[Two cases of acute myelogenous leukemia complicated with fatal gastrointestinal tract bleeding after treatment with idarubicin and cytarabine]

We describe herein two newly diagnosed patients with acute myelogenous leukemia (AML), who were treated twice with an idarubicin hydrochloride (IDR)-containing regimen as a response-orientated induction therapy. Both patients had severe gastrointestinal tract hemorrhage complications at their nadir. The two patients were as follows: a 35-year-old male, FAB-M4, and a 47-year-old female, FAB-M0. They received the same induction chemotherapy (IDR 12 mg/m2 for four days and cytarabine 100 mg/m2 for ten days). No response (NR) was obtained in either, so they underwent the same regimen again. During the period of myelosuppression, they developed severe gastrointestinal hemorrhage. One died of sepsis, and the other of acute respiratory distress syndrome without a recovery in bone marrow. The fetal gastrointestinal tract complications may have been due to severe myelosuppression and mucosal damage in these patients. Careful observation will be needed to prevent such severe complications after the treatment with IDR.

Oculopharyngeal muscular dystrophy in a Japanese family with a short GCG expansion (GCG)(11) in PABP2 gene

Clinicopathological and molecular genetic findings on a new Japanese family with oculopharyngeal muscular dystrophy are reported. The family has 54 members, ten of whom are affected (seven male and three female), in 3 generations. Three affected males, one affected female and one unaffected female of seven living siblings in the third generation were examined. Bilateral ptosis developed in the 4th and 5th decades in the three male cases, and in the 7th decade in the female, and this was followed by diplopia, nasal voice, dysphagia and muscle weakness. In addition, severe external ophthalmoplegia, dysphonia, and proximal amyotrophy were prominent in this family. Electromyographs revealed myogenic/neurogenic changes, and computed tomography disclosed selective muscle wasting with fatty replacement, predominantly in the lower extremities. Muscle biopsy in the four affected patients showed variation in fiber size, and the presence of small angulated fibers and occasional rimmed vacuoles. Electron microscopic examination revealed an accumulation of filamentous inclusions in muscle fiber nuclei. DNA analysis identified that (GCG)(6) in the PABP2 gene was expanded to (GCG)(11) in the four affected cases examined. All studies were negative in the one unaffected. These results confirm that OPMD is caused by GCG short expansion and provides insights into the genetic mechanisms which may contribute to adult onset myopathy, confined to oculopharyngeal muscles.

P-ANCA-positive Wegener's granulomatosis presenting with hypertrophic pachymeningitis and multiple cranial neuropathies: case report and review of literature

An autopsy case of hypertrophic pachymeningitis and multiple cranial neuropathies is reported. A 53-year-old woman with paraplegia and various neurological signs which developed over a 2 year period was diagnosed as having an epidural mass with thickened dura mater extending from the lower cervical to the thoracic spinal cord. In addition, bilateral episcleritis, blephaloptosis, and blindness of the right eye with various cranial nerve deficits were found to be caused by the mass lesions involving the paranasal sinuses, orbit, and the cavernous sinus. Perinuclear antineutrophil cytoplasmic antibody (p-ANCA) was positive, but cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) was negative by enzyme-linked immunosorbent assay. The partially removed epidural mass with hypertrophied dura mater and biopsy of the paranasal lesions showed chronic granulomatous inflammation with vasculitis. The remaining lesions resolved with steroid therapy with remarkable neurological improvement. The positive p-ANCA test, paranasal involvement, the report of a similar histopathological case and a review of the literature on granulomatous pachymeningitis suggest the presence of p-ANCA-positive Wegener's granulomatosis with central nervous system involvement characterized by hypertrophic pachymeningitis and/or multiple cranial neuropathies.

[A case of ureterocalicostomy for refractory renal calculi]

We have sometimes encountered intractable cases of nephrolithiasis, even though ESWL and endourology have dramatically developed at the present time. We could obtain satisfactory result in the treatment of intractable right nephrolithiasis with ureterocalicostomy.

CASE

The patient was a 39-year-old man having undergone PNL, ESWL, pyelolithotomy for right nephrolithiasis. Ten-odd stones, measuring 5-20 mm in diameter, were detected, and his IVP revealed mild hydronephrosis with the ureteropelvic junction stenosis. Pyeloplasty was thought to be difficult to perform. Thus the stones were removed through an incision made on the lowermost portion of the kidney followed by ureterocalicostomy on September 9, 1993. After clamping of the renal artery, the lowermost portion of the renal parenchyma was resected, and the lower calyx was sufficiently exposed. Adequate hemostasis of the cut surface was made, and the renal artery was then declamped. Many stones, measuring 20 mm or less, were removed through the lower calyx, and the lower calyx and the ureter were anastomosed. After operation, ESWL was additionally performed for residue stones. The IVP in July 1997 demonstrated the sufficiently patent anastomosed site without hydronephrosis or recurrence of nephrolithiasis.

