[Preoperative portal embolization for induction of liver hypertrophy]

Preoperative portal embolization (PVE) is now widely used to induce hypertrophy of the anticipated liver remnant. Here, pathophysiology, indications, technical procedures, and problems of PVE are reviewed and our experience of 105 PVEs is presented. The reported complication rate after PVE is low (0-10%) and the increment of the future remnant liver volume is 12% of total liver volume (range: 7-27%). The resection rate after PVE ranged from 58% to 100%. In our series of 105 PVEs, the morbidity rate was 3.8%, the future remnant liver increased by about 10% of total liver volume, and 34 patients (32.4%) did not undergo planned extended hepatectomy. After hepatectomy, hepatic failure occurred in one patient (< 1%). In conclusion, although PVE is a safe procedure for enlarging the future remnant liver, more appropriate indication criteria should be established.

A synthetic dDAF (CD55) gene based on optimal codon usage for transgenic animals

The human DAF (CD55) gene was chosen as a representative molecule in a xenotransplantation study. The gene was synthesized in order to adapt its codons to those which are more frequent in mammals, especially pigs, and the expression levels were then examined in Chinese hamster ovarian (CHO) cells, swine endothelial cell (SEC) and transgenic mice. A significant increase in protein production with no detectable mRNA elevation was observed in the transfectants of synthetic DAF (sDAF), compared with the wild-type DAF (wtDAF) and delta-SCR1 wild-type DAF (Delta1wtDAF). Consistent with the in vitro data, the expression of DAF in mice that carry sDAF was higher than Delta1wtDAF in many organs, especially the pancreas. The sDAF showed a high level of expression in SEC and transgenic mice, suggesting that it will be useful in the development of transgenic pigs with high levels of expression.

Identification of hepatic venous territories in liver resection by using color Doppler ultrasonography: report of two cases

OBJECTIVE

Resection of the hepatic vein because of the proximity of tumors may result in increased congestion in the noncancerous parenchyma, which in turn may lead to functional hepatic volume loss and postoperative hepatic failure, especially in a case of low hepatic reserve. However, to our knowledge, no technique for estimating the extent of dependent hepatic venous territories before hepatic resection has been established. We examined the possibility of using color Doppler ultrasonography for this purpose.

METHODS

A color Doppler system and a linear array transducer equipped with multiple Doppler frequencies ranging from 7 to 13 MHz were used intraoperatively. Two patients with hepatocellular carcinomas were examined. By tracking entire branches of the targeted vessel, from the trunk to the terminal branches extending to the liver surface, it was possible for the boundaries of the dependent areas to be projected and marked on the liver surface with either ink or electrocautery.

RESULTS

In both cases, this method was effective for either minimizing the congestive area or preserving the hepatic mass that was being drained via aberrant routes.

CONCLUSIONS

Identification of hepatic venous territories by means of color Doppler ultrasonography may provide new information about intrahepatic blood circulation and may increase the safety and curability of hepatic resection.

Role of CD4+ T cells in the rat to mouse cardiac xenotransplantation

T cell subsets involved in rejection of xenografts were analyzed using a rat to mouse cardiac xenotransplant model. Proliferating response and interleulin-2 (IL-2) production in recipients' spleen cells were almost completely abrogated by elimination of L3T4+ T cells, but not by elimination of Lyt2.1+ T cells. Cytotoxic T lymphocyte (CTL) activities were mediated by both L3T4+ and Lyt2.1+ T cells with the help of IL-2-producing L3T4+ T cells. Administration of anti-L3T4 monoclonal antibody (mAb) into recipient mice resulted in a significant prolongation of graft survival (mean graft survival was 29.2 days). Moreover, anti-L3T4 mAb treatment plus thymectomy led to indefinite graft survival. Anti-rat endothelial cell (EC) antibody production in the grafted mice was remarkably suppressed by anti-L3T4 mAb treatment. In contrast, Lyt2.1 mAb treatment did not prolong the graft survival and did not suppress anti-EC antibody production. These results indicated the absolute requirement of L3T4+ T cells in the rejection of rat to mouse cardiac xenografts.

