A case of recurrent follicular cholangitis leading to decompensated cirrhosis after left-sided hepatectomy

Follicular cholangitis (FC) is a rare non-neoplastic biliary tract disease first reported in 2003. A 74-year-old woman underwent extended left hepatectomy with a diagnosis of intrahepatic cholangiocarcinoma. Histopathological examination of the surgical specimen demonstrated no malignant findings, and lymphocytic infiltration with lymphoid follicles was observed within the bile duct wall. Along with immunohistochemical findings, the patient was diagnosed with FC. More than 3 years after surgery, the patient exhibited elevated hepatobiliary enzymes and total bilirubin. Endoscopic retrograde cholangiography revealed stricture and dilation from the extrahepatic bile duct to the right intrahepatic bile duct. Histopathological findings uncovered lymphocytic infiltration without malignant results. It was concluded that bile duct stricture due to FC had newly developed in her remnant liver. Subsequently, the patient developed hypoalbuminemia, and abdominal computed tomography revealed atrophy of the remnant liver and ascites accumulation. Esophagogastroduodenoscopy exposed the development of esophageal varices, which were not observed preoperatively. The patient was diagnosed with decompensated liver cirrhosis accompanied by portal hypertension. This case strongly suggests that long-term follow-up after surgery may be required for patients with FC for screening of potential new bile duct stricture and progression to liver cirrhosis due to cholestasis.

A case of acute obstructive suppurative pancreatic ductitis complicated with acute cholangitis diagnosed only after the removal of a pancreatic duct stent

Acute obstructive suppurative pancreatic ductitis (AOSPD) is a rare complication of chronic pancreatitis that presents with high fever and abdominal pain. A 63-year-old man underwent plastic bile duct stent and plastic pancreatic duct stent (PDS) placement for benign stricture in the intrapancreatic bile and pancreatic ducts associated with chronic pancreatitis; the stents were routinely replaced. Seven months after the last replacement, the patient presented to our hospital with dark urine but without fever or abdominal pain. Subsequent blood tests revealed elevated levels of hepatobiliary enzymes, white blood cells, and C-reactive protein. However, the pancreatic enzyme levels remained unchanged, and abdominal computed tomography showed the absence of inflammation around the pancreas. He was initially diagnosed with acute cholangitis (AC) due to bile duct stent dysfunction and subsequently underwent emergency endoscopic retrograde cholangiopancreatography. As obstruction of the PDS was suspected, both bile duct stent and PDS were replaced. Although the collected bile did not exhibit purulence, a white purulent fluid was released after replacing the PDS. Cultures from the bile and pancreatic exudates revealed the presence of Klebsiella oxytoca. Consequently, the patient was diagnosed with AOSPD and AC. In this patient, endoscopic retrograde cholangiopancreatography was performed after the diagnosis of AC alone; however, relying solely on AC treatment might not have ameliorated the patient's condition. The patient did not complain of any abdominal pain and was diagnosed with AOSPD only after the replacement of his PDS. Our case suggests that AOSPD may be a pitfall in the identification of the source of inflammation in patients with chronic pancreatitis.

Investigation of risk factors for metachronous recurrence in patients with early gastric adenocarcinoma by miRNA-mRNA integral profiling

The mechanism of metachronous recurrence (MR) after performing endoscopic treatment for early gastric adenocarcinoma (GAC) and eradicating Helicobacter pylori (H. pylori) is unknown. To elucidate the mechanism and risk factors of MR, we analyzed gene expression at multiple locations of the gastric mucosa. We selected each five patients with MR and without MR (control), after early GAC treatment and eradication of H. pylori. Mucosal tissue was collected from four sites in the stomach of each patient as biopsy specimens for mRNA sequencing, gene set enrichment analysis, and microRNA (miRNA) sequencing. We also performed correlation analysis and target prediction on pathways. As a result, endoscopically, the MR group had more intestinal metaplasia and enlarged folds. A total of 384 mRNAs presented changes in expression and 31 gene sets were enriched in the MR group. Immune-related pathways were enriched in the entire stomach, and the IFN-α response had the highest enrichment score. Additionally, 32 miRNAs revealed changes in their expression. Correlation analysis and target prediction with genes in the gene set of IFN-α response revealed that 10 miRNA-mRNA pairs presented a significant correlation. Immune-related pathways with miRNAs in the gastric mucosa after H. pylori eradication may be a risk factor for MR.

Diagnostic value of the serum lactate level as a predictor of bacteremia in patients with acute cholangitis

BACKGROUND

Patients with acute cholangitis (AC) have increased mortality when associated with bacteremia. This study aimed to evaluate the predictive ability of serum lactate (Lac) for positive bacteremia in patients with acute cholangitis.

METHODS

In this single-center, retrospective study, 138 consecutive patients with AC were analyzed. Their blood samples were collected and Lac was measured.

RESULTS

A total of 50 patients showed grade I, 50 showed grade II, and 38 showed grade III severity according to the Tokyo Guidelines 2018. Positive bacteremia was observed in 71 patients, of which 15 showed grade I, 25 showed grade II, and 31 showed grade III severity. Logistic regression analysis showed that Lac was a significant predictor of bacteremia. The area under the curve of Lac and procalcitonin (PCT) for bacteremia were 0.737 and 0.780, respectively. The optimal cutoff values for bacteremia were 17 mg/dL and 2.8 ng/mL, with sensitivity of 69.0% and 68.3%, respectively. Sensitivity of Lac and PCT for bacteremia in grade I was 58.3% and 25.0%, respectively. Three patients died from AC, all of whom were positive for bacteremia and hyperlactatemia.

CONCLUSION

Lac is useful for predicting bacteremia in patients with AC.

