New multi-disciplinary treatment modality with RALS for patients with esophageal cancer

Esophageal cancer is frequently found when it is already in the advanced stage and curative surgery for such cases is consequently difficult to perform. The new multi-disciplinary treatment for esophageal cancer presented here was, therefore, conceived to improve both the survival rate and quality of life of these patients. This combined treatment modality consists of limited surgery, external irradiation, intracavitary irradiation with remote-controlled after-loading system (RALS) and peri-operative chemotherapy. In the present series, 45 patients with esophageal cancer received esophagectomy and on another 11 patients bypass operation was performed. All patients were treated with this multi-disciplinary treatment after operation. A 3 cm-wide thin gastric tube was made from the greater curvature of the stomach of the patient using an autosuture apparatus (PLC55 or GIA). In the bypass operation, the jejunum was anastomosed to the original esophagus in the Roux-en Y fashion and jejunostomy was performed on the oral side of the Roux loop. A silastic tube of 9 mm inner diameter was inserted from the jejunostomy and placed into the original esophagus for the purpose of postoperative intracavitary irradiation with RALS. For the patients receiving esophagectomy, a similar silastic tube was also placed in the posterior mediastinum for intracavitary irradiation with RALS. The indication of the bypass operation was i) a tumor length longer than 9 cm on the X-ray film and/or ii) direct invasion to the aortic wall evident by CT or MRI examination. Two weeks after the operation, external irradiation to the mediastinum with Linac 10 MV X-ray, and to the bilateral cervical regions with Linac 15 MeV electron beam, was started. The irradiation doses were 30 Gy (2 Gy/day, 5 times/ week) and 48 Gy (4 Gy/day, 3 times/week), respectively. The intracavitary irradiation with RALS was started shortly before the end of the external irradiation period and was delivered from a 60Co source. The total dose was 24 Gy (6 Gy/day, once a week) for the esophagectomized cases, and 18 Gy for the bypassed cases. Two or three weeks after the termination of the radiotherapy, chemotherapy with cisplatinum and 5-fluorouracil was performed and repeated every 6 months for 2 years. All patients could eat normally and were discharged after finishing the first chemotherapy session. The overall 5-year survival rate was 49% for the esophagectomized cases and 11% for the bypassed cases. The longest survival time in the bypassed cases was 5 years and 4 months. Neither operative death nor severe complications were experienced during the treatment period. The results indicate that this newly developed multi-disciplinary treatment with RALS can improve the prognosis and the quality of life not only in the esophagectomized patients but also in the bypassed patients with advanced esophageal cancer.

High-risk human papillomavirus infection and overexpression of p53 protein in squamous cell carcinoma of the esophagus from Japan

The present study was undertaken in order to investigate the possible involvement of high-risk human papillomavirus (HPV; types 16 and 18) or the overexpression of p53 protein in 123 Japanese patients with esophageal squamous cell carcinoma (SCC) from five different institutions. We detected HPV DNA in 30.1% (37/123) by in situ hybridization (ISH). Of these 123 cases, HPV type 16 was detected in 22 cases and HPV type 18 in 23 cases. In addition, HPV types 16 and 18 were detected simultaneously in eight cases. We found an almost similar incidence of HPV infection at five different places in Japan. Then, among these patients, 24 fresh tumor samples were also examined for screening the presence of HPV DNA using dot blot hybridization (DBH) and polymerase chain reaction (PCR). We detected HPV DNA in 20.8% (5/24) by DBH and in 12.5% (3/24) by PCR. P53 protein overexpression was found in 34.1% (43/123) by immunohistochemistry (IHC). Furthermore, in 43 cases from Kochi Medical School, the group positive for p53 antibody statistically showed worse survival rate than the group negative for both HPV DNA and p53 antibody. Judging from these results obtained in the present study, HPV infection and p53 overexpression are frequently detected and involved in the carcinogenesis of esophageal SCC in Japan. We also found that no significant geographical difference of both HPV infection and p53 overexpression of esophageal SCC was seemingly present in Japan.

