Pancreatoduodenectomy for periampullary tumors: a univariate and multivariate analysis of the parameters influencing the morbidity, mortality, and survival rates

A total of 69 patients who underwent a pancreatoduodenectomy (PD) for a periampullary tumor in the Department of Surgery I, Kyushu University Hospital from January 1980 to December 1993 were analyzed in order to identify the parameters influencing the morbidity, mortality and survival rates. Anastomotic leakage was seen in 15 of the 69 patients; at the site of a pancreatojejunostomy in nine and at the site of a biliojejunostomy in six. A univariate analysis of complications based on 16 factors showed that major intraabdominal complications (anastomosis leakage and intrabdominal hemorrhage and abscess) were significantly affected by blood loss (> or = 1600 g vs < 1600 g, p < 0.05). Two of the 69 patients died within one month after PD, and the mortality rate was 3%. A univariate analysis of the survival rates of the 69 patients based on the 16 parameters showed that a history of jaundice, the serum level of albumin, and the nature of disease (i.e. malignant or benign) significantly influenced the survival rates (p < 0.05). The year of operation, the age of the patients, the serum level of total bilirubin, the operation time and the operative blood loss were not significant variants. A multivariate Cox regression analysis on these three profound factors showed that malignant disease significantly influenced the clinical course of patients with PD (p < 0.01). With proper patient selection and operative techniques, PD can thus be safely performed for a wide variety of diseases, in virtually any age group.

Cytokine production in five tumor cell lines with activity to induce cancer cachexia syndrome in nude mice

To identify the so-called toxohormone, which is a tumor-derived factor with activity to induce cancer cachexia syndrome in tumor-bearing animals, 5 human cancer cell lines with this activity were studied for cytokine production. Tumor cell products with activity to inhibit lipoprotein lipase (LPL) were shown to play an important role in the development of the cancer cachexia syndrome. All culture media conditioned by the 5 cell lines possessed LPL-inhibitory activity. However, the activity differed with the cell line. In order to characterize the activity, we examined whether the cultured cells produced cytokines with activity to inhibit LPL. A melanoma cell line, SEKI, and a neuroepithelioma cell line, NAGAI, were found to express a large amount of leukemia inhibitory factor (LIF) mRNA. Furthermore, both of these cell lines were demonstrated to produce a large amount of LIF protein, and plasma levels of LIF were extremely elevated in SEKI- and NAGAI-bearing nude mice, indicating that LIF produced by the tumor cells induced cancer cachexia syndrome in the animals. Thus, LIF fulfills the requirements for a toxohormone, except for suppressive activity on liver catalase. In contrast, the mechanisms responsible for cachexia in the MKN-1-, LX-1- and LS180-bearing mice remain unknown. These findings suggest that various types of bioactive substances produced by cancer cells could be toxohormones.

[A case of tuberculosis in which hemoptysis was caused by bleeding from intercostal arteries]

A 60-year-old man was referred to our hospital because of persistent hemoptysis. Chest roentgenogram and computed tomogram revealed that the right hemithorax was almost completely occupied by solid material with scattered calcifications. Mycobacteria were detected in the sputum culture. Administration of antituberculosis agents began after admission. Four months after admission, massive hemoptysis occurred. Topical treatment via fiberoptic bronchoscopy resulted in no improvement. Surgical resection of the right lung would probably have been difficult because of the almost complete collapse of the right lung and the extensive calcifications within the right hemithorax. Angiographic examination revealed extravasation of contrast medium from the right 7th, 8th, 9th, 10th, and 12th intercostal arteries. After transcatheter embolization of each of these intercostal arteries, hemoptysis stopped. It is unclear how bleeding from intercostal arteries caused massive hemoptysis, but the bleeding may have caused a right hemothorax that drained into an airway.

Cryptococcal prostatitis in a patient with Behçet's disease treated with fluconazole

A 55-year-old man with Behçet's disease presented acute urinary retention due to Cryptococcus neoformans infection of the prostate. The disease was localized to the prostate. The infection was successfully treated only with fluconazole. The patient remains well without evidence of systemic or local infection at 32 months.

