Clonality in myelodysplastic syndromes: demonstration of pluripotent stem cell origin using X-linked restriction fragment length polymorphisms

Restriction fragment length polymorphisms (RFLP) of the X-chromosome genes phosphoglycerate kinase (PGK) and hypoxanthine phorphoribosyltransferase (HPRT) were used to determine the clonal nature of myelodysplastic syndromes (MDS) in 22 patients. These included eight with refractory anaemia (RA), four with RA with ring sideroblasts (RARS), six with RA with an excess of blasts (RAEB), three with RAEB in transformation (RAEB-T), and one with chronic myelomonocytic leukaemia (CMML). Monoclonal X-inactivation patterns were observed in 19/22 patients. The remaining three cases, one each with RA, RARS and RAEB, were of polyclonal composition. Separated T-lymphocyte and granulocyte fraction analyses in six patients of the former cases revealed that T-lymphocyte as well as granulocyte fractions showed a monoclonal pattern of X-inactivation. These results support the view that the majority of MDS arise from a pluripotent stem cell capable of myeloid and lymphoid differentiation.

[A case of mitral regurgitation treated by combined superior transseptal approach and electrophysiological examination of the sinus node function]

A 67-year-old man with mitral regurgitation underwent mitral valvoplasty and annuloplasty successfully. Combined superior transseptal approach was adopted to expose the mitral valve, because the left atrium was small. The exposure of the mitral valve was excellent. But this approach cannot avoid damaging the sinus node artery, so that why the sinus node function was examined electrophysiologically before and after the operation. Sino-atrial conduction time (SACT) and corrected sinus node recovery time (CSRT) were measured as the indices of the sinus node function. Both SNCT and CSRT after the operation was within normal range. As far as this case, combined superior transseptal approach, which gave good exposure of the mitral valve but needed to cut the sinus node artery, did not deteriorate the sinus node function.

Acquired epidermoid tumour in the thoracic spinal canal

Acquired spinal epidermoid tumours are rare, and probably caused by skin fragments that have been transplanted by trauma or lumbar puncture. They almost always occur in the region of the cauda equina. We present an acquired spinal epidermoid tumour at the T 10 level, with pathological confirmation. A skin fragment had migrated to a site where it developed into a tumour.

Posterior cranial fossa dural arteriovenous malformation with a varix mimicking a thrombosed aneurysm: case report

Dural arteriovenous malformations (AVMs) in the posterior cranial fossa are relatively infrequent. Intradural haemorrhage is one of their specific complications. Angiographic demonstration of varices or aneurysmal structures is one of the hallmarks of severe cases. We report a patient with posterior cranial fossa dural AVM associated with a varix mimicking a thrombosed aneurysm on CT and MRI. Internal carotid and vertebral angiography failed to demonstrate an aneurysm, but external carotid injection revealed a dural AVM affecting the sigmoid sinus, and a varix. The AVM was completely eliminated by embolization. When a dural AVM is suspected clinically selective angiography should be performed to confirm the diagnosis even when CT or MRI do not show dilated vessels.

Scanning electron microscopic observations of the arachnoid granulations in monkeys with cerebrospinal fluid hypotension

The changes in arachnoid granulations following the depletion of cerebrospinal fluid (CSF) were investigated by scanning electron microscopy (SEM) and transmission electron microscopy (TEM). In the normal tissue, the arachnoid granulations located at the inner walls of the superior sagittal sinus and the straight sinus had bulging protrusions of various sizes, as viewed with the SEM. With TEM, the outermost cells covering the surface of the arachnoid granulations had "giant vacuoles" in the cytoplasm. With CSF hypotension, the arachnoid granulations were smaller in size and the outermost layer of cells were thinner. The vacuoles in the outer layer were not developed. In the apical region of the individual arachnoid granulations with CSF hypotension, the arachnoid cells were densely clustered under the endothelial cells. With recovery to normal CSF pressure, the arachnoid cells appeared to protrude between the endothelial cells covering the apical portion of the arachnoid granulation.

