCR cycles. After obtaining ethics committee approval and informed consent from the parents in the index family, chorionic villus sampling was performed. FCAS-PCR analysis using chorionic villus DNA disclosed that the fetus was homozygous for the mutation. To confirm the diagnosis, direct sequencing analysis of the genomic PCR fragment was performed, and showed the same results as those of the FCAS-PCR analysis. FCAS-PCR proved to be helpful for carrier screening and prenatal diagnosis in TSD families in the Japanese population. It would also be a useful DNA-diagnostic method for many other inherited disorders.

Estradiol-delivering vaginal rings for hormone replacement therapy

OBJECTIVES

This study was undertaken to determine the relief of climacteric symptoms by vaginal rings delivering estradiol and to monitor estrogen levels.

STUDY DESIGN

Rings releasing in vitro either 60 or 140 microg/d estradiol were used by 35 women who had undergone hysterectomy for each dose level. Hot flash and night sweat incidences, vaginal conditions, and complaints were recorded at clinic visits pretreatment and at 1 week, 2 weeks, 1 month, and monthly thereafter through 6 months. Serum samples were assayed for estradiol, estrone, and estrone sulfate.

RESULTS

Hot flash incidence was reduced by about 80% with either ring. Vaginal conditions and mood were improved. Fourteen of 70 women discontinued ring use during the trial, 5 because of ring expulsions. Mean (+/-SD) estradiol levels were 123 +/- 48 and 307 +/- 93 pmol/L for the low and high dosage levels, respectively. Mean estrone levels exceeded estradiol levels by 1.7-fold for the higher dosage ring and 2.6-fold for the lower dosage ring. Increases in estrone sulfate concentrations were many times greater than those of estradiol or estrone.

CONCLUSIONS

Vaginal rings are an acceptable method of delivery for periods of >/=6 months of doses of estradiol that reduce vasomotor symptoms and improve vaginal conditions. There was little difference in these responses between the 2 dosage levels.

Regulation of circulating levels of IGF-I in pregnant rats: changes in nitrogen balance correspond with changes in serum IGF-I concentrations

Serum IGF-I concentrations in rats decrease significantly in late pregnancy. To determine if the reduction in serum IGF-I concentrations is attributable to circulating GH or maternal nutritional status, we investigated the effect of treatment with recombinant human GH (rhGH: 100 microgram/rat per day) on IGF-I concentrations during late pregnancy, and evaluated the relationship between maternal nitrogen balance and IGF-I concentrations. Serum IGF-I concentrations and maternal nitrogen balance ((nitrogen intake)-(nitrogen content in faeces and urine)-(nitrogen content in fetus and placenta)) were measured by RIA and the Dumas method. In non-pregnant rats treated with rhGH for 3 days, serum IGF-I concentrations (835.4+/-59.5 ng/ml; P<0.01) were significantly greater than in those animals treated with saline (319.6+/- 95.6 ng/ml). In the pregnant rats, however, there was no significant difference in serum IGF-I between those treated with rhGH (151. 1+/-43.0 ng/ml) and those treated with saline (142.0+/- 39.9 ng/ml) from day 17 to 19 of pregnancy. Maternal nitrogen balance in the pregnant rats increased significantly from day 4 to day 10 of pregnancy (169.5+/-57.4 and 196.1+/- 33.4 mg/day, respectively; P<0. 05) compared with non-pregnant controls (31.9+/-19.9 mg/day) and decreased markedly from day 12 of pregnancy (79.8+/-60.1 mg/day; P<0. 05) onwards, to 14.9+/-47.8 mg/day on day 20 of pregnancy (P<0.01), significantly different from the value on day 10 of pregnancy. The mean difference in maternal nitrogen balance between pregnant and non-pregnant rats was positively correlated (r=0.87, P<0.01) with the mean difference in maternal IGF-I concentrations, using linear regression analysis. These results support the conclusion that the circulating concentration of IGF-I in pregnant rats is associated with the change in nitrogen balance, but not with circulating GH.

Molecular bases for the actions of ovarian sex steroids in the regulation of proliferation and apoptosis of human uterine leiomyoma