DISCUSSION

Anastomosis between the lower calyx and the ureter is an effective therapeutic method because it dose not interfere urine stream or small stone passage. However, it is not easy to make anastomosis in this site because the calyceal wall is very fragile. Several cases have been reported to have stenosis in the anastomosed site. We supposed that it is an excellent method for the treatment of refractory nephrolithiasis if the procedure is selected only for appropriate candidates.

Cytomorphometric differentiation of intraductal proliferative breast lesions

BACKGROUND

Although cytologic examination has been an indispensable procedure for the diagnosis of various breast diseases, it is often difficult to make a precise diagnosis of intraductal proliferative breast lesions preoperatively. The present study attempts to clarify the differentiation of the lesions by the cytologic morphometric approach.

METHODS

Cytologic specimens from 21 intraductal lesions, including nine ductal carcinomas in situ (DCIS), seven ductal hyperplasias (DH), and five papillomas were evaluated. Using a microscope connected to a computerized video system, the mean nuclear area, the perimeter, the form factor, the largest to smallest diameter ratio of the nuclei (LS ratio), and the coefficient of variation of the nuclear area (NACV) were measured and analyzed.

RESULTS

The mean nuclear area and perimeter were significantly higher in the cases of DCIS than in DH (p < 0.01) and papilloma (p < 0.005). Similarly, DCIS had higher NACV values than the other groups (p < 0.05 and p < 0.005, respectively). There were no significant differences in form factor or LS ratio.

CONCLUSIONS

The quantitative estimation of cytologic nuclear features is useful for preoperative differential diagnosis of intraductal proliferative lesions of the breast.

Electron microscopic observation of intracellular expression of mRNA and its protein product: technical review on ultrastructural in situ hybridization and its combination with immunohistochemistry

In situ hybridization (ISH) at the electron microscopic (EM) level is essential for elucidating the intracellular distribution and role of mRNA in protein synthesis. Three different approaches have been applied by the investigators in this EM-ISH study: preembedding method; non-embedding method using ultrathin frozen sections; and postembedding method. In order to obtain satisfactory morphological preservation and retain the messages, we routinely utilized 6 microns-thick frozen sections fixed in 4% paraformaldehyde for the preembedding method and tissues embedded in LR White resin for the postembedding method. The hybridization signal intensity by the postembedding method was lower, and non-specific signals were relatively frequent, in comparison with the preembedding method. The preembedding method thus appears to be easier and better than the postembedding method from the viewpoint of applicability and preservation of mRNA, although quantitative analysis of the expression of mRNA is rather difficult in the preembedding method. EM-ISH is considered to be an important tool for clarifying the intracellular localization of mRNA and the exact site of specific hormone synthesis on the rough endoplasmic reticulum. The simultaneous visualization of mRNA and encoded protein in the same cells using preembedding EM-ISH and subsequent postembedding immunoreaction with protein A colloidal gold complex is also described. This ultrastructural double-staining method for mRNA and encoded protein can be expected to provide an important clue for elucidating the intracellular correlation of mRNA translation and secretion of translated protein.

Minimally invasive retroperitoneal approach for lumbar corpectomy and reconstruction

Anterior decompressive surgery with spinal fusion is considered an effective treatment for thoracolumbar fractures and tumors. However, it is also known to be associated with considerable surgical approach–related trauma. The purpose of this study was to show that lumbar corpectomy and spinal reconstruction can be performed via a minimally invasive retroperitoneal (MIR) approach and therefore, the surgical approach–related trauma can be reduced.

The hospital records and radiological studies obtained in five patients (mean age 67.4 years, range 59-76 years) who underwent lumbar corpectomy and spinal fusion via an MIR approach were studied retrospectively. Four patients presented with osteoporotic compression fractures at L-2 and L-3 and one patient with metastatic disease at L-4 from prostate cancer. In all patients neurological deficits due to cauda equina compression were demonstrated.

The MIR approach provided excellent exposure to facilitate complete spinal decompression and reconstruction in all patients, as verified on follow-up x-ray studies. All patients improved clinically. A 1-year follow-up record, available for four patients, showed evidence of continuing clinical improvement and, radiographically, a solid fusion or a stable compound union and anatomically correct reconstruction.