[Expression of epidermal growth factor receptor in adult human airway epithelium--application of AMeX method]

To elucidate the role of epidermal growth factor (EGF) in the maintenance and repair of airway epithelial cells in adult humans, we investigated immunohistochemically whether EGF receptor (EGFR) is expressed in these cells. In the present study, we employed the AMeX method (Sato et al., 1986) for tissue preparation. We first examined the expression of EGFR in peripheral lung tissue and bronchial tissue obtained at surgery from thirteen adult patients with lung carcinoma. The results showed that there was no positive staining for EGFR in the bronchial surface epithelium, bronchial glandular cells, bronchiolar epithelium or alveolar lining cells. There was also no expression of EGFR in cells comprising areas of basal cell hyperplasia and epidermoid metaplasia in the bronchus, or alveolar cell hyperplasia and columnar cell metaplasia in fibrotic lung tissue. Second, we examined the expression of EGFR in regenerating distal airway epithelial cells, which were experimentally produced by xenotransplantation of human lung tissue into the subcutaneous tissue of nude mice. There was also no expression of EGFR at any stage of regeneration from one week through six weeks after the transplantation. It is concluded that EGFR is not expressed, at least at an immunohistochemically detectable level, by airway epithelial cells of adult humans, not only in the quiescent state but also under conditions in which epithelial cells are stimulated to replicate. Thus, it appears unlikely that the EGF/EGFR system plays an important role in either maintenance or repair of airway epithelial cells in adult humans.

[Activity of ATP-dependent protease and steroid metabolism in the human placenta]

Placenta play the important role of nourishment of fetus and for the regulation of fetal and maternal steroid metabolism. Steroid metabolism is synthesized in mitochondria and levels of enzymes in steroid metabolism are regulated by the rate of synthesis and degradation of these enzymes. Therefore, we studied protease in human placental mitochondria to clarify regulation mechanism of steroid-synthesizing enzymes. 50 micrograms of human early and term placenta homogenate, proteins were analyzed by immunoblotting technique after SDS-polyacrylamid gel electrophoresis. ATP-dependent protease was detected using antiserum raised against purified bovine adrenocortical ATP-dependent protease and avidin-biotin complex method. ATP-dependent protease activity was assayed using 14C-Caseins a substrate. Five cell fractions of homogenate placenta were electrophorated and antibody-stained using ATP-dependent protease, cytochrome P-450 scc and adrenodoxin antibody after the blotting, and the quantity was analyzed by the densitometry and the method of De Douve. We had the following results: 1) ATP dependent protease is present in human placenta and localized in mitochondria. 2) ATP dependent protease decomposes adrenodoxin reductase in human placenta. 3) ATP dependent protease present in almost same consistent in early and term placenta and there is no significant difference. It is suggested as follows that the ATP dependent protease in human placenta participates in the regulation of steroid hormone through the metabolism of steroid synthetic enzyme.

[A surgically treated case of acute pulmonary embolism owing to deep vein thrombosis of the leg mainly caused by uterine myoma]

A 49-year-old woman with deep vein thrombosis of the left leg suddenly complained of slight dyspnea during her hospitalization. Enhanced chest CT and pulmonary arterial DSA revealed pulmonary emboli, while phlebography of the left leg and lower abdominal CT showed a uterine myoma compressing the left external iliac vein, which was regarded as a chief cause of deep vein thrombosis of the left leg. The patient became dyspneic severely with a rapid increase of pulmonary arterial pressure and a decrease of arterial oxygen pressure. Therefore, pulmonary embolectomy and deep vein thrombectomy of the left leg and pelvis was performed using a cardiopulmonary bypass. Hysterectomy was also performed after weaning the bypass. The postoperative course was uneventful without recurrence of pulmonary embolism. This was a very rare case of pulmonary embolism, because, as far as we investigated, no literature has reported deep vein thrombosis of the leg caused by uterine myoma. We emphasize the availability of the enhanced CT for diagnosis of pulmonary embolism.

