Malignant perihilar biliary obstruction: magnetic resonance cholangiopancreatographic findings

OBJECTIVE

We studied the efficacy of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of malignant perihilar biliary obstructions, with reference to endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 40 patients with malignant perihilar biliary obstructions, who underwent both MRCP (Magnetom Vision; Siemens, Erlangen, Germany; projection technique and multislice plus maximum intensity projection) and ERCP examinations, were studied. The study group included hilar cholangiocarcinoma (Klatskin tumor) in 26 patients, icteric hepatocellular carcinoma in four patients, gallbladder carcinoma in five patients, and metastasis from other than hepatobiliary origin in five patients. Axial and coronal magnetic resonance (MR) images were added simultaneously to the MRCP. The mean serum bilirubin level on admission was 11.5 mg/ml (range, 2.8-28.5 mg/ml). The presence and extent of malignant biliary obstruction were determined with both MRCP and ERCP following the known criteria: an abrupt and irregular character of a distal narrow segment, a proportionally dilated biliary tree proximally, and an irregularly shaped intraluminal filling defect. The efficacy of the MRCP examination in detecting the presence of biliary obstruction, its anatomical extent, and the underlying cause, respectively, was compared to that of ERCP.

RESULTS

MRCP examination was successfully performed on all patients, whereas ERCP examination was unsuccessful in two patients. Both MRCP and ERCP were very effective in detecting the presence of biliary obstructions (40 of 40 vs. 38 of 38, p = 1.0). MRCP was superior in its investigation of anatomical extent (34 of 40 vs. 24 of 38, p = 0.015) and the cause of the jaundice (31 of 40 vs. 22 of 38, p = 0.023) compared to ERCP. Specifically, the performance of MRCP is promising for the interpretation of cholangiocarcinoma (22 of 26) and gallbladder carcinoma (five of five), but is relatively ineffective for the interpretation of icteric HCC (two of four) and metastasis (two of five).

CONCLUSION

MRCP represented an ideal noninvasive diagnostic tool for the evaluation of malignant perihilar biliary obstructions with reference to ERCP.

Dermatofibroma is a clonal proliferative disease

Benign fibrous histiocytoma of the skin or dermatofibroma (DF) has been regarded as a fibrohistiocytic tumor. Whether DF is a neoplastic growth or a reactive process has not been settled. Since a neoplastic process is clonal in nature, clonal analysis of DF was conducted to see if DF is a clonal disease. Fresh specimens of 13 DFs and 2 hypertrophic scars obtained from female patients were studied. The adjacent nonlesional skin tissues served as controls. The clonal analysis was based on the methylation pattern of the polymorphic X-chromosome linked androgen-receptor gene (HUMARA). Eight DFs and 1 hypertrophic scar were heterozygous at the androgen receptor gene and could be analyzed. All 8 informative DFs showed a significant reduction in one of the allelic bands compared with the corresponding bands of the nonlesional tissue after Hha I digestion. Therefore, DF is a clonal proliferative disease. In contrast, 1 hypertrophic scar showed a polyclonal pattern of X-chromosome inactivation. We conclude that DF is a clonal disease favoring a neoplastic process.

Octreotide treatment for a malignant islet cell tumor with variable hormone secretion: case report

It is well known that an islet cell tumor can secrete multiple hormones depending on its cell type. We report the case of a 70-year-old woman who initially presented with peptic ulcer symptoms, an elevated serum gastrin level, and multiple liver tumors. Liver biopsy and distal pancreatectomy were performed, and the pathological diagnosis was malignant islet cell tumor. Additionally, the immunohistochemical staining revealed scattered positivity for gastrin, and then also positivity for insulin 14 months later. A subsequent hypoglycemic episode and elevated serum gastrin and insulin levels suggested that the disease had developed into a condition of multiple hormone secretion. The plasma gastrin and insulin levels decreased from 584 pg/ml and 90.8 microIU/ml to 49.1 pg/ml and 20.9 microIU/ml, respectively, 5 days after treatment with subcutaneous octreotide 100 micrograms every 6 to 8 hours. In addition, follow-up computed tomography showed shrinkage of the metastatic liver tumors. In conclusion, we found a case of malignant islet cell tumor with variable hormone secretion which could be effectively controlled with octreotide.

Telomerase activity is a useful marker to distinguish malignant pancreatic cystic tumors from benign neoplasms and pseudocysts

BACKGROUND

Pancreatic serous cystadenoma, mucinous cystic neoplasms, ductal adenocarcinoma with cystic change, and pseudocysts are a spectrum of pancreatic cystic lesions. Their management strategy and prognosis are extremely diverse. Imaging study, cytology, and analysis of the tumor markers of cyst fluid are not always reliable in differentiation of these disease entities.

MATERIALS AND METHODS

Fifteen patients with pancreatic cystic neoplasms (including six mucinous cystadenocarcinomas, two mucinous cystic neoplasms with borderline malignancy, two mucinous cystadenomas, and five serous cystadenomas), 4 patients with pancreatic ductal adenocarcinomas with cystic change, and 10 patients with pseudocysts were studied. Echo-guided or computed tomography-guided biopsies of pancreatic cystic lesions and their normal counterparts were conducted on all patients prior to operation or other management. The specimens were assayed for telomerase activity by using TRAP (telomere repeat amplification protocol). The level of telomerase activity in each specimen was semiquantitated as strong, moderate, weak, and none. The final diagnoses were made from histopathological examination of surgically resected or biopsied specimens. The efficacy of telomerase activity as a tumor marker to predict malignancy of pancreatic cystic lesions was evaluated.

RESULTS

Three of the four pancreatic ductal adenocarcinomas with cystic change had strong or moderate telomerase activity; four of the six mucinous cystadenocarcinomas had moderate or weak telomerase activity; one of the two mucinous cystadenomas with borderline malignancy had weak telomerase activity; and none of their normal counterparts had detectable telomerase activity. In contrast, none of the two mucinous cystadenomas, five serous cystadenomas, and 10 pseudocysts had detectable telomerase activity. Based on these results, the sensitivity of telomerase activity for prediction of malignancy or premalignancy of pancreatic cystic lesions was 67%, the specificity was 100%, and the positive and negative predictive values were 1.0 and 0.81, respectively. The overall accuracy was 86%.

CONCLUSIONS

The differential expressions of telomerase activity have been detected specifically in malignant and premalignant pancreatic cystic tumors, but not in benign cystic neoplasms or pseudocysts. The implications of these results are that telomerase activation takes part in the malignant transformation of pancreatic cystic neoplasms and that telomerase activity is a useful marker to distinguish malignant pancreatic cystic tumors from benign neoplasms and pseudocysts.

Schistosoma japonicum infection presenting with colon perforation: case report

Colon perforation can be caused by a variety of entities, including iatrogenic trauma, tumors, ischemia, inflammatory bowel disease, and steroid use. Parasitic infection rarely leads to colon perforation. Secondary peritonitis results from mixed microorganism infection, including enterococci, enteric bacilli, and anaerobes. A combination of an optimal antibiotic regimen and surgical intervention is of paramount importance. Nevertheless, intra-abdominal infections usually have a high mortality rate. Schistosomiasis occurs worldwide. S. japonicum infection is endemic in Asia. The most common complications of gastrointestinal schistosomiasis are periportal fibrosis, intestinal polyposis, and bowel stricture. Rarely, schistosomiasis results in colon perforation. The diagnosis of schistosome infections is based on ova in stool or tissue specimens, and/or immunologic diagnostic tests. The most effective anti-schistosomiasis agent is praziquantel. Herein, we describe an unusual case of colon perforation associated with Schistosoma japonicum infection, which resulted in severe peritonitis and led to the patient's death.

Primary hepatic epithelioid hemangioendothelioma: case report

Hepatic epithelioid hemangioendothelioma (HEH) is a very rare vascular tumor of the liver. It usually affects adult women and presents as multiple hepatic nodules with mainly peripheral distribution. It poses special difficulties for clinicians in its diagnosis and treatment because of its non-specific clinical manifestations and findings on imaging, and it is easy to be misdiagnosed pathologically. Its clinical course and prognosis are variable but supposed to be intermediate between hemangioma and angiosarcoma. The primary treatments of choice are radical resection or liver transplantation. We report a 62-year-old man with right upper quadrant abdominal pain of several days' duration, who was initially misdiagnosed as having a liver abscess. Finally, HEH was diagnosed on the basis of positive immunohistochemical staining for factor VIII-related antigen in tumor cells. This case could serve to highlight the pitfalls in diagnosing this rare tumor. Increasing the index of suspicion and familiarity with the radiological and histological characteristics of this tumor would facilitate the accurate diagnosis and thus avoid unnecessary interventions.

Recurrent fetal thyrotoxicosis in a woman with Graves' disease: case report

The thyroid stimulating immunoglobulins are generally believed to be the cause of hyperthyroidism in Graves' disease. Placental transfer of these antibodies from a mother with autoimmune thyroid disease can result in fetal thyroid disorders. We report the case of a 31-year-old woman who had a history of Graves' disease. She received thyroxine therapy for post thyroidectomy hypothyroidism. Two years after the thyroidectomy, she became pregnant. Unfortunately, intrauterine fetal death occurred in midgestation. One year later, she became pregnant again. In the 26th week of gestation, fetal thyrotoxicosis was diagnosed using clinical pictures, including fetal tachycardia and cardiomegaly, and a hormonal evaluation of a periumbilical blood sampling (T4: 18 micrograms/dl, T3: 65.3 ng/dl, TSH: < 0.03 microU/ml) was performed. Antimicrosomal antibodies were not detectable in either the maternal or fetal blood. In this case, high levels of TBII were detected during pregnancy and crossed the placenta to result in a thyrotoxic fetus in the second pregnancy. We recommend that both the regular monitoring of the thyrotropin receptor antibodies of pregnant women with a history of autoimmune thyroid disease, and routine measurements of the fetal heart rate and intrauterine growth during gestation be mandatory for the early detection of fetal thyroid disorders. Cordocentesis for measuring fetal thyroid function is helpful in reaching a definite diagnosis and for guiding therapy.

Goniosurgery for prevention of aniridic glaucoma

OBJECTIVE

To report the long-term success and complications of modified goniosurgery to prevent aniridic glaucoma, an entity that typically is difficult to control medically or surgically.

DESIGN

A retrospective review of the medical charts.

RESULTS

Fifty-five eyes in 33 patients who had aniridia without glaucoma and who underwent goniosurgery were identified. Ninety-one procedures were performed on the 55 eyes by 1 surgeon (D.S.W.). Each eye had an average of 1.65 procedures and an average of 200 degrees of goniosurgery. Average age at time of initial goniosurgery was 36.6 months. There were no operative complications. No eye had a decrease in visual acuity at last follow-up. All eyes had a preoperative intraocular pressure (IOP) less than 21 mm Hg. At last follow-up (average, 9 years 6 months; range, 8 months to 24 years), 49 eyes (89%) had IOPs less than 22 mm Hg without medications. The remaining 6 eyes (11%) had IOPs of 22 mm Hg or less with up to 2 types of eyedrops.

CONCLUSIONS

Without prophylactic goniotomy, aniridic glaucoma may be expected in half of patients, and when it occurs, it is extremely difficult to control. Prophylactic goniosurgery in selected eyes of young patients with aniridia may be effective in preventing aniridic glaucoma.

Tracheal neurilemmoma mimicking bronchial asthma--a dilemma of difficult diagnosis: case report

Tracheal tumors are often overlooked as a cause of pulmonary symptoms until they reach an advanced state. They are often presented with a prolonged cough and shortness of breath. Most tracheal tumors in adults are cancerous (80% to 90%). Benign tracheal tumors are rare in adult patients. A case history is presented of a 19-year-old patient with a rare tracheal neurilemmoma. He was treated as having bronchial asthma initially, but his signs and symptoms did not improve with traditional therapy. The possibility of the presence of an upper airway obstruction was not raised until the typical "inspiratory tubular sound" was heard. Flow-volume loop testing, bronchoscopy, and three-dimensional computed tomography (3-D CT) confirmed the diagnosis of upper airway obstruction caused by a tracheal tumor. Therefore, surgical intervention rather than bronchoscopic removal was performed without difficulty. The patient was leading a stable life 8 months after a surgical resection. The presence of an upper airway obstruction can be proven by flow-volume loop testing and 3-D CT. Further pathologic confirmation can be accomplished by bronchoscopy. High suspicion of an upper airway obstruction such as a tracheal lesion should be raised when bronchial asthma patients fail to respond to conventional treatment.

A patient with bilateral primary adrenal lymphoma, presenting with fever of unknown origin and achieving long-term disease-free survival after resection and chemotherapy

Primary adrenal lymphoma is extremely rare. We describe a 64-year-old female patient who presented with fever of unknown origin. Imaging studies demonstrated bilateral bulky adrenal masses. She underwent bilateral adrenalectomy and the pathological diagnosis was large cell immunoblastic (B-cell) lymphoma. She received adjuvant combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone in the following 6 months. She has been relapse free for 52 months. To the best of our knowledge, this case has the longest disease-free survival among those reported. The present case indicated that primary adrenal lymphoma should be included in the differential diagnosis of fever of unknown origin and/or suprarenal mass. Chemotherapy following surgical resection may be considered the treatment of choice.

Prediction of tacrolimus blood levels by using the neural network with genetic algorithm in liver transplantation patients

The neural network (NN) is a technique using an artificial intelligent concept in predicting outcomes by using various input variables. Tacrolimus pharmacokinetics has wide inter- and intra-subject variability and it is often difficult to predict its blood concentrations by dose alone. The objectives of this study are to select the clinically significant variables and to predict the blood concentration of tacrolimus in liver transplant patients by NN combined with genetic algorithm (GA). A total of thirty-two adult liver transplant patients from the University of Iowa Hospitals and Clinics were selected and the patients' data were retrospectively collected. These patient were randomly assigned into two groups: either the training group (n = 10), or testing group (n = 22). A back propagation (BP) NN was developed which contained two hidden layers. A dynamic BP NN based on the time series concept was trained by using the current and previous data sets to predict the trough levels of tacrolimus. The mean of the NN prediction for tacrolimus blood levels was not significantly different from the observed value by a paired t-test comparison (12.05+/-2.67 ng/ml vs. 12.14+/-2.64 ng/ml, p = 0.80). The average difference of the testing sets between the observed and predicted levels was 1.74 ng/ml with a range from 0.08 to 5.26 ng/ml which is clinically acceptable range. Thirty-seven out of 44 data sets (84%) in the testing group were within 3.0 ng/ml of the observed values. This study demonstrated that tacrolimus blood concentrations are precisely predictable in liver transplant patients using patients variables by NN.

Absence of APC gene mutation in the mutation cluster region in hepatocellular carcinoma

APC gene mutations have been demonstrated not only in colorectal carcinoma but also in a variety of human cancers. To define the possible role of mutations of the APC gene in hepatocarcinogenesis, we examined 46 pairs of hepatocellular carcinomas and corresponding non-tumorous liver tissue by polymerase chain reaction and single strand conformation polymorphism. All 46 hepatocellular carcinomas had no altered electrophoretic mobility to suggest the presence of APC gene mutation in the mutation cluster region. We also examined the possible loss of heterozygosity of APC and MCC gene loci by fragment length polymorphism analysis and by polymerase chain reaction. None of the cases showed a loss of heterozygosity at the APC and MCC gene loci. The results suggested that the possibility of APC and MCC as the gene defect in the genesis of human hepatocellular carcinoma may be very rare.

Primary hepatic angiosarcoma: report of a case involving environmental arsenic exposure

Hepatic angiosarcoma is a rare malignant tumor with a rapidly fatal course. It has become a subject of interest because of its intimate relationship with environmental carcinogens, such as thorium dioxide (Thorotrast), vinyl chloride monomer, and arsenic. We describe a case of a chronic hepatitis B surface antigen carrier, with a 20-year history of environmental exposure to arsenical-containing agricultural herbicides and bactericides, who developed a hepatic angiosarcoma. He died due to rupture of the hepatic angiosarcoma with acute hemoperitoneum 9 weeks after initial diagnosis. This is a rare case of primary hepatic sarcoma, especially in Taiwan where hepatocellular carcinoma is endemic. This case not only serves to give more evidence of the relationship between hepatic angiosarcoma and arsenical exposure, but also demonstrates the key point in the differential diagnosis of liver tumors. Increased familiarity with this disease will facilitate correct diagnosis and help to improve management of the condition in the future.

Lymphadenopathy in an oriental with ankylosing spondylitis

We report a case of a patient suffering from enlargement of multiple lymph nodes and low back pain for one year. The diagnosis of ankylosing spondylitis was made by bilateral sacroilitis and HLA-B27 positivity. Lymph nodes biopsy revealed lymphoid hyperplasia. No other cause for the lymphadenopathy was found after a thorough study. Furthermore, high serum IgA and C-reactive protein which were most likely related to active ankylosing spondylitis existed together with lymph node enlargement. Therefore, it was a case of ankylosing spondylitis associated with generalised lymphadenopathy which was the first reported in an oriental person. Several other possible cases also existed. We suggested that ankylosing spondylitis should be considered for young adult patients with lymphadenopathy.

Hepatocellular carcinoma complicated with coexisting hepatolithiasis: pitfalls in diagnosis and management

Nineteen patients with hepatocellular carcinoma associated with hepatolithiasis were retrospectively analyzed. Eleven of the 19 patients presented with hepatolithiasis-related biliary infection. Diagnosis was erroneously assumed to be hepatolithiasis alone, liver abscess, or cholangiocarcinoma in five of 11 patients before surgery was attempted. Middle-age, male sex, liver cirrhosis, hepatitis B or C infection, abnormal alpha-fetoprotein, and negative carcinoembryonic antigen raised the suspicion of associated hepatocellular carcinoma rather than cholangiocarcinoma in patients with hepatolithiasis. Antibiotics and nonoperative methods to resolve biliary infection first, followed by hepatectomy, in selected cases, to eradicate hepatocellular carcinoma and hepatolithiasis simultaneously provides the best chance for long-term survival. Otherwise, patients often died of hepatolithiasis-related biliary sepsis rather than hepatocellular carcinoma per se in the long run.

Emergence of an S gene mutant during thymosin alpha1 therapy in a patient with chronic hepatitis B

The presence of a hepatitis B virus S gene mutant was investigated in a patient being treated with thymosin alpha1. He was seropositive for hepatitis B e antigen throughout therapy but was intermittently seronegative for hepatitis B surface antigen (HBsAg) by an RIA. Sequence analysis revealed an S gene mutant in HBsAg-seronegative serum with two consecutive amino acid substitutions: threonine115-to-isoleucine and threonine116-to-asparagine, whereas no amino acid substitution or deletion was found in the pre-S region. A site-directed mutagenesis experiment confirmed that these mutations were responsible for the failure to detect HBsAg. In summary, an S gene mutant was identified in an HBsAg-seronegative patient. The mutations were located outside the putative "a" determinant. The emergence of an S gene mutant during thymosin alpha1 treatment suggests that enhanced host immunity against HBsAg may play a role in its antiviral activity.

Characteristics of local electrograms with diastolic potentials: identification of different components of return pathways in ventricular tachycardia

BACKGROUND

Diastolic potentials are often sought as a possible site for catheter ablation in post-infarct ventricular tachycardia. However, delivery of energy at such sites is often unsuccessful. The purpose of this study was to determine the characteristics of local electrograms with diastolic potentials and to identify activation pattern which might indicate the critical portion of the return path of the ventricular tachycardia reentry circuit.

METHODS

In 17 patients with post-myocardial infarction ventricular tachycardia, 30 ventricular tachycardias were mapped with an 112 bipolar endocardial balloon at the time of surgery. Diastolic mapping of the return tract in ventricular tachycardia was performed. Four activation patterns were observed (15 figure 8 patterns, 2 circular patterns, 2 biregional patterns and 11 monoregional patterns). Of 3,360 local electrograms, 207 (6.2%) demonstrated a diastolic potential in ventricular tachycardia. They were classified into following four categories, based on the appearance and timing of the systolic component. Type A-1 electrogram: systolic activation was of low amplitude (< 2 mV) and was prolonged (> or = 100 msec), but preceded the onset of the surface QRS in ventricular tachycardia. Type A-2 electrogram: systolic activation was of low amplitude, was prolonged, but followed the onset of the surface QRS. Type B electrogram: systolic electrogram was fractionated, but relatively normal amplitude (2.0-3.6 mV). Type C electrogram: systolic electrogram was almost normal.

RESULTS

Of all electrograms with diastolic potentials, three type A-1 electrograms (1.4%) were located at the exit of the return pathway, 11 type A-1 electrograms (5.3%) were located at the pre-exit site. No type A-1 was found at an entrance/bystander area. 21 type A-2 electrograms (10.1%) were at the pre-exit and 83 type A-2 electrograms (40.2%) were located at the entrance/bystander area, but such electrograms were never found at the exit site. 71 type B electrograms (34.3%) and 18 type C electrograms (8.7%) were located at the entrance/bystander area. To distinguish the type A-2 electrograms at the pre-exit site from those at the entrance/bystander area, the diastolic potential to QRS interval was measured. This interval at the pre-exit was significantly shorter than that at the entrance/bystander area (-47.2 +/- 10.7 vs -96.3 +/- 31.3 msec, p = 0.0001).

CONCLUSION

Type A-1 electrograms indicated the exit or pre-exit site of return pathway. Type A-2 electrograms with diastolic potential to QRS interval < -50 msec indicated the pre-exit site. However, the other types of local electrograms with diastolic potential did not indicate the critical portion of the ventricular tachycardia circuit. These observations may be helpful during catheter mapping and ablation of patients with post-infarct ventricular tachycardia.

CONDENSED ABSTRACT

Diastolic potentials are often sought to direct catheter ablation in post-infarct ventricular tachycardia. We investigated the characteristics of local electrograms showing diastolic activity in an attempt to determine whether critical portions of the ventricular tachycardia circuit could be identified by a typical "signature." In 17 patients with a remote myocardial infarction, 30 ventricular tachycardias were mapped with 112 bipolar endocardial balloon at the time of surgery. Diastolic potentials in association with low amplitude (< 2 mV) and prolonged (> or = 100 msec) systolic electrograms preceding the onset of QRS were found at the exit site and pre-exit site of return pathway. A similar systolic electrogram occurring after QRS onset with a diastolic potential to QRS interval of < -50 msec was found at the pre-exit site. However, other local electrograms with diastolic activity were at sites remote from the exit or pre-exit of the return pathway. These observations may be helpful during catheter mapping and ablation in patients with ventricular tachycardia.

Hypopharyngeal carcinoma with clinical peritoneal carcinomatosis: a report of two patients

Most patients with hypopharyngeal carcinomas show advanced disease, either at the primary site or in the neck, at the time of diagnosis. Despite intensive therapy, a great number of recurrences and distant metastases can be observed. The most common metastatic sites are the lung and bone, and only in autopsy cases has peritoneum carcinomatosis been mentioned as a metastatic site. Since January 1992, two of 78 patients (2.3%) with advanced hypopharyngeal squamous cell carcinomas (SCCs) treated initially by chemotherapy in our department developed clinical peritoneal carcinomatosis during their natural courses. Both patients were man patients with advanced locoregional disease at stage T4N3. Their clinical peritoneal carcinomatosis appeared during chemotherapy, with good disease control above the clavicle. Both patients eventually died of sepsis within 1 month after diagnosis of the peritoneal carcinomatosis. The authors suggest that peritoneal carcinomatosis is not as rare as previously believed, and should be included in the differential diagnosis in patients with advanced hypopharyngeal SCC with abdominal symptoms. Peritoneal carcinomatosis appears to be refractory to chemotherapy, and carried a poor prognosis in patients in the present study.

Increased level of exhaled nitric oxide and up-regulation of inducible nitric oxide synthase in patients with primary lung cancer

Monocyte-macrophage series have an important role in host surveillance against cancer. The cytotoxic/cytostatic activity of macrophages is, to a great extent, attributed to the up-regulation of inducible nitric oxide synthase (iNOS) and production of nitric oxide (NO). Here, in 28 patients with primary lung cancer and 20 control subjects, we measured the concentration of exhaled NO and nitrite in epithelial lining fluid (ELF) using a chemiluminescence NO analyser, and studied NOS expression in alveolar macrophages (AM) and lung tissues by flow cytometry; immunohistochemical analysis was also undertaken. The mean fluorescence intensity (FI) of iNOS expression in AM was significantly increased in patients with lung cancer (tumour side 263.5 +/- 15.2 FI, normal side 232.4 +/- 18.6 FI; n = 28) compared with that in control subjects (27.3 +/- 3.2 FI; n = 20, P< 0.001). The level of exhaled NO from cancer patients (16.9 +/- 0.9 p.p.b.; n = 28) was significantly higher than that in the control group (6.0 +/- 0.5 p.p.b.; n = 20, P < 0.001). The level of nitrite was also significantly higher in ELF from cancer patients (tumour side 271.1 +/- 28.9 nM and normal side 257.4 +/- 19.6 nM vs control subjects 32.9 +/- 4.1 nM; P< 0.001). The intensity of iNOS expression in AM was correlated with the level of exhaled NO (rs = 0.73, n = 76, P< 0.001) and the nitrite released in ELF (rs = 0.56, n = 76, P< 0.001). The nitrite generation of cultured AM from patients with lung cancer was significantly enhanced compared with that of control subjects after culture for 24 h (tumour side 5.75 +/- 0.69 and normal side 5.68 +/- 0.58 microM per 106 cells vs control group 38.3 +/- 3.6 nM per 106 cells; P< 0.001). The distribution of iNOS was identified in AM, tumour-associated macrophages, endothelium, chondrocytes, airway epithelium of both lungs and malignant cells (adenocarcinoma and alveolar cell carcinoma) of cancer patients. cNOS was labelled in alveolar macrophages, endothelial cells and nerve elements from lung tissue. Our results indicate that, in patients with primary lung cancer, the production of NO from alveolar macrophages was increased as a result of the up-regulation of iNOS activity. The increased NO production was not specific to the tumour side and might be attributed to the tumour-associated non-specific immunological and inflammatory processes of the host.

Serum vitamin D metabolite levels and the subsequent development of prostate cancer (Hawaii, United States)

OBJECTIVES

Because several serum studies of vitamin D metabolites have produced equivocal results on their relation to prostate cancer risk, the purpose of this study is to evaluate this association further.

METHODS

A nested case-control study in a cohort of 3,737 Japanese-American men examined from 1967 to 1970 was conducted in Hawaii (United States). At the time of examination, a single blood specimen was obtained, and the serum was frozen. After a surveillance period of over 23 years, 136 tissue-confirmed incident cases of prostate cancer were identified. Their stored sera and those of 136 matched controls were measured for the following: 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, calcium, phosphorus, and parathyroid hormone.

RESULTS

There were no notable differences between cases and controls in their median serum levels of the five laboratory measurements. Odds ratios (OR) for prostate cancer, based on the quartiles of serum levels in controls, were also determined. The ORs for the highest quartiles relative to the lowest were 0.8 (95 percent confidence interval [CI] = 0.4-1.8) for 25-hydroxyvitamin D and 1.0 (CI = 0.5-2.1) for 1,25-dihydroxyvitamin D.

CONCLUSION

It is possible that the lack of sufficient numbers of study subjects with low vitamin D levels affected the results. Nonetheless, the findings suggest that there is a lack of a strong association between vitamin D and prostate cancer.

Frequency of Epstein-Barr virus-associated gastric adenocarcinoma in Taiwan

Eighty-two gastric adenocarcinomas (32 intestinal and 50 diffuse type) were investigated for the presence of Epstein-Barr virus (EBV) DNA by amplifying the 78-bp fragment from the EBNA1 gene with polymerase chain reaction. EBV was detected in 17 (20.7%) of the 82 gastric tumorous specimens. Of these 17 EBV-positive cases, only one was EBV-positive in the adjacent non-tumorous tissue. EBV-positive gastric adenocarcinoma was present in 15.6 and 24.0% of the intestinal and diffuse type tumors, respectively, but within the two classes there was significant non-homogeneity by type. EBV was found more frequently in adenocarcinomas of the tubular (25%) and poorly differentiated (30.3%) types. EBV involvement was found more in male than in female patients. Eighty of the 82 tumors were also checked for the prevalence of p53 gene mutation. Of the 17 EBV-positive gastric adenocarcinomas, only two showed p53 gene mutations. The p53 mutation rate was lower in EBV-positive tumors (11.8%) than in EBV-negative tumors (25.4%).

Accuracy of frozen section diagnosis in gynecology

OBJECTIVE

A retrospective study was undertaken to evaluate the accuracy of frozen section diagnosis in gynecological surgery.

METHODS

We compared the results of 792 consecutive gynecological frozen section diagnoses with their final diagnoses from January 1991 to June 1996. Slides for which the frozen section diagnosis was uncertain or incompatible with the final diagnosis were reviewed by an attending pathologist to determine the possible causes.

RESULTS

A total of 299 ovarian, 390 lymph node, 56 uterine lesions, and 77 other tissue samples were obtained. The frozen section diagnosis was compatible with the final diagnosis in 97.5% of cases. The sensitivity for nonbenign lesions was 90.9%, and the specificity was 99.5%. There were no false positives or overestimated cases; 1.3% of cases were falsely negative, 0.4% underestimated the degree of malignancy, and 0.9% were uncertain. Possible causes for incompatible or uncertain frozen section diagnoses were analyzed. The accuracy of frozen section diagnoses for ovarian, lymph node, uterine, and other tissues was also evaluated. Frozen section was found to identify correctly 13 of 17 ovarian malignancies metastaic from other organs, 14 of 15 germ cell malignancies, and 3 of 4 dysgerminomas. The low sensitivity in ovarian borderline malignancy was due to the even lower sensitivity in its mucinous subgroup. The relationship between section numbers and accuracy of frozen section diagnosis in mucinous ovarian tumors was assessed.

CONCLUSIONS

Frozen section diagnosis in gynecology is sufficiently accurate for clinical use, with a low false negative rate and an even lower false positive rate. Most incompatible frozen section diagnoses occurred in ovarian lesions, especially in mucinous ovarian tumors. Performing multiple sections (at least one section for every 10 cm in diameter) is recommended in the frozen section diagnosis of mucinous ovarian tumors.

Solitary extramedullary plasmacytoma in the retroperitoneum

Solitary extramedullary plasmacytoma is an uncommon neoplasm and occurs most frequently in the upper respiratory tract. Herein, we reported a solitary extramedullary plasmacytoma in the retroperitoneum. A 28-year-old man presented with obstructive jaundice and a retroperitoneal tumor. Ultrasound-guided biopsy confirmed that the lesion was a plasma cell neoplasm. A detailed investigation showed that no other sites were involved. The tumor got a moderate reduction following local irradiation, and a complete remission was achieved after 12 courses of adjuvant chemotherapy. Therefore, the possibility of a solitary extramedullary plasmacytoma should be considered in the differential diagnosis of obstructive jaundice without a history of multiple myeloma.

Hepatocellular carcinoma presenting as jaundice, hemobilia, and acute pancreatitis: a case report

A 48-year-old asymptomatic male hepatitis B virus carrier presented with a 2-day history of fever, chills, right upper quadrant abdominal pain, and jaundice. Shock was detected on admission. Emergency abdominal computed tomography (CT) scanning without contrast enhancement showed the features of acute pancreatitis. Hemobilia, edematous pancreatitis, cholestasis and cholecystitis were found on exploratory laparotomy. Neither stone nor active bleeding were detected on intraoperative choledochoscopic examination. Postoperative T-tube cholangiography one month later revealed non-opacification of the left intrahepatic duct. The patient's abdominal pain and hemobilia recurred. Celiac angiography and CT scanning with contrast showed two hepatocellular carcinomas (HCC) in the left lobe of the liver. This is the first case report in the English literature of HCC presenting as jaundice, hemobilia, and acute pancreatitis.

Human prostate cells synthesize 1,25-dihydroxyvitamin D3 from 25-hydroxyvitamin D3

Epidemiological and laboratory data support a role for vitamin D in the growth and differentiation of human prostatic cells. These findings prompted us to ask whether prostatic cells could convert 25-hydroxyvitamin D3 (25-OH-D3), the major circulating metabolite of vitamin D3, to 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], the hormonally active metabolite, in a manner similar to cultured human keratinocytes. Therefore, we investigated three well-characterized human prostate cancer cell lines, LNCaP, DU 145, and PC-3; two primary cultures of cells derived from noncancerous human prostates (one normal and one benign prostatic hyperplasia); and primary cultures of normal human keratinocytes for their ability to synthesize 1,25(OH)2D3. Assays were performed in the presence of 25-OH-D3 as the enzyme substrate and 1,2-dianilinoethane, an antioxidant and free radical scavenger, and in the presence and absence of clotrimazole, a cytochrome P450 inhibitor. DU 145 and PC-3 cells produced 0.31 +/- 0.06 and 0.07 +/- 0.01 pmol of 1,25(OH)2D3/mg protein/h, respectively. No measurable 1,25(OH)2D3 was detected in LNCaP cells. The normal and benign prostatic hyperplasia primary cultures and keratinocyte cultures produced 3.08 +/- 1.56, 1.05 +/- 0.31, and 2.1 +/- 0.1 pmol of 1,25(OH)2D3/mg protein/h, respectively, using a calf thymus receptor binding assay to measure 1,25(OH)2D3 in the presence of 1,2-dianilinoethane. The identity of the analyte as 1,25(OH)2D3 was supported by high performance liquid chromatography using [3H]25-OH-D3 as the enzyme substrate and a solvent system that is specific for 1,25(OH)2D3. The production of 1,25(OH)2D3 in the prostate cancer cell lines and in the primary cultures was completely inhibited in the presence of clotrimazole. This report demonstrates that two of three human prostate cancer cell lines, as well as primary cultures of noncancerous prostatic cells, possess 1alpha-hydroxylase activity and can synthesize 1,25(OH)2D3 from 25-OH-D3. Together with recent data indicating that 1,25(OH)2D3 inhibits the invasiveness of human prostate cancer cells (G. G. Schwartz et al., Cancer Epidemiol. Biomark. Prev., 6: 727-732, 1997), these data suggest a potential role for 25-OH-D3 in the chemoprevention of invasive prostate cancer.

Efficacy of thymosin alpha1 in patients with chronic hepatitis B: a randomized, controlled trial

Thymosin alpha1 (Talpha) is an immune modifier that has been shown in a pilot study to be effective for chronic hepatitis B; this requires confirmation. Ninety-eight patients with clinicopathologically proven chronic hepatitis B were randomly allocated to 3 groups: 1) group A received a 26-week course of Talpha with a 1.6-mg subcutaneous injection two times a week (T6 group); 2) group B received the same regimen as group A, but Talpha therapy extended for 52 weeks (T12 group); and 3) group C served as a control group and was followed up for 18 months without specific treatment (T0 group). The three groups were comparable in clinicohistological features at entry. The complete virological response rate (clearance of serum hepatitis B virus [HBV] DNA and hepatitis B e antigen [HBeAg]) was higher in group A (40.6%) and group B (26.5%) than in group C (9.4%) (group A vs. group C: P=.004; group B vs. group C: P=.068) when assessed 18 months after entry, although complete response rates among these three groups were similar when first assessed at the end of therapy. There was a trend for complete virological response to increase or accumulate gradually after the end of Talpha therapy. None of the responders lost hepatitis B surface antigen. Blinded histological assessment showed a significant improvement in treated patients, particularly in lobular necroinflammation and scores excluding fibrosis. No significant side effects were observed. These results suggest that a 26-week course of Talpha therapy is effective and safe in patients with chronic hepatitis B.

Hepatocellular carcinoma presenting as pyogenic liver abscess: characteristics, diagnosis, and management

We performed a 17-year retrospective analysis of 10 cases of hepatocellular carcinoma presenting as pyogenic liver abscess. Spontaneous tumor necrosis and biliary obstruction caused by tumor thrombi, superimposed with bacterial infection, were the two major pathogeneses. Exact diagnosis of the underlying hepatocellular carcinoma was made for five of the 10 patients before management was attempted. Main clinical manifestations included fever, chills, right-upper-quadrant pain, malaise, anorexia, jaundice, and hepatomegaly. Characteristics such as middle age and male sex, seropositivity for hepatitis B and/or hepatitis C, chronic liver disease, unexplained anemia, marked weight loss, and a severely inversed albumin/globulin ratio raise suspicions about the underlying hepatocellular carcinoma. Management strategies included percutaneous drainage (n = 3), surgical drainage (n = 4), and hepatectomy (n = 3) in addition to administration of parenteral antibiotics in all cases. The prognosis was dismal, with a mean survival of 3.5 months (range, 8 days to 6 months).

Surgical results in patients with dual hepatitis B- and C-related hepatocellular carcinoma compared with hepatitis B- or C-related hepatocellular carcinoma

BACKGROUND

The purpose of our study was to report on the surgical outcomes of patients with hepatocellular carcinoma (HCC) with dual hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and to assess the differences in the surgical results between those patients and the patients with hepatitis B- or hepatitis C-related HCC.

METHODS

The operative outcomes of 13 patients with hepatitis B surface antigen (HBsAg)-positive and hepatitis C antibody (HCV Ab)-positive (the BC-HCC group) results, 57 patients with HBsAg-positive and HCV Ab-negative (the B-HCC group) results, and 34 patients with HBsAg-negative and HCV Ab-positive (the C-HCC group) results, who had undergone hepatic resection from 1991 to 1995, were compared.

RESULTS

The operative mortality rate within 1 month after operation for patients with BC-HCC was 7.7%. No statistically significant difference was found compared with the patients with B-HCC and C-HCC (5.3% and 5.9%, respectively). The postoperative course of patients with BC-HCC was complicated by liver failure, postoperative ascites, and wound infection in one patient each. Also, no statistically significant difference was found among the groups (23.1%, 22.8%, and 20.5% for patients with BC-HCC, B-HCC, and C-HCC, respectively). The overall 1-, 3-, and 5-year survival rates of patients with BC-HCC in this series were 75%, 50%, and 40%, respectively. The postoperative recurrence rate was 66.7%. No statistically significant differences were found between the various groups of the virus-related HCC on the overall survival rate and disease-free survival rate.

CONCLUSIONS

Hepatic resection for HCC in patients with dual HBV and HCV infections was associated with slightly higher operative morbidity and mortality rates, but there were no statistical differences compared with hepatitis B- or C-related HCC regarding the survival and recurrence rates.

Hereditary neurological tumor syndromes: clues to glioma oncogenesis?

The author reviewed five hereditary neurological tumor syndromes associated with gliomas: Li-Fraumeni cancer syndrome, neurofibromatosis type 1 (NF1) and type 2 (NF2), tuberous sclerosis (TS), and Turcot syndrome. In each case, clinical manifestation, genetic localization, and protein function were identified. Correlation with glioma oncogenesis demonstrated the following associations: 1) p53 mutation (Li-Fraumeni) with astrocytoma progression; 2) NF1 mutation (NF1) with pilocytic astrocytomas; and 3) NF2 mutation (NF2) with ependymoma formation. The role of the TS gene and the adenomatous polypopsis coli gene (Turcot syndrome) in glioma oncogenesis is not clear. Because tumorigenesis is a multistep process, it would be premature to equate a specific germline mutation with the multiple somatic mutations required for glioma formation. However, identification of specific germline genetic mutations provides a model for the multiple tumor suppressor genes involved in glioma pathogenesis.

Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature

OBJECT

The authors aimed to develop management strategies for the treatment of herniated thoracic discs and to define indications for selection of surgical approaches. Symptomatic thoracic discs requiring surgery are rare. Between 1971 and 1995, 71 patients with 82 herniated thoracic discs were surgically treated by the authors. The treated group included 34 men and 37 women whose ages ranged from 19 to 75 years, with a mean age of 48 years. The most common sites of disc herniation requiring surgery were from T-8 to T-11. Evidence of antecedent trauma was present in 37% of the patients. Preoperative symptoms included pain (localized, axial, or radicular) in 54 (76%) of the 71 patients, evidence of myelopathy, that is, motor impairment in 43 (61%), hyperreflexia and spasticity in 41 (58%), sensory impairment in 43 (61%), and bladder dysfunction in 17 (24%).

METHODS

Radiological diagnosis for the patients in this series was accomplished by means of myelography, computerized tomography myelography, or magnetic resonance imaging. Classification of the disc location into two groups reveals that 94% were centrolateral and 6% were lateral. Evidence of calcification was present in 65% of patients, and in 7% intradural extension was noted at surgery. Ten patients (14%) were found to have multiple herniations. Four surgical approaches were used for the removal of these 82 disc herniations: transthoracic in 49 (60%), transfacet pedicle-sparing in 23 (28%), lateral extracavitary in eight (10%), and transpedicular in two (2%). Postoperative evaluation revealed improvement or resolution of pain in 47 (87%) of 54, hyperreflexia and spasticity in 39 (95%) of 41, sensory changes in 36 (84%) of 43, bowel/bladder dysfunction in 13 (76%) of 17, and motor impairment in 25 (58%) of 43. Complications occurred in a total of 12 (14.6%) of 82 discs treated surgically. Major complications were seen in three patients and included perioperative death from cardiopulmonary compromise, instability requiring further surgery, and an increase in the severity of a preoperative paraparesis.

CONCLUSIONS

Review of this series, with the attendant complications, together with evaluation of several contemporary thoracic disc series, has facilitated the authors' decision-making process when considering the comprehensive management of these patients, including the selection of a surgical approach.

"Hotness" stability of chicken hot-wing products as affected by preparation methods and storage

Chicken hot-drumettes containing 2% cayenne pepper were prepared using three different cooking methods and stored under two different temperatures for "hotness" evaluation. Results demonstrated that the hotness of the samples were highest when products were cooked in a microwave oven, followed by convection oven, and least hot by deep-fat frying. Regardless of the cooking method, the degree of hotness of the hot-drumette decreased drastically during refrigerated storage. Results also indicated that the loss of hotness was associated with the increase of 2-thiobarbituric acid (TBA) values in the product. The addition of antioxidants such as butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), rosemary, and sodium nitrate during preparation or vacuum packaging retarded lipid oxidation of chicken hot-drumettes and retarded the loss of hotness of the products during refrigerated storage.

Recombinant human morphogenetic protein: its future role in spinal fusions

The marriage of basic scientific research and clinical application often leads to profound advances in our understanding of various disease processes and how they may be ameliorated. One such fortuitous combination has been the discovery of bone morphogenetic proteins (BMPs) and their potential application in spinal fusions. The goal of this article is to introduce the neurosurgeon to the basic biology of this protein family, current experimental data (in vitro and in vivo models) demonstrating their effectiveness in enhancing bony fusions, and preliminary clinical trials utilizing BMP in long bone fusions. Using this information, a proposal for the use of BMP in spinal fusions under various clinical scenarios will be discussed.

Up-regulation of the cAMP/PKA pathway inhibits proliferation, induces differentiation, and leads to apoptosis in malignant gliomas

Manipulation of signal transduction pathways has been increasingly used to modulate tumor growth. We have investigated the effects of up-regulation of the cAMP/protein kinase A (PKA) pathway in cell lines and primary cultures of malignant gliomas. The malignant glioma cell line A-172 was treated with agonistic cAMP analogs dibutyryl cyclic AMP (dcAMP) and 8-bromo-cyclic AMP (8-Br-cAMP), an adenylate cyclase activator (forskolin), and a phosphodiesterase inhibitor (3-isobutyl-1-methyl-xanthene [IBMX]). Proliferation was determined by 3H-thymidine assay. Differentiation was measured by morphologic changes, glial fibrillary acidic protein (GFAP) content, and invasion potential. Apoptosis was measured quantitatively by the TUNEL method, which labels DNA fragments using terminal transferase. Agonistic cAMP analogs, forskolin, and IBMX were found to decrease proliferation in A-172 cells after 24 hours. Treatment with 8-Br-cAMP for 24 hours caused an increase in GFAP and decrease in invasion. Apoptosis was induced after 48 hours in the presence of synergistic cAMP analogs for the Type II PKA isozyme, but not Type I PKA isozyme. Activation of PKA by increasing cAMP levels (forskolin, IBMX) or directly by cAMP analogs correlated with decreased proliferation, increased differentiation, and induction of apoptosis in A-172 cells. Modulation of the cAMP/PKA pathway may thus represent a possible target site for treating malignant gliomas.

Frequent allelic loss on chromosomes 4q and 16q associated with human hepatocellular carcinoma in Taiwan

To define the critical region of liver-specific tumor suppressor genes in human hepatocellular carcinoma (HCC), we analyzed 30 cases of hepatocellular carcinoma using nine 4q and six 16q microsatellite polymorphic DNA markers. We observed one major common deleted region which was flanked by D4S175-D4S1625 and there may be two tumor suppressor genes on chromosome 16q associated with HCC. An extensive study of allelotyping of human HCC was therefore carried out in the candidate region on arms of chromosome 4q with additional tumor tissues and more informative microsatellite DNA markers. These data imply that at least one putative tumor suppressor gene is located in the human chromosome 4q26-q27 region and provides very useful information for further construction of a long-range physical restriction map and thereafter cloning of the putative tumor suppressor gene.

Clinical studies of mucin-producing cholangiocellular carcinoma: a study of 22 histopathology-proven cases

OBJECTIVE

We present the clinical features and outcomes of 22 surgically treated and histopathology-proven cases of mucin-producing cholangiocellular carcinoma (MPCCC).

BACKGROUND

Cholangiocellular carcinoma (CCC) is an uncommon malignancy. Unlike hepatocellular carcinoma, it is difficult to set up a high-risk group, and a specific tumor marker has yet to be found. Chronic liver disease is usually not found to be associated with CCC. Information about patients with MPCCC is limited, and the frequency of MPCCC in all patients with CCC has not been reported.

METHODS

The clinical features of 22 surgically treated and histopathology-proven cases of MPCCC were reviewed, including morbidity, mortality, and follow-up results. Factors that may influence the outcomes were also analyzed. Clinical features and outcomes of 148 patients with non-mucin-producing cholangiocellular carcinoma (non-MPCCC) were also summarized for comparison.

RESULTS

Of 170 cases of CCC, 22 (12.9%) were MPCCC. Imaging studies were important in the differential diagnosis of CCC. Operative findings (e.g., gross appearance of the liver, mucobilia found by common bile duct exploration, choledochoscopic findings, and frozen section) were useful in the diagnosis of MPCCC. Surgical procedures included common bile duct exploration, or hepaticostomy, and intraoperative choledochoscopy in all 22 patients. Hepatic resection was done in 14 of the 22 cases (63.6%). No early surgical mortality was noted. Wound infections (two patients), bile leak (one patient), and intraabdominal abscess (one patient) were the postoperative complications. The 1-, 2-, 3-, 4-, and 5-year survival rates were 86.5%, 68.5%, 59.0%, 38.5%, and 31.0%, respectively. A significant difference in survival pattern was found between the MPCCC and non-MPCCC patient groups. Patients with hepatic resection had a significantly better prognosis than those without resection. Although patients with hepatolithiasis had a better survival pattern than those without hepatolithiasis, the difference was not statistically significant.

CONCLUSIONS

We present the clinical features and outcomes of 22 surgically treated and histopathology-proven cases of MPCCC. Patients with hepatic resection were found to have better survival rates.

Vitamin D and its major metabolites: serum levels after graded oral dosing in healthy men

We determined the quantitative relationships between graded oral dosing with vitamin D3, 25(OH)D3, and 1,25(OH)2D3 for short treatment periods and changes in circulating levels of these substances. The subjects were 116 healthy men (mean age, 28 +/- 4 years, with usual milk consumption of < or = 0.47 l/day and mean serum 25(OH)D of 67 +/- 25 nmol/l). They were distributed among nine open-label treatment groups: vitamin D3 (25, 250 or 1250 micrograms/day for 8 weeks), 25(OH)D3 (10, 20 or 50 micrograms/day for 4 weeks) and 1,25(OH)2D3 (0.5, 1.0 or 1.0 microgram/day for 2 weeks). All treatment occurred between January 3 and April 3. We measured fasting serum, calcium, parathyroid hormone, vitamin D3, 25(OH)D and 1,25(OH)2D immediately before and after treatment. In the three groups treated with vitamin D3, mean values for circulating vitamin D3 increased by 13, 137 and 883 nmol/l and serum 25(OH)D increased by 29, 146 and 643 nmol/l for the three dosage groups, respectively. Treatment with 25(OH)D3 increased circulating 25(OH)D by 40, 76 and 206 nmol/l, respectively. Neither compound changed serum 1,25(OH)2D levels. However, treatment with 1,25(OH)2D3 increased circulating 1,25(OH)2D by 10, 46 and 60 pmol/l, respectively. Slopes calculated from these data allow the following estimates of mean treatment effects for typical dosage units in healthy 70-kg adults: an 8-week course of vitamin D3 at 10 micrograms/day (400 IU/day) would raise serum vitamin D by 9 nmol/l and serum 25(OH)D by 11 nmol/l; a 4-week course of 25(OH)D3 at 20 micrograms/day would raise serum 25(OH)D by 94 nmol/l; and a 2-week course of 1,25(OH)2D3 at 0.5 microgram/day would raise serum 1,25(OH)2D by 17 pmol/l.

Scar endometriosis

BACKGROUND

Scar endometriosis may develop after pelvic operations, such as cesarean section, tubal ligation, hysterotomy and hysterectomy. This prompted us to demonstrate the proper diagnosis; management and prophylactic procedure of scar endometriosis.

METHODS

Twelve patients with scar endometriosis were diagnosed by clinical symptoms and signs, including a painful scar mass related to the menstrual cycle and cyclic bleeding from scars. Preoperative ultrasound needle aspiration cytology was arranged in three patients without painful mass. The management comprised complete surgical excision and selective medical treatment. Postoperative follow-up was scheduled at six-month intervals.

RESULTS

Except for two patients who complained of scar pain but no palpable mass during menstruation, there was no evidence of recurrence in the other 10 patients.

CONCLUSIONS

Diagnosis of scar endometriosis should involve detailed history taking and pelvic examination. Concerning the role of needle aspiration cytology, it still remains controversial. Several prophylactic procedures have been presented to prevent decidual contamination of the wound. Complete surgical excision including the adjacent fascia or skin is the proper treatment of scar endometriosis.

Goniosurgery for prevention of aniridic glaucoma

PURPOSE

We conducted a retrospective study to report the long-term success and complications of modified goniosurgery to prevent aniridic glaucoma, an entity that typically is difficult to control medically or surgically.

METHODS

Fifty-five eyes in 33 patients who had aniridia without glaucoma and who had goniosurgery were identified. Ninety-one procedures were performed on 55 eyes by 1 surgeon (D.S.W.). Each eye had an average of 1.65 procedures and an average of 200 degrees of goniosurgery. Average patient age at time of initial goniosurgery was 37 months. There were no operative complications.

RESULTS

No eye had a decrease in visual acuity at last follow-up. All eyes had a preoperative intraocular pressure (IOP) of less than 21 mm Hg. At last follow-up (average, 9 years 6 months; range, 8 months to 24 years), 49 eyes (89%) had IOP of less than 22 mm Hg without medications. The remaining 6 eyes (11%) had IOP of less than or equal to 22 mm Hg with up to 2 eye drops. Of 224 aniridic eyes of 112 patients that were seen for eye care by 1 of the authors (D.S.W.), 119 eyes (53%) demonstrated glaucoma, as defined by IOP of greater than 21 mm Hg.

CONCLUSIONS

Without prophylactic goniotomy, aniridic glaucoma may be expected in half of patients, and when it occurs, it is extremely difficult to control. Prophylactic goniosurgery in selected eyes of young patients with aniridia is effective in preventing aniridic glaucoma.

Tuberculoma of the liver presenting as a hyperechoic mass on ultrasound

An unusual case of hepatic macronodular tuberculoma is presented. As demonstrated by CT, the tuberculoma replaced the entire lateral segment of the left lobe of liver and resembled an infiltrative tumour. On ultrasound, the tuberculoma presented as a hyperechoic lesion, in contrast to a round hypoechoic mass which is usually seen in this condition. Hepatic macronodular tuberculomas are not uncommonly misdiagnosed as primary or secondary liver tumours by imaging studies, and the definite diagnosis is usually established by liver biopsy. The prognosis of hepatic macronodular tuberculoma is usually very good with effective treatment.

[Cognition, needs, satisfaction, and emotional responses for home care in bone marrow transplantation patients]

Bone marrow transplantation (BMT) is an aggressive treatment which can induce considerable physical and psychological stresses. Patients face various problems in self care and psychological adjustment after discharge from the hospital. The purpose of this study was to explore the cognition, needs, satisfaction, and emotional responses toward home care in BMT patients and the factors influencing them. Forth BMT patients were enrolled from the outpatient clinic of BMT in a medical center. A descriptive research design was adopted. Cognition, needs, satisfaction, anxiety and depression for home care in these patients were collected by questionaires. The results showed that BMT patients had inadequate knowledge about how to care for themselves at home. High need and low satisfaction on disease adjustment and home care were found in these patients. All patients experienced anxiety and depression. Occupation, education, and socioeconomic status were found to affect patient's cognition. Religious belief influenced needs and satisfaction for home care in these patients. Sex and social-economic status emotional reaction of patients. This study will help health personnel understand the cognition, needs and satisfaction for home care in BMT patients. It can be used as a reference for organizing discharge plan and extending the continuity of care for BMT patients.

Calcium absorptive effects of vitamin D and its major metabolites

The absorptive response to graded doses of vitamin D3, 25(OH)D, and 1,25(OH)2D was measured in healthy adult men after treatment periods of eight, four, and two weeks, respectively. While no relationship was found between baseline absorption and serum vitamin D metabolite levels, all three vitamin D compounds significantly elevated 45Ca absorption from a 300 mg calcium load given as part of a standard test meal. 1,25(OH)2D was active even at the lowest dose (0.5 microgram/day), and the slope was such that doubling of absorption would occur at an oral dose of approximately 3 micrograms/day. 25(OH)D was also active in elevating absorption and did so without raising total 1,25(OH)2D levels. On the basis of the dose response curves for 1,25(OH)2D and 25(OH)D, the two compounds exhibited a molar ratio for physiological potency of approximately 100:1. The absorptive effect of vitamin D3 was seen only at the highest dose level (1250 micrograms, or 50,000 IU/day) and was apparently mediated by conversion to 25(OH)D. Analysis of the pooled 25(OH)D data from both the 25(OH)D- and vitamin D3-treated groups suggests that approximately one eighth of circulating vitamin D-like absorptive activity under untreated conditions in winter may reside in 25(OH)D. This is a substantially larger share than has been predicted from studies of in vitro receptor binding.

Histopathology and pathobiology of hepatotropic virus-induced liver injury

The present report concerns current knowledge regarding immunopathogenesis that can be applied in the interpretation of histopathological changes in acute and chronic viral hepatitis. The histopathological features of viral hepatitis have not been changed and light microscopic examination remains essential for making a diagnosis and classification of chronic hepatitis and for the provision of objective parameters on grading and staging. However, new understanding and knowledge of viral pathogenesis, host immune responses, the biological behaviour of the causative viral agents and, in particular, viral interference in multiple hepatotropic viral infections must be taken into consideration in the interpretation of histopathological and immunopathological findings of liver tissues. This report also presents some histopathological analyses on multiple hepatotropic viral infections. It can be concluded that the diagnostic histological criteria for acute hepatitis remain applicable in such settings. However, the cause of acute flare up in chronic hepatitis could not be determined without clinical, virological and serological information. Routine histopathology cannot distinguish a new infection from an acute exacerbation due to a high level of viral replication or mutant virus. A repertoire of immunocytochemical stainings for viral antigens is helpful, but caution must be exercised in suggesting a specific viral aetiology due to the fact that suppression of pre-existing viral antigens can be pronounced when the new or concurrent infection is hepatitis C virus related.

Valtrac-secured intracolonic bypass device: an experimental study

PURPOSE

The intracolonic bypass tube has been used both experimentally and clinically to protect the anastomotic site. A newly designed intracolonic bypass, the Valtrac-secured intracolonic bypass, which consisted of a biofragmentable anastomosis ring (BAR) and was connected with a soft, thin vinyl tube, was used in the colon approximately 5 to 10 cm proximal to the anastomotic site. The distal end of the vinyl tube is passed through the colonic anastomosis to the anus to bypass the fecal stream.

METHODS

Eighteen piglets were divided into three groups of six each. Group A piglets underwent colon resection and rough anastomosis with large gaps between sutures, followed by Valtrac-secured intracolonic bypass. Group B piglets underwent the same procedures, but a colonic outlet obstruction also was done with pursestring sutures tied over the anus. Group C piglets underwent colon resection and rough anastomosis, but no intracolonic bypass tube was inserted (as in the control group).

RESULTS

All Group A and Group B piglets survived. Passage of the BARs occurred approximately two weeks later. As the barium enema passed through the bypass tube, it showed a patent BAR-secured tube and intact anastomosis with no leakage. In Group C, anastomotic leakage occurred in four of six piglets, three of which died. Barium enema showed leakage at the anastomotic site.

CONCLUSIONS

In the animal model we used, our new intracolonic bypass device proved to be a simple, safe, reliable means of protecting the anastomotic site and, thereby, eliminated the need for a diverting colostomy. Still we need further steps to test its potential in clinical use.

Expression of integrin subunits and CD44 isoforms in psoriatic skin and effects of topical calcitriol application

Increasing evidence suggests involvement of integrins and CD44 isoforms in the pathogenesis of psoriasis, contributing to uncontrolled keratinocyte proliferation, neovascularization, and invasion of inflammatory cells. We have analyzed immunohistochemically in situ expression of integrins (CD29, CDw49b, CDw49c, CDw49e, CDw49f) and CD44 isoforms (CD44 standard, CD44 var/v6, CD44 v10) on frozen sections of normal and psoriatic skin (nonlesional skin, lesional skin before and along with topical calcitriol treatment). We did not observe visual changes of immunoreactivity in normal as compared to nonlesional psoriatic skin, while the staining pattern of CDw49c, CDw49f, and CD29 was severely altered in untreated lesional psoriatic skin. Most markedly, CDw49c, CDw49f, and CD29 were focally upregulated in suprapapillar epidermal compartments of lesional psoriatic skin, a staining pattern that is in accordance with the phenomenon that was described by Pinkus as "squirting papilla". Additionally, an increased proportion of inflammatory and endothelial cells revealed immunoreactivity for CD44(std.) in untreated lesional psoriatic as compared to nonlesional psoriatic or normal skin. After 8 weeks of topical calcitriol treatment (15 micrograms/g ointment), the staining pattern for CDw49c, CDw49f and CD29 was markedly changed in epidermis of lesional psoriatic skin, reverting to the staining pattern characteristic for the nonlesional psoriatic or normal human skin, although epidermal expression of CDw49f was still upregulated and CDw49e-, CDw49f-, CD29-, and CD44(std.)-immunoreactive inflammatory and endothelial cells were still to be found in the dermal compartment.