The MIR approach allows anterior lumbar spine surgery to be performed less invasively. The efficacy and safety of this technique compared with the conventional retroperitoneal approach to lumbar spine surgery should be further investigated in a larger series.

Dynamical systems analysis of arterial blood pressure signals in relation to heart rate fluctuations in chick embryos

We attempted a new approach based on a modern dynamical system theory to reconstruct the arterial blood pressure signals in relation to heart rate fluctuations of developing chick embryos. The dynamical systems approach in general is to model a phenomenon that is presented by a single time series record and approximate the dynamical property (e.g. heart rate fluctuations) of a system based only on information contained in a single-variable (arterial blood pressure) of the system. The time-series data of the arterial blood pressure was reconstructed in 3-dimensional space to draw characteristic orbits. Since the reconstructed orbits of the blood pressure should retain information contained in the pressure signals, we attempted to derive instantaneous heart rate (IHR) from the reconstructed orbits. The derived IHR presenting HR fluctuations coincided well with the IHR obtained conventionally from the peak-to-peak time intervals of the maximum blood pressure. Movements of the reconstructed orbits of the arterial blood pressure in 3-dimensional space reflected HR fluctuations (i.e. transient decelerations and accelerations).

Hand-assisted laparoscopic distal gastrectomy with abdominal wall-lift method

We performed a hand-assisted laparoscopic resection of the distal stomach for treatment of gastric cancer with use of an abdominal wall-lift method. The surgeon's left hand, which was inserted through a right lower quadrant incision, was extremely useful in accomplishing D2 lymph node dissection, application of a pursestring instrument, and approximation of a circular stapler to carry out a Billroth I anastomosis. Abdominal wall-lift enabled us to perform the gastrectomy without any concern about gas leakage. The combination of the wall-lift method and hand assistance seems to further enlarge the possibilities of laparoscopic procedures, especially in gastrointestinal surgery.

[Spontaneous epidural hematoma after open heart surgery: case report]

Acute epidural hematoma not associated with head injury is rarely encountered and is known as spontaneous epidural hematoma. To our knowledge, only five cases with epidural hematoma after open-heart surgery have been published. Pathogenesis and preventive measures have not yet been determined. We report a case of such spontaneous epidural hematoma and consider the possible pathogenesis. A 12-year-old female received a radical operation for severe subaortic stenosis. The intraoperative course was uneventful except for massive hemorrhage which was adequately controlled. Postoperatively, she was moved to the CCU still not having aroused from anesthesia. Eleven hours later, it was found that her pupils were fixed and dilated. CT scan demonstrated a huge bifrontal epidural hematoma with disappearance of the basal cistern. Even though immediate emergency evacuation was performed, the patient died of acute brain swelling four days after the operation.

Dephosphorylation of phytate by using the Aspergillus niger phytase with a high affinity for phytate

A phytase (EC 3.1.3.8) with a high affinity for phytic acid was found in Aspergillus niger SK-57 and purified to homogeneity in four steps by using ion-exchange chromatography (two types), gel filtration, and chromatofocusing. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the purified enzyme gave a single stained band at a molecular mass of approximately 60 kDa. The Michaelis constant of the enzyme for phytic acid (18.7 +/- 4.6 microM) was statistically analyzed. In regard to the orthophosphate released from phytic acid, a significant difference between a low K(m) phytase from A. niger SK-57 and a high K(m) phytase from Aspergillus ficuum was recognized.

Preoperative chemotherapy for advanced esophageal cancer and relation with histological effect

The results of surgical treatment for advanced esophageal cancer remain extremely poor. Irradiation and chemotherapy are not superior to surgery. Perioperative morbidity and the influence on long-term survival of a combination of surgery and preoperative chemotherapy were investigated in patients with advanced esophageal cancer. Forty-nine patients with advanced esophageal squamous cell carcinoma were subjected to preoperative chemotherapy of cisplatin-5-fluorouracil. Fifty-seven patients were chosen as a historical control group who had not undergone chemotherapy before surgery but had the same histological stages as the chemotherapy group. The response to chemotherapy was assessed by histological studies of surgical specimens. The survival rates noted no significant difference between preoperative chemotherapy plus surgery and a resection alone. However, subclassification according to the grading of chemotherapeutic effectiveness showed that, compared with control, preoperative chemotherapy was beneficial to high responders (P = 0.01), ineffective in low responders (P = 0.61), and detrimental to nonresponders (P = 0.03). Postoperative morbidity was significantly higher in the chemotherapy group than in the control group (P = 0.02). These findings suggest that preoperative chemotherapy is necessary only for high responders and we therefore need to reliably identify non-, low, and high responders before chemotherapy to improve the survival and quality of life of patients with advanced esophageal cancer.