Key roles of nitric oxide and cyclic GMP in nonadrenergic and noncholinergic inhibition in rat ileum

Nonadrenergic and noncholinergic (NANC) inhibitory responses in circular and longitudinal muscles of the rat ileum were studied separately in vitro. Localized distension with a small balloon caused relaxation of the circular muscle on the anal side of the distended region. Nitro-arginine inhibited the relaxation and L-arginine counteracted the effect of nitro-arginine. Treatment of the preparation with superoxide dismutase (SOD) and methylene blue resulted in enhancement and inhibition, respectively, of the relaxation induced by distension. Nitric oxide caused relaxation of the circular muscle in a dose-dependent manner. 8-Bromo cyclic GMP (cGMP) caused relaxation of the circular muscle. Electrical transmural stimulation caused relaxation followed by a rebound contraction of the longitudinal muscle. Nitro-arginine inhibited the relaxation and L-arginine counteracted this inhibition. Similar results to those in the circular muscle were obtained in the longitudinal muscle with SOD, methylene blue, nitric oxide and 8-bromo cGMP. Electrical field stimulation increased the cGMP content of the longitudinal muscle preparation. Nitric oxide also increased the cGMP content of smooth muscle cells obtained from circular and longitudinal muscles of rat ileum. Preincubation of smooth muscle cells with methylene blue inhibited the effect of nitric oxide on the cGMP content. These results suggest a key role of cGMP in NANC inhibitory responses in rat ileum. The factors mediating the responses are discussed.

In situ performance tests of soft-x-ray multilayer mirrors exposed to synchrotron radiation from a bending magnet

The performance of soft-x-ray multilayer mirrors of Mo/Si, Rh/Si, and Ru/Si has been tested in situ during ~ 15-h exposure to white synchrotron radiation from a bending magnet of the Photon Factory (Tsukuba, Japan) ring. The power density on the sample surface was ~ 0.14 W/mm(2). The tests were made by measuring the intensity of the reflected beam from the test mirrors with a detector unit consisting of a carbon filter and an aluminum cathode. The detector unit served as an effective narrow-band detector for the intense radiation of 85-105 eV reflected from the test mirrors. The Mo/Si and Rh/Si multilayer mirrors were found to be quite stable against continuous irradiation, whereas the Ru/Si multilayer mirror showed a definite decrease in the reflected-beam intensity.

Ki-1-positive large-cell anaplastic lymphoma with protean manifestations including central nervous system involvement

A 26-year-old female with Ki-1-positive large-cell anaplastic lymphoma is reported. The neoplastic cells were phenotypically and genotypically of T cell origin. Initially, neoplastic cells invaded the skin and lymph nodes, and then invaded the sternal and vertebral bones, ribs and the iliopsoas muscle. Central nervous system (CNS) involvement with paraplegia, large tumor mass formation in her breast and pleural infiltration ensued in succession. This case illustrates the protean manifestations of Ki-1-positive large cell anaplastic lymphoma complicated with CNS involvement.

Performance of a wideband soft x-ray polarizer

Performance of a Ru/Si multilayer polarizer of the doublecrystal monochromator type is evaluated in the soft x-ray region. Its polarization was found to be higher than 99.5% at 89 and 97 eV.

[A case report of controlled aortic root reperfusion (CARP) following global myocardial ischemia during surgery for severe mitral stenosis with tricuspid regurgitation]

The use of controlled aortic root reperfusion (CARP) as additional myocardial protection in cardiac surgery has been employed at University of Alabama at Birmingham Since 1986. This technique has been applied to a patient in Japan undergoing mitral valve replacement and tricuspid annuloplasty and favorable results were obtained. The CARP method consists of two consecutive procedures following global myocardial ischemia, that is, terminal warm blood cardioplegic reperfusion and selective controlled coronary perfusion. When the repair was almost completed, the CARP technique was initiated with warm blood (37 degrees C) from an oxygenator, and the initial phase was hyperkalemic (K+ 20 mEq/1, 3 min). [Terminal warm blood cardioplegic reperfusion] This was followed by normokalemic warm blood (without interruption) from the pump oxygenator infused through a cardioplegic needle into the isolated aortic root with the aortic cross-clamp still in place (10 to 20 min). [Selective controlled coronary perfusion] Terminal warm blood cardioplegic reperfusion induced electromechanical quiescence initially which allowed rapid repletion of adenosine triphosphate and improved cardiac function. Selective controlled coronary perfusion with normokalemic warm blood permits necessary and sufficient coronary blood flow following global ischemia even when systemic arterial pressure fell and coronary vascular resistance rose. On considering these two points, we consider that the CARP technique offers excellent myocardial protection in accelerating the recovery of myocardial function following global ischemic damage. The CARP method offers useful assistance in cardiac surgery particularly for patients who have abnormal preoperative cardiac function and who have experienced long periods of global myocardial ischemia.