Uterine leiomyomas appear during the reproductive years and regress after menopause, indicating the ovarian steroid-dependent growth potential. In order to characterize the molecular mechanism of sex steroidal regulation of leiomyoma growth, we examined whether sex steroids could influence the proliferation of leiomyoma cells. As epidermal growth factor (EGF) has been shown to mediate estrogen action and play a crucial role in regulating leiomyoma growth, we also investigated the effects of sex steroids on EGF and EGF receptor (EGF-R) expression in leiomyoma cells. In cultures of leiomyoma cells, the addition of either estradiol (E(2); 10 ng/ml) or progesterone (P(4); 100 ng/ml) resulted in an increase in proliferating cell nuclear antigen (PCNA) expression in the cells, whereas in cultures of normal myometrial cells, the addition of E(2) augmented PCNA expression in the cells, but P(4) did not. Immunoblot analysis revealed that leiomyoma cells contained immunoreactive EGF and that P(4) treatment resulted in an increase in EGF expression in the cells, whereas E(2) treatment resulted in a lower EGF expression in the cells. By contrast, E(2) treatment augmented EGF-R expression in cultured leiomyoma cells, but P(4) did not. These results indicate that P(4) upregulates the expression of PCNA and EGF in leiomyoma cells, whereas E(2) upregulates the expression of PCNA and EGF-R in those cells. It is, therefore, conceivable that P(4) and E(2) act in combination to stimulate the proliferative potential of leiomyoma cells through the induction of EGF and EGF-R expression. We also found that Bcl-2 protein, an apoptosis-inhibiting gene product, was abundantly expressed in leiomyoma relative to that in normal myometrium and that Bcl-2 protein expression in leiomyoma cells was upregulated by P(4), but downregulated by E(2). It seems, therefore, likely that P(4) may also participate in leiomyoma growth through the induction of Bcl-2 protein in leiomyoma cells. The abundant expression of Bcl-2 protein in leiomyoma cells may be one of the molecular bases for the enhanced growth of a leiomyoma relative to that of normal myometrium in the uterus.

Management of acute chylothorax with hydrops fetalis diagnosed in the third trimester of pregnancy

A fetus with large pleural effusion and hydrops fetalis diagnosed in the third trimester was successfully treated with prompt vaginal delivery followed by drainage of the pleural cavity, after confirmation of congenital chylothorax and re-expansion of the lung with prenatal thoracentesis.

[Acquired progressive esotropia and acquired strabismus fixus]

BACKGROUND AND PURPOSE

We previously reported on acquired convergent strabismus fixus and its incomplete type of esodeviation, which we named acquired progressive esotropia. In this study, we tried to confirm that the esotropia was acquired and progressive and to determine the most appropriate surgical procedure.

SUBJECTS AND METHODS

Forty-three cases, 32 of acquired progressive esotropia and 11 of acquired convergent strabismus fixus with severe myopia, were rechecked to evaluate their clinical and physiological features. Thirty-seven cases underwent strabismus surgery and the surgical results were also evaluated.

RESULTS

We obtained positive proof that the esodeviation was an acquired situation and progressed into convergent strabismus fixus from some pictures at a young age. The condition of some of these patients developed into convergent strabismus fixus in a short time. Combined recession-resection operation and transposition of superior and inferior rectus muscles were effective for the patients without severe abducting disorders.

CONCLUSION

We must make a certain diagnosis of progressive esotropia in the early stages, because the condition of some of these patients will develop into strabismus in a short time if we miss the appropriate time for surgery.

Stromal Leydig cell tumor of the ovary. Case report and literature review

The stromal Leydig cell tumor is a very rare benign tumor originating from the ovarian stroma. Only seven cases have been reported, all in postmenopausal women, except for one in a 15-year-old girl. In the present case, masculinization developed over a few months in a 24-year-old woman. The serum concentration of testosterone was 4.7 ng/ml before operation. Left salpingo-oophorectomy and wedge resection of the right ovary were performed. The encapsulated left ovarian tumor was an ovarian stromal Leydig cell tumor on microscopic examination.

Comparison of magnetic resonance imaging and ultrasonography in the early diagnosis of interstitial pregnancy

OBJECTIVE

To investigate the usefulness of ultrasonography (USG) and magnetic resonance imaging (MRI) in the early diagnosis of interstitial pregnancy.

STUDY DESIGN

Four cases of interstitial pregnancy that showed characteristic ultrasonographic and MRI findings were studied. All cases received cornual resection, and the presence of interstitial pregnancy was confirmed by pathologic examination.

RESULTS

Three of four cases had a gestational sac in the uterine cornu or a protruding cornual mass and myometrium between the sac and uterine cavity on both USG and MRI. In the remaining case, preoperative diagnosis was inconclusive because no gestational sac was demonstrated by USG or MRI. Color flow mapping was conducted in three cases and revealed prominent peritrophoblastic blood flow.

CONCLUSION

The findings suggest that USG combined with color flow mapping is the first choice in the early diagnosis of interstitial pregnancy. MRI, which is an extremely expensive imaging technology, should be used only if transvaginal USG with color flow mapping is inconclusive in ruling out the diagnosis of interstitial pregnancy.

Clinical features and surgery for acquired progressive esotropia associated with severe myopia

PURPOSE

The purpose of this study was to evaluate the clinical and physiological findings and to determine the most appropriate surgical procedure for acquired progressive esotropia with severe myopia.

METHODS

Thirty-eight cases of acquired progressive esotropia with severe myopia were examined to evaluate their clinical and physiological findings. All cases were divided into four groups according to the limitation of their abduction. The eyeball in group IV is fixed in an extremely adducting position. Thirty-one cases underwent strabismus surgery; medial rectus muscle recession and lateral rectus muscle resection in 23 cases, transposition of superior and inferior rectus muscles (modified Jensen procedure included) in eight cases.