[Pulmonary alveolar proteinosis associated with myelodysplastic syndrome]

A 57-year-old man with myelodysplastic syndrome developed dyspnea on exertion in September 1993. Chest X-ray film showed diffuse infiltrative shadows in the middle and lower lung fields on both sides. The infiltrates were prominent in the perihilar regions but less so in the periphery, consistent with a "bat wing pattern." Milky fluid was obtained by bronchoalveolar lavage. The specimens obtained from transbronchial lung biopsy were compatible with the pathological findings of pulmonary alveolar proteinosis with amorphous periodic acid-Sciff-positive materials in the alveolar spaces. Impaired function of alveolar macrophages was demonstrated from their abnormally low phagocytosis of FITC-labeled latex beads. Whole lung lavage under general anesthesia was done twice, but the patient died because of progression of respiratory failure.

[Traumatic carotid-cavernous aneurysm after removal of cancer of the upper jaw: a case report]

A case of a traumatic carotid-cavernous aneurysm after removal of cancer of the upper jaw was reported. A 63-year-old male complaining of massive epistaxis from the left nostril was admitted to our clinic. He had suffered from cancer of the left upper jaw and had been treated with radical operation. During the surgical procedure, massive bleeding which was considered to be from the left internal carotid artery, suddenly occurred. The hemorrhage was somehow controlled by packing with oxidized cellulose. He experienced recurrent massive epistaxis after admission. Cerebral angiograms revealed an anterior-medially projecting aneurysm arising from the cavernous portion of the left internal carotid artery. He had a good cross circulation from right to left on compression of the left carotid artery. This aneurysm at the carotid-cavernous portion was produced as a result of injury during an operation for cancer of the upper jaw. To prevent disastrous bleeding from the aneurysm, the aneurysm was then successfully treated by the trapping of extra-and intracranial carotid ligation in combination with left STA-MCA anastomosis. There was no recurrence of epistaxis after the operation. However, a low-grade fever persisted before operation and a blood culture showed MRSA sepsis after the operation. Intensive chemotherapy was performed for this MRSA sepsis, he died of the accompanying DIC. Although aneurysmal epistaxis following a severe closed head trauma is a well-known phenomenon, an iatrogenic carotid-cavernous aneurysm presenting with recurrent massive epistaxis is rare. Several comments were made about the iatrogenic carotid cavernous aneurysm, and the necessity of early diagnosis and treatment was emphasized.

The protein kinase C isoforms leading to MAP-kinase activation in CHO cells

Stimulation of CHO cells with phorbol ester caused transient activation of mitogen-activated protein kinase (MAP-kinases with 42 and 44 kDa). A similar treatment of CHO cells which overexpress a massive amount of the alpha- or delta-isoform of protein kinase C (PKC) resulted in the prolonged activation of MAP-kinase and eventually in the appearance of mostly dikaryotic, sometimes tetrakaryotic cells. The results suggest that the delta-isoform, as well as the alpha-isoform, has a potential to cause MAP kinase activation. Unusual activation of the PKC/MAP-kinase pathway, however, may lead to abnormal cytokinesis.

Effects of early introduction of intensive insulin therapy on the clinical course in non-obese NIDDM patients

In order to reconsider the extent of indication of insulin therapy in non-insulin dependent diabetes mellitus (NIDDM), we performed the following trial in a prospective fashion. At the beginning phase of treatment for diabetes, we introduced intensive insulin therapy in 22 non-obese (Body mass index approximately 24 kg/m2) NIDDM patients without proliferative retinopathy, who were selected in a standardized fashion, avoiding any arbitrary choice. None had received oral hypoglycemic agents (OHA) or insulin yet. By administering insulin 3 or 4 times a day, strict glycemic control was attained and maintained, and then the insulin dose was gradually lowered while keeping good glycemic control. In patients whose glycemic control was maintained at an excellent level for more than 7 days under an insulin dosage lower than 8 u/day, insulin therapy was discontinued. As a result, 15 patients (68%) attained good glycemic control both without insulin and OHA almost within a month and 6 patients (27%) shifted to OHA. It is recommended to introduce intensive insulin therapy in non-obese NIDDM patients without proliferative retinopathy and to aim at attaining good glycemic control both without insulin and OHA.

The role of angiogenesis in the tumor growth of Syrian hamster pancreatic cancer cell line HPD-NR

BACKGROUND/AIMS

New therapeutic approach is required for pancreatic cancer, one of the most intractable malignancies. The role of angiogenesis in the tumor growth of a Syrian hamster pancreatic cancer cell line HPD-NR, which closely resembles its human counterpart, was investigated.