[A case of T cell lymphoma of the lung]

A 70-year-old woman complained of cough, sputum and fever. Chest roentgenogram showed a mass-like lesion with pleural effusion in the left thorax. Bronchoscopy revealed a polypoid lesion at the orifice of left B10 and mucosal swelling of the left lower lobe bronchi. The biopsied material of the polypoid lesion was diagnosed as malignant lymphoma (diffuse small cell type by LSG classification) and the immunohistochemical examination showed monoclonal proliferation of T lymphocytes. The atypical lymphocytes which were positive for T lymphocyte surface marker were detected in the pleural effusion. There was no evidence of metastasis in any part of the body under clinical examinations, and the lung was thought to be a primary site of the lymphoma. The doubling time of tumor was estimated to be 134 days. Four-drug combination chemotherapy resulted in a marked decrease of the tumor size. Immunohistochemical study to determine the subpopulation of lymphoma cells are required for diagnosis of pulmonary lymphoma, because the biological characters of T cell lymphoma might differ from those of B cell lymphoma.

Perioperative monitoring of total body water by bio-electrical impedance in children undergoing open heart surgery

Knowledge of the changes in total body water (TBW) following cardiac surgery (OHS) in children would be of value in fluid therapy and in researching the causes and management of capillary leak. We have validated a bioelectrical impedance technique (BEI) for non-invasive estimation of TBW in children after OHS. We report the use of this method in a longitudinal study. Twenty patients (mean age 4.7 years +/- 3.5 (SD), mean weight (WT) 16.2 kg +/- 1 kg) undergoing a variety of complex OHS procedures were studied from 1 day preoperatively to 4 days postoperatively. Anaesthetic and basic bypass (CPB) techniques were uniform. Six patients underwent CPB at less than 20 degrees C, 10 at 20 degrees - 25 degrees C and 4 at 26 degrees - 33 degrees C. TBW (BEI), core (ctemp) and peripheral (ptemp) temperatures and fluid balance (TFB) were recorded at frequent intervals. TBW (by BEI) rose (P less than 0.001) following CPB in all patients from 62% +/- 9% (SD) body weight preoperatively to 73% +/- 13% in the ICU (an increase of 11% +/- 5%). TBW remained significantly elevated until the 3rd postoperative day. Multivariate analysis (MVA) confirmed that TBW was significantly related to TFB, but not to ctemp or ptemp. MVA also revealed smaller patient size (height and weight), younger age and longer CPB time as incremental risk factors for the rise in TBW.

CONCLUSIONS

(1) BEI permits the non-invasive study of TBW in children after OHS, when TBW variation may be considerable. (2) The smaller the child and the longer the CPB, the greater the rise in TBW. (3) The technique should be a valuable tool in researching the major water fluxes associated with CPB in children.

[A study on reduction rate of tumor volume by irradiation in germinoma, malignant lymphoma, and medulloblastoma]

A relationship between radiation dose and reduction rate of tumor volume was studied in 10 patients with germinoma, nine with malignant lymphoma, and seven with medulloblastoma, in order to evaluate the effect of irradiation on these tumors. Germinomas showed either mono- or biphasic reduction of the volume with increased radiation dose in semi-logarithmic expression, irrespective of their size. All patients are well without relapse except for one that was lost because of transfer. The reduction rate of tumor volume was slightly less in malignant lymphomas and medulloblastomas than that in germinomas and the former two showed less uniformity of response to irradiation according to each case. Malignant lymphomas tended to regrow during irradiation period or early after the period and the effect of irradiation seemed to be related to the size of the tumor. Medulloblastomas did not completely disappeared during irradiation period, but delayed effect of irradiation was recognized after the period.

[Clinical usefulness of 67Ga-citrate scintigraphy combined early image in malignant lymphoma--detection of abdominal lesions]

