Efficacy of intentional undersized thoracic endovascular repair for Stanford type B aortic dissection

OBJECTIVES

Thoracic endovascular aneurysm repair (TEVAR) is widely used for the treatment of aortic dissection. Endograft oversizing is a risk factor for stent graft-induced new entry tears and retrograde type A aortic dissection. However, there is no clear consensus on the optimal graft size selection for Stanford type B acute or subacute aortic dissection (TBAD). Herein, we examined the safety and efficacy of TEVAR using an intentionally undersized endograft to treat TBAD.

METHODS

This retrospective chart review study included 82 patients who underwent TEVAR for acute or subacute Stanford TBAD between 2015 and 2022. We measured the true lumen diameter just distal to the subclavian artery and opted for a stent graft of the same diameter. In instances where deformation resulting from false lumen pressure displacement was pronounced, we measured the diameter at the site just proximal to the subclavian artery. Patients' characteristics, procedural, in-hospital, and follow-up data, and aortic remodeling were analyzed. The aortic diameter was analyzed using one-way analysis of variance followed by Dunnett's test. Survival and freedom from re-intervention were estimated using Kaplan-Meier curves.

RESULTS

The follow-up rate was 98.4%. The mean age was 58.3 ± 12.3 years and 76 were men (92.7%). The mean diameters of the stent graft and native proximal landing zone were 30.9 ± 3.2 mm and 30.8 ± 3.0 mm, respectively. The oversize rate of the stent graft in relation to the native proximal aortic diameter was 0.3 ± 4.7%. In-hospital mortality was observed in one patient, retrograde type A aortic dissection in one patient, distal stent graft-induced new entry tear in zero patients, and type 1a endoleak in 22 patients (26.8%). Type 1a endoleaks, characterized by antegrade false lumen blood flow originating from the primary entry, in 12 patients spontaneously disappeared within 1 year of follow-up. According to aortic remodeling, 59 (86.8%) patients achieved complete aortic remodeling at the aortic arch level and 51 (75.0%) at the 8th thoracic vertebral level. The diameters of the aortic arch and descending aorta were significantly reduced compared with the postoperative measurements (P <0.001). Survival rates were 97.5% and 93.6% at 1 and 3 years, respectively. Freedom from re-intervention was 84.7% and 84.7% at 1 and 3 years, respectively.

CONCLUSIONS

Intentionally undersized TEVAR was safe and achieved acceptable aortic remodeling despite a high rate of type 1a endoleaks. A type 1a endoleak was acceptable as it primarily diminished during the mid-term follow-up.

Delayed migration due to shortening of the lower part of AFX endograft's main body in angled fusiform abdominal aortic aneurysm

We encountered two fusiform abdominal aortic aneurysm cases with delayed AFX endograft (Endologix Inc) migration >4 years after placement. These cases showed shortening and slight angulation of the main body in the anteroposterior direction. We speculate that the potential mechanism relates to the AFX portion that is easily shortened at the bifurcation of its stent structure. This portion might contribute to delayed migration after slight angulation of the main body. Preoperative three-dimensional computed tomography should be performed from the anteroposterior and lateral views. Although the AFX is useful for narrow bifurcations, one should consider the patient's anatomy before deciding to use an AFX endograft.

[Transient Left Ventricular Dysfunction after Giant Coronary Aneurysm Resection and Repair of Coronary Arteriovenous Fistula with Coronary Artery Bypass Grafting:Report of a Case]

Coronary artery aneurysm with coronary arteriovenous fistula is a relatively rare clinical setting. We report a surgical case of a 69-year-old male with a giant coronary artery aneurysm, finding coronary arteriovenous fistula on computed tomography (CT). We performed complete aneurysm excision and coronary artery bypass grafting with the left internal thoracic artery to the posterolateral branch. The fistula was located between the giant aneurysm on the circumflex artery and the coronary vein close to the coronary sinus, closed with aneurysm sac. The postoperative CT found no residual aneurysm and fistula. However, the great cardiac vein was thrombosed, and the impeded venous flow by the thrombus seemed to reduce the left ventricular ejection fraction (LVEF). Four months after the operation, the LVEF improved to the preoperative level.

Two Cases of Endovascular Repair with the Stent Graft for Retrograde Type A Acute Aortic Dissection with Complications

Thoracic endovascular aortic repair (TEVAR) is used to treat retrograde type A acute aortic dissection (RTAAD). In case 1, a 52-year-old man, who was conservatively managed, reported worsening back pain. Emergency TEVAR was performed 7 days after onset. After deploying two GORE Conformable TAG (CTAG) in the descending aorta, his symptoms disappeared. In case 2, a 52-year-old man with progressive worsening resistant hypertension, renal dysfunction, and respiratory failure despite maximal medical therapy underwent TEVAR 8 days after onset. A CTAG was deployed from the left subclavian artery under rapid pacing, and two Zenith Dissection stents were placed, which resolved complications. In both cases, after 6 months, computed tomography (CT) scan showed complete resorption of the false lumen in the ascending aorta. TEVAR for RTAAD with complete thrombosis of false lumen in the ascending aorta can be an alternative to surgery when the primary tear is located in descending aorta.