Quantitation and visualization of ultraviolet-induced DNA damage using specific antibodies: application to pigment cell biology

The major types of DNA damage induced by sunlight in the skin are DNA photoproducts, such as cyclobutane pyrimidine dimers (CPDs), (6-4)photoproducts (6-4PPs) and Dewar isomers of 6-4PPs. A sensitive method for quantitating and visualizing each type of DNA photoproduct induced by biologically relevant doses of ultraviolet (UV) or sunlight is essential to characterize DNA photoproducts and their biological effects. We have established monoclonal antibodies specific for CPDs, 6-4PPs or Dewar isomers. Those antibodies allow one to quantitate photoproducts in DNA purified from cultured cells or from the skin epidermis using an enzyme-linked immunosorbent assay. One can also use those specific antibodies with in situ laser cytometry to visualize and measure DNA photoproducts in cultured cells or in the skin, using indirect immunofluorescence and a laser-scanning confocal microscope. This latter method allows us to reconstruct three-dimensional images of nuclei containing DNA photoproducts and to simultaneously examine DNA photoproducts and histology in multilayered epidermis. Using those techniques, one can determine the induction and repair of these three distinct types of DNA photoproducts in cultured cells and in the skin exposed to sublethal or suberythematous doses of UV or solar simulated radiation. As examples of the utility of these techniques and antibodies, we describe the DNA repair kinetics following irradiation of human cell nuclei and the photoprotective effect of melanin against DNA photoproducts in cultured pigmented cells and in human epidermis.

Insulin and somatostatin releasing islet cell tumor caused hypoglycemia

We report a hypoglycemic case with normal insulin levels, which was caused by an islet cell tumor that was releasing insulin and somatostatin. A fasting test suggested the over secretion of insulin. Moreover, this hypoglycemia was enhanced by the inhibitory effect of somatostatin on the secretion of insulin counter-regulatory hormones, such as glucagon, in addition to the autonomous secretion of insulin from the tumor. In cases of hypoglycemia with apparently normal insulin levels, the measurement of somatostatin and various provocative tests are recommended. Arterial stimulation venous sampling (ASVS) was useful to detect the location of this functioning islet cell tumor.

Autoantibody responses to cardiolipin and DNA in infancy: association with lymphocytic panniculitis

We report an infant with anticardiolipin (aCL) antibodies who presented with erythematous nodular skin lesions and elevated liver enzyme levels. The cutaneous manifestation was histologically lymphocytic lobular panniculitis with vasculitic and hemorrhagic changes. The infant also had low levels of anti-double stranded DNA (dsDNA) and anti-single stranded DNA (ssDNA) antibodies. There were no detectable antibodies to small nuclear ribonucleoproteins including Ro/SSA and La/SSB. His mother was consistently seronegative for any of these antibodies. Without corticosteroid therapy, cutaneous lesions resolved and anticardiolipin antibodies, but not anti-dsDNA and ssDNA antibodies, normalized within 16 months after the onset of the disease. Our patient demonstrated an uncommon presentation of aCL related cutaneous manifestation, the presentation with panniculitis being only the third such patient reported in the literature. Of great interest was the appearance of aCL antibodies and skin lesions during very early infancy.

[Indication and outcome of extended right hemihepatectomy combined with pancreatoduodenectomy for bile duct carcinoma]

During the past 10 years, we have performed extended right hemihepatectomy combined with pancreatoduodenectomy (rtHPD) in eight patients with bile duct carcinoma. We compared the results in these patients with those in 43 bile duct carcinoma patients who underwent extrahepatic bile duct resection with more extensive hepatectomy than hemihepatectomy. Our indication for rtHPD is bile duct carcinoma of the diffuse type involving the intrapancreatic bile duct. For patients with obstructive jaundice, biliary drainage was performed preferentially in the part of the liver to be preserved. Portal vein embolization was performed before extended right hemihepatectomy or left trisectorectomy. Complete external drainage of pancreatic juice followed by second-stage pancreatojejunostomy was performed in five rtHPD patients. There were no hospital deaths or hepatic failures. There were four 5-year survivors after rtHPD. There was no significant difference between the cumulative 5-year survival rates after rtHPD (71%) and non-HPD (42%). Patients with bile duct carcinoma whose prognosis can be improved only by rtHPD exist and should be treated by rtHPD. However, considering the reported high mortality rate after this procedure, rtHPD should not be performed in an institution where its safety cannot be guaranteed.