In order to improve the diagnostic accuracy in detecting abdominal lesions of malignant lymphoma, we studied prospectively the usefulness of 67Ga-citrate scintigraphy combined 5 to 6-hour early image with conventional 72-hour delayed image after injection. During the period from July 1986 to September 1988, total 41 67Ga-citrate scintigrams performed on 28 patients with malignant lymphoma (3 Hodgkin's disease, 25 non-Hodgkin lymphoma) were evaluated between early and delayed image regarding to such points as follows; 1) the physiologic bowel uptake of 67Ga-citrate, 2) detection of abdominal lesions indicated by other diagnostic modalities involving computed tomography, lymphography and ultrasonography. Following results were obtained: 1) Prominent bowel uptake of 67Ga-citrate thought to be difficult to interpret the scintigram was observed in only 1 of 41 (2%) on early image versus 13 of 41 (32%) on delayed image. 2) Known lesion sites were detected in 24 of 31 (77%) on early image versus 21 of 31 (68%) on delayed image, resulting in 26 of 31 (84%) in combination with both images. 3) There were 2 false-positive and 5 false-negative lesions. Two false-positive lesions on early image were explained by physiologic hepatic uptake with ill-defined outline and bladder uptake. On the other hand, all of 5 lesions on delayed image were explained by prominent bowel uptake. 4) Two patients were revealed higher splenic uptake comparing with hepatic uptake on both images, later proved to be diffuse splenic involvement without evidence of lesions on other diagnostic modalities. 5) The lesions less than 2 cm in diameter could not be detected in both images.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurinoma of the oculomotor nerve: CT and MR features

The authors present a case of neurinoma of the oculomotor nerve without evidence of von Recklinghausen disease. The literature is reviewed and CT and magnetic resonance findings are discussed.

Unusually early recoarctation after extended end-to-end anastomosis in a neonate

A seven-day-old neonate with aortic coarctation and hypoplastic aortic arch underwent extended end-to-end repair with no residual gradient. Eleven hours after repair, femoral pulses were not palpable and recoarctation was confirmed by echocardiography. After failure of prostaglandin E2 infusion, a radically extended end-to-end anastomosis was performed eight days after initial repair. No recoarctation was evident 10 months after the second repair. The unusually early recoarctation was presumably due to residual and active duct tissue in the repair margins.

[Intrathoracic pacemaker implantation in children]

In order to minimize the complications, we introduced the intrathoracic implantation method since 1976. Until 1988, 12 children underwent this method. A pacemaker generator was exchanged in 8 patients, 12 times, because of battery exhaust. Compared with the conventional method (abdominal wall implantation), the complications such as electrode fracture, which was related to the implantation sites, were reduced. Furthermore it was very useful from the cosmetic viewpoint. Although an exchange of generator was very easily done at the first time, it was very difficult at the second time, due to rib fusion accompanying with children's growth.

[Basic and clinical studies on a new method for detecting anti-Mycoplasma pneumoniae antibody, using high density particles]

We developed a new method for detecting anti-Mycoplasma pneumoniae antibody, using high density particles (HDP). We characterized the HDP, and also studied the clinical applicability of the HDP agglutination method (HDPA). HDP were uniform, spherical particles, having a specific gravity of 2.0 and a mean particle volume of 18 fl. Adsorption of IgG by HDP was approximately 2 times that by polystyrene latex. The sensitized antigen to the HDP, extracted from the Mycoplasma pneumoniae (Mac strain) bound specifically to the anti-Mycoplasma pneumoniae antibody. With HDPA, the antibody was determined within 30 minutes, which was more rapid than with other routine methods such as complement fixation test, passive hemagglutination test and particle agglutination test (PA). HDPA showed excellent correlation with PA. However, the titers with HDPA were generally 2 to 5 tubes higher than that with PA. A follow-up study on 7 cases of mycoplasma pneumonia revealed remarkably high titers of anti-Mycoplasma pneumoniae antibodies in the acute phase of mycoplasma pneumonia by HDPA, compared to that by PA. HDPA is highly sensitive and specific test for detection of anti-Mycoplasma pneumoniae antibody, and useful for rapid diagnosis of mycoplasma pneumonia.

Glycidyl methacrylate-styrene copolymer latex particles for immunologic agglutination tests

New latex particles for immunologic agglutination reaction were prepared by a seeded polymerization technique for the emulsifier-free copolymerization of styrene and glycidyl methacrylate. The surface of the latex particles was presumed to be dotted with hydrophilic domains, giving stability to the particles. The remaining areas, to which many antigens or antibodies were strongly adsorbed, were hydrophobic. Various groups of the glycidyl methacrylate-styrene latex particles were coated with human immunoglobulin G, and immunologic agglutinating potencies were compared by the box-titration method. Immunologic reactivities of the latex particles decreased with an increase of glycidyl methacrylate content at concentrations of 1 mol% or higher. Latex particles containing 0.5 to 0.75 mol% GMA caused strong immunologic agglutination besides showing good stability, indicating the availability of these latex particles. Glycidyl methacrylate-free polystyrene latex particles caused non-specific agglutination, while the immunologic agglutinating ability of glycidyl methacrylate-styrene latex particles, prepared by the unseeded polymerization technique was weak.