[Splenic Injury during Replacement of the Thoracoabdominal Aorta]

Extraperitoneal approach is commonly employed for thoracoabdominal aortic repair via Stoney incision. It is supposedly rare to encounter abdominal visceral bleeding during that procedure. However, the spleen may spontaneously adhere to the adjacent peritoneum, which could induce incidental injury to the spleen by its anterior mobilization during extraperitoneal approach. Unless we bare its potential risk in mind, bleeding from the spleen may be overlooked, which results in hemodynamic deterioration. We have experienced 3 cases of splenic injury that necessitated hemostatic maneuvers for bleeding during and just after the thoracoabdominal aortic repair.

Sex Differences in Salivary Oxytocin and Cortisol Concentration Changes during Cooking in a Small Group

Background: Oxytocin (OT), a neuropeptide, has positive effects on social and emotional processes during group activities. Because cooking is an integrated process in the cognitive, physical, and socio-emotional areas, cooking in a group is reported to improve emotion and cognition. However, evidence for efficacy in group cooking has not been well established at the biological level. Methods: To address this shortcoming, we first measured salivary levels of OT and cortisol (CORT), a biomarker of psychological stress, before and after group cooking for approximately 1 h by people who know each other in healthy married or unmarried men and women. We then compared the initial OT and CORT concentrations with those during individual non-cooking activities in isolation. Results: Baseline OT concentrations before group and non-group sessions did not significantly differ and OT levels increased after both types of activity in men and women. In men, however, the percentage changes of OT levels in the first over the second saliva samples were significantly small during cooking compared with those in individual activities. In women, however, such a difference was not observed. In contrast, the mean salivary CORT concentrations after group cooking were significantly decreased from the baseline level in both sexes, though such decreases were not significant after individual activity sessions. The sex-specific differences were marital-status independent. Conclusion: These results indicate that OT and CORT concentrations after two activity sessions by a familiar group changed in opposite directions in a sex-specific manner. This suggests that, because cooking is experience-based, we need to consider the sex-specific features of group cooking if we apply it for intervention.

[Surgical Embolectomy for Acute Massive Pulmonary Thromboembolism Requiring Percutaneous Cardiopulmonary Support after Thoracoabdominal Aorta Replacement]

A 48-year-old man was admitted to our hospital and underwent thoracoabdominal aorta replacement. Eight days postoperatively, he developed severe dyspnea and transient drop in blood pressure suddenly following walk rehabilitation. Contrast-enhanced computed tomography showed thrombi in the bilateral main pulmonary artery. Respiratory failure and unstable hemodynamics developed, which required percutaneous cardiopulmonary support (PCPS). Because catheter embolectomy and thrombolytic therapy via pulmonary artery catheter were not effective, surgical thrombectomy was performed. PCPS was successfully removed on the following day. The patient was extubated on postoperative day 10 and discharged without complications on day 46 following rehabilitation. It is important to save a critically ill patient with acute pulmonary embolism requiring PCPS, and surgical treatment should be performed without delay in such patients.

Genetic analysis of hMLH1 in transitional cell carcinoma of the urinary tract: promoter methylation or mutation

PURPOSE

Loss of DNA mismatch repair due to diminished expression or mutation of hMLH1 is associated with genomic instability followed by cancer. We performed genetic analyses of hMLH1 to determine whether hMLH1 alterations have a role in urothelial tumorigenesis.

MATERIALS AND METHODS

We examined genomic DNA from 118 sporadic transitional cell carcinomas, including 83 bladder and 35 renal pelvis or ureter cases, for aberrant promoter methylation and mutation in the hMLH1 gene. Immunohistochemical reactivity to hMLH1 protein and genome instability in these transitional cell carcinomas were also studied.

RESULTS

Two of the 118 cases (1.7%) had microsatellite instability and hMLH1 promoter methylation with loss of or reduced hMLH1 protein expression. A single transitional cell carcinoma (0.8%) without microsatellite instability had an hMLH1 missense mutation with a C-to-T transition, resulting in the substitution Arg217 --> Cys. Immunostaining with antihMLH1 antibody was found in this transitional cell carcinoma.

CONCLUSIONS

To our knowledge these findings provide the first in vivo evidence for the type and frequency of possible involvement of promoter methylation and mutation of hMLH1 in sporadic urothelial transitional cell carcinoma. They also suggest that hMLH1 alterations may not account for many cases of sporadic transitional cell carcinoma tumorigenesis.