Effect of cerebrospinal fluid shunting on experimental syringomyelia: magnetic resonance imaging and histological findings

The histological changes associated with syringomyelia after reduction of the syrinx size were investigated after cerebrospinal fluid shunting in experimental syringomyelia in the rabbit. Five weeks after syringomyelia was induced by the injection of kaolin into the cisterna magna in Japanese white rabbits, ventriculosubgaleal shunting or syringoepidural shunting were performed. After 1 week magnetic resonance (MR) imaging and histological examination were then carried out. Five of 11 shunted animals showed postoperative reduction of syrinx size on MR imaging. Grossly, some specimens showed cavity collapse and parenchymal healing, and others showed a small residual syrinx in the dorsal horn. The most dramatic histological changes occurred in the gray matter. Specimens with syrinx collapse showed rarefaction and tearing of the gray matter, with mild glial reaction. The edematous gray matter showed both degeneration and regeneration, with neuronal processes surrounded by edema fluid. Reactive astrocytes were observed mainly at the margin of the residual syrinx. Some astrocytic processes invested the extraaxonal space and gray matter lacked supportive tissue. Greater reduction of the syrinx after shunting operation was correlated with more regeneration and less degeneration, and the white matter was edematous and histological changes were milder. Syrinx shrinkage occurred after shunting in this experimental model of syringomyelia. The selective vulnerability of gray matter even after shunting may explain discrepancies between imaging findings and clinical features in this disease. The study supports the potential benefit from early treatment, considering the associated morphological findings of regeneration.

Pituitary somatotroph adenoma producing growth hormone (GH)-releasing hormone (GHRH) with an elevated plasma GHRH concentration: a model case for autocrine and paracrine regulation of GH secretion by GHRH

An acromegalic patient with a pituitary somatotroph adenoma associated with an extremely elevated plasma GHRH concentration is presented. The preoperatively high concentration of plasma GHRH returned to the normal level after successful removal of the adenoma. GHRH production and GHRH gene expression were confirmed in the adenoma by studies including immunohistochemistry and in situ hybridization. Expression of GHRH receptor messenger ribonucleic acid was verified by in situ hybridization. Immunohistochemical double staining for GH and GHRH revealed their colocalization in single adenoma cells. These findings confirmed the autocrine or paracrine regulation of GH production by endogenous GHRH from the adenoma cells. GHRH synthesis in the pituitary gland has recently been demonstrated, however, there have been no previous reports of a GHRH-producing pituitary somatotroph adenoma associated with an elevated plasma GHRH concentration. The existence of this GHRH-producing adenoma suggests a possible role of locally generated GHRH in the progression of somatotroph adenomas, i.e. the monoclonally established somatotroph adenomas develop further under the influence of locally produced GHRH. The demonstration of GHRH production by this somatotroph adenoma is of importance in clarifying the autocrine or paracrine regulation of GH production and the progression of human somatotroph adenomas.

Thermoregulatory responses of the inbred heat-tolerant FOK rat to cold

The responses of inbred heat-tolerant FOK rats to cold were compared with those of Wistar King A/H (WKAH) and Std:Wistar (WSTR) strains. The fall of colonic temperature during cold exposure was unexpectedly smaller in FOK than in other groups, but the onset of shivering was delayed in FOK. Norepinephrine (NE)-induced in vivo oxygen consumption and the mitochondrial uncoupling protein 1 level of brown adipose tissue (BAT) were not different among the groups, but the cold-induced increases in in vivo oxygen consumption as well as plasma glycerol and free fatty acids were higher in FOK than in other groups. In vitro NE-induced oxygen consumption of BAT was less in FOK than WSTR, but not WKAH. The magnitude of the NE-induced increase in blood flow through BAT was higher in FOK than in other groups. These results suggest that FOK paradoxically have a high capacity for nonshivering thermogenesis in spite of their high capacity for heat tolerance, probably due to an increased lipid utilization and improved circulation of BAT.

Non-traumatic acute paraplegia associated with cervical disc herniation: a case report

BACKGROUND

Acute paraplegia attributable to disc herniation is known to occur most frequently at the thoracic level. We report a rare case of non-traumatic acute paraplegia caused by disc herniation at the cervical level. Preoperative magnetic resonance imaging (MRI) of the present case demonstrated a spinal cord lesion as a cause of paraplegia. Although this symptom is believed to disappear rapidly after surgical treatment, there have been a few reported cases with poor neurologic recovery and permanent deficits.

