Microsatellite instability in patients with multiple primary cancers of the gastrointestinal tract

BACKGROUND

Little is known about the genetic alterations in multiple primary cancers of the gastrointestinal tract. Microsatellite instability (MSI) is frequently observed in hereditary non-polyposis colorectal cancer (HNPCC), and multiple primary cancers is a feature of this syndrome.

AIMS

To identify MSI incidence, target gene mutation, and mismatch repair (MMR) protein status in patients with multiple primary cancers of the gastrointestinal tract.

SUBJECTS

Fifty seven cancers from 22 Japanese patients with multiple primary cancers of the stomach, duodenum, colon, and rectum.

METHODS

MSI was examined at 5-7 microsatellite loci. Mutation analysis for TGFbetaRII, IGFIIR, and BAX was performed in cancers with MSI. MMR protein status was examined by immunohistochemical analysis using a monoclonal antibody against hMSH2 and hMLH1.

RESULTS

MSI was observed in 16 of 22 patients (73%) and in 29 of 57 lesions (51%). High frequency MSI (MSI-H) was found often in patients with multiple cancers in the same organ (p = 0.042), especially in multiple gastric cancer patients (p = 0.038). In contrast, patients with multiple cancers in different organs had a tendency to show low frequency MSI (MSI-L) or microsatellite stable (MSS) phenotype. Both target gene mutation and decreased expression of MMR protein were found only in seven lesions of three patients with MSI at more than four microsatellite loci.

CONCLUSIONS

These results suggest that genetic instability may play an important role in the development of multiple gastrointestinal cancers but there may be different genetic alterations between multiple gastrointestinal cancers of the same and different organs.

[Anesthetic management for mitral valve replacement in a patient with mitral stenosis and dilated cardiomyopathy]

A 42-year-old man with dilated cardiomyopathy and rheumatic mitral stenosis underwent mitral valve replacement. Prior intravascular fluid administration and infusion of dopamine and dobutamine stabilized hemodynamics during the induction of anesthesia. High-dose fentanyl at pre-cardiopulmonary bypass period and circulatory assist with milrinone and intraaortic balloon pumping after the bypass enabled us to obtain stable hemodynamics. Preoperative dobutamine stress test provided us the effective information for circulatory management in this patient.

[Anesthetic management of an infant with pulmonary atresia and ventricular septal defect accompanied by excess pulmonary blood flow for systemic-pulmonary shunt operation]

A 6-month-old infant had pulmonary atresia with ventricular septal defect (PA + VSD) accompanied by excess pulmonary artery flow via major aortopulmonary collateral artery, underwent aortopulmonary shunt with artificial graft under midazolam-fentanyl anesthesia. After the administration of protamine, arterial oxygen saturation gradually decreased. We suspected that hypotension and decrease in cardiac output induced by protamine caused the decrease in pulmonary blood flow via central shunt. It is suggested that pulmonary blood flow should be maintained by using an inotropic agent and a selective pulmonary arterial dilator such as prostaglandin E1 in a patient with PA + VSD after the institution of aorto-pulmonary shunt, because the patient with excess pulmonary flow has been reported to have high pulmonary resistance due to pulmonary abnormalities such as stenosis and thrombosis.

Hypokalemia with syncope caused by habitual drinking of oolong tea

A 61-year-old woman developed hypokalemia, atrioventricular block and ventricular tachycardia with syncope after habitual drinking 2 to 3 liters of oolong tea per day. She had been suffering from rheumatoid arthritis and Sjögren's syndrome and her serum albumin was decreased (2.9 g/dl). Oolong tea contains caffeine at approximately 20 mg/dl. Great quantities of caffeine can induce hypokalemia. The serum protein binding caffeine is albumin. Accordingly, in patients with hypoalbuminemia, caffeine is apt to induce hypokalemia. This case suggested that great quantities of oolong tea, one of the so-called "healthy" drinks, result in serious symptoms for patients with hypoalbuminemia.

[Anesthetic management for pericardial fenestration in a hypertrophic cardiomyopathy (HCM) patient with massive pericardial effusion]

A 65 year-old male with HCM had progressively increased pericardial effusion. He also had atrial fibrillation (af), cardiac systolic dysfunction and chronic renal failure needing hemofiltration. Pericardial fenestration was carried out to improve diastolic function. Anesthetic management with fentanyl plus low-dose propofol infusion and postoperative analgesia with epidural morphine were effective for hemodynamic stability to prevent myocardial depression and to control ventricular response to atrial fibrillation. Intraoperative trans-esophageal echocardiography (TEE) monitoring was very useful for fluid therapy, inotropic support and estimation of systolic and diastolic function.

Chronic ischemic colonic lesion caused by phlebosclerosis with calcification

We report here two patients in both of whom ileus finally developed and chronic ischemic colonic lesion caused by phlebosclerosis with calcification was diagnosed. We believe that phlebosclerosis is an old-fashioned diagnostic term, but appropriate here because of the remarkable calcification of the sclerotic walls of the colic veins that seems to be one of the most important hallmarks of this previously unrecognized, "new" condition. Phlebosclerosis could be a novel type of ischemic colitis because of its unique clinical presentations, although the pathogenesis of this unusual venopathy remains unknown.

Doppler echocardiographic method to determine early and late diastolic filling volume separately. Validation and relationship between filling velocity and volume

We devised a pulsed Doppler echocardiographic method of separately calculating early diastolic filling volume (EDFV) and late diastolic filling volume during atrial contraction (LDFV) and observed a relationship between diastolic filling volume and velocity in thirty patients with coronary artery disease. By analysing the transmitral flow velocity curve and mitral valve motion, EDFV and LDFV were measured on the basis of the equality of left ventricular inflow and outflow volumes. The Doppler-determined EDFV and LDFV correlated well with those obtained from the left ventricular filling curve produced by left ventriculography. Angiographic EDFV and LDFV were measured from the time (t)-volume (V) curve, using the t-dV/dt curve to define early and late diastolic phases. A good correlation was found between Doppler and angiographic EDFV (y = -3.0 + 1.0 x, r = 0.98, p = 0.0001, n = 20), Doppler and angiographic LDFV (y = 1.6 + 1.0 x, r = 0.86, p = 0.0001), and also between Doppler and angiographic EDFV/LDFV (y = 0.05 + 0.9 x, r = 0.93, p = 0.0001). EDFV and the peak early diastolic filling velocity were significantly correlated (E velocity; y = 25 + 0.51 x, r = 0.48, p = 0.0068), while LDFV and the peak late diastolic filling velocity during atrial contraction (A velocity) were not. Our results validate the method of calculating EDFV and LDFV separately and suggest that early diastole in the left ventricle has flow volume dependency, but that the late diastole filling velocity during atrial contraction may be regulated by other factors such as increased left atrial contraction.

A case of pulmonary reaction with skin eruption showing a positive peripheral lymphocyte stimulation test result for ethambutol

We report a case of an elderly male whose pulmonary reaction with skin eruption occurred in the initial phase of chemotherapy composed of isoniazid, rifampicin, and ethambutol (EB). A peripheral lymphocyte stimulation test (LST) showed a positive reaction only to EB. The blood serum analysis of the patient when this reaction occurred revealed an elevated titer of antinuclear antibody. Computed tomography (CT) scan films of the chest when the pulmonary reaction occurred showed multifocal subpleural consolidations. There has been only one reported case of EB-induced pulmonary reaction and its clinical course was very similar to ours. However, LST results and computed tomography (CT) scan findings of the chest were not documented in that case.

[Anesthetic management for renal tumor extending to the inferior vena cava]

A 58 year-old woman underwent radical nephrectomy, thrombectomy and ileo-cecal resection for renal tumor with thrombus involving the inferior vena cava and ascending colon cancer. In a patient having tumor thrombus extending to the vena cava, recognition of the position of the thrombus is important for surgical and anesthetic management in pre- and intra-operative periods. Transesophageal echocardiography (TEE) enabled us to visualize the real-time movement and deformity of thrombus by surgical manipulation and compression during operation. TEE seemed also very useful not only in understanding the hemodynamics during operation but also in detecting the residual tumor and the blood flow in liver and the inferior vena cava after operation.

The effect of lesionectomy and the perilesional GABAergic neuronal changes in alumina cream-induced focal motor epilepsy in cats

The effect of lesionectomy depends on the reversibility of the epileptogenic changes in the perilesional cortex. We studied how the perilesional GABAergic neuronal changes are related to the effect of lesionectomy in the alumina cream-induced focal epilepsy model in cats. Sequential changes of GABAergic neurons and spike activities were measured after the micro-injections of alumina cream (AC). Alumina granulomas were excised 15 days and 40 days after the injections. At day 20 following the AC injection, GABAergic neurons were decreased 25 to 40% compared with those in the contralateral intact cortex. At day 40, a significant increase of spike activities occurred. GABA positive cells were decreased more than 50% compared with those in the contralateral cortex. At day 80, significant cell loss in perilesional cortex was demonstrated. The effect of lesionectomy was greater in the early excised group than in the late excised group. Decrease of GABAergic neuron was more severe in the late excised group compared to the early excised group. Our results indicate that more than 50% reduction of perilesional GABA neurons may be a critical point in epileptogenesis in this model. Lesionectomy alone prior to a 50% reduction in perilesional GABAergic neurons may be sufficient for seizure control. With these data it is still unclear whether these findings contribute to the choice between lesionectomy alone and lesionectomy with resection of the perilesional cortex. Further study is needed to understand the difference between the AC epilepsy model and human chronic epilepsy.

Usefulness of MRA in the Treatment of Dural AVM

We report 5 cases of dural AVMs, in which MRA images were considered very useful for evaluating the effectiveness of treatments, such as transvenous embolization therapy.

MRA by time of flight method (TOF) with contrast medium for dural AVMs involving the cavernous sinus (dural CCFs) is necessary to assess the caliber of superior ophthalmic veins (SOVs) prior to treatment as well as immediately after treatment and during follow-up.

MRA for dural AVM at the transverse-sigmoid sinus is useful for verifying thrombosed sinus in the dural AVM prior to transvenous embolization therapy and necessary to determine the approach to the nidus of the dural AVM2.

[Anesthetic managements for pericardiectomy of three patients with constrictive pericarditis]

We experienced three patients with constrictive pericarditis who underwent pericardiectomy. Percutaneous cardiopulmonary support (PCPS) was carried out in two patients because of unstable hemodynamics caused by massive bleeding or cardiac compression due to surgical manipulation. In the other patient with severe tachycardia, we prepared PCPS before the induction of anesthesia, and could manage the whole course of anesthesia satisfactorily. It is suggested that PCPS is the most reliable way to support hemodynamics during anesthesia in patients with constrictive pericarditis.

Double-orifice mitral valve in an elderly patient with tetralogy of Fallot

The patient was a 67-year-old man receiving medical treatment for tetralogy of Fallot at our hospital. A routine follow-up echocardiogram revealed a double orifice mitral valve (DOMV) associated with his tetralogy of Fallot. DOMV is often associated with endocardial cushion defect, however, DOMV associated with tetralogy of Fallot is extremely rare in elderly patients.

Evaluation of sialyl Lewisx antigen in the skin and the sera of patients with psoriasis vulgaris

The roles of sialyl-Lewisx antigen were evaluated in the pathogenesis of psoriasis. Sialyl-Lewisx expression was investigated immunohistochemically in the epidermis of normal human skin and erythematous lesional skin of psoriasis vulgaris by avidin-biotin-peroxidase complex procedures. A few sialyl-Lewisx positive dendritic cells were detected in the epidermis of normal human skin. In 7 out of 9 cases of psoriasis vulgaris, the number of sialyl-Lewisx-positive epidermal dendritic cells increased in the erythematous lesion over the adjacent normal skin; there were no marked changes in the numbers of CD1a-positive cells in the epidermis between the two skin types. In the double immunofluorescence studies, more than half of the sialyl-Lewisx-positive epidermal cells in psoriatic erythema were stained with a monoclonal Lag antibody that specifically reacts with Birbeck granules and related structures of human Langerhans cells. Furthermore, we determined the changes in serum levels of sialyl-Lewisx antigens in patients with psoriasis. Although levels in the sera were not significantly elevated over those of controls, the increases correlated with the degree of disease activity. These findings suggest that sialyl-Lewisx antigen is possibly involved in the development of psoriasis.

Acne fulminans coexisting with pyoderma gangrenosum-like eruptions and posterior scleritis

A 30-year-old Japanese man presented with an erythematous, papulonodular eruption on his face and upper trunk, which rapidly progressed into severely exuberant, ulcerative lesions with a confluent tendency. His other symptoms included a high fever and general malaise. Complete blood cell counts showed neutrophilia with increased percentages of myelocytes and metayelocytes. The systemic administration of corticosteroids improved his skin lesions, leaving scars and milia. During tapering of corticosteroids, however, the patient developed posterior scleritis of his eyes and pyoderma gangrenosum-like eruptions on the lower legs. Our patient's history suggests that pyoderma gangrenosum-like eruptions and posterior scleritis are disorders associated with acne fulminans.