Primary Hepatic Other Iatrogenic Immunodeficiency-Associated Lymphoproliferative Disorders After Methotrexate Therapy

Prior reports described cases of lymphoproliferative diseases occurring after methotrexate (MTX) administration, which are called methotrexate-associated lymphoproliferative disorders (MTX-LPDs). It has become clear that these lymphoproliferative diseases also occur following treatment with other immunosuppressive drugs, and they have been termed as other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPDs). In most of these cases, the duration of immunosuppressive drugs is very long, on the order of years. In the present study, we evaluated the development of lymphoproliferative disease despite the short duration of immunosuppressive treatment and determined the tumor doubling time. A 71-year-old woman was diagnosed with adult-onset Still's disease. The patient was administered prednisone 30 mg per day starting on February 25, 2022 and MTX 6 mg per week starting 2 weeks later. Because she was a hepatitis B virus (HBV) carrier, nucleic acid analog therapy was also started to prevent HBV activation. Eight weeks later, biweekly tocilizumab was started. After 5 months of MTX administration, a solitary liver tumor measuring 37 × 32 mm2 was detected. Three months later, repeat computed tomography revealed that the liver tumor had grown rapidly to 7 cm in diameter. We considered the possibility of OIIA-LPDs and stopped MTX therapy. Biopsy specimens of the liver tumor exhibited lymphocyte proliferation, which was consistent with OIIA-LPDs. The doubling time for tumor growth was 33 days. Despite withdrawing MTX for 6 weeks, the tumor continued to grow, and thus, the patient was referred to the hematology unit. In previously reported cases of MTX-LPDs of hepatic origin, the average duration of MTX administration was 7.3 (2 - 13) years. This report describes a primary hepatic OIIA-LPDs-associated tumor that rapidly increased in size after an extremely short period of MTX administration.

The long-term effect of biologics in patients with ulcerative colitis emerging from a large Japanese cohort

To gain a better understanding of the effects of biologics, we evaluated clinical outcomes in patients with moderate to severe exacerbations of ulcerative colitis (UC). This retrospective, multicenter study retrieved the entire clinical courses of UC patients who began treatments between 2004 and 2018. All exacerbations and clinical parameters, including treatment details for exacerbations and both remission and re-exacerbation dates, were identified during the observation period. Two different endpoints, the cumulative incidence rates of surgical resection and re-exacerbation, were evaluated separately in moderate to severe exacerbation events. Among 1401 patients, 1626 exacerbation events were determined according to a partial Mayo score (remission: < 2, mild: 2-4, moderate: 5-7, and severe: > 7). During the observation period, as administration rates of biologics increased, both surgical resection and hospitalization rates decreased, for 959 moderate to severe exacerbation events. We confirmed that biologics significantly reduced the cumulative re-exacerbation rate in moderate to severe exacerbation events during the study period compared with suboptimal therapies (a 0.507-fold decreased risk according to COX regression analysis, P < 0.001). However, they had not enough impact in reducing the cumulative incidence rate of surgical resection in moderate to severe exacerbation events that were corticosteroid-refractory or dependent (a 0.878-fold decreased risk according to COX regression analysis, P = 0.606). Biologics may improve remission duration, but these agents had no significant impact in reducing the risk of surgical resection in moderate to severe active UC.

Development and evaluation of a double-check support system using artificial intelligence in endoscopic screening for gastric cancer

BACKGROUND

This study aimed to prevent missing gastric cancer and point out low-quality images by developing a double-check support system (DCSS) for esophagogastroduodenoscopy (EGD) still images using artificial intelligence.

METHODS

We extracted 12,977 still EGD images from 855 cases with cancer [821 with early gastric carcinoma (EGC) and 34 malignant lymphoma (ML)] and developed a lesion detection system using 10,994 images. The remaining images were used as a test dataset. Additional validation was performed using a new dataset containing 50 EGC and 1,200 non-GC images by comparing the interpretation of ten endoscopists (five trainees and five experts). Furthermore, we developed another system to detect low-quality images, which are not suitable for diagnosis, using 2198 images.

RESULTS

In the validation of 1983 images from the 124 cancer cases, the DCSS diagnosed cancer with a sensitivity of 89.2%, positive predictive value (PPV) of 93.3%, and an accuracy of 83.3%. EGC was detected in 93.2% and ML in 92.5% of cases. Comparing with the endoscopists, sensitivity was significantly higher in the DCSS, and the average diagnostic time was significantly shorter using the DCSS than that by the trainees. The sensitivity, specificity, PPV, and accuracy in detecting low-quality images were 65.8%, 93.1%, 79.6%, and 85.2% for "Blur" and 57.8%, 91.7%, 82.2%, and 78.1% for "Mucus adhesion," respectively.

CONCLUSIONS

The DCSS showed excellent capability in detecting lesions and pointing out low-quality images.

Long-term outcomes of cold snare polypectomy for superficial non-ampullary duodenal epithelial tumors

BACKGROUND AND AIM

The effectiveness of cold snare polypectomy (CSP) for superficial non-ampullary duodenal epithelial tumors (SNADETs) regarding long-term outcomes is not fully clarified. This study aimed to investigate long-term outcomes of CSP for SNADETs.

METHODS

Patients diagnosed with sporadic SNADETs and treated with CSP at Chiba University Hospital between March 2015 and May 2018 were retrospectively analyzed. Long-term outcomes, short-term outcomes, and adverse events were investigated.

RESULTS

In total, 35 patients with 46 lesions were included. The en-bloc resection rate was 97.8%. Thirty-seven lesions (80.4%) were diagnosed as adenomatous. The R0 resection rate for adenomatous lesions was 70.3%. Follow-up investigations more than 12 months after CSP were completed for 35 adenomatous lesions (94.6%). The median observation period after CSP was 48 months. One patient whose observation period was only 3 months died from chronic heart failure with cardiac sarcoidosis 6 months after CSP. No patient died from SNADETs. The relapse-free survival rate at 12 months after CSP was 97.1%. One recurrence (2.7%) was observed 12 months after CSP. We removed the recurrence lesion with CSP and cold forceps polypectomy. No new recurrence occurred within the observation period. No perforation or post-operative bleeding occurred for CSP.

CONCLUSIONS

Cold snare polypectomy for diminutive and small SNADETs is a safe and useful procedure with a high en-bloc resection rate and long-term local control capability.

Clinical Characteristics of Esophageal Motility Disorders in Patients With Heartburn

Background/Aims

Esophageal motility disorders (EMDs) contribute to the pathophysiology of gastroesophageal reflux disease. However, the causes of EMDs and their impact on gastroesophageal reflux disease-associated symptoms remain unknown. This study aims to elucidate clinical features associated with various types of EMDs in patients with heartburn symptoms.