[Adoptive immunotherapy by intra-arterial infusion of ATLAK or Allo-TLAK cells in patients with head and neck cancer]

For clinical application of adoptive immunotherapy, it is necessary to prepare a sufficient number of autologous tumor specific effector cells. A large amount of peripheral blood lymphocytes was obtained by leukapheresis using a Heamonetics V50 pheresis system. Autologous tumor- and lymphokine-activated killer (ATLAK) cells were induced by autologous mixed lymphocyte tumor cell culture (autologous MLTC) and further activation with recombinant interleukin-2 (rIL-2). Another problem was the difficulty of obtaining a sufficient number of highly activated effector cells to reach the target tumor tissue. Direct infusion of effector cells into a feeding artery was effective for cell accumulation in the target. ATLAK cells were infused into maxillary artery in 4 patients with maxillary squamous cell carcinoma. The results indicated that the therapy was effective for reduction of the tumor mass. After immunotherapy, surgery was performed and the tissues were histologically examined. Degenerated tumor cells and intensive infiltration by mononuclear cells and macrophages were seen in the surrounding fibrous tissue. However, the quantity of fresh autologous tumor cells available from open biopsy was limited. Allogeneic cultured tumor cell line was used as stimulator of lymphocytes instead of autologous tumor cells. The killing activity of the allogeneic tumor and lymphokine activated killer (Allo-TLAK) cells was significantly induced against the autologous tumor cells. Antitumor effect was observed in 5 out of 9 patients. Side effects were minor, such as slight fever and blood eosinophilia, which may be due to the rIL-2 function. These results indicate that this method of therapy is an effective form of adoptive immunotherapy.

[Surgical consideration of ruptured abdominal aortic aneurysms]

During the recent 18 and a half years, 30 cases of ruptured abdominal aortic aneurysm (including four cases of A-V fistula) were operated at Saiseikai Utsunomiya Hospital. In 26 cases, a conventional graft replacement was performed. In other four cases, axillo-bifemoral bypass (in the cases ruptured into the colon) or other methods were used. Overall operative mortality rate was 26.7%. However, during the last 9 years, operative results were improved (21.7%, 5 deaths out of 23 cases). Amount of intraoperative blood loss influenced the operative results greatly. Other operative risk factors included preoperative shock, preoperative severe cerebrovascular or cardiovascular complications, and postoperative thromboembolism. Factors of recent improvement in mortality included; establishment of emergency system which resulted in earlier operation after the patient's arrival at the hospital, use of occlusive balloon for bleeding control, heparin administration before the aortic clamp for preventing peripheral thromboembolism and introduction of autotransfusion system for reducing the amount of blood transfusion.

[CT appearance of uterine adenomyosis]

CT findings in 37 cases with pathological diagnosis of uterine adenomyosis were reviewed retrospectively. The attenuation coefficient of adenomyosis is almost same as normal parenchyma on both plain and enhanced CT. The margin was obscure except for one case. In focal type, deviation of the endometrium and deformity of the uterus may be a clue to the detection of adenomyosis. But differential diagnosis of adenomyosis from leiomyoma with ill-defined margin was very difficult. In diffuse type, the uterine body is swollen without deviation of the endometrium. This type can be diagnosed if the endometrium identified clearly.

Disease and pregnancy in adolescent girls

The frequency of visits to the outpatient clinic, chief complaints, and pregnancies of adolescent girls were analyzed. The age distribution of adolescent girls who visited the clinic showed that the higher the age, the higher the frequency of menstrual cycle abnormalities. Recently, increased sexual activity has been seen in teenagers and has caused problems, especially the increase in teenage pregnancies, contributing to increases in induced abortion. To avoid unwanted pregnancy of unmarried teenagers, intensive sex education is essential, as well as provision of contraceptives.