METHODS

Angiogenic activity was measured as stimulation of growth of human umbilical vein endothelial cells (HUVEC), and angiogenic factors produced by HPD-NR cells were identified by reverse-transcription polymerase chain reaction and Northern blot analysis. Then in vitro and in vivo antitumor effects of a potent angiogenesis inhibitor, O-(chloroacetylcarbamoyl)fumagillol (AGM-1470), were examined.

RESULTS

The conditioned medium of HPD-NR cells stimulated the growth of HUVEC, and four hamster angiogenic factors were detected with an overexpression of transforming growth factor alpha and vascular endothelial growth factor messenger RNAs. AGM-1470 specifically inhibited the growth of HUVEC and that of HPD-NR tumors in vivo with decreased vascularity of the tumors but not the growth of HPD-NR cells in vitro.

CONCLUSIONS

The results suggest that angiogenesis plays an important role in tumor growth of HPD-NR cells and can be a new target of medical therapy for pancreatic cancer.

Identification of two transcripts of AML1/ETO-fused gene in t(8;21) leukemic cells and expression of wild-type ETO gene in hematopoietic cells

The t(8;21) is a common chromosomal abnormality, preferentially associated with acute leukemia showing features of myeloid differentiation. Recently, two genes--AML1, which has a unique runt domain, and ETO (MTG8)--have been isolated from the chromosomal breakpoint. In this study, we isolated and identified two fused transcripts from a leukemic cell line carrying t(8;21). AML1 and ETO were fused at the same position in these transcripts. One of the transcripts codes a unique domain, including two zinc finger domains and three proline- and one leucine-rich region. The other transcript codes only for one proline- and leucine-rich region but lacks zinc finger domains. We demonstrated by polymerase chain reaction (PCR) analysis that 1) these two transcripts are consistently expressed in leukemic cells with t(8;21) obtained from patients and 2) expression of AML1 was not restricted to the particular stage of hematopoietic differentiation but was present in all hematopoietic cells investigated. We also provide evidence that two wild types of ETO transcripts containing the region of the ETO gene in fused transcripts are expressed in hematopoietic cells from different lineages. The widespread expression of AML1 and ETO in hematopoietic cells suggests a fundamental role of these proteins in hematopoiesis. Furthermore, the differences in the carboxy termini of ETO may modulate the activity of fused proteins resulting from the chromosomal translocation t(8;21).

In vitro and in vivo antibacterial activities of BO-2727, a new carbapenem

BO-2727, a new injectable carbapenem, was evaluated for its in vitro and in vivo antibacterial activities in comparison with those of biapenem, meropenem, imipenem, cefpirome, and ceftazidime. BO-2727 had activity comparable to that of imipenem against methicillin-susceptible staphylococci and streptococci, with MICs at which 90% of strains tested (MIC90s) are inhibited being equal to 0.5 microgram/ml or less. Against methicillin-resistant staphylococci, BO-2727 was the most active among the antibiotics tested, with MIC90s ranging from 4 to 8 micrograms/ml. BO-2727 was highly active against members of the family Enterobacteriaceae, Haemophilus influenzae, and Moraxella catarrhalis, with MIC90s ranging from 0.006 to 2 micrograms/ml. BO-2727 was also highly active against Pseudomonas aeruginosa (imipenem-susceptible strains), for which the MIC90 was 2 micrograms/ml, which was lower than those of imipenem, cefpirome, and ceftazidime and comparable to those of biapenem and meropenem. Differences in activity between BO-2727 and the other carbapenems against imipenem-resistant P. aeruginosa were particularly striking (MIC90, 8 micrograms/ml). Furthermore, BO-2727 displayed a high degree of activity against many of the ceftazidime-, ciprofloxacin-, and/or gentamicin-resistant isolates of P. aeruginosa. The in vivo efficacy of BO-2727 against experimental septicemia caused by gram-positive and gram-negative bacteria, including methicillin-resistant Staphylococcus aureus and imipenem-resistant P. aeruginosa, reflected its potent in vitro activity and high levels in plasma.