Multinucleated giant cells in submucosal layer of human urinary bladder: an immunohistochemical and electron microscopic study

Multinucleated giant cells (MGC) detected in the submucosal layer of human urinary bladder mainly associated with transitional cell carcinoma were examined immunohistochemically and ultrastructurally. The cases examined totaled 29, namely 14 cases with transitional cell carcinoma and another 15 cases mostly with malignancy in other organs. Histologically, MGC were smooth, irregular or dendritic in shape, and tended to increase in number in the vicinity of cancer or marked inflammation. They were consistently positive for not only vimentin, but also MB-2, and CD34, and were mostly positive for proliferating cell nuclear antigen (PCNA), but not MIB-1 (Ki-67) and HLA-DRalpha antigens. On occasion, antibodies to alpha-smooth muscle actin (alpha-SMA), muscle actin (M-actin), CD68 (KP-1) and alpha subunit of S-100 protein also yielded positive reactions. Interestingly, aggregated short bulbous processes were ultrastructurally observed on their surface in parts. These findings suggested that MGC in the submucosal layer of human urinary bladder were MB-2 and CD34-positive multipotential mesenchymal cells with no mitotic activity expressing fibroblastic (vimentin), myofibroblastic (alpha-SMA), or histiocytic (CD68) markers mostly in the vicinity of malignancy, and that these MGC were formed by fusion of mononuclear cells expressing identical markers with those of MGC. Further investigations are needed to clarify the exact function of MGC in human urinary bladder.

Nephrogenic adenoma of the bladder in a chronic hemodialysis patient

BACKGROUND

Nephrogenic adenoma is an uncommon, benign metaplastic lesion occurring in the urothelium, usually as a response to chronic irritation or trauma. It is rarely encountered in hemodialysis patients. Endoscopically, these lesions can easily be mistaken for malignant tumors.

METHODS/RESULTS

We report on a case of nephrogenic adenoma of the bladder in a chronic hemodialysis patient that was large and mistakenly diagnosed as transitional cell carcinoma in the initial biopsy. Histopathological examination of the total cystectomy specimen demonstrated the correct diagnosis of nephrogenic adenoma.

CONCLUSION

Increased awareness by urologists and pathologists of nephrogenic adenoma may lead to its more accurate diagnosis.

[Long-term clinical outcome of extracorporeal shock wave lithotripsy monotherapy for staghorn calculi]

We treated 97 patients with staghorn calculi by ESWL monotherapy using a Lithostar Lithotriptor (Siemens) between January 1989 and December 1996. Seventeen patients (18 renal units) out of 45 patients (47 renal units) who could be followed up for more than 12 months after ESWL had no stones on radiographs at 3 months after the treatment. The actuarial non-recurrence (or stone-free) rate was 88.9% at 1 year, 79.0% at 3 years, and 63.2% at 5 years after ESWL (Kaplan-Meier method). The actuarial non-regrowth rate (regrowth < 1 mm) was 96.6% at 1 year, 72.8% at 3 years, and 63.7% at 5 years (Kaplan-Meier method). History of urinary stones was a significant risk factor for stone recurrence, while patient sex, affected side, stone number, pyuria (> or = 10/HPF), hydronephrosis on DIP, and staghorn type were not significantly associated with stone recurrence or regrowth (Cox proportional hazard model). Late complications associated with ESWL included renal dysfunction (serum Cr > or = 1.1 mg/dl) in 2 patients, hypertension (> or = 160 mmHg) in 3, and renal atrophy (two-dimensional size < or = 80%) in 5. ESWL exerted adverse effects in a session-dependent manner on the kidney resulting in renal atrophy. Therefore, we highly recommend that ESWL should be limited to less than 10 sessions.

Prognostic significance of cyclin E and p53 protein overexpression in carcinoma of the renal pelvis and ureter

Cyclin E gene alteration in the cell cycle plays an important role in carcinogenesis, while p53 protein affects different phase checkpoint pathways by activating p21WAF1/CIP1 in the normal cell cycle. We immunohistochemically examined the expression of cyclin E and p53 proteins in 121 patients with transitional cell carcinoma (TCC) of the renal pelvis and ureter to determine their significance for tumour behaviour and patient prognosis. Cyclin E and p53 immunostaining of the nucleus was observed in 36 tumours (29.8%) and 35 tumours (28.9%) respectively. A significant percentage, 69.4% (25 out of 36 tumours), of the cyclin E-positive tumours exhibited simultaneous labelling for p53 (P < 0.05). Mirror-section technique was performed in five selected double-positive tumours to identify cancer cells that were nuclei positive for both cyclin E and p53. The prevalence of cases simultaneously exhibiting both cyclin E and p53 immunostaining was higher in the high-grade tumours (P < 0.01) than in the other types of tumours. Patients with TCCs coexpressing cyclin E and p53 had a significantly poorer prognosis than those expressing neither cyclin E nor p53 (P < 0.001). These in vivo findings provide evidence for cyclin E protein overexpression in TCCs intimately associated with p53 alteration and suggest that simultaneous overexpression of both cyclin E and p53 is related to tumour behaviour and poor prognosis.