[Portal embolization and second-stage pancreatojejeunostomy improve operative outcomes in patients with advanced biliary carcinoma]

Lethal complications after resection of more than two-thirds of the hepatic parenchyma with pancreatoduodenectomy (PD) are hepatic failure and leakage from pancreatoenterostomy. Twenty-two patients underwent hepatectomy with PD due to advanced biliary carcinoma. Extended hemihepatectomy (EH) with PD was performed in 16 and other types of hepatectomy with PD in 6. The percent volume of the liver to be preserved increased from 31.5% to 43.5% after portal venous branch embolization, which was performed to prevent postoperative hepatic failure. There were no operative and hospital deaths in these 22 patients. Only one patient had a prolonged serum total bilirubin level elevation postoperatively, although the level was less than 5.0 mg/dl. Since leakage from pancreatogastrostomy occurred in 2 of 4 patients who underwent pancreatogastrostomy, second-stage pancreatojejunostomy was chosen to avoid pancreatic fistula in the remaining 18 patients. In 11 patients who underwent EH with PD due to diffuse bile duct carcinoma, the cumulative 1-, 3-, and 5-year survival rates were 90.9%, 64.9%, and 64.9%, respectively. Because EH and PD provides an opportunity for long-term survival for patients with diffuse bile duct carcinoma, prevention of lethal postoperative hepatic failure and leakage from pancreatoenterostomy is important.

Abnormalities of primitive myeloid progenitor cells expressing granulocyte colony-stimulating factor receptor in patients with severe congenital neutropenia

To define the basis for faulty granulopoiesis in patients with severe congenital neutropenia (SCN), the expression of granulocyte colony-stimulating factor receptor (G-CSFR) in primitive myeloid progenitor cells and their responsiveness to hematopoietic factors were studied. Flow cytometric analysis of bone marrow cells based on the expression of CD34, Kit receptor, and G-CSFR demonstrated a reduced frequency of CD34(+)/Kit(+)/ G-CSFR(+) cells in patients with SCN. The granulocyte-macrophage colony formation of CD34(+)/Kit(+)/G-CSFR(+) cells in patients was markedly decreased in response to G-CSF alone and to the combination of stem cell factor, the ligand for flk2/flt3, and IL-3 with or without G-CSF in serum-deprived semisolid culture. In contrast, no difference in the responsiveness of CD34(+)/Kit(+)/G-CSFR(-) cells was noted between patients with SCN and subjects without SCN. These results demonstrate that the presence of qualitative and quantitative abnormalities of primitive myeloid progenitor cells expressing G-CSFR may play an important role in the impairment of granulopoiesis in patients with SCN. (Blood. 2000;96:4366-4369)

Guillain-Barré syndrome in a child with systemic lupus erythematosus and anti-Ro/SSA and anti-La/SSB autoantibodies

We report a 9-year follow-up of a girl with systemic lupus erythematosus (SLE) and probable Sjögren's syndrome. At the age of 7 years, the patient developed a chilblain-like eruption with features of SLE, including leucopenia, oral ulcers, positive rheumatoid and antinuclear antibodies and positive anti-dsDNA, anti-Ro/SSA and anti-La/SSB antibodies. At the age of 13 years she developed Guillain-Barré syndrome, which completely resolved with aggressive treatment, including high-dose corticosteroids and the use of plasma exchange followed by intravenous gammaglobulin.

Relationship between doubling time of liver metastases from colorectal carcinoma and residual primary cancer

BACKGROUND

The doubling times of liver metastases were calculated in order to clarify their usefulness in predicting the presence of residual cancer in the abdominal cavity in patients who had undergone curative resection of primary colorectal cancer.

PATIENTS AND METHODS

Tumor doubling times were calculated retrospectively in 22 patients by serial measurement of the size of their liver metastases.

RESULTS

Patients with a tumor doubling time of less than 92.4 days had a significantly poorer prognosis than those with a doubling time more than or equal to 92.4 days (p < 0.05). Local recurrence or peritoneal dissemination was significantly more likely to occur when the tumor doubling time was less than 92.4 days than when it was more than or equal to 92.4 days (p < 0.01).

CONCLUSION

The doubling time of hepatic metastases in patients with colorectal carcinoma may be a useful prognostic indicator, with patients who have a shorter tumor doubling time carrying a greater risk of residual primary cancer in the abdominal cavity.