RESULTS

The medial rectus muscle recession with the lateral rectus muscle resection procedure was effective in the early stage of acquired progressive esotropia patients. Transposition procedure was effective in the severe abducting limited patients.

CONCLUSIONS

As the recession & resection procedure is easier than the transposition procedure, we recommend performing surgery in the earlier stage of the abducting disorder before the eyeball is fixed in an extremely adducting position.

Two cases of primary pulmonary hypertension diagnosed during pregnancy

Primary pulmonary hypertension (PPH) is a rare clinical entity with a high mortality in pregnancy, delivery and postpartum. This paper describes two clinical cases of PPH diagnosed in pregnancy with different severity and outcomes; Case 1 was diagnosed as PPH at 34 weeks of gestation with pulmonary arterial pressure of 60 mmHg and delivered successfully by cesarean section with uneventful postoperative course. Case 2 was diagnosed as PPH at 26 weeks of gestation with pulmonary arterial pressure of 120 mmHg and delivered by cesarean section but died on the 7th day after the operation because of serious and progressive pulmonary hypertension. Patients with primary pulmonary hypertension should avoid pregnancy because of the high mortality, although some cases including ours have been reported with positive outcome.

[Ebstein's anomaly associated with left ventricular dysfunction: a case report]

A 66-year-old man presented with Ebstein's anomaly associated with left ventricular dysfunction. He had been followed since 40 years of age for cardiomegaly and arrhythmia, and experienced episodes of orthopnea at the age of 64. He was referred to our hospital in April 1997 because of lower extremity edema. Physical examination revealed dilated external jugular vein, tenderness of the right hypocondorium, and lower extremity edema. Electrocardiography confirmed atrial fibrillation. Transthoracic echocardiography revealed bilateral atrial and ventricular dilation, and paradoxical septal movement. The apical four-chamber view demonstrated 15 mm apical displacement of the septal leaflet. Color Doppler echocardiography revealed moderate tricuspid regurgitation. Transesophageal echocardiography revealed low echoic and hypoplastic tricuspid valve. Left ventriculography showed diffuse hypokinesis, and the ejection fraction was 49%. The coronary artery was normal. Atrial septal defect was not detected. Diffuse fibrosis, which may be found in the hearts of patients with Ebstein's anomaly at autopsy may have been responsible for the left ventricular depressed systolic function in this patient.

Ineffective use of a detachable snare for colonoscopic polypectomy of large polyps

BACKGROUND

Colonoscopic polypectomy of large polyps may be associated with complications such as bleeding. Use of a detachable snare may reduce the risk of bleeding. We describe several instances in which the use of such a device proved to be ineffective.

METHODS

A detachable snare was used for colonoscopic polypectomy of large polyps in 18 patients (20 polyps), also applied at the residual stalk after conventional polypectomy in 5 patients (5 polyps), and evaluated retrospectively.

RESULTS

Sixteen of the 20 polyps were pedunculated, and 4 were semi-pedunculated. In 3 of the 4 semi-pedunculated lesions, the loop slipped off after polypectomy because the lesions were cut close to the site of encirclement. Bleeding occurred in 4 cases because of transection by the loop of a thin stalk (4 mm) before polypectomy (1), slipping of the loop in a semi-pedunculated lesion (1), or insufficient tightening of the loop (2). After conventional polypectomy, we could not effectively snare the residual stalk because of flattening in 3 of the 5 lesions.

CONCLUSIONS

Use of the detachable snare for polypectomy of thin stalked or semi-pedunculated lesions may result in technical failure of this technique. The stalk should be fully encircled with the snare before polypectomy. The detachable snare is difficult to apply at the residual stalk after conventional polypectomy.

Up-regulation by progesterone of proliferating cell nuclear antigen and epidermal growth factor expression in human uterine leiomyoma