Methods

Of the 511 patients who underwent high-resolution manometry, 394 who were evaluated for heartburn symptoms were examined. Patients subjected to high-resolution manometry were classified into 4 groups outflow obstruction group, hypermotility group, hypomotility group, and normal motility group. Symptoms were evaluated using 3 questionnaires. Patient characteristics and symptoms for each EMD type were compared with those of the normal motility group.

Results

Of the 394 patients, 193 (48.9%) were diagnosed with EMDs, including 71 with outflow obstruction, 15 with hypermotility, and 107 with hypomotility. The mean dysphagia score was significantly higher in each of the 3 EMD groups compared with those with normal motility. The mean acid reflux and dyspepsia scores were significantly lower in the outflow obstruction group (P < 0.05). The mean body mass index and median Brinkman index were significantly higher in the hypermotility group (P = 0.001 and P = 0.018, respectively), whereas the mean diarrhea and constipation scores were significantly lower in the hypomotility group (P < 0.05).

Conclusions

The results of our study indicate that different EMDs have distinct characteristics. Cigarette smoking and high body mass index were associated with esophageal hypermotility. Assessment of the dysphagia symptom scores may help identify patients with EMDs.

Genetic profiles of Barrett's esophagus and esophageal adenocarcinoma in Japanese patients

The genetic characteristics of Barrett’s esophagus (BE) and esophageal adenocarcinoma (EAC) in the Japanese population is unclear. This study aims to investigate the genetic characteristics from nondysplastic BE (NDBE) to early EAC in Japan. Clinical information was collected. Moreover, the genetic profile of NDBE without concurrent dysplasia, early EAC, and surrounding BE were also investigated using endoscopic biopsy samples and formalin-fixed, paraffin-embedded specimens from Japanese patients by targeted next-generation sequencing. Immunohistochemical staining for p53 was also performed for EAC lesions. Targeted NGS was performed for 33 cases with 77 specimens. No significant difference exists in the NDBE group between the number of putative drivers per lesion in the short-segment Barrett’s esophagus (SSBE) and long-segment Barrett’s esophagus (LSBE) [0 (range, 0–1) vs. 0 (range, 0–1). p = 1.00]. TP53 putative drivers were found in two patients (16.7%) with nondysplastic SSBE. TP53 was the majority of putative drivers in both BE adjacent to EAC and EAC, accounting for 66.7% and 66.7%, respectively. More putative drivers per lesion were found in the EAC than in the NDBE group [1 (range, 0–3) vs. 0 (range, 0–1). p < 0.01]. The genetic variants of TP53 in the Japanese early EAC were similar to those in western countries. However, TP53 putative drivers were detected even in Japanese patients with nondysplastic SSBE. This is significant because such nondysplastic SSBE might have higher risk of progressing to high-grade dysplasia or EAC. The risks of progression may not be underestimated and appropriate follow-ups may be necessary even in patients with SSBE.

Trial registration: This study was registered at the University Hospital Medical Information Network (UMIN000034247).

Comprehensive mutational analysis of background mucosa in patients with Lugol-voiding lesions

Somatic mutations including the background mucosa in patients with Lugol-voiding lesions (LVLs) are still not well known. The aim of this study was to evaluate the somatic mutations of the background mucosa in patients with LVLs (Squamous cell carcinoma (SCC), intraepithelial neoplasia (IN), and hyperplasia). Twenty-five patients with LVLs (9 with SCC, 6 with IN, and 10 with hyperplasia) were included. A targeted sequence was performed for LVLs and background mucosa using an esophageal cancer panel. Each mutation was checked whether it was oncogenic or not concerning OncoKB. In LVLs, TP53 was the most dominant mutation (80%). Furthermore, 72% of TP53 mutations was putative drivers. In background mucosa, NOTCH1 was the most dominant mutation (88%) and TP53 was the second most dominant mutation (48%). Furthermore, 73% of TP53 mutations and 8% of NOTCH1 mutations were putative drivers. Putative driver mutations of TP53 had significantly higher allele frequency (AF) in SCC than in IN and hyperplasia. Conversely, putative driver mutations of NOTCH1 did not have a significant accumulation of AF in the progression of carcinogenesis. Furthermore, in SCC, AF of TP53 mutations was significantly higher in LVLs than in background mucosa, but not in IN and hyperplasia. Regarding NOTCH1, a significant difference was not observed between LVLs and background mucosa in each group. The background mucosa in patients with LVLs already had putative driver mutations such as TP53 and NOTCH1. Of these two genes, TP53 mutation could be the main target gene of carcinogenesis in esophageal SCC. Clinical Trials registry: UMIN000034247.

Impact of ineffective esophageal motility on chemical clearance in patients with gastroesophageal reflux symptoms

Ineffective esophageal motility (IEM) is the most common manometric abnormality in gastroesophageal reflux disease (GERD). However, the impact of IEM on esophageal chemical clearance has not been fully investigated. This study aimed to determine the impact of IEM on esophageal chemical clearance in patients with GERD. A total of 369 patients with GERD symptoms who underwent upper endoscopy and high-resolution manometry (HRM) test were retrospectively analyzed. The relationship between IEM and erosive esophagitis was examined. In addition, the impact of IEM on chemical clearance was examined in patients who underwent an additional combined multichannel intraluminal impedance-pH (MII-pH) test. Esophageal chemical clearance capability was evaluated via postreflux swallow-induced peristaltic wave (PSPW) index and acid clearance time (ACT). Of 369 patients, 181 (49.1%) had esophageal motility disorders, of which 78 (21.1%) had IEM. The proportion of IEM patients in those with erosive esophagitis and those without were 16.2% and 21.7%, respectively, and no significant difference was observed (P = 0.53). After excluding patients other than those with IEM and normal esophageal motility, 64 subsequently underwent MII-pH test. The median values of the PSPW index in the IEM and normal esophageal motility group were 11.1% (4.2%-20.0%) and 17.1% (9.8%-30.6%), respectively. The PSPW index was significantly lower in the IEM group than in the normal esophageal motility group (P < 0.05). The median ACT values in the IEM group and normal esophageal motility group were 125.5 (54.0-183.5) seconds and 60.0 (27.2-105.7) seconds, respectively. The ACT was significantly longer in the IEM group than in the normal esophageal motility group (P < 0.05). In conclusion, IEM was found to be associated with chemical clearance dysfunction as measured against the PSPW index and ACT. As this condition could be a risk factor for GERD, future treatments should be developed with a focus on chemical clearance.