[A case of myokymia with abnormal F responses]

We reported a case of myokymia with abnormal F response. A 60-year-old male with chronic alcoholism was admitted to our hospital with complaint of muscle cramp in both legs just after drinking. Neurological examination revealed muscle pain and weakness of the legs, absence of bilateral Achilles tendon reflexes and prominent myokymia in his right quadriceps femoris and left calf muscles. The electrophysiological examination showed reduced conduction velocity, high amplitude, increased number of phases and long duration of F responses suggesting increased excitability of motoneuron pool. The epidural nerve block brought about a disappearance of the myokymia and an improvement of the abnormal features of F response. The myokymia gradually tended to be milder in the clinical course. The relationship between the myokymia and the abnormal F responses indicated that the increased excitability of spinal motoneurons might play an important role on the generation of myokymia of this patient.

Spectroscopic studies on the mechanism of the topa quinone generation in bacterial monoamine oxidase

Electron paramagnetic resonance (EPR), circular dichroism (CD), and optical absorption spectroscopies have been used to investigate the copper-dependent autoxidation process generating the 6-hydroxydopa (topa) quinone cofactor in the recombinant phenethylamine oxidase from Arthrobacter globiformis. The cupric ion bound to the copper/topa quinone-less, inactive enzyme is first reduced to Cu(I), as inferred from the spectroscopic features observed under strictly anaerobic conditions. Cu(I) is also detectable chemically with a Cu(I)-specific chelating agent, bathocuproinedisulfonate. Introduction of a limited amount of oxygen then leads to the formation of a paramagnetic species (g = 2.004) that is stable for over several to 10 min but vanishes swiftly upon addition of sufficient oxygen. Strikingly, the hyperfine EPR structure of the organic radical is almost identical with that of the topa semiquinolamine observed in the copper/topa quinone-containing, active enzyme anaerobically reduced with substrate. Concomitant with the generation of topa quinone exhibiting characteristic optical absorption and CD bands under fully aerobic conditions, the bound copper finally shows EPR signals typical of nonblue type II Cu(II) and optical absorption around 700 nm with negative CD above 700 nm. None of these spectral changes are evoked in the binding of Cu(II) to the Tyr382-->Phe mutant enzyme, indicating that the precursor Tyr382 to topa quinone participates in the initial reduction of bound copper and serves as the origin of the transiently formed semiquinone radical. The prosthetic cupric ion plays an essential role, by changing its redox state, in the oxidative modification of the tyrosyl phenol ring, leading to topa quinone.

[Familial hyperparathyroidism]

Recently, not only the multiple endocrine adenomatosis (MEN)-associated type but also the type which can be isolated from MEN syndrome have been widely accepted in the classification of familial hyperparathyroidism. Analysis of gene markers specific to MEN syndrome contributed markedly to the establishment of isolated familial hyperparathyroidism. We attempted an analysis of 15 pedigrees in the report of familial hyperparathyroidism in which MEN syndrome was actively ruled out. In 7 pedigrees, adenoma alone was seen while in 2 pedigrees was hyperplasia alone seen. In 6 pedigrees parathyroid carcinoma was also admitted (other members of the pedigree were affected with parathyroid adenoma or hyperplasia). There were 5 pedigrees in which cementifying fibroma or ossifying fibroma of the jaw was associated with familial hyperparathyroidism. The association of parathyroid carcinomas or benign jaw tumors should be paid attention.

Transient expression of a brain/embryonic-type myosin heavy chain isoform (MIIB2) in regenerating rat liver

The expressions of non-muscle-type (MIIA) and brain/embryonic-type (MIIB2) myosin heavy-chain isoforms in regenerating rat liver were examined. In regenerating liver after partial hepatectomy, the level of MIIA was nearly constant, while that of MIIB2 increased transiently. The level of MIIB2 was very low in normal livers, and increased gradually and then declined with a peak at the 4th day, when the regeneration was almost completed. The level of proliferating cell nuclear antigen was highest at the 2nd day. Serine dehydratase activity in the liver decreased on partial hepatectomy, began to increase at the 5th day, and reached 71% of the control at the 7th day. These results suggest that MIIB2 plays a role in reconstruction or differentiation of the regenerating tissues rather than in proliferation of hepatocytes.

Incilaria mucus agglutinated human erythrocytes

The body surface mucus from the land slug, Incilaria fruhstorferi, not only opsonized sheep red blood cells (SRBC) and agglutinated human types A and B erythrocytes (HRBC) but also caused hemolysis of B type HRBC 12 h after agglutination. The mucus-induced hemagglutination was specifically inhibited by a low concentration of N-acetyl D-galactosamine (GalNAc), and all of this activity was completely inactivated by heating at 56 degrees C for 30 min. SDS-polyacrylamide gel electrophoresis of water soluble fraction of the mucus showed that this fraction contained several proteins, the molecular mass of the main band being 35 KD.