Hepatic cirrhosis: magnetisation transfer contrast in the globus pallidus

The magnetisation transfer ratio (MTR), a quantitative tissue characteristic, and the pallidal index were measured in the globus pallidus of 37 patients with hepatic cirrhosis and 37 control subjects. The MTR decreased with severity of the disease, as indicated by the serum total bililubin, indocyanine green 15-min retention rate, and plasma ammonia. The pallidal index correlated significantly with haematological parameters, although the correlation coefficients tended to be lower than those between MTR and haematological parameters. This change in MTR corresponded to the results of the manganese chloride experiments. T1 shortening in the pallidum of patients with cirrhosis is presumably caused by paramagnetic effects, and possibly attributed to manganese deposition.

The Two Nuclei in the Dikaryon of the Homobasidiomycete Coprinus cinereus Change Position after Each Conjugate Division

We constructed a common-AB diploid strain of Coprinus cinereus and mated this to a compatible haploid strain to construct a diploid-haploid dikaryon. We examined the positions of the diploid and haploid nuclei in the apical and subapical cells of the dikaryon by fluorescence microscopy and microfluorometry. In 60% of apical cells the leading nucleus (the nucleus proximal to the hyphal apex) was diploid and the second nucleus (the nucleus distal to the apex) was haploid, whereas in the remaining 40% of apical cells the order of the two nuclei was reversed. It was also observed that in 97% of hyphae examined the order of the diploid and haploid nuclei was reversed between the apical cell and the subapical cell. Based on these observations, we conclude that the two nuclei alternate in taking the leading and second positions in the apical cell at almost every conjugate division in the dikaryon. Copyright 1998 Academic Press.

Use of high-performance liquid chromatography as an extraction procedure for analysis of triazolam in decomposed human muscle by gas chromatography-mass spectrometry

A reliable and sensitive method for the determination of triazolam in human muscle using gas chromatography-mass spectrometry (GC-MS) is described. The drug was extracted from decomposed human muscle using three-step liquid-liquid extraction and HPLC which was performed isocratically on a conventional ODS column with a mobile phase of 0.01 M phosphate buffer (pH 6.5)-acetonitrile (7:3). Estazolam was used as an internal standard. GC-MS analysis was performed on a DB-5 capillary column. Excellent linearity was obtained over the concentration range 1-200 ng/g. The lower limit of detection was approximately 0.5 ng/g. Forensic application of the present method was also described.

The well-balanced nucleoside-nucleotide mixture "OG-VI" for special medical purposes

Nucleotides and nucleosides are essential components in all cells. However, nucleotides have not been supplied in parenteral nutrition regimens. We developed a well-balanced nucleoside-nucleotide mixture "OG-VI" and examined its effect in animals under some stressed conditions. OG-VI was composed of 30 mmol/l of inosine, 30 mmol/l of guanosine monophosphate, 30 mmol/l of cytidine, 22.5 mmol/l of uridine and 7.4 mmol/l of thymidine. The whole body protein turnover increased significantly in rats receiving total parenteral nutrition (TPN) with OG-VI solution after 70% hepatectomy, compared with rats receiving normal TPN without OG-VI (122.1 +/- 20.9 mgN.kg-1.h-1 vs. 97.4 +/- 10.1 mgN.kg-1.h-1, P < 0.01, n = 10). OG-VI significantly enhanced protein synthesis while it did not decrease protein breakdown. The effect of OG-VI on myocardium after hypoxic challenge was also examined in rats. The creatine phosphate (PCr)/inorganic phosphate (Pi) was decreased in normal rat myocardium after hypoxic challenge. However, in the rats administered OG-VI, PCr/Pi was maintained at baseline level and did not decrease after hypoxia. There was no significant change in the level of adenosine triphosphate (ATP) between before and after hypoxic challenge in myocardium of the rats administered OG-VI. In the rats receiving normal saline, instead of OG-VI, the ATP level decreased significantly after hypoxic challenge (4132 +/- 276 nmol/g tissue, n = 3, vs. 3439 +/- 465 nmol/g tissue, n = 5, P < 0.05). These data suggested that the well-balanced nucleoside-nucleotide mixture, OG-VI improved nitrogen metabolism and might stimulate synthesis of high-energy phosphate in recovery after severe surgical stress.