Long-term use of proton pump inhibitors does not affect ectopic and metachronous recurrence of gastric cancer after endoscopic treatment

Objective: Long-term administration of proton pump inhibitors (PPIs) after eradication of Helicobacter pylori infection has been reported to increase the risk for development of gastric cancer (GC). We investigated whether long-term administration of PPI affects ectopic and metachronous recurrence of GC after endoscopic treatment.Methods: Participants were 687 patients who underwent endoscopic treatment for GC from January 2005 to March 2018. Questionnaire surveys and medical record reviews of medications, including PPIs, H₂ receptor antagonists and low-dose aspirin (LDA) were conducted for all patients. The influence of PPI in ectopic and metachronous recurrence of GC was evaluated with Cox's proportional hazard analysis.Results: Patients who did not respond to the questionnaire and those who underwent additional treatment after endoscopic treatment were excluded from analyses; 418 patients were included. During an average observation period of 1608 days (range, 375-4993 days), 136 patients (32.5%) took PPIs for more than 1 year and 94 took PPIs for more than 3 years; of those, 40 had ectopic and metachronous recurrences. Cox's proportional hazards analysis revealed that long-term use of PPIs (for both 1 year and 3 years) was not a risk factor for recurrence. In addition, age, severity of gastric atrophy, long-term use of LDA, current infection with H. pylori, and cure achieved with the first endoscopic treatment were also not risk factors for recurrence.Conclusions: Long-term use of PPIs does not affect ectopic and metachronous recurrence of GC after endoscopic treatment.

[Techniques and arts of mediastinal lymph nodes dissection for lung cancer]

The outcomes ofhe operations for the lung cancer depends on the quality of the hilar and mediastinal lymph nodes dissection. Especially in the mediastinal lymph nodes dissection, techniques and arts are indispensable for reliable and promising results in the lung cancer surgery. The essence of procedures of mediastinal lymph nodes dissection are as follows, ( ystematic and sharp lymph nodes dissection as a group, precise and perfect removal of lymph nodes with adjacent fatty tissues based on the anatomical structures, retrograde lymph nodes dissection from the view point of prevention of lymph node metastasis and consequent distant metastasis. Satisfactory and confidential lymph nodes dissection requires attentive assistance of the coworker-surgeons providing good fields of vision. Nowadays minimally invasive approaches by means of thoracoscopic techniques are considered to be smart and welcomed widely in the current thoracic surgery. However, essential for the lung cancer surgery is trying to choose between the operability of radical operation and the degree of minimal invasion. According to a standard rule of ND2a lymph nodes dissection, procedures of upper and middle mediastinal lymph nodes dissection under postero-lateral thoracotomy are summarized.

[Median approach for the right upper lobe lung cancer patient with impaired pulmonary function]

We report the usefulness of a median approach to the right upper lobe lung cancer with impaired pulmonary function. Patient was a 68-year-old man with chronic obstructive pulmonary disease and primary right upper lobe (S1) lung cancer with suspected anterior mediastinal invasion (cT4N0M0). Thoracoscopy excluded mediastinal invasion, but a median sternal incision was made to avoid injuring respiratory muscles and postoperative respiratory complications. We successfully performed systematic mediastinal lymph node dissection (ND2a) after right upper lobectomy. The patient was discharged on the 10th postoperative day without any events. He eventually underwent additional chemotherapy because of the liver metastasis confirmed at 8 months after the operation. In right upper lobe lung cancer patients with impaired pulmonary function, a median approach seems useful for intraoperative respiratory management and the sparing of respiratory muscles which will reduce the possibility of postoperative respiratory complications.

[Surgical approach for histopathological determination of anterior mediastinal malignant lymphoma]

In a retrospective review of all patients who admitted our hospital between January 1992 and December 2006, we identified 9 with anterior mediastinal malignant lymphoma. They represented 6.8% of the 133 patients with mediastinal tumor. Histology revealed 3 cases of primary mediastinal large B-cell lymphoma, 2 of Hodgkin lymphoma, 2 of precursor T-lymphoblastic lymphoma and 2 of thymic extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) lymphoma. Careful attention should be paid to the relatively high incidence of malignant lymphoma in the anterior mediastinal tumors. It is highly important to differentiate of malignant lymphoma from other diseases that shape anterior mediastinal tumor to avoid unnecessary operation. Early and accurate diagnosis of these tumors is also important because some of these patients require immediate treatment by hematology specialists.

[Congenital bronchoesophageal fistula in an adult; an undiscribed mechanism of symptom tolerance]

We present a case of a congenital bronchoesophageal fistula in a 61-year-old woman. She was referred to hospital because of postprandial heart burn. Three-dimensional (3D) computed tomography (CT) demonstrated an anastomosis between her right intermediate bronchus and esophagus. In spite of direct communication between her bronchus and esophagus, she has never suffered severe infection. We visualized the orifice of fistula closed with mucosal flap in swallowing by means of a bronchofiberscope. The delay of a diagnosis was explained by symptom tolerance. Some theories as to the symptom tolerance are found in literatures, but we supposed to find an undiscribed mechanism; closure of the orifice in swallowing. The fistula was surgically closed.

[Pulmonary staple granuloma mimicking lung cancer; report of a case]

A 67-year-old man was referred to our hospital with chief complaints of bloody sputum and an abnormal chest shadow. He had a history of chronic renal failure and surgery for right pneumothorax. During dialysis treatment 2 years ago, an examination revealed a mass shadow with spiculation in the apex of the right lung. Subsequently, he noted bloody sputum, and the shadow became larger. Serum Progastrin-releasing-peptide (GRP) levels remained within the range of 70-80 pg/ml at the previous clinic, but were elevated to 109 pg/ml on admission to our hospital. These findings suggested lung cancer developing around the scar due to pneumothorax surgery, and we performed an operation. The resected tumor was a granuloma formed around a staple with a polytetra-fluoroethylene (PTFE) sheet, showing no evidence of malignancy. The patient's postoperative course was uneventful, and the serum Pro-GRP level fell to 60 pg/ml.