Purification and characterization of three mitogenic lectins from the roots of pokeweed (Phytolacca americana)

Three mitogenic lectins, designated PL-A, PL-B, and PL-C, were purified from the roots of pokeweed (Phytolacca americana) using Q-Sepharose column chromatography followed by gel filtration on Sephadex G-75, hydrophobic chromatography on Butyl-Toyopearl, and FPLC on a Mono-Q column. PL-A, PL-B, and PL-C are acidic proteins having isoelectric points of 4.35 and their apparent molecular masses were 22, 48, and 21 kDa by SDS-polyacrylamide gel electrophoresis in the presence of 2-mercaptoethanol, respectively. The three lectins have similar amino acid compositions rich in half-cystine and similar N-terminal sequences, indicating that they are homologous proteins. Identical sequences of N-terminal regions and six corresponding tryptic peptides in PL-A and PL-B suggested that PL-A may be an N-terminal half fragment of PL-B. Although all of three lectins have mitogenic activities, PL-B is a mitogenic lectin with the most potent hemagglutinating and mitogenic activities, and PL-C has almost no hemagglutinating activity.

Relation between markers for viral hepatitis and clinical features of Japanese patients with hepatocellular carcinoma: possible role of alcohol in promoting carcinogenesis

To assess the relationship between hepatitis virus markers and the clinical features of hepatocellular carcinoma (HCC), we measured markers for hepatitis B virus (HBV) and hepatitis C virus (HCV) in 88 Japanese patients with HCC. Twelve (14%) patients were HBsAg-positive and 67 (76%) were anti-HCV-positive (both c100-3 and c11/c7). HCV-RNA was detected in 8 (38%) of the 21 anti-HCV-negative patients by PCR, so that 75 patients (85%) were infected with HCV. Of the HBsAg-negative patients infected with HCV with no history of blood transfusion, the mean age of the alcoholics (consumption > 80 g ethanol daily for at least 10 years) was lower than that of the non-alcoholics (60 years vs. 65 years, P < 0.05). Among the HBsAg-negative and anti-HCV (or HCV-RNA)-positive patients with a history of blood transfusion, the mean interval between the time of blood transfusion and the diagnosis of HCC in the alcoholics was shorter (21 years) than that in the nonalcoholics (27 years), but the difference was not statistically significant. We conclude that infection by both HCV and HBV may play a role in the development of HCC, and that alcohol consumption may promote carcinogenesis.

[MR imaging of intramuscular hemangiomas]

Magnetic resonance images of eight surgically confirmed intramuscular hemangiomas were correlated with the pathologic findings. T1- and T2-weighted images were obtained in all cases; STIR images were also obtained in six cases, and fat-suppressed enhanced images in seven cases. All eight hemangiomas showed markedly high signal intensity on T2-weighted images. Linear and round low-signal-intensity components within hemangiomas corresponded to fibrous tissues, high flow vessels and phleboliths. Fat-suppressed enhanced images were superior to images without fat suppression in defining the extent of lesions. STIR images were useful in defining the extent of hemangiomas with infiltration into surrounding tissues. MRI is useful for distinguishing intramuscular hemangiomas from other soft tissue tumors and also supplies valuable information about the extent of the lesions.

[Clinical usefulness of polyamino acid particle agglutination test for detection of anti-HTLV-I antibody]

A new artificial carrier particle agglutination test using polyamino acid (polyamino PA) was developed for anti HTLV-I assay. We carried out the comparative study on anti-HTLV-I among polyamino PA, gelatin PA, EIA and WB methods. All of 76 ATL, 20 HAM/TSP, 53 patients with uveitis and 50 HTLV-I carriers were seropositive and 50 HTLV-I non carriers were seronegative with four methods. Eighteen of 503 patients include autoimmune diseases showed seropositive by polyamino PA and gelatin PA. One of 19 seropositives by EIA was false positive. All of 25 sera showed non-specific reaction by the gelatin PA were clearly negative by the polyamino PA. This is due to the fact that the polyamino acid particle has a greater specific gravity as carrier. The final judgement was got within 45 minutes. It was earlier more 30 minutes than the gelatin PA. The polyamino PA is a simple, rapid, sensitive and specific method. Therefore, it is useful for mass screening and clinical diagnosis.