Prediction of severe obstruction to right ventricular outflow after repair of tetralogy of Fallot and pulmonary atresia

Cineangiograms were available for a quantitative retrospective study along with complete clinical information in 96 patients who underwent intracardiac repair of tetralogy of Fallot with pulmonary atresia. Multivariate analysis determined that the risk factors for too high a ratio (greater than or equal to 1) between the peak pressure in the right ventricle and that in the left, in the operating room about 30 minutes after repair, were as follows: size of the patient, small size of the right and left pulmonary arteries, and a larger number of large aortopulmonary collateral arteries. When, according to the multivariate equation, the predicted probability of this ratio being equal to or greater than 1 is 50% or more, consideration may be given to preliminary operations before repair; when the predicted probability is 70% or more, complete repair at that stage may be unwise.

Survival, functional status, and reoperations after repair of tetralogy of Fallot with pulmonary atresia

DATA

Among 139 patients who underwent repair of tetralogy with pulmonary atresia, survival rates at 1 month and at 1, 5, 10, and 20 years were 85%, 82%, 76%, 69%, and 58%, respectively. The hazard function (instantaneous risk of dying) was greatest immediately after operation and declined thereafter, but a low constant hazard persisted for as long as the patients were followed up. Multivariately, the postrepair ratio between peak right ventricular and left ventricular pressures measured in the operating room provided the most information relative to the probability of death after repair, and cardiopulmonary bypass time the next. When morphologic abnormalities of the pulmonary circulation were considered in the multivariate analysis for risk factors for death, the size of the pulmonary arteries provided the most information, followed by the number of large aortopulmonary collateral arteries. The postrepair peak right ventricular/left ventricular pressure ratio was lower the day after operation than in the operating room in 65% of the patients in whom the measurements were made. Recurrent or residual ventricular septal defects necessitating rerepair occurred in four patients (3% of hospital survivors). Most surviving patients were in New York Heart Association class I at the time of follow-up.

INFERENCES

Early, intermediate, and long-term survival is less good after repair of tetralogy with pulmonary atresia than after repair of tetralogy with pulmonary stenosis. This is related primarily to the greater prevalence of high peak right ventricular/left ventricular pressure ratio measured in the operating room in the former group. Both the postrepair peak right ventricular/left ventricular pressure ratio in the operating room and the probability of death are inversely related to the size of the pulmonary arteries and directly to the number of large aortopulmonary collateral arteries. This and inferences from other risk factors may be helpful in achieving better results in the future.

The structure of the pulmonary circulation in tetralogy of Fallot with pulmonary atresia. A quantitative cineangiographic study

Cineangiograms of 172 patients with tetralogy of Fallot and pulmonary atresia were qualitatively and quantitatively analyzed retrospectively.

FINDINGS

Twenty-eight (16%) patients had congenital absence of the central and unbranched hilar portions of the left or right pulmonary artery or both, and thus had congenitally nonconfluent pulmonary arteries. Five additional patients (3%) with originally confluent pulmonary arteries had nonconfluent ones because of an end-to-end surgical shunt, as did seven others (4%) because of thrombosis of one pulmonary artery. Among the 132 patients with confluent right and left pulmonary arteries, 70 (53% of 132) had incomplete arborization (distribution) of one or both, as did 23 (82% of 28) of those with congenitally nonconfluent pulmonary arteries (P for difference = 0.005). Ten (36% of 28) of the latter group had fewer than 10 pulmonary vascular segments (normal is 20) in continuity with central pulmonary arteries, compared with four (3%) of the former group. The proximal left and right pulmonary arteries were small but variable in size in all groups (median value 1.05 McGoon ratio), but were largest in the patients with confluent pulmonary arteries. Seventy-nine (60% of 132) patients with confluent left and right pulmonary arteries had large aortopulmonary collateral arteries, as did 100% of those with congenitally nonconfluent pulmonary arteries (P less than 0.001). The number of large aortopulmonary collateral arteries correlated inversely with the completeness of arborization of the left and right pulmonary arteries (P less than 0.0001). Inferences: Most patients with tetralogy and pulmonary atresia have gross morphologic abnormalities in the pulmonary vasculature and differ quantitatively in this regard from those with tetralogy and pulmonary stenosis. The prevalences of the various types of these abnormalities are considerably interrelated.