[Pulmonary actinomycosis developing diffuse phregmone after pneumonectomy]

The patient was a 75-year-old male who consulted the department of respiratory tract internal medicine in our hospital for left chest pain occurring from the beginning of December 2003. Chest X-ray indicated a tumorous shadow in the left lower lung field. A chest CT also revealed an irregularly shaped mass shadow in the left lower lobe. Since bronchoscopy failed to establish a definitive diagnosis, the patient was referred to our department for surgery to undertake thoracotomy. After left pneumonectomy being performed based on a suspicion of lung abscess, pathological examination of specimen from the resected left lung showed sulfur granules which led to the diagnosis of pulmonary actinomycosis. Because of the diffuse phregmone developing around the surgical wound, benzylpenicillin potassium administration was started, and was continued for a further 6 months on an outpatient basis. Pulmonary actinomycosis is a relatively rare chronic pulmonary infection. It is often difficult to distinguish pulmonary actinomycosis from other pulmonary disease such as lung cancer because of the similarity of their appearance on X-ray or CT, and almost all cases of pulmonary actinomycosis are diagnosed by thoracotomy.

[Large cell carcinoma with chest wall infiltration combined with contralateral giant bulla]

A 48-year-old male consulted the department of respiratory medicine for right precordial pain occurring from the beginning of May 2004. Chest X-ray indicated a tumorous shadow in the right upper lung field and a large left lung cyst. Although chest wall infiltration was suspected based on computed tomography (CT) demonstrating a mass lesion in the right S2, there was no significant swelling of the mediastinal lymph node. On the left side, the lung was markedly compressed by a large cyst in the left upper lobe. Since bronchoscopy failed to establish a definitive diagnosis, the patient was referred to our department for surgery based on a suspicion of malignant pulmonary tumor. Considering both the risk of perioperative complications due to the left cystic lesion at surgery for right lung lesion and the improvement of respiratory function by removing cystic lesion of the left lung, the left side operation was preceded by the right side. Although postoperative examinations of respiratory function did not demonstrate any particular improvement, the results of selective right pulmonary artery obstruction test supported the possibility of pulmonary lobectomy. Therefore, the right upper lobectomy and ND 2a mediastinal dissection combined with chest wall resection was subsequently performed. Postoperative pathological diagnosis revealed that the tumor was a stage IIB large cell carcinoma of pT3N0M0 with costal infiltration.

[Diplopia and blepharoptosis associated with orbital emphysema following thoracotomy with lung cancer; report of a case]

BACKGROUND

Orbital emphysema is a common complication of trauma and fracture of orbital bones. However, subcutaneous emphysema also can rarely lead to orbital emphysema. We reported the clinical and radiological findings in a patient with diplopia and blepharoptosis following thoracotomy for lung cancer.

CASE

A 76-year-old man had undergone left inferior lobectomy and ND 2 a in October 2002, based on the clinical diagnosis of stage IB lung squamous cell carcinoma. He presented with diplopia and blepharoptosis several days following thoracotomy. Chest X-ray demonstrated extensive subcutaneous emphysema, and physical examination also revealed diffuse subcutaneous emphysema including face and palpebrae. Head computed tomography (CT) revealed subcutaneous emphysema in the infratemporal fossa bilaterally. His diplopia and blepharoptosis gradually resolved, and he was discharged with no visual complaints on the fourteenth postoperative day.

CONCLUSIONS

Subcutaneous emphysema can lead to diplopia and orbital emphysema in the absence of orbital trauma. Early surgical intervention for air leakage is highly recommended to avoid both the orbital emphysema and the visual complications in the event that subcutaneous emphysema should get to including face or palpebrae.

[Conservative therapy for recurrent bronchial stump fistula occurred after surgery for lung cancer with cerebrovascular disease]

BACKGROUND

Although pyrothorax caused by bronchial stump fistula is 1 of the most severe respiratory complications frequently encountered after surgery for lung cancers, it is very difficult to prevent the development of pyrothorax. However, conservative treatment for bronchial stump fistula occurred after surgery for lung cancer was successfully performed in 1 of our elderly lung cancer patients with a history of cerebrovascular events.

CASE

Patient was a 74-year-old man who developed cerebral infarction in October 2000, and was continuously undergoing rehabilitation for left hemiplegia. Chest computed tomography (CT) demonstrated a tumorous lesion in the right S6. Clinical diagnosis of stage IA squamous cell carcinoma was made. His performance status (PS) was degree IV, and he required complete assistance. In addition, since several abnormal florae were detected by preoperative examinations of sputum, the development of postoperative respiratory complications was suspected. In April 2001, thoracoscopy-assisted right inferior lobectomy and nodal dissection 1 (ND 1) were performed. Although the patient developed bronchial stump fistula on the 6th hospital day, it was successfully treated by conservative procedures after second surgery.

CONCLUSION

Conservative therapy under nutritional management mainly consisting of central venous nutrition may be useful for some surgically treated lung cancer patients with bronchial stump fistula when they have mild inflammation and the reduction of pyrothorax cavity can be expected by re-expansion of the residual lobes of the lung.

The chemotactic effect of a dermal papilla cell-derived factor on outer root sheath cells

The effect of cultured normal human dermal papilla cells (DPCs) and conditioned medium prepared with cultured DPCs on chemotactic migration of human hair outer root sheath cells (ORSCs) was examined quantitatively. ORSCs showed significantly increased migration toward both cultured DPCs and the conditioned medium suggesting that DPCs produce and secrete a paracrine factor(s), which attracts hair follicle epithelial cells. Some soluble factors, which are reportedly produced by DPCs, such as insulin-like growth factor-I (IGF-I), hepatocyte growth factor (HGF), vascular endothelial cell growth factor (VEGF), and transforming growth factor-beta1 (TGF-beta1), were also examined. ORSCs showed dramatically increased migration toward IGF-I and HGF at concentrations of 1-10 ng/ml. On the other hand, neither VEGF nor TGF-beta1 showed any effect on the chemotaxis of ORSCs. It is interesting that all factors involving mitogenic activity did not always have chemotactic activity for ORSCs. This is the first report to establish that IGF-I and HGF have not only a growth stimulatory but also a chemotactic effect on ORSCs. In addition, the method presented here may help to simplify chemotaxis assays of any type of epithelial keratinocytes with poor mobility.