[A case of chromophobe cell renal carcinoma]

We report a case of chromophobe cell renal carcinoma. A 59-year-old female was admitted to our hospital with asymptomatic gross hematuria. Abdominal computerized tomography showed an approximately 4 cm. minimally enhancing mass in the left kidney. Angiography revealed a hypovascular tumor in the left kidney. Under the diagnosis of renal cell carcinoma, left radical nephrectomy was performed. The cut surface of the tumor was beige in color with few foci of hemorrhage and necrosis. Microscopically, the tumor was composed of the cells with voluminous reticulated cytoplasm stained lightly with routine hematoxylin and eosin. Hale's colloidal iron staining demonstrated a positive cytoplasmic reaction. Pathological diagnosis was chromophobe cell renal carcinoma. Chromophobe cell renal carcinoma is a recently established subtype of renal cell carcinoma, which has rarely been reported in Japan.

Cyclin A overexpression in carcinoma of the renal pelvis and ureter including dysplasia: immunohistochemical findings in relation to prognosis

Several in vitro studies have shown that cyclin A gene alteration in the cell cycle plays an important role in carcinogenesis. We immunohistochemically examined the expression of cyclin A protein in 120 patients with transitional cell carcinoma (TCC) of the renal pelvis and ureter, including adjacent dysplastic lesions to determine their significance for the tumor behavior and patient prognosis. Cyclin A immunostaining of the nucleus was observed in 29 tumors (24.2%). Furthermore, 17 cyclin A-positive tumors (58.6%) had dysplastic lesions positive for cyclin A antibody. The prevalence of cases exhibiting cyclin A staining was higher in the high grade (P < 0.01) and invasive tumors (P < 0.05) than in the other types of tumors. In the selected 117 cases, patients whose TCCs expressed a high level of cyclin A protein had a significantly poorer prognosis than those without cyclin A expression (P < 0.01). These in vivo findings provide the first evidence for frequent and redundant cyclin A protein overexpression in TCC and suggest that cyclin A overexpression is related to the tumor behavior and patient prognosis. In addition, our observations indicate that overexpression of cyclin A may be one of the early events, at least in some cases, in the carcinogenesis of TCC.

Extracorporeal shock wave lithotripsy-induced renal laceration

After extracorporeal shock wave lithotripsy (ESWL), perinephric hematomas, while uncommon, are a serious complication involving the risk of blood transfusion and subsequent impairment of renal function. We report a rare case of ESWL-induced renal laceration in which an expanding retroperitoneal hematoma required blood transfusion but was treated successfully without surgical intervention.

Free thyroxine concentrations in serum measured by equilibrium dialysis in chronic renal failure

The serum concentration of free thyroxine (FT4) is often low in patients with chronic renal failure (CRF) with low serum concentrations of triiodothyronine (T3). We evaluated the serum FT4 concentration by using both an equilibrium dialysis RIA kit (D-FT4) and a labeled-antibody kit (M-FT4) in two different groups of CRF patients, undergoing chronic hemodialysis (HD, n = 145) or not (non-HD, n = 30), and in a group of normal healthy subjects (n = 58). Thyroid peroxidase antibodies and thyroglobulin antibodies were not detected in any patient. Serum FT4 concentrations (mean +/- SD, pmol/L) by the D- and M-FT4 assays were, respectively, 21.5 +/- 4.6 and 16.6 +/- 2.0 in the healthy subjects, 17.8 +/- 4.3 and 13.9 +/- 3.6 in the non-HD patients, and 16.9 +/- 4.9 and 10.7 +/- 1.9 in the HD patients. By the D-FT4 assay, results for both CRF groups were significantly different from those for the healthy group (P &lt;0.01), as were the results for each pair of groups by the M-FT4 assay (P &lt;0.01). FT4 values were reported as being within the healthy reference range by D-FT4 in 73 of 113 HD subjects who had low T3 and low M-FT4 values. Serum FT4 concentrations measured by both assay kits showed a significant inverse correlation with the serum concentration of creatinine (P &lt;0.01), but the serum concentrations of sex-hormone-binding globulin did not differ significantly among the three groups. Our results indicate that the low FT4 concentration measured by D-FT4 in patients with CRF, particularly those on HD, probably reflects the actual, mild nonthyroidal illness of renal failure.

Free thyroxine concentrations in serum measured by equilibrium dialysis in chronic renal failure

The serum concentration of free thyroxine (FT4) is often low in patients with chronic renal failure (CRF) with low serum concentrations of triