[A juxtaglomerular cell tumor. Analysis of immunohistochemistry, electron microscopy and in situ hybridization]

We present a case of juxtaglomerular cell tumor measuring 8 mm in diameter in the right kidney. The hypertension was cured and plasma renin activity returned to normal level following tumor resection with partial nephrectomy. We studied histopathologic, electron microscopic, and immunohistochemical findings of the tumor. The majority of tumor cells stores renin granules in cytoplasm. In situ hybridization confirmed us that the most tumor cells produce renin. We use the digoxigenin labeled 0.6-kb length RNA probe of human renal renin, the specificity was analyzed by competition assay (1:50).

Spinal cord segments controlling the canine vas deferens and differentiation of the primate sympathetic pathways to the vas deferens

This study was undertaken to explore the spinal cord segments controlling the canine and human vas deferens and differentiation of the mammalian sympathetic pathways to the vas deferens. Thoracolumbar white communicating rami (WCR) were electrically stimulated in the dogs. Stimulation of the 1st, 2nd, 3rd, and 4th lumbar WCR elicited an elevation of intraluminal pressure of the vas deferens in 2, 10, 16, and 14 of 20 dogs examined, respectively, whereas stimulation of sympathetic chain (between the 13th thoracic and 1st lumbar ganglia), 13th thoracic WCR, intermesenteric plexus, and 5th lumbar WCR showed no response in any of the 10, 2, 12, and 5 dogs examined, respectively. Anatomical study of the 118 human lumbar splanchnic nerves of 55 cadavers showed that almost all lumbar splanchnic nerves (96%) originated from L2 and/or L3 sympathetic chain ganglia (L1-2 spinal cord levels). Comparative anatomical study of the mammalian sympathetic pathways to the vas deferens showed that the caudal mesenteric plexus is not divided in rats, rabbits, cats, and dogs and is partially divided into two plexuses in monkeys and completely in humans and that separation of the sympathetic component in the pelvic nerve (isolation of the sacral splanchnic nerve) is in progress in the primate. These results indicate that spinal cord segments controlling the vas deferens are L1-4 in the dog and probably L1-2 in humans and that differentiation of the sympathetic nerve pathways is proceeding at both main and compensatory pathways to the vas deferens in the primate.

Sympathetic efferent pathways projecting to the vas deferens

The abdominal and pelvic sympathetic nervous system controlling the vas deferens has elaborate mechanisms to preserve its function against various injuries. The main sympathetic signals to the vas deferens proceed the common pathway in mammalians, which consists of the lumbar splanchnic nerve, caudal mesenteric plexus, hypogastric nerve, pelvic plexus and its branches. On the way of this common pathway, some signals cross to the other side of the body at the level of the caudal mesenteric plexus and/or the pelvic plexus. The preganglionic axons passing through the hypogastric nerve very likely provide a bilateral innervation to postganglionic neurons in the pelvic plexuses, which also exhibit crossing to the bilateral vasa deferentia. The sympathetic nerves originating from the thoracic spinal cord are of minor importance in contraction of the vas deferens but possibly influence it by the hormonal system consisting of the major splanchnic nerve and the adrenal medulla. When the common pathway is interrupted, various compensatory mechanisms are generated: enhancement of the remaining sympathetic pathways or reorganization of synaptic connection in the pelvic plexus. Surgical reconstruction of the transected hypogastric nerve is possible and cross-innervation mechanism via the hypogastric nerve can also be preserved. Elevation of intraluminal pressure at the cauda epididymis/proximal vas deferens induced by nerve impulse pushes the spermatozoa out to the ampulla and distention of the wall of the ampulla triggers its contraction to emit the content into the urethra. After seminal emission, a portion of the seminal fluid remaining in the vas deferens moves in a retrograde direction to the cauda epididymis for the next emission. It remains to be seen whether similar mechanisms in animals are at work in humans.

[Bilateral homonymous hemianopsia with atrial fibrillation]

We encountered an 80-year-old man with sudden bilateral visual disturbance. When he was admitted to the hospital, his blood pressure was 138/70 mmHg, and an ECG revealed atrial fibrillation. Neurological examination showed only bilateral homonymous hemianopsia with no nystagmus or impairment of eye movement. He did not have paralysis cerebellar ataxia, or speech disturbance. Therefore, there was no evidence of obstruction of the thalamogeniculate or thalamoperforating artery. Magnetic resonance imaging of the brain showed cerebral infarctions in both occipital lobes. Perimetry showed bilateral homonymous hemianopsia; the left side of the macula was spared. The lack of neurological deficit other than bilateral homonymous hemianopsia indicates that only the right and left cortical branches of the posterior cerebral artery were occluded.

Cosmetic orchiectomy using pedicled fibro-fatty tissue graft for prostate cancer: a new approach

OBJECTIVE

To preserve the appearance of a normal scrotum at orchiectomy, a pedicled fibro-fatty tissue graft was inserted in the lumen of the tunica vaginalis.

METHODS

42 testes of 21 patients with metastatic prostate cancer were treated. A pedicled fibro-fatty tissue graft prepared from the region between the spermatic cord and the scrotal septum was inserted in the lumen of the tunica vaginalis following epididymis-sparing orchiectomy under local or spinal anesthesia.

RESULTS

A pedicled fibro-fatty tissue graft which reached the epididymal tail was prepared in all instances. The average postoperative volume of the scrotal content was 18 ml (range 5-30 ml). Postoperative complications were scrotal edema, sensation of traction at the inguinal region and epididymitis. All but 1 patient were satisfied with the appearance of the scrotum and achieved sufficient androgen ablation. Mean follow-up was 8 (3-11) months.

CONCLUSION

This cosmetic orchiectomy is a safe, simple and economical procedure to preserve the appearance of a normal scrotum; it also achieves the reliable result of androgen deprivation.

Advanced testicular germ cell tumor in a hemophilic patient with human immunodeficiency virus infection

A stage IIIB anaplastic seminoma which occurred in an HIV-infected hemophilia is reported. The patient with hemophilia A was 36 years old and had been seropositive for HIV antibody for 3 years. Inguinal orchiectomy and subsequent chemoradiotherapy for retroperitoneal lymphadenopathy were performed and a marker negative partial response was obtained. In spite of a low initial CD4+ lymphocyte count (90/microliter), the patient tolerated the treatment well without life-threatening opportunistic infection. Although factor VIII supplement was performed, continuous bleeding from the operative wound made postoperative care difficult.

Cutaneous hemangioma of the penis successfully treated with sclerotherapy and ligation

A cutaneous hemangioma of the penis extending from the proximal portion of the glans to the prepuce of an 18-year-old man was successfully treated by sclerotherapy with polidocanol and interrupted ligation of the hemangioma.

[High dose chemotherapy with peripheral blood stem cell transplantation (PBSCT) For advanced testicular cancer]

Five patients with metastatic testicular cancer of advanced extent according to the Indiana University criteria were enrolled into this study. All tumors were non-pretreated non-seminomas. Initially all patients were treated with standard dose etoposide, ifosfamide and cisplatin (VIP) regimen. The response of two cycles of VIP was evaluated by tumor markers and diagnostic imagings. Two of the five patients showed a good response to VIP and subsequently achieved a pathological complete response (pCR) following surgical resection of residual masses after 3 or 5 courses of VIP. However, they suffered from severe myelosuppression and underwent peripheral blood stem cell transplantation (PBSCT) following the final course of VIP. The remaining three patients unlikely to be cured by VIP underwent chemotherapy consisting of high dose ICE:ifosfamide (6-10 g/m2 over 4days) carboplatin (1,500 mg/m2 over 4 days), etoposide (1,600-2,400 mg/m2 over 4 days) combined with PBSCT. This regimen resulted in one partial response (PR) with marker-negative and two PR with marker-positive. Residual masses were removed in all three patients and viable tumor cells were found in two. Of the five patients enrolled, four patients (80%) remain disease-free with minimal follow-up of 20 months, and the remaining one died of cancer 10 months after PBSCT. No serious side effects or complications were encountered. This study shows that standard dose induction therapy of VIP followed by early salvage chemotherapy of high dose ICE with PBSCT is well tolerated and effective in the treatment of advanced poor-risk testicular cancer.

A new criterion combining ST/HR slope and deltaST/deltaHR index for detection of coronary artery disease in patients on digoxin therapy

We evaluated the clinical value of a new index combining deltaST/delta heart rate (HR) index and ST/HR slope for diagnosing coronary artery disease (CAD) in patients on digoxin therapy. Exercise treadmill tests were performed by 72 patients on digoxin therapy. Simple HR-adjusted indexes of ST-segment depression during exercise (deltaST/deltaHR index) and the decline calculated from the final 12 data points relating ST-segment depression to HR (ST/HR slope) were determined. A new index was obtained by subtracting the deltaST/deltaHR index from the ST/HR slope. On thallium scintigraphy, 37 of the 72 patients showed reversible perfusion defects related to the diseased coronary artery. The new index derived from this ST-HR relation was 4.1 +/- 3.6 microV/beats/min in the ischemic group and 1.3 +/- 1.0 microV/beats/min in the group of patients without ischemia (p <0.0001). An ST-HR relation > or = 1.5 was found in 33 of the 37 patients in the ischemic group, and in 7 of the 35 patients without ischemia (p <0.0001). The sensitivity of this criterion for prediction of myocardial ischemia was 89%, the specificity was 80%, and the predictive accuracy was 85%. Thus, this new ST-HR index is useful for detecting CAD in patients on digoxin therapy.

Preservation of ejaculatory function by reconstruction of the canine hypogastric nerve

OBJECT

The hypogastric nerve (HGN) plays a crucial role in the primary functions of ejaculation: sperm transport through the vas deferens, secretion of prostatic fluid, and bladder neck closure. This study was undertaken to explore the possibility of restoring HGN function to the seminal tract and preserving its cross-innervation mechanism to the seminal tract after HGN-HGN reattachment.

METHODS

Responses of the vas deferens/epididymis, prostate, and bladder neck to electrical stimulation of the lumbar splanchnic nerve (LSN) or the HGN and occurrence of antegrade ejaculation as a result of manual penile stimulation were examined in dogs that had undergone HGN-HGN reattachment. Eighteen months after the procedure had been performed bilaterally, 23 LSNs were electrically stimulated. In 17 LSNs this stimulation elicited elevation of vasal pressure (12 nerves bilaterally); in 18 LNs, bladder neck pressure; and in 15 LSNs, prostate contraction. After retransection of the right HGN in the dogs that had undergone HGN-HGN reattachment, 11 right-sided LSNs were stimulated; in seven LSNs, the stimulation elicited elevation of vasal pressure (five bilaterally), in seven bladder neck pressure, and in six prostate contraction. Twelve left-sided LSNs were stimulated; in seven LSNs, the stimulation elicited elevation of vasal pressure (four bilaterally), in six bladder neck pressure, and in six prostate contracton. Each of the 12 HGN stimulations made proximal to the site that had been sutured in dogs that had HGN-HGN reattachment caused responses of the three organs specified above that were comparable to those in control dogs. Manual penile stimulation elicited antegrade ejaculation in all three dogs examined.

CONCLUSIONS

The results of this study show that the function of the HGN in the seminal tract can be preserved after HGN-HGN reattachment and that restoration of its cross-innervation mechanism is possible.

Chromophobe cell renal carcinoma in childhood

We report the first case of chromophobe cell renal carcinoma in childhood. A 12-year-old boy presented gross hematuria following minor trauma. He was diagnosed as having a left renal tumor 45-mm in diameter. Radical nephrectomy was performed. One year later the boy was well.

Mechanisms of limited maximum coronary flow in severe single-vessel coronary artery disease in humans due to vertical steal

We evaluated the usefulness of a decrease in the average peak velocity from 4 to 10 minutes after infusion of dipyridamole for detecting myocardial ischemia in 50 patients, including patients with a prior myocardial infarction. The decrease in the average peak velocity from 4 to 10 minutes associated with vertical steal and combined with a coronary flow reserve of < 1.6 had a high predictive value for myocardial ischemia in patients with or without prior myocardial infarction.

[Small cell carcinoma of the urinary bladder: a case report and review of the Japanese literature]

A 50-year-old man presented with asymptomatic gross hematuria which he had first noticed 3 months earlier. Clinical examinations revealed a non-papillary, broad-based tumor on the left lateral wall of the urinary bladder with a clinical stage of T3N0M0. The pathological diagnosis of a transurethral biopsy tissue specimen was small cell carcinoma. Neoadjuvant intraarterial infusion chemotherapy using cisplatin and adriamycin was initially administered but proved to be ineffective. Thus, we performed a radical cystectomy. The tumor tissue was apparently homogenous and composed of small cells arranged in sheets and solid patterns, and was staged to be pT3bR1L2V0N0. An electron microscopic study confirmed small cell carcinoma with neurosecretory granules. Postoperatively, 4 courses of adjuvant chemotherapy consisting of cisplatin, etoposide and ifosfamide were administered. The patient is alive without any evidence of tumor recurrence 26 months after the operation.

A new predictor of restenosis after successful percutaneous transluminal coronary angioplasty in patients with multivessel coronary artery disease

With the goal of improving prediction of restenosis after percutaneous transluminal coronary angioplasty (PTCA) for multivessel coronary artery disease (CAD), we evaluated the usefulness of serial exercise treadmill tests. We previously reported that an increase in the deltaST/delta heart rate (HR) index at follow-up over the value obtained several days after PTCA was useful for detecting restenosis following PTCA for 1-vessel CAD. In that report, comparison of the deltaST/deltaHR index was made based on measurements from the lead disclosing the greatest ST displacement before PTCA. This method was not applicable to patients with multivessel CAD. Seventy-eight patients with multivessel CAD before and several days after PTCA and just before follow-up performed exercise treadmill tests. Simple HR-adjusted indexes of ST-segment depression during exercise (deltaST/deltaHR index) and the sum of the deltaST/deltaHR index in leads II, III, aVF, V4, V5, and V6 (sigma deltaST/deltaHR index) were determined. We compared the predictive power of an increase in sigma deltaST/deltaHR index at follow-up with that of a positive exercise treadmill test and a positive thallium scintigram for restenosis. At follow-up, 37 of the 78 patients showed restenosis. The sigma deltaST/deltaHR index had increased in 30 of these 37 patients (81%), and in 12 of the 41 patients (29%) without restenosis. An increase in sigma deltaST/deltaHR index had a significantly higher sensitivity than the other methods and a significantly higher specificity than a positive exercise treadmill test.

[Metastatic tumor of spermatic cord and tunica vaginalis testis from gastric cancer: a case report]

A 62-year-old man with advanced gastric cancer was admitted with a swelling of the left scrotum. He had undergone subtotal and total gastrectomies 10 and 5 years earlier, respectively. A hard mass was palpated along the left spermatic cord associated with hydrocele testis. A left high orhiectomy was performed. Multiple small nodules were noted on the surface of the tunica vaginalis. Also, a tumor in the spermatic cord was present at the level of the internal inguinal ring, protruding into the peritoneal cavity and adherent to the colon. Peritonitis carcinomatosa was recognized. Histopathological diagnosis was tubular adenocarcinoma showing extensive vascular invasion, consistent with a metastasis from gastric cancer.

[Human T-lymphotropic virus type 1 uveitis in children]

We report here five pediatric patients with human T-lymphotropic virus type 1 (HTLV-I) uveitis. The patients were one boy and four girls aged between 3 and 14 years. The transmission route was considered to be breast feeding from their mothers. All patients had unilateral uveitis and the ocular symptoms were similar to those in HTLV-I uveitis in adults. The ocular inflammation responded to therapy with topical or systemic corticosteroids, but recurred in three patients. HTLV-I provirus DNA was detected by polymerase chain reaction (PCR) from infiltrating cells in the anterior chamber in one patient. The percentage of HTLV-I-infected cells in the peripheral blood mononuclear cells was measured by quantitative PCR, and the values were high (2.9 approximately 7.3%) in three cases tested as compared with an asymptomatic carrier. These five cases show that HTLV-I uveitis can be induced in a relatively short period (3 approximately 10 years) after the viral infection, and that HTLV-I uveitis should be considered as one possible etiology of uveitis in children, particularly in a viral endemic area.

Sympathetic efferent pathways projecting bilaterally to the vas deferens in the rat

BACKGROUND

The laterality of the signals passing through the splanchnic nerves to the vas deferens has not been well studied.

METHODS

The present study was designed to determine the bilateral distribution of sympathetic nerves to the rat vasa deferentia by measuring intravasal pressure (VP) responses to electrical stimulation of left lumbar splanchnic nerves (LSN) following consecutive transections of more distal nerves.

RESULTS

L2-L6 LSN stimulation increased VP bilaterally. Left VP responses decreased slightly (< 20%) after section of the right hypogastric nerve (HGN) and then were abolished by subsequent section of branches (B-M-APG) between the left major pelvic (MPG) and accessory pelvic ganglia (APG). Left VP responses were decreased by > 80% after section of left HGN, not changed further by subsequent section of commissural branches (CB-MPG) between the MPG, and completely eliminated by section of commissural branches between the APG (CB-APG). Right VP responses were decreased slightly (< 20%) by section of the left HGN and then abolished by section of the right B-M-APG. These responses were also decreased by > 70% by section of right HGN, not changed by section of CB-MPG, but then completely eliminated by section of CB-APG.

CONCLUSIONS

These results indicate that the left lumbar sympathetic pathway to the vas deferens is distributed bilaterally and exhibits two crossing points at the level of the inferior mesenteric ganglion and APG.

Involvement of the adrenal medulla in ejaculatory reactions in the dog

To explore the peripheral signal controlling ejaculatory reactions, contraction of the seminal tract and seminal emission were monitored in the dog during electrical stimulation of the lumbar and greater splanchinc nerves in the presence or absence of sympathetic pathways connecting the lumbar sympathetic trunk to the seminal tract including the vas deferens, prostate and bladder neck. Electrical stimulation of the lumbar splanchnic nerve caused seminal emission, elevation of intraluminal pressure of the vas deferens and bladder neck, and contraction of the prostate without elevation of blood pressure. Transection of all peripheral sympathetic nerve pathways to the seminal tract completely blocked these responses. Electrical stimulation of the greater splanchnic nerve caused a marked elevation of blood pressure as well as the responses described above in both the presence and absence of peripheral sympathetic nerve pathways to the seminal tract. However, clamping the adrenal veins bilaterally blocked all of the above responses and declamping immediately reversed the block. Serum levels of epinephrine, norepinephrine and dopamine were significantly increased by electrical stimulation of the greater splanchnic nerve, while cortisol levels remained unchanged. Furthermore, intravenous administration of epinephrine (5 micrograms/kg) caused responses similar to those elicited by stimulating the greater splanchnic nerve. Dogs in which all sympathetic pathways to the seminal tract had been transected chronically showed retrograde ejaculation during manual penile stimulation. The above results indicate possible involvement of the greater splanchnic nerve and adrenal medulla in ejaculatory reactions in the dog.

Bacillus Calmette-Guérin enhances production and secretion of type IV collagenases in peripheral blood mononuclear cells

Intravesical administration of bacillus Calmette-Guérin (BCG) is an effective and widely accepted treatment for superficial bladder cancer. Rapid progression of the disease after BCG therapy, however, has been reported in some cases refractory to the treatment. We examined whether BCG treatment and coexistence of peripheral blood mononuclear cells (PBMCs) alter the invasive potential of bladder cancer cells. Production and secretion of two type IV collagenases, matrix metalloproteinase (MMP) 2 and MMP 9, by PBMCs from five healthy donors or bladder cancer cells (T24, JTC 30, and JTC 32) were evaluated by gelatin zymography, western blot analysis, and northern blot analysis. Invasion of bladder cancer cells was also examined using reconstituted basement membrane (Matrigel). BCG (5, 50, and 500 micrograms/ml) had no effect on secretion of MMP 2 and MMP 9 by bladder cancer cells, but increased the production and secretion of MMP 9 by PBMCs in a dose-dependent manner. The coexistence of PBMCs increased invasion of T24 cells and BCG further enhanced the invasion. Thus, BCG promotes invasion of bladder cancer cells under certain conditions. An increase in the secretion of MMP 9 by PBMCs may account in part for the effect.

Sympathetic efferent pathways projecting to the bladder neck and proximal urethra in the rat

The sympathetic innervation of the rat bladder neck and proximal urethra (BN/PU) was investigated by measuring BN/PU pressure responses to electrical stimulation of a left lumbar splanchnic nerve (LSN) following consecutive transections of more distal nerves. L2-L6 LSN stimulation increased BN/PU pressure. BN/PU pressure responses did not change after section of the right hypogastric nerve (HGN) but significantly decreased after subsequent sectioning of the commissural branches (CB-MPG) between the right and left major pelvic ganglia (MPG) (22%) and the commissural branches (CB-APG) between right and left accessory pelvic ganglia (APG) (30%). In other animals BN/PU pressure responses were slightly decreased (< 11%) after sectioning the left HGN and then significantly decreased by subsequent sectioning of the CB-MPG (< 21%) and CB-APG (< 36%). BN/PU pressure responses were decreased by sectioning the branches from the MPG to the APG (25%) or postganglionic nerves (MPG-PN) from the MPG to the BN/PU (37%). When the HGN on one side and all branches from the MPG on the contralateral side except for the CB-MPG were transected, increases in BN/PU intraluminal pressure were still elicited by LSN stimulation but were eliminated by transection of the CB-MPG. These results indicate that the left lumbar sympathetic pathway to the BN/PU passes through multiple crossing points at the level of the inferior mesenteric ganglion, MPG and APG and that this pathway could maintain closure of the internal urethral sphincter following various unilateral neural injuries.

Reorganization of the innervation of the vas deferens after sympathetic decentralization

Reorganization of autonomic efferent pathways to the rat vas deferens was noted after chronic (30 days) sympathetic decentralization produced by hypogastric nerve (HGN) transection. In normal rats, electrical stimulation of the HGN elicited an increase in vasal pressure (VP) bilaterally, whereas pelvic nerve (PN) stimulation did not alter VP. However, after unilateral HGN transection, stimulation of the PN on the transected side but not on the normal side increased VP. The decentralized vas exhibited larger VP responses to stimulation of the contralateral HGN in comparison with the normal vas. After bilateral HGN transection, PN-induced VP responses were elicited at lower stimulus intensities than in rats with unilateral transections. PN-induced VP responses were blocked by hexamethonium and prazosin but were not altered by atropine. Distension of the vas lumen occurred after decentralization. PN-induced VP responses were not detectable in extremely distended vas. These data indicate that, after degeneration of sympathetic preganglionic axons, decentralized adrenergic ganglion cells are reinnervated by parasympathetic or sympathetic preganglionic pathways and that the reinnervation influences vasal function.

Increase in the delta ST/delta heart rate (HR) index: a new predictor of restenosis after successful percutaneous transluminal coronary angioplasty

With the goal of improving the prediction of restenosis after percutaneous transluminal coronary angioplasty (PTCA), we evaluated the usefulness of the delta ST/delta heart rate (HR) index derived from serial exercise treadmill tests. Exercise treadmill tests were performed by 125 patients with single-vessel coronary artery disease before and several days after PTCA, and just before follow-up angiography 3 to 12 months later. Simple HR-adjusted indexes of ST-segment depression during exercise (delta ST/delta HR index) were derived. We compared the usefulness of the increase in delta ST/delta HR index at follow-up over the value obtained several days after PTCA for prediction of restenosis with that of a positive exercise treadmill test and a positive thallium scintigram at follow-up. At follow-up, 47 of the 125 patients showed restenosis. The delta ST/delta HR index increased in 43 of 47 patients in the restenosis group and in 18 of 78 patients without restenosis (p < 0.0001). Separate analysis of each criterion revealed the following respective values for sensitivity, specificity, and positive and negative predictive values for prediction of restenosis; increased delta ST/delta HR index of follow-up: 91%, 77%, 70%, and 94%; positive exercise treadmill test: 83%, 65%, 59%, and 86%; and positive thallium scintigram: 79%, 78%, 69%, and 86%. The increased delta ST/delta HR index had a significantly (p < 0.05) higher sensitivity than the positive thallium scintigram and a significantly (p < 0.01) higher specificity than the positive exercise treadmill test. An increased delta ST/delta HR index at follow-up identifies subgroups of patients who are at high risk for restenosis after PTCA.

[A case of renal cell carcinoma with hyperglycemia]

A 71-year-old male with hyperglycemia was incidentally found to have a right renal tumor. Hyperglycemia had been controlled by administration of 34 units of insulin. Immediately after radical nephrectomy, hyperglycemia was improved to be able to stop insulin. His fasting blood glucose level remained within normal limits without any treatment. Laboratory studies, however, failed to reveal any endocrinopathy derived from renal cell carcinoma responsible for the diabetic state.