Uterine leiomyoma is the most common smooth muscle cell tumor of the myometrium. Estrogen and progesterone (P4) are believed to be physiological regulators of leiomyoma growth. We recently showed that Bcl-2 protein, an apoptosis-inhibiting gene product, was abundantly expressed in leiomyoma relative to its expression in the normal myometrium and that Bcl-2 protein expression in cultured leiomyoma cells was up-regulated by P4, but down-regulated by 17 beta-estradiol (E2). To further characterize the molecular mechanism of sex steroidal regulation of leiomyoma growth, we examined the effect of menstrual phase on proliferating cell nuclear antigen (PCNA) expression in leiomyoma and investigated whether sex steroids could influence PCNA expression in leiomyoma cells cultured under serum-free conditions by immunoblot and immunohistochemical analyses. As epidermal growth factor (EGF) has been shown to mediate estrogen action and to play a crucial role in regulating leiomyoma growth, we also investigated the effects of sex steroids on the expression of EGF and EGF receptor (EGF-R) in cultured leiomyoma cells. The PCNA labeling index in leiomyomas was much greater in the secretory, P4-dominated, phase than in the proliferative phase of the menstrual cycle and was significantly higher than that in the adjacent normal myometrium throughout the menstrual cycle. In monolayer cultures of leiomyoma cells, the addition of either E2 (10 ng/mL) or P4 (100 ng/mL) resulted in an increase in PCNA expression in the cells compared to that in control cultures, whereas in monolayer cultures of myometrial cells, the addition of E2 augmented PCNA expression in the cells, but P4 did not. Immunoblot analysis of proteins extracted from cultured leiomyoma cells revealed that leiomyoma cells contained immunoreactive EGF with a molecular mass of 133 kDa and that the addition of P4 resulted in a remarkable increase in the expression of 133- and 71-kDa immunoreactive EGF in the cells compared to that in control cultures, whereas the addition of E2 resulted in a somewhat lower expression of immunoreactive EGF in the cells. Furthermore, immunocytochemical analysis with a monoclonal antibody to human EGF-R demonstrated that the treatment with E2 augmented EGF-R expression in the cells compared to that in untreated cells, but P4 did not. The concentrations of sex steroids used were within the physiological tissue concentrations found in leiomyomas and myometria. These results indicate that P4 up-regulates the expression of PCNA and immunoreactive EGF in leiomyoma cells, whereas E2 up-regulates the expression of PCNA and EGF-R in those cells. As it is evident that EGF plays a crucial role as a local factor in regulating leiomyoma growth, the P4-induced increase in PCNA expression in leiomyoma cells may be mediated by P4-induced enhanced expression of EGF-like proteins in the cells, whereas the E2-induced increase in PCNA expression in leiomyoma cells may be mediated by E2-induced enhanced expression of EGF-R in those cells. It is, therefore, conceivable that P4 and E2 act in combination to stimulate the proliferative potential of leiomyoma cells through the induction of EGF-like proteins and EGF-R expression in uterine leiomyoma.

Prenatal diagnosis of fetal urogenital abnormalities with oligohydramnios by magnetic resonance imaging using turbo spin echo technique

Turbo spin echo technique is a sequence that enables T2 weighted magnetic resonance (MR) images to be obtained in a few seconds. The purpose of this study is to evaluate the usefulness of this sequence in the prenatal diagnosis of fetal urogenital abnormalities associated with oligohydramnios, which make the ultrasound examination inconclusive. Two fetuses suspected of having prune belly syndrome and polycystic kidney on ultrasound examination were studied by MR imaging using turbo-spin echo method in utero. The images were compared with prenatal ultrasonography or post-mortem findings. In both fetuses, abnormalities were diagnosed correctly. This sequence is useful because it provides images of diagnostic quality in a very short scanning time.

Serum deprivation-induced apoptosis in cultured porcine granulosa cells is characterized by increased expression of p53 protein, Fas antigen and Fas ligand and by decreased expression of PCNA

Although serum deprivation induces apoptosis in several cell lines, biochemical characterization of the apoptosis in primary granulosa cells (GCs) induced by serum deprivation has rarely been reported. In the present study, GCs from small follicles of porcine ovaries were precultured under a serum-containing condition for seven days, then stepped down to a serum-free condition and cultured for the subsequent two days. GCs were subjected to DNA fragmentation and immunoblot analyses. Data indicated that serum deprivation induced GC apoptosis characterized by DNA laddering, which was associated with decreased expression of proliferating cell nuclear antigen (PCNA) and increased expression of p53 protein, Fas antigen and Fas ligand. Serum deprivation also resulted in an increase in a 115 kDa protein expression despite no detectable expression of a 66 kDa c-myc protein. This suggests that serum removal from primary GCs may activate multiple apoptotic pathways such as a p53-associated pathway and a Fas-Fas ligand pathway.

Biology of human trophoblast

In order to elucidate the regulation of placental growth, we have characterized the expression of proliferating cell nuclear antigen (PCNA), apoptotic DNA fragmentation and bcl-2 protein in human placenta during pregnancy. PCNA and bcl-2 protein expression were examined by immunohistochemical techniques, while the occurrence of apoptotic DNA fragmentation was assessed by in situ analysis of DNA 3'-end labeling method. Both PCNA expression and apoptotic DNA fragmentation were found in cytotrophoblasts (C-cells), being most abundant in early placenta, less abundant in midterm placenta and least abundant in term placenta. In contrast, bcl-2 protein expression was found in syncytiotrophoblasts (S-cells), being least abundant in early placenta, less abundant in midterm placenta and most abundant in term placenta. These data indicate that early placenta is characterized by the highly proliferative activity of C-cells associated with the increased occurrence of apoptosis, whereas term placenta is characterized by the abundant expression of bcl-2 protein in S-cells. Furthermore, effects of EGF on the proliferative activity and differentiated function of trophoblasts were investigated using an organ culture system. Explants of trophoblastic tissues were cultured with or without EGF, in the presence or absence of 10(-8)M triiodo-L-thyronine (T3) in a serum-free condition. In 4-5 week placentas, EGF and EGF receptor were almost exclusively localized in C-cells, and EGF augmented the proliferative activity of C-cells without affecting the ability to secrete hCG and hPL. By contrast, in 6-12 week placentas, EGF and EGF receptor were predominantly localized in S-cells, and EGF stimulated hCG and hPL secretion without affecting the proliferative activity of C-cess. The addition of T3 (10(-8)M) resulted in an increased secretion of immunoreactive EGF by cultured placental explants. These findings suggest that EGF acts as a local factor in regulating early placental growth and function in synergy with thyroid hormone. On the other hand, progesterone selectively inhibited pleise hCG (alpha, beta) mRNAs expression and decreased hCG secretion in normal placental tissues, whereas choriocarcinoma did not respond to progesterone. This suggests that inhibitory regulation of hCG synthesis in choriocarcinoma is different from normal placenta. It was also found that in molar trophoblasts and choriocarcinoma cells PCNA expression was high, but both bcl-2 protein and apoptotic signal expression were low. Characterization of choriocarcinoma hCG revealed that there are striking differences in carbohydrate structures between normal hCG and choriocarcinoma hCG. Sialic acid content in choriocarcinoma hCG was extremely lower compared to that in normal hCG. The detection of the alteration in hCG sugar chains is useful for biochemical diagnosis of choriocarcinoma.

Conservative management of post-operative peritoneal cysts associated with endometriosis

OBJECTIVE

To describe the usefulness of fine-needle aspiration cytology and drainage, followed by long-acting GnRH-agonist therapy in the management of post-operative peritoneal cysts with endometriosis.

METHODS

In six women who were diagnosed as having post-operative peritoneal cysts with endometriosis, fine-needle aspiration cytology and drainage was performed. Thereafter, four patients were treated with long-acting GnRH-agonists for 6 months. Two patients refused the treatment.

RESULTS

In all patients fine-needle aspiration yielded specimens which consisted of a population of mesothelial cells. The mean follow-up time was 4 years (range 3.5-5). The four patients treated with long-acting GnRH-agonists show no evidence of recurrence. In two patients who had no additional treatment, the recurrence of the cyst was noted 2 months and 5 months after the drainage.

CONCLUSION

Combination of fine-needle aspiration cytology and drainage and subsequent long-acting GnRH-agonist therapy can be a useful conservative management of post-operative peritoneal cysts associated with endometriosis.

Autoimmune causes of recurrent pregnancy loss

Recurrent pregnancy loss (RPL) is the loss of 3 or more spontaneous and consecutive pregnancies. There are many causes, such as genetic, anatomic, hormonal, medical and immunologic causes. Two theories, the alloimmune and the autoimmune theories, explain the immunologic cause. The Antiphospholipid Antibody (APA) Syndrome is considered as the autoimmune cause of RPL. It involves two antibodies, Lupus anticoagulant (LAC) and the anti-cardiolipin antibody (ACA). The rate of LAC is 7% and of ACA is 15%, among pregnant women. These two antibodies are believed to cause thrombosis in the maternal circulation, leading to the events that lead to the fetal losses. Women with these antibodies, along with other factors, are believed to be at high risk for RPL. The diagnostic criteria for the APA syndrome include elevated LAC or ACA serum levels and clinical findings of thrombosis, thrombocytopenia and RPL. Presently, the medical treatment of the APA syndrome includes heparin, low-dose aspirin, and immunoglobulins. There must also be an active attempt to search for other causes of RPL among patients with APA syndrome, such as anatomic, endocrinologic, anatomic and medical problems. Management of RPL should also include extensive counseling for the patient and her family.

[Expression of transforming growth factor-alpha and myc oncoprotein in the human ovary during follicular growth, atresia and corpus luteum formation regression]

OBJECTIVE

To investigate the expression of transforming growth factor (TGF)-alpha and myc oncoprotein on human follicular development and atresia in vitro.

METHODS

Ovarian tissues were obtained from 36 women with regular menstrual cycles who underwent abdominal hysterectomy for a variety of gynecological conditions. Expression of TGF-alpha and myc protein in the ovarian tissues was examined by immunohistochemical technique.

RESULTS

In primordial follicale only the oocyte showed intense immunostaining for both TGF-alpha and myc oncoprotein. Immunostaining for TGF-alpha in granulosa cells and theca interna cells became apparent in the follicles of preantral stage. With the increase in the size of follicles the intensity of immunostaining in the oocyte decreased, whereas the staining intensity of the granulosa and theca cells increased, and persisted in the corpus luteum and further intensifying during the midluteal phase. myc protein expression in granulosa cells was apparent only in the preantral follicle stage. In the regressing corpus luteum, expression of both TGF-alpha and myc oncoprotein was restricted only in the peripheral theca lutein cells adjacent to the central core of scar issue. In atretic follicles theca interna cells exhibited prominent immunostaining for TGF-alpha and myc protein.

CONCLUSION

TGF-alpha and myc oncoprotein combination play a role as intraovarian regulators through autocrine and paracrine mechanism and may participate in remodelling the initial growth of the oocyte, follicular growth, differentiate and apoptosis.

Increased expression of Bcl-2 protein in human uterine leiomyoma and its up-regulation by progesterone

Uterine leiomyoma is the most common benign smooth muscle cell tumor of the myometrium. Although Bcl-2 protein is known to be an apoptosis-inhibiting gene product and to prevent apoptotic cell death in a variety of cells, there are no published data regarding whether human leiomyomas express Bcl-2 protein. In the present study, we examined the expression of Bcl-2 protein in leiomyomas in comparison with that in the normal myometrium using an immunohistochemical method and immunoblot analysis with a monoclonal antibody to human Bcl-2 protein. Furthermore, we investigated whether sex steroid hormones could influence the levels of Bcl-2 protein expression in leiomyoma cells cultured in vitro under serum-free, phenol red-free conditions. Immunohistochemical staining for Bcl-2 protein was prominent in leiomyoma cells, but was scarcely present in normal myometrial smooth muscle cells. The expression of Bcl-2 protein in leiomyoma cells was most abundant in the secretory, progesterone-dominated, phase of the menstrual cycle, but was less abundant in the proliferative phase of the menstrual cycle. Western blot analyses of leiomyoma and myometrium tissue extracts revealed that Bcl-2 protein, with a molecular mass estimated at approximately 26 kDa, was abundantly present in leiomyoma tissue extracts, but was undetectable in normal myometrial tissue extracts. In monolayer cultures of uterine leiomyoma cells under a serum-free condition, the addition of progesterone (100 ng/mL) resulted in a striking increase in Bcl-2 protein expression in the cultured leiomyoma cells relative to that in control cultures, whereas the addition of 17 beta-estradiol (10 ng/mL) resulted in a reduction in Bcl-2 protein expression in the cells. The concentrations of sex steroids used were within the physiological tissue concentrations found in leiomyomas and myometrium. The present results suggest that the abundant expression of Bcl-2 protein may have a molecular basis characteristic of leiomyomas in the human uterus and that progesterone may play a vital role in the enhanced expression of Bcl-2 protein in human uterine leiomyoma cells.

[Tumor necrosis factor alpha regulates the proliferative activity and differentiated function of granulosa cells: in vitro study with a porcine model]

Ovarian folliculogenesis is a dynamic process during which follicles undergo growth and differentiation. It is now evident that various growth factors interact with FSH to modify follicular growth and function. In the present study, the effects of tumor necrosis factor alpha (TNF alpha) on the proliferative potential and steroidogenic ability of granulosa cells were examined in vitro as a function of follicular growth by using a porcine model. Porcine granulosa cells obtained from small (1-2mm), medium (3-5mm) and large (6-12 mm) follicles were cultured under serum-free conditions in the presence or absence of FSH (100 ng/ml) and IGF-1 (100 ng/ml), with or without various concentrations of TNF alpha. The proliferative activity of cultured granulosa cells was assessed by immunocytochemical techniques with a monoclonal antibody to proliferating cell nuclear antigen (PCNA) and by [3H]-thymidine uptake, while differentiated functions of granulosa cells were assessed by determining the ability to secrete progesterone and 17 beta-estradiol. The addition of FSH and IGF-I augmented the proliferative activity and steroidogenic ability of cultured granulosa cells. The increases in proliferative activity and steroidogenic ability caused by treatment with FSH and IGF-I were significantly reduced by the concomitant treatment with TNF alpha in culture of granulosa cells. The inhibitory effect of TNF alpha on the proliferative activity was prominent in small follicle granulosa cells, whereas the inhibitory effect of TNF alpha on estradiol secretion was very strong in large follicle granulosa cells. The inhibitory effect of TNF alpha on progesterone secretion was apparent regardless of the stage of follicular growth. These results suggest TNF alpha participation in regulating the proliferation and differentiation of granulosa cells. In appears that the biological action of TNF alpha on granulosa cells may shift from the inhibition of proliferative activity in immature follicles to the inhibition of differentiated function in mature follicles during the course of follicular growth.

Immunological evidence for the expression of the Fas antigen in the infant and adult human ovary during follicular regression and atresia

Immunohistochemical localization of the Fas antigen in the infant and adult human ovary during follicular growth, regression, and atresia was examined by the avidin/biotin immunoperoxidase method with a monoclonal antibody to the Fas antigen. Western blotting was used to confirm the presence of the Fas antigen protein. In primordial and primary follicles within the normal adult ovary, only the oocyte showed moderate immunostaining for the Fas antigen. In secondary and antral follicles, only the oocyte showed weak staining for the Fas antigen, while in preovulatory follicles, neither the oocyte nor the granulosa and theca cells were immunostained for the Fas antigen. In corpora lutea, the Fas antigen staining became apparent in the granulosa lutein cells during the early luteal phase and intensified during the mid luteal phase, while the theca lutein cells became positive for the Fas antigen staining during the mid luteal phase. During the late luteal phase, the staining intensity of the Fas antigen in the regressing corpora lutea further increased. As the regressing corpora lutea were converted into corpora albicans, the staining intensity decreased, and the corpora albicans and stromal cells were negative for the Fas antigen. In atretic primordial and primary follicles, only the degenerating oocyte showed the Fas antigen staining. By contrast, in atretic antral follicles, the Fas antigen staining was profound in the degenerating granulosa cells at the early stage of atresia, and at the mid stage of atresia it was intensified in the cell surface of the scattered granulosa cells and became apparent in the theca cells. At the late stage of atresia the Fas antigen remained only in the hypertrophied theca cells. In the infant ovary, only the oocyte in primordial and primary follicles exhibited intense staining for the Fas antigen. In the postmenopausal ovary, the Fas antigen staining was entirely negative. Western blot analysis revealed the presence of the Fas antigen protein with a molecular mass of 45 kDa in luteal tissues. On the basis of the recent evidence, that the Fas antigen mediates an apoptotic signal in a variety of cells, the abundant expression of the Fas antigen in the regressing corpora lutea and atretic follicles suggests that the Fas antigen participates in luteal regression and follicular atresia through the apoptotic process. Furthermore, notable expression of the Fas antigen in the oocyte of primordial and primary follicles within the infant and adult human ovary followed by the decrease in the Fas antigen expression in the oocyte with the advance of follicular maturation suggests that the Fas antigen expression in the oocyte may play a role in follicular selection.

Comparison of immunocytologic localization of insulin-like growth factor binding protein-4 in normal and polycystic ovary syndrome human ovaries

The cytologic localization and cellular levels of insulin-like growth factor binding protein-4 (IGFBP-4) in follicular and stromal compartments of normal and polycystic ovary syndrome (PCOS) ovaries during follicular growth and regression were investigated by the avidin/biotin immunoperoxidase method with a polyclonal antibody to human IGFBP-4, and a comparative assessment of IGFBP-4 expression in normal and PCOS ovaries was provided. In normal human ovaries, IGFBP-4 was immunolocalized to the oocyte throughout follicular growth, while the surrounding granulosa and theca cells were negligible for IGFBP-4 immunostaining in primordial, preantral and antral follicles. IGFBP-4 immunostaining became apparent, however, in the lutein cells of corpora lutea and the granulosa and theca cells of atretic follicles. In PCOS ovaries, prominent immunostaining for IGFBP-4 was apparent not only in the oocyte, but also in the surrounding granulosa cells in preantral follicles. In antral follicles from PCOS women without hyperinsulinemia, IGFBP-4 immunostaining was more prominent in the granulosa cells than the theca cells, whereas in antral follicles from PCOS women with hyperinsulinemia IGFBP-4 immunostaining was more prominent in the theca cells than the granulosa cells. Furthermore, in atretic follicles within PCOS ovaries IGFBP-4 immunostaining was prominent in the theca cells, regardless of the association of hyperinsulinemia. These results demonstrate for the first time that there is a great difference in cellular expression of IGFBP-4 between normal and PCOS human ovaries. In light of the high affinity of IGFBP-4 for IGF-1, the abundant expression of IGFBP-4 in granulosa and theca cells of preantral and antral follicles of PCOS ovaries may lead to decreases in the bioavailability of IGF-I in those follicles. The decrease in IGF-I-mediated stimulation of gonadotropin actions on granulosa and theca cells in preantral and antral follicles may impair the induction of aromatase activity, causing an androgenic microenvironment which is characteristic of atretic follicles and PCOS follicles.

Results of surgery for paralytic exotropia due to oculomotor palsy

In 138 cases of paralytic exotropia due to oculomotor palsy, transposition of the superior oblique muscle and resection of the medial rectus muscle were carried out. Surgery was performed with or without recession of the lateral rectus muscle. The long-term prognosis for 4 years or more was observed in 35 cases. We found that the same results could be obtained by selecting transposition of the superior oblique muscle in cases of complete palsy and resection of the medical rectus muscle in cases of incomplete palsy. There was no benefit in combining resection of the medial rectus muscle when performing the transposition of the superior oblique muscle. Regardless of which method was used, a combination with recession of the lateral rectus muscle greatly improved the effectiveness of the procedure.

Immunohistochemical evidence for the presence of tumor necrosis factor-alpha in the infant and adult human ovary

The cytologic localization and cellular levels of tumor necrosis factor-alpha (TNF alpha) in the human ovary during follicular growth and regression were examined by the avidin/biotin immunoperoxidase method with a specific antibody to human recombinant TNF alpha. In the infant ovary, TNF alpha immunostaining was present only in the oocyte within the primordial follicles. TNF alpha immunostaining was also present within the oocyte in primordial follicles of the adult ovary. Positive immunostaining for TNF alpha in granulosa cells became apparent in preantral follicles, while that in theca interna cells began to appear at the antral follicle stage. The staining intensity of the oocyte increased as the oocyte reached the preovulatory stage. The intensity of immunostaining for TNF alpha in the granulosa and thecal cells increased as the follicle became larger and matured. In corpora lutea, the immunostaining for TNF alpha persisted in the granulosa lutein and theca lutein cells and intensified in the mid luteal phase. In the regressing corpora lutea, TNF alpha immunostaining in the luteal cells decreased as the regression advanced. Regressed corpora lutea with a central core of scar tissue were bordered by macrophage-like cells which exhibited intense immunostaining for TNF alpha. In the cortex region, the corpus albicans was negative for TNF alpha immunostaining, whereas macrophage-like cells peripheral to the corpus albicans exhibited intense immunostaining for TNF alpha. In the medullary region, the corpus albicans and surrounding stromal cells were totally negative for TNF alpha. By contrast, in the early atretic stage, the degenerating oocyte showed weak immunostaining for TNF alpha, while the granulosa and theca interna cells showed moderate immunostaining for TNF alpha. In the late atretic stage, the immunostaining for TNF alpha in the scattered granulosa cells became negligible, whereas the theca interna cells showed intense immunostaining for TNF alpha. The results obtained indicate that the oocyte is the primary intrafollicular site of TNF alpha localization within the ovary and that TNF alpha may participate in regulating follicular growth, regression and atresia.

Histopathological assessment of lymph node metastasis in patients with gastric cancer

BACKGROUND/AIMS

Lymph node dissection has been carried out for two decades in Japan, resulting in improved survival of patients with gastric cancer. By analyzing dissected nodes of resected advanced gastric cancers, we intend to determine which parameter(s) are more concerned in node metastasis.

PATIENTS AND METHODS

Curative gastrectomy with dissection of lymph nodes was performed for 78 of the 108 patients with advanced gastric cancer. Metastases were found in 171 of 1359 nodes (13%) dissected. In each node, the maximum and minimum diameters were measured, and the ratio of the former to the latter was calculated.

RESULTS

The minimum diameter of node was closely related to node metastasis. When the minimum diameter in node metastatic criteria was "3 mm or more", a sensitivity of 81% and specificity of 54% were calculated. In false negative node, signet-ring cell carcinoma (SIG) (33%) and poorly differentiated adenocarcinoma (POR) (22%) were more frequently found as primary lesions. Half or more of these nodes were invaded by only a few carcinoma cells. When the primary lesion is histologically SIG or POR, endoscopic treatment is contraindicated for possible nodes metastasis.

CONCLUSIONS

It is impossible to distinguish nodes with micrometastasis from nodes without metastasis. The minimum diameter of node is more important in node metastasis of gastric cancer than the maximum diameter of node or the ratio of both.

[Surgical and botulinum toxin treatment in two cases of abnormal retinal correspondence-exotropia with congenital homonymous hemianopsia]

We report 2 unusual cases of congenital occipital hemianopsia associated with abnormal retinal correspondence (ARC)-exotropia. Two Japanese males, 25 and 28 years of age, visited our hospital for surgical correction of manifest exotropia with dissociated vertical deviation and overaction of the superior oblique muscle. Visual field examination demonstrated homonymous hemianopsia with approximately 5 to 10 degrees of macular sparing. Visually evoked potential examination showed small amplitude similar to dissociated vertical deviation patients in all half-field stimulation. Electrooculogram examination demonstrated defective pursuit to the ipsilateral side. Some investigators have speculated that progressive exotropia compensates for homonymous hemianopsia and is a rare contraindication for strabismus surgery. To confirm the deterioration of motor and visual functions before surgery in these patients, we tried injections of botulinum A type toxin into the lateral rectus muscle ipsilateral to the hemianopsia. Contrary to the hypothesis, our patients had no change in their binocular visual fields and visual function. Finally, we performed recession of the lateral rectus muscle, so that both patients were satisfied with their ocular alignment, with no marked change of visual behavior.

[Computed tomography findings in convergent strabismus fixus]

X-ray computed tomography (CT) of the eyeball and orbit revealed the cause of eye movement disorder in convergent strabismus fixus. The findings suggest that the disease can be diagnosed and treated at an early stage. Twelve cases of progressive esotropia with high myopia and 20 cases with normal visual acuity served as subjects in this study. The CT slice was parallel to the German horizontal plane, and the lens and medial and lateral rectus muscles were scanned. The average axial length of the affected eyes was significantly longer than in normal eyes. In progressive esotropia, the characteristic CT findings are an elongated eyeball, mechanical contact between the eyeball and lateral wall of the orbit, and a downward displacement of the lateral rectus muscle. Thus, it is reasonable to conclude that eye movement disorder in convergent strabismus fixus results from weakness of the lateral rectus muscle which has been displaced downward due to compression of the eyeball against the orbital wall.