Correlation between occurrence of exudative epidermitis and exfoliative toxin-producing ability of Staphylococcus hyicus

Staphylococcus hyicus was isolated from healthy pigs and pigs affected with exudative epidermitis (EE). Thirty seven strains (P-7 to P-43) were isolated from pigs affected with EE on 8 farms while 131 strains were isolated from healthy pigs bred on 2 farms in Japan. Isolation rate for pigs affected with EE was 100% while that for healthy pigs was 35.4%. The biochemical and cultural characteristics of the isolates from healthy and diseased pigs were identical except for the Voges-Proskauer reaction. The culture supernatant of many isolates caused skin exfoliation in 1-day-old chickens. Therefore, many isolates were considered to produce S. hyicus exfoliative toxin (shET). The rate of shET production by the isolates from piglets affected with EE was 87.5%, while that of the isolates from healthy pigs was 76.1%. shETs were divided in two serotypes by immunodiffusion. Piglets experimentally infected with shET-producing and nonproducing strains were observed. Local skin erythema at the inoculation site was observed with nonproducing strains and disappeared within 48 h, while the skin erythema at the sites inoculated with shET-producing strains did not disappear until 7 days after inoculation. Typical clinical signs, such as exfoliation, exudation and crusting were observed only in the piglets inoculated with shET-producing strains.

[Experimental study on hypertensive crises in epileptic seizures--changes in pial artery diameter, intracranial pressure and regional cerebral blood flow]

It is well known that severe hypertension occurs during epileptic seizures, but little information is available concerning these hypertensive crises. We therefore investigated them by monitoring regional cerebral blood flow (rCBF), intracranial pressure (ICP) and pial artery diameter (PAD) in paralyzed mechanically-ventilated cats with penicillin-induced seizures. The animals were assigned to two groups. In one (Group H), they were maintained in an untreated state. In the other (Group C), spinal cord injury was performed in advance to prevent the rise in arterial blood pressure during the seizures. In both groups, the values of the various parameters increased during seizure activity, but the increases in group H, were greater than in group C. In both groups, PAD, rCBF and ICP increased immediately at the onset of the seizures with no hypertension. In group H, further increases in PAD, rCBF, and ICP were found concurrent with the elevation of arterial blood pressure in the latter half of the seizure, while in group C, rCBF decreased concurrent with the increase in ICP in the latter half of the seizure, although PAD was found to be maximal. These findings suggest that hypertensive crises during epileptic seizures represent a protective mechanism to maintain perfusion pressure.

Cutaneous colonization with staphylococci influences the disease activity of Sézary syndrome: a potential role for bacterial superantigens

It has previously been shown that circulating Sézary cells respond in vitro to superantigenic staphylococcal exotoxins in a manner that is restricted by their V beta usage. This study was conducted to examine whether cutaneous colonization with Staphylococcus aureus influences the activity of the skin lesions of Sézary syndrome, and whether S. aureus isolated from patients with Sézary syndrome stimulates circulating Sézary cells in vitro. Two patients with Sézary syndrome, whose skin was colonized with S. aureus, were treated with antibacterial agents, and the relation between the severity of the skin disease and the degree of S. aureus colonization was assessed. In addition, the patients' peripheral blood mononuclear cells were cultured in the presence of mitomycin C-treated S. aureus or superantigenic staphylococcal toxins. The antibacterial treatment improved the skin disease, and eliminated S. aureus in both patients. In one patient, 98% of the peripheral blood mononuclear cells bore V alpha 2V beta 17 of the T-cell receptor, indicative of the presence of an extremely high percentage of circulating Sézary cells. The peripheral blood lymphocytes from this patient responded well in vitro to superantigenic staphylococcal enterotoxin (SE), but not to SEA or toxic shock syndrome toxin-1, or to mitomycin-treated S. aureus isolated from the same patient. Cutaneous colonization by S. aureus influences the disease activity of CTCL, possibly by activation of Sézary cells by bacterial superantigenic exoproteins.

Approach through the temporal horn of the lateral ventricle for clipping of large dorsal type basilar bifurcation aneurysms

The authors describe an approach through the temporal horn of the lateral ventricle which proved to be useful for clipping of a large dorsal type basilar bifurcation aneurysms. It facilitates the preservation of the perforating arteries behind the aneurysm, because it gives sufficient working space to move the aneurysm dome. Furthermore this approach avoids many of the disadvantages of other approaches, especially the risk of iatrogenic injuries of the Sylvian or Labe's vein.