Wall correction factors for calibration of plane-parallel ionization chambers with high-energy photon beams

Most dosimetry protocols recommend that calibration of plane-parallel ionization chambers be performed in an electron beam of sufficiently high energy by comparison with cylindrical chambers. For various plane-parallel chambers, the 1997 IAEA TRS-381 protocol includes an overall perturbation factor pQ for electron beams, a wall correction factor p(wall) for a 60Co beam and the product of two wall corrections k(att)k(m) for 60Co in-air calibration. The recommended values of p(wall) for plane-parallel chambers, however, are limited to certain phantom materials and a 60Co beam, and are not given for other phantom materials and x-ray beams. In this work, the p(wall) values of the commercially available NACP, PTW/Markus and PTW/Roos plane-parallel chambers in a solid water phantom have been determined with 60Co and 4 and 10 MV photon beams. The k(att)k(m) values for the NACP and PTW/Markus chambers have also been obtained. The wall correction factors p(wall) and k(att)k(m) have been determined by intercomparison with a calibrated Farmer chamber. The average value of p(wall) for these plane-parallel chambers was 1.005 +/- 0.1% (1 SD) for 60Co beams and 1.007 +/- 0.2% (1 SD) for both 4 MV and 10 MV photons. The k(att)k(m) values for the NACP and PTW/Markus chambers were about 1.5% lower than other published data.

[Clinical evaluation of kampo medication, mainly with wen-pi-tang, on the progression of chronic renal failure]

Previous studies have shown that Kampo (traditional Chinese) prescriptions, mainly Wen-Pi-Tang (Onpi-to, [symbol see: text]), have a useful effect in patients with chronic renal failure (CRF). We aimed to examine the long-term effect of Kampo prescriptions on serum creatinine (Cr) among patients with CRF. Patients with serum Cr levels of 2 mg/dl more were enrolled if they had at least 4 recordings of serum Cr in the previous 6 months or more, and were followed-up until the start of dialysis. Eight patients aged 24-59 years with serum Cr 4.5 mg/dl were enrolled in the study for 40 to 402 weeks (mean; 228.1 +/- 118.8 weeks). The cause of CRF was chronic glomerulonephritis in 7 patients and systemic lupus erythematosus in 1 patient. The end points of the study were the slope of the reciprocal of the serum Cr concentration plot against time using Mitch's method, and the predicted period of pre-dialysis. The predicted pre-dialysis period was defined as an increase in serum Cr by 10 mg/dl. As a result, the individual slopes were improved in 6 of 8 cases, in particular, in 4 of 5 Wen-Pi Tang-treated cases. The average slope was improved significantly (p < 0.01) in Wen-Pi-Tang-treated cases, although it showed only a tendency to improve in all 8 cases. The predicted pre-dialysis period was prolonged from 79.2 +/- 74.8 weeks to 389.5 +/- 355.4 weeks and 55.6 +/- 37.0 weeks to 262.4 +/- 145.8 weeks in all 8 cases and Wen-Pi-Tang-treated cases, respectively. The observed pre-dialysis period was 228.1 +/- 118.8 weeks, which showed that Kampo prescriptions prolonged the predicted period for 186 additional weeks. In conclusion, this study demonstrated that the Kampo prescriptions, consisting mainly of Wen-Pi-Tang, retarded the progression of CRF.

Cerebriform intradermal nevus: a case of scalp expansion on the galea

We report here a 7-year-old Japanese girl with cerebriform intradermal nevus (CIN). By placement of expanders on the galea, her scalp was expanded more easily with less discomfort than is expected when the expanders are placed under the galea. An immunohistochemical study on the expression of proliferating cell nuclear antigen suggested higher proliferative activity of nevus cells from the CIN lesion than that of cells from congenital or acquired intradermal nevi. The high proliferative activity appeared to be associated with a growth spurt of the lesion.

Sintered bone implantation for the treatment of benign bone tumours in the hand

We report the results of treatment of benign bone tumours in the hand with curettage and sintered bone implantation using bovine sintered bone (True Bone Ceramics). There were 22 patients who underwent sintered bone implantation in our department in 1984 or later. The follow-up survey period varied from 9 months to 11 years and 2 months (mean, 5.8 years). Recurrence of tumours and complications such as infection or fracture were not observed, and there were no clinical symptoms. X-rays revealed new bone formation connecting the implanted blocks to bone. Sintered bone was not absorbed, and lucent zones around the implants or other abnormal findings were not observed. Bone union was achieved in all patients who had pathological fractures before surgery.

Changes in the extracellular matrix on the surface of sintered bovine bone implanted in the femur of a rabbit: an immunohistochemical study

The interface of implanted True Bone Ceramics (TBC; sintered bovine bone; Koken, Tokyo, Japan) was examined. In the primary experiment, TBC was implanted into the bone marrow of a rabbit's femur. The extracellular matrices (types I, II, and III collagens and fibronectin) of decalcified specimens collected 1-48 weeks postoperatively were immunohistochemically examined. Undecalcified sections collected 6 weeks postoperatively were used for line analyses of calcium and phosphorus, by a scanning electron microscope-electron probe microanalysis (SEM-EPMA) method. In a secondary experiment, TBC was implanted into an osteochondral defect of a femoral condyle, harvested 1-12 weeks postoperatively, and decalcified to examine the extracellular matrices at the interface. In the bone marrow in the early phase, TBC had absorbed quantities of fibronectin. Immature bone (containing both types I and III collagens) in direct apposition to the ceramic surface had matured (containing type I collagen alone) in the TBC pores. SEM-EPMA revealed the continuity of high levels of calcium and phosphorus at the TBC-bone interface. In the secondary experiment, enchondral ossification or fibrous tissue formation was observed near the articular surface. However, in the subchondral layer, direct bone formation was observed in the TBC pores. It was concluded that TBC has excellent bioactivity for inducing maturation of new bone matrix on porous surfaces.

Immunohistochemical localization of thyroid hormone nuclear receptors in human hair follicles and in vitro effect of L-triiodothyronine on cultured cells of hair follicles and skin

To investigate the cellular basis of the action of thyroid hormone on hair follicles, we studied the immunohistochemical localization of thyroid hormone receptors (TRs) in human scalp skin using a mouse monoclonal antibody, TR alpha 1 (C4) against TRs. Immunoreactive TRs were detected in the nuclei of the outer root sheath cells (ORSCs), dermal papilla cells (DPCs), fibrous sheath cells of hair follicles, hair arrector pili muscle cells and sebaceous gland cells. However, nuclei of hair matrix cells were not clearly stained with TR alpha 1 (C4). The epidermis showed positive nuclear staining by the antibody. Ductal and secretory portions of eccrine sweat glands were also stained with the antibody as we had expected. In the dermis, almost all the cell components including fibroblasts, vascular endothelial and smooth muscle cells, and Schwann cells were positively stained. Immunofluorescence also showed TRs expression in cultured ORSCs, DPCs, epidermal keratinocytes and dermal fibroblasts. L-triiodothyronine stimulated the proliferation and/or metabolism of all these four types of cells significantly, although there was variation at the rate of stimulation. Whereas, structurally similar, but metabolically inactive analog, reverse T3 had no effect. These results demonstrate the presence of thyroid hormone nuclear receptors in human hair follicles. Furthermore, the presence of TRs in different cell types in the skin suggests numerous direct effects of thyroid hormone on this target tissue.

Magnesium lithospermate B ameliorates cephaloridine-induced renal injury

To determine whether magnesium lithospermate B ameliorates renal injury induced by cephaloridine, the effect of cephaloridine was investigated in rats given magnesium lithospermate B for 20 days preceding cephaloridine administration and in control rats given no magnesium lithospermate B. In the control rats, blood and urinary parameters and the activity of radical-eliminating enzymes in the renal tissue deviated from the normal range, indicating damage to the kidneys. In contrast, rats given magnesium lithospermate B showed decreased urine volume, increased urinary osmotic pressure, and decreased urinary levels of glucose, protein, sodium and potassium, denoting less damage to the kidney. In this group, the urinary nitrite/nitrate ratio, and the activities of superoxide dismutase and catalase in the renal tissue were increased, while the malondialdehyde levels were decreased, suggesting the involvement of radicals in the normalizing of kidney function. The increased levels of urea nitrogen in the blood of rats with induced renal failure were also lowered by administering magnesium lithospermate B.

Magnesium lithospermate B ameliorates cisplatin-induced injury in cultured renal epithelial cells

A study was conducted to clarify whether magnesium lithospermate B ameliorates cisplatin-induced renal injury in terms of lactate dehydrogenase and malondialdehyde leakage from LLC-PK1 cells in culture. Magnesium lithospermate B was shown to suppress the cytotoxicity of cisplatin, the suppressive effect increasing with the dose of magnesium lithospermate B.

Proof that green tea tannin suppresses the increase in the blood methylguanidine level associated with renal failure

The effects of a green tea tannin mixture and its individual tannin components on methylguanidine were examined in rats with renal failure. The green tea tannin mixture caused a dose-dependent decrease in methylguanidine, a substance which accumulates in the blood with the progression of renal failure. Among individual tannin components, the effect was most conspicuous with (-)-epigallocatechin 3-O-gallate and (-)-epicatechin 3-O-gallate, while other components not linked to gallic acid showed only weak effects. Thus, the effect on methylguanidine was found to vary among different types of tannin.

Magnesium lithospermate B suppresses the increase of active oxygen in rats after subtotal nephrectomy

Subtotally nephrectomized rats were found to have decreased activities of superoxide dismutase (SOD) and catalase, and spin trapping with 5,5-dimethyl-1-pyrroline-N-oxide (DMPO) showed that the amount of hydroxyl radical in the residual kidney tissue was greater than that in normal rat kidney. This indicated both direct and indirect involvement of free radicals in renal failure. In contrast, rats given magnesium lithospermate B (10 mg/kg body weight) orally for 30 days after subtotal nephrectomy showed restoration of SOD and catalase activities to almost normal levels. Hydroxyl radical, which is highly reactive and for which there is no scavenger system in the body, was decreased markedly in kidney homogenates obtained from rats given magnesium lithospermate B and in an experimental system for hydroxyl radical production to which magnesium lithospermate B was directly added. The increased levels of uremic toxins in the blood were also low in rats given magnesium lithospermate B. This indicates that magnesium lithospermate B helps to inhibit the progression of renal failure by scavenging radicals.

Inhibitory effect of green tea on injury to a cultured renal epithelial cell line, LLC-PK1

When cells from a cultured renal epithelial cell line, LLC-PK1, were cultured under hypoxic conditions (oxygen concentration of 2% or less) before reoxygenation was applied (95% air, 5% CO2), the leakage of lactate dehydrogenase (LDH) into the medium increased. This phenomenon was inhibited in the presence of dimethyl sulfoxide, a hydroxyl radical scavenger, suggesting the involvement of free radicals. Such oxidative stress was significantly inhibited by a green tea extract, and more potently by a tannin mixture. On the other hand, under ordinary culture conditions (95%, air, 5% CO2), there was cell injury, although the LDH leakage was less than that under hypoxia/reoxygenation, and such injury was inhibited by the green tea extract and the tannin mixture.

Clinical and histopathological studies in children with supraventricular tachycardia

To determine whether myocardial changes in patients with supraventricular tachycardia (SVT) are primary or secondary to persistent tachycardia, 11 patients with SVT were studied. These patients were divided into 2 groups with respect to the type of SVT. Group I consisted of 5 patients with incessant SVT and one with multifocal atrial tachycardia, while group II consisted of 4 patients with paroxysmal supraventricular tachycardia and one with short-run supraventricular premature contraction. All of the patients underwent electrophysiological study and endomyocardial biopsy from the right ventricle following routine cardiac catheterization. In group II, there were no significant abnormalities in the clinical and hemodynamic parameters. In group I, 3 patients had clinical features of dilated cardiomyopathy including abnormal ECG, chest X-ray and hypokinesis on left ventriculography. Induction and termination of SVT were possible in 2 patients in group I and in 4 of the 5 patients in group II. The only significant histologic difference between group I and group II was fibrosis. A high incidence of histopathological abnormalities, such as hypertrophy, degeneration, interstitial fibrosis and disarray was observed in both groups. The incidence of significant pathology was higher in group I than in group II. Almost all of the patients were given antiarrhythmic drugs. One patient underwent a successful surgical procedure and normal cardiac function returned after resection of the foci of the right atrium. Our present results suggest that patients with SVT who have incessant or recurrent SVT should undergo not only intracardiac electrophysiologic study but also endomyocardial biopsy for the evaluation of myocardial damage, since SVT might be the initial sign of cardiomyopathy.

Molecular biological analysis of the effects of ginsenoside-Rb2 on albumin mRNA in streptozotocin-induced diabetic rats

The mechanisms of the mRNA synthesis-promoting action of ginsenoside-Rb2, were investigated at the gene level. Rot analysis suggested that the previously reported increase in RNA polymerase activity as a result of administration of ginsenoside-Rb2 might be because of its effect on a specific gene. In this regard, albumin mRNA, which is expressed specifically in the liver, was assayed by northern blot hybridization using albumin cDNA in normal rats, diabetic control rats and diabetic rats given ginsenoside-Rb2. When the level of albumin mRNA in normal rats was set at 100, the level was reduced markedly to 32 in diabetic control rats. In contrast, in diabetic rats given ginsenoside-Rb2 the level was 0.54, significantly higher (69%) than that in diabetic rats given no ginsenoside-Rb2. In addition, poly(A)+RNA was purified from total RNA and subjected to hybridization, and poly(A)+RNA bands with different charges were measured by densitometry. The results of the measurement revealed changes dependent on the charge, and this was confirmed by autoradiography. We found no significant difference in the transcription activity of albumin mRNA, however, it showed only a tendency to increase. This suggests that ginsenoside-Rb2 has some effect on post-transcriptional regulation of the stability of mRNA itself. The results of Rot analysis suggest that ginsenoside-Rb2 affects a specific gene alone.

Effectiveness of green tea tannin on rats with chronic renal failure

The effects of green tea tannin on nephrectomized rats were examined. There were increases in blood urea nitrogen, serum creatinine, and urinary protein, and a decrease in creatinine clearance in the nephrectomized control rats, whereas better results for these parameters were obtained in rats given green tea tannin after nephrectomy, demonstrating a suppressed progression of the renal failure. When the renal parenchyma was partially resected, the remnant kidney showed a decrease in the activity of radical scavenger enzymes. Green tea tannin, however, was found to lighten the kidney under such oxidative stress. Mesangial proliferation and glomerular sclerotic lesions, which were conspicuous in the rats that were not given green tea tannin after nephrectomy, were also relieved.

Immunohistochemical detection of p53 tumor suppressor protein in porokeratosis

We examined 9 Japanese cases of porokeratosis (4 of the plaque type, 2 of disseminated superficial actinic porokeratosis, 2 of disseminated superficial porokeratosis, and one of giant porokeratosis) for the expression of p53 tumor suppressor protein immunohistochemically, using two anti-p53 antibodies, CM1 and DO1. The same results were obtained with both antibodies. The epidermis central to the cornoid lamellae was positive in 8 of 9 specimens. On the other hand, the peripheral epidermis was positive in 2 of the 9 cases. The epidermis beneath the cornoid lamellae was positive in 3 of the 9 cases. The frequency of p53 positivity was significantly higher in the epidermis central to cornoid lamellae over that beneath or peripheral to them (Fisher's exact probability test, p < 0.05). The majority of squamous cell carcinoma cells arising on giant porokeratosis stained with CM1 and DO1. These data may suggest that the abnormal p53 expression has some relevance to the skin carcinogenesis of porokeratosis.

Confirmation that magnesium lithospermate B has a hydroxyl radical-scavenging action

Male LWH: Wistar rats were given creatinine (Cr) intraperitoneally at a dose of 1.00 g/kg body weight, and the urine was collected for 3 h after administration. Magnesium lithospermate B, a compound newly isolated from Salviae Miltiorrhizae Radix, was administered intraperitoneally 30 min before and 30 min after Cr administration. The excretion of urinary creatol and methylguanidine induced by Cr decreased in a dose-dependent manner. Since we have already shown that the main contributor to the Cr-->creatol oxidation step is the hydroxyl radical, magnesium lithospermate B may act as a radical scavenger.

Effects of a component of green tea on the proliferation of vascular smooth muscle cells

The effects of a component of green tea on the proliferation of smooth muscle cells were measured in terms of [3H]thymidine uptake. When green tea tannin mixture was added to the medium of cultured smooth muscle cells, it suppressed the proliferation of the cells dose-dependently. Similarly to the effects of the green tea tannin mixture, (-)-epigallocatechin 3-O-gallate, its main ingredient, had an inhibitory effect on smooth muscle cell proliferation at a low concentration. (-)-Epicatechin 3-O-gallate was also an effective component. Among four types of gallate-free tannin, (-)-epigallocatechin, (-)-epicatechin, and (+)-catechin showed significant dose-dependent inhibition of smooth muscle cell proliferation. However, caffeine and theanine were found to have no such action.

The promoting action of magnesium lithospermate B on the kinin-prostaglandin E2 system in the kidney

The effect of magnesium lithospermate B purified from Salviae Miltiorrhizae Radix on the kinin-prostaglandin E2 system was investigated using kidney slices and isolated kidney microsomes. Magnesium lithospermate B markedly increased the amount of thiobarbituric acid-reactive substances produced by incubation of arachidonic acid in renal slices. Enhancement of arachidonic acid-mediated oxygenation of 1,3-diphenylisobenzofuran was also observed in renal microsomes from rats treated with magnesium lithospermate B, indicating an increase of prostaglandin biosynthesis. Furthermore, magnesium lithospermate B significantly increased the synthesis of prostaglandin E2 in renal slices, but the magnesium lithospermate B-mediated response was blunted with kinin antagonist. On the basis of the above results, it is apparent that magnesium lithospermate B exerts an influence on the prostaglandin system via kinin receptors.