Sensitive detection of human globin chains by microbore high-performance liquid chromatography and its forensic application

This paper describes a simple and sensitive high-performance liquid chromatographic (HPLC) method for the detection of human globin chains in blood and bloodstains. The method involves direct injection of the filtered samples of dilute hemolysates or bloodstain extracts onto a microbore C4 reversed-phase column (2.1 mm I.D.) with UV detection at 220 nm. Microbore HPLC offers a significant improvement in sensitivity with little loss of the resolution of globin chains and only small variations in the determination of gamma chain composition. The detection limit of hemoglobin (Hb) was 0.1 microgram, which is equivalent to about 1 nl of fresh whole blood. Umbilical cord blood could be differentiated from adult blood in stains that were up to twenty weeks old, by the presence of gamma globin chains. The present method will be useful for detection of abnormal Hbs and for the determination of gamma chain composition in clinical laboratories, as well as in the practice of forensic science for the analysis of minute amounts of blood and bloodstains.

Genetic variation at five STR loci in subpopulations living in Turkey

Five short tandem repeat (STR) systems HumVWA, HumTH01, HumCD4, HumF13B and HumFES were investigated in 2 subpopulations living in Turkey (Laz Turks and Kurds). The population genetic data were compared to a Turkish population sample from the Adana area. A closer genetic relationship was found to the Laz Turks than to the Kurdish sample which was also confirmed by phylogenetic tree reconstruction with seven populations from three major ethnic groups (Caucasian, Asian and African). In contrast to the Laz and Adana populations the Kurdish sample showed relatively low heterozygosity values and deviations from Hardy-Weinberg equilibrium in four of the five systems.

Detection of toluene in an adipoceratous body

A 24-year-old male was found dead in a car left in a river for about 3 months. The cadaver was almost adipoceratous and autopsy findings revealed that there were neither remarkable injuries nor lethal diseases. Toluene, ethanol, 1-propanol, 2-propanol, 1-butanol, dimethyl sulfide, dimethyl disulfide, isovaleraldehyde and n-butyl n-butyrate were detected in the specimens collected at the autopsy by head space gas chromatography/mass spectrometry (GC/MS). The toluene concentrations (micrograms/g) were 31.0 in brain, 10.6 in liver, 5.4 in kidney, 15.0 in skeletal muscle and 187.1 in adipose tissue. The presence of diatom in lung, liver and kidney suggested that death was caused by drowning. So far as we know, this is the first report of detection of toluene in an adipoceratous body.

Solitary pancreatic metastasis occurring eight years after nephrectomy for renal cell carcinoma. A case report and surgical review

CONCLUSION

Pancreatic metastasis from renal cell carcinoma is extremely rare. The average time between nephrectomy and the diagnosis of metachronous metastases is reported to exceed 10 yr. Therefore, the initial diagnosis may be neglected in the cases of prolonged disease-free interval. When it does occur simultaneously or metachronously, aggressive surgical resection, when possible, seems to be the most effective treatment for this metastatic lesion.

BACKGROUND

An 81-yr-old female patient, who 8 yr previously had undergone right radical nephrectomy for renal cell carcinoma, presented with solitary pancreatic metastasis, which was successfully treated with a distal pancreatectomy. Only 66 cases of clinically diagnosed renal cell carcinoma metastatic to the pancreas are reported in the world literature and 49 of the patients (including ours) underwent a definitive surgical resection. Our case, treated by distal pancreatectomy, and a review of the relevant literature including all reported cases of renal cell carcinoma metastatic to the pancreas, are presented.

RESULTS

The patient was well without any evidence of recurrence at 22 mo after the operation.

Secondary carnitine palmitoyltransferase deficiency in chronic renal failure and secondary hyperparathyroidism

A 14-year-old girl, having mental and growth retardation with end stage renal disease, was affected by a stroke-like attack. The attack was associated with transient low density areas at both sides of the parietal portion on head CT. Lactic acidosis, hypertrophic cardiomyopathy, angina pectoris-like attacks, hypertension and hyperparathyroidism were also observed and they were supposedly due to mitochondrial cytopathy. No morphological or biochemical abnormalities were found on the mitochondrial respiratory chain. However, muscle carnitine palmitoyltransferase (CPT) activity was significantly low, which was restored to a normal level after hyperparathyroidism was controlled by alphacalcidol administration. Furthermore, we also found two more chronic renal failure patients with secondary hyperparathyroidism, as well as the primary hyperparathyroidism patient showing markedly low muscle CPT activity. These findings suggest the possible contribution of parathyroid hormone to lipid metabolism in skeletal muscle and to the myopathic manifestations often seen in hyperparathyroidism.

Induction of apoptotic cell death in rat thymus and spleen after a bolus injection of methamphetamine

We examined whether methamphetamine (MAP) induced apoptotic cell death in vivo. Male Wistar rats were injected intraperitoneally with 25 mg MAP/Kg body weight and were sacrifice at 4, 8 and 24 h. As early as 4 h after a single dose of MAP, DNA ladder bands representing DNA fragmentation into multiples of the internucleosomal DNA length of about 180 by were observed by gel electrophoresis in thymic and splenic DNA. DNA from control rats injected with 1 ml physiological saline/Kg body weight showed no ladder band patterns. The proportion of fragmented DNA from the thymus increased in a time-dependent manner up to 8 h and faint ladder band patterns were observed at 24 h, indicating that cell death via apoptosis occurred at an early stage and then apoptotic bodies were scavenged. DNA fragmentation in the thymus and spleen induced with MAP was also confirmed by the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) method in situ. In control thymus samples, stained cells were numerous in the cortex but sparse in the medulla. At the boundary area between the cortex and medulla, stained cells were seen as a layer. In the MAP-treated rats, stained cells were increased and dispersed equally in the cortex and medulla. In control spleen samples, stained cells were numerous in all areas excluding the germinal centers. Cells at the germinal centers were stained intensively in MAP-treated rat spleen. Light microscopical analyses allowed us to identify lymphocytes during the course of apoptotic cell death. Electron microscopic studies showed morphological landmarks for the process of cellular apoptosis in both organs e.g. lymphocytes with chromatin condensed into crescents at the periphery of the nuclei and apoptotic bodies. These result indicate that MAP induced cell death of the thymic and splenic lymphocytes via apoptosis.

[One-stage repair of interrupted aortic arch with ventricular septal defect]

Three neonates with type A interrupted aortic arch were successfully repaired through a median sternotomy incision during profound hypothermia and circulatory arrest in the past one year. Two aortic cannulas, a small plastic one (Cardicorp) in the ascending aorta and a long one inserted through the pulmonary artery and patent ductus arteriosus into the descending aorta. Two Pacifico's venous cannulas were inserted into superior and inferior vena cavae respectively. No dissection and encircling were required around three major branches from the aortic arch and both right and left pulmonary arteries. During a cooling phase a large ventricular septal defect was closed followed by circulatory arrest. It was possible to resect a patent ductus arteriosus and mobilize the descending thoracic aorta for anastomosis to the side of the ascending aorta without removal of the aortic cannula in the aorta. New instruments and development of cardiopulmonary bypass could bring a successful one-stage repair of interrupted aortic arch with ventricular septal defect more safely and easily than before.

Single photon emission computed tomography to determine effective hepatic blood flow and intrahepatic shunting

The noninvasive determination of effective hepatic blood flow, intrahepatic shunted blood flow, intrahepatic shunt index, and total hepatic blood flow was investigated by using the sequential single photon emission computed tomography. This method was performed for a period of 10 minutes following an intravenous injection of 99mTc-(Sn)-N-pyridoxyl-5-methyltryptophan and a venous blood sampling. This study comprised 8 healthy volunteers, 16 patients with chronic hepatitis, and 33 patients with liver cirrhosis. The intrahepatic shunt index measured with this method coincided with the intrahepatic shunt index determined by catheterization, indicating the high reliability of this procedure. The effective hepatic blood flow in patients with liver cirrhosis was significantly lower than that in the healthy controls and the chronic hepatitis group. The intrahepatic shunted blood flow was significantly higher in patients with liver cirrhosis compared with the flow in healthy controls. The intrahepatic shunt index was also significantly higher in patients with liver cirrhosis compared with the index of healthy controls and those with chronic hepatitis. No substantial differences were noted in the total hepatic blood flow among the three groups. The effective hepatic blood flow, the intrahepatic shunted blood flow, and the intrahepatic shunt index, correlated with the serum albumin concentration, the serum cholinesterase level, and the plasma indocyanine green attenuation rate. From these results, it was concluded that the present procedure constitutes a reliable and effective method for the noninvasive determination of hepatic blood flows. Consequently, it will be of high clinical value for assessing the functional and the pathological alterations of the liver.

Malignant melanoma with mesenteric metastasis causing an intrapelvic abscess: report of a case

We present herein the case of a 66-year-old woman with disseminated malignant melanoma in whom a metastasis in the ileal mesentery ruptured into the peritoneal cavity causing an acute abdomen. The patient suddenly developed lower abdominal pain and a computed tomography (CT) scan of the pelvis confirmed the presence of an intrapelvic abscess. At emergency laparotomy, a 10 x 10 cm ruptured metastatic melanoma was found in the ileal mesentery, which demonstrated no communication with the ileum itself. To our knowledge, no other case of an acute abdomen being caused by the rupture of mesenteric metastatic melanoma lacking any communication with the bowel lumen has ever been reported.

[Repair of total anomalous pulmonary venous connection in asplenia syndrome without cardiopulmonary bypass]

Two infants with asplenia syndrome underwent repair of total anomalous pulmonary venous connection (TAPVC) without cardiopulmonary bypass (CPB). Both patients had other complex cardiac anomalies; pulmonary atresia, univentricular heart, etc. The first patient previously received a left modified Blalock-Taussig shunt. The common chamber (pulmonary venous confluence) was anastomosed to the right side atrium using a side-biting clamp. Though both patients had good postoperative course immediately after surgery, they subsequently died 43 days and 4 months after surgery, respectively. We conclude that relief of TAPVC can be accomplished without CPB and allowing easier and simpler postoperative care.

Prolonged occurrence of Moraxella bovis infection on a restricted heifer farm

An epizootiologic study was conducted for infectious bovine keratoconjunctivitis (IBK) on a large grassland farm rearing a total of 1,300-1,400 heifers during May to October in both 1991 and 1992. Heifers were examined for infection with Moraxella bovis, and isolation of M. bovis from the affected eyes and from Asian face flies (Musca bezzii Patton et Cragg) swarming on the heifer face was carried out. During the observation period, 10.7% of the heifers in 1991 and 5.3% of the heifers in 1992 were affected with IBK. Eight M. bovis isolates were isolated from the ocular swabs of affected heifers with IBK for 2 years and identified by biochemical examinations and Southern DNA-DNA hybridization, but no M. bovis was obtained from 331 Asian face flies tested. Plasmid profile analysis showed that two plasmids (35-kb and 4.0-kb) were commonly found in all 8 M. bovis isolates. This indicates that M. bovis isolates with the same plasmid profile were widely disseminated on this farm for 2 years.

[Operative indications and treatment in elderly patients with esophageal cancer]

A recent study indicates that infection of human papillomavirus (HPV) may cause esophageal cancer and that it takes several decades from infection of HPV to developing cancer. Even in early stage esophageal cancer, lymph node metastasis is usually observed in the mediastinum, abdomen and neck regions. As patients with esophageal cancer are potentially in a malnutritional state because of disturbance of intake before treatment, active nutritional support should be performed before and after surgery. An objective nutritional assessment is necessary for nutritional support. The nutritional assessment index (NAI) can be applied to elderly patients because there is no difference in nutritional parameters between elderly and young patients. From the point of view that surgical treatment has limitations concerning complete curability, we employed a remote after loading system (RALS) into a multidisciplinary treatment called the Kochi system, which consists of a combination of surgery, radiation therapy and chemotherapy. This multidisciplinary method of treatment greatly contributes to survival and quality of life of esophageal cancer patients especially in elderly cases.