CASE DESCRIPTION

A 61-year-old female with a history of minor neck pain suffered from non-traumatic acute paraplegia attributable to cervical disc herniation. She underwent emergency surgery consisting of vertebrectomy, removal of herniated discs, and anterior fusion. Postoperative neurologic improvement was slow due to the cervical spinal cord lesion at the central portion of the cord, which was detected by the preoperative and postoperative MRIs.

CONCLUSION

We emphasize that the MRI study is crucial for the management of patients with acute neck pain associated with cervical canal stenosis. Surgical treatment should not be delayed to avoid permanent neurologic deficits. Anterior decompression with vertebrectomy is recommended to decompress the injured spinal cord in the narrow cervical spinal canal; however, a cord lesion detected by MRI may indicate an incomplete surgical outcome.

Hsl7p, a negative regulator of Ste20p protein kinase in the Saccharomyces cerevisiae filamentous growth-signaling pathway

In the budding yeast, Saccharomyces cerevisiae, protein kinases Ste20p (p21(Cdc42p/Rac)-activated kinase), Ste11p [mitogen-activated protein kinase (MAPK) kinase kinase], Ste7p (MAPK kinase), Fus3p, and Kss1p (MAPKs) are utilized for haploid mating, invasive growth, and diploid filamentous growth. Members of the highly conserved Ste20p/p65(PAK) protein kinase family regulate MAPK signal transduction pathways from yeast to man. We describe here a potent negative regulator of Ste20p in the yeast filamentous growth-signaling pathway. We identified a mutant, hsl7, that exhibits filamentous growth on rich medium. Hsl7p belongs to a highly conserved protein family in eukaryotes. Hsl7p associates with the noncatalytic region within the amino-terminal half of Ste20p as well as Cdc42p. Deletions of HSL7 in haploid and diploid strains led to cell elongation and enhancement of both haploid invasive growth and diploid pseudohyphal growth. However, deletions of STE20 in haploid and diploid greatly diminished these hsl7-associated phenotypes. In addition, overexpression of HSL7 inhibited pseudohyphal growth. Thus, Hsl7p may inhibit the activity of Ste20p in the S. cerevisiae filamentous growth-signaling pathway. Our genetic analyses suggest the possibility that Cdc42p and Hsl7p compete for binding to Ste20p for pseudohyphal development when starved for nitrogen.

Craniocervical junction synovial cyst associated with atlanto-axial dislocation--case report

A 51-year-old female presented with a rare case of synovial cyst at the cruciate ligament of the odontoid process associated with atlanto-axial dislocation, manifesting as a history of headache and numbness in her left extremities for 5 months, and progressive motor weakness of her left leg. Neuroimaging studies revealed a small cystic lesion behind the dens, which severely compressed the upper cervical cord, and atlanto-axial dislocation. The cyst was successfully removed via the transcondylar approach. C-1 laminectomy and foramen magnum decompression were also performed. Posterior craniocervical fusion was carried out to stabilize the atlanto-axial dislocation. The cyst contained mucinous material. Histological examination detected synovial cells lining the fibrocartilaginous capsule. Synovial cysts of this region do not have typical symptoms or characteristic radiographic features. Careful preoperative evaluation of the symptoms and a less invasive strategy for removal of the cyst are recommended.

Lobular involvement: prognostic indicator for invasive ductal carcinoma of the breast

One of the striking microscopic appearances of breast carcinoma is malignant transformation of the epithelium of an entire lobule, although the lobular architecture is still preserved. We termed this pathological feature 'lobular involvement'. An investigation was carried out to determine whether lobular involvement would be a useful prognostic indicator for invasive ductal carcinoma. One hundred and fifty cases of invasive ductal carcinoma were included in this study. The lobular involvement, as well as the conventional prognostic factors, was evaluated to find out the correlation with the overall and relapse-free survivals by univariate and multivariate analyses. The lobular involvement was identified in 31 of 150 patients (20.6%). Of the patients with lobular involvement, two had experienced recurrence (6.5%) and one had died (3.2%). The lobular involvement and lymph node metastases were significantly and independently correlated with the overall and relapse-free survivals. The presence of lobular involvement was statistically correlated with the favorable outcome. Lobular involvement can be assumed as a new prognostic indicator for invasive ductal carcinoma.