[Esophageal cancer developing 13 years after radiotherapy of lung cancer]

This paper reports on an autopsied case manifesting an esophageal cancer that had developed 13 years after radiotherapy for lung cancer. The patient was a 61-year-old man. He was found to have a squamous cell carcinoma of the right lower bronchus with a swelling of the mediastinal and left supraclavicular lymph nodes in July of 1973. He received 60 Gy of irradiation in the right lung, the mediastinum, and the left supraclavicular region. Later, after doing well until August of 1986, a squamous cell carcinoma of the esophagus was found at the upper intrathoracic site. Thus, he also received additional radiotherapy but died of pneumonia after this local recurrence 7 months later. At autopsy, no local recurrence of the primary lung cancer was found. The site of esophageal cancer was far from that of the primary lung cancer though it was included in the previous treatment ports. This suggests the possibility that the primary esophageal cancer had been induced by therapeutic irradiation. So far as we know, this is the first report of esophageal cancer that may have developed after irradiation for lung cancer.

Formation and propagation of brain oedema fluid around human brain metastases. A CT Study

Computerized tomography (CT) was used to examine the time-course of the propagation of extravasated contrast medium from small brain metastases into the peritumoural oedematous white matter, following infusion of 200 ml of meglumine amidtrizoate for 3 hours. Four patients with a metastatic brain tumour were examined. CT scans at identical levels were taken 1.5, 3, 6, 9, and 12 hours after start of contrast infusion. Following 4-7 days of dexamethasone treatment (8-12 mg/day i.v.) the examination was repeated. A contrast-enhanced area was observed surrounding the clearly delineated tumours, expanding gradually in a circular fashion into the peritumoural white matter oedema. The expanding circular enhancement was measured planimetrically on the various scans. From these values, the increase in radius/hr respectively in volume/hr was calculated, assuming a spherical geometry. This enabled a determination of the rate of oedema fluid formation and of the speed of oedema fluid propagation. The formation rate of oedema fluid amounted to 0.5-3.2 ml/hour and the speed of oedema fluid spreading to 1.9 mm/hour. Following treatment with dexamethasone the formation rate of oedema fluid is reduced by 30-50%. The important clinical implications of these new findings are discussed.

Suppressor cells in the effector phase of autologous cytotoxic reactions in cancer patients

Cytotoxicity was induced in lymphocytes (CL) from 10 out of 15 patients by autologous mixed lymphocyte tumor cell culture and further cultivation with recombinant interleukin-2. In cells from 3 of the 10 patients, cytotoxicity was suppressed by more than 50% when autologous peripheral blood mononuclear cells (PBMC) from the patients with large tumors were added to the autologous killing system. The cells responsible for suppressing the cytotoxicity in the effector phase were adherent or nonadherent to plastic depending on the patient examined. The T cell fraction from 1 patient significantly suppressed the cytotoxic activity, and this suppression was seen only in the autologous system. On the other hand, plastic adherent cells but not T cells from PBMC of 2 subjects suppressed the cytotoxic activity of CL. The reason why the main cell population suppressing the CL activity differed among the patients is unclear. However, the findings that the suppression was mostly abrogated following resection of the tumor mass suggested that suppressor cells, either of macrophage lineage or T cells, are induced in patients with a large tumor mass. This speculation is supported by the finding that the PBMC from a patient with tumor recurrence regained the suppressive activity.

Autologous immune response of tonsillar lymphocytes

Tonsillar (TL) and peripheral blood lymphocytes (PBL) from patients with pustulosis palmaris et plantaris (PPP) or recurrent tonsillitis (RT) were analysed for their proliferative response of T-cells upon stimulation with non-T-cells in the autologous mixed lymphocyte reaction (AMLR). TL and PBL from the same donor were cultured in the AMLR for up to 7 days. Maximum proliferation was observed after a 6-day culture in PBL, whereas that of TL was observed on the 3rd day of the culture. It was also observed that the AMLR of TL in patients with PPP was significantly (p less than 0.01) lower than in patients with RT. On the other hand, it has previously been proved by an immunofluorescence study that there is an identical antigenicity between tonsillar epithelium and skin. From this result, a blastoid transformation study of TL and PBL from patients with PPP was performed by using homologous or autologous skin extracts. Both homologous and autologous skin extract induced blastoid transformation of TL but PBL scarcely responded. These results may support the opinion that an auto-immunological mechanism may take part in the onset of PPP.