A case report of gastric cancer associated with sarcoid reactions in the regional lymph nodes and liver

Epithelioid cell granulomas identical to those of systemic sarcoidosis are occasionally observed within malignant neoplasms, particularly in the lymphatics draining a primary tumor. These histologic changes have been termed sarcoid reactions and are easily confused with systemic sarcoidosis. This report describes an extremely rare case of gastric cancer accompanied by sarcoid reactions in the regional lymph nodes and liver parenchyma near a tumor metastasis. A 63-year-old woman with advanced gastric cancer was treated by subtotal gastrectomy with dissection of the regional lymph nodes and local excision of the liver tissue involved by metastasis. Microscopic examination of the resected lymph nodes and liver disclosed the presence of sarcoid-like granulomas. The absence of any clinical manifestations and the negative results of the Kveim test, chest radiograph, and laboratory tests, including that for the serum angiotensin converting enzyme excluded the possibility of systemic sarcoidosis. The presence of a sarcoid reaction in the liver parenchyma adjacent to a metastasis has never been reported previously.

Estimation of local vital reactions in severely burned tissues of guinea pig skin using C3a or C3a desArg as a marker

We observed changes in levels of anaphylatoxin C3a and/or its desArg (C3a/C3a desArg) peptides in the local site of severely burned skin tissues of guinea pigs using immuno-Western blotting methods. The C3a/C3a desArg peptides, which were probably generated during complement activation, were detected at significant levels from 30 min to 72 h following burn injury in an area limited to 3 mm from the wound edge. Levels of these peptides showed a tendency to be highest in that area 24 h after burn infliction. In postmortem injuries, C3a/C3a desArg peptides could not be detected. These peptides were detected in antemortem wounds up to at least 2 days at 22 degrees C and up to 3 days at 4 degrees C after death, although decreases in levels were found. Lower concentrations of these peptides were also found in postmortem burns in which postmortem hypostasis appeared strongly. These results suggest that, except for injuries of the area with obvious postmortem hypostasis, detection of C3a/C3a desArg can be useful for estimation of vital reactions in many kinds of wounds during inflammation.

A new marker for estimation of bloodstain age by high performance liquid chromatography

The applicability of a new marker for estimation of bloodstain age by reverse-phase high performance liquid chromatography (HPLC) is described. Using a microBondasphere C18 column with a two step linear gradient of 10.5-46.25% acetonitrile in 0.1% trifluoroacetic acid, an intriguing peak (unidentified) at a retention time of about 5 min was observed on chromatograms from human adult bloodstains and designated as 'X'. The area of this peak, which could be detected in extracts of bloodstains, but not in their fresh whole blood, increased with time. The ratios of the X area to heme area in bloodstains stored at room temperature and 4 degrees C for up to 52 weeks old linearly correlated with stain age by plotting on a double logarithmic scale. In bloodstains exposed to fluorescent light at room temperature, the regression equation calculated from the ratios (Rx) and the ages of stains in weeks (W) is ln(1000.Rx) = 1.1084 + 0.3937.ln(7.W), and the coefficient of correlation (r) is 0.9776 (n = 144, P < 0.001). When stains were stored at 37 degrees C, the ratio transformed into logarithms correlated linearly with stain age. The regression equation describing the relationship in bloodstains exposed to fluorescent light at 37 degrees C is ln(1000.Rx) = 2.4477 + 0.0866.W (r = 0.9826, n = 144, P < 0.001). The results of the present study suggest that the HPLC method may be applicable to the estimation of bloodstain age.

Hashimoto's thyroiditis in HTLV-I carriers

We describe two HTLV-I virus carriers who have biopsy-proven Hashimoto's thyroiditis. The first patient, a 64-year-old female, has had goiter and hypothyroidism since the age of 56. The second patient, a 66-year-old male, developed hyperthyroidism and goiter at the age of 44, but at present he is hypothyroid. Both patients are positive for anti-thyroid antibodies and anti-HTLV-I virus antibody. Findings of the thyroid biopsy specimens were consistent with Hashimoto's thyroiditis. These data suggest that Hashimoto's thyroiditis develops in HTLV-I carriers who have no clinical evidence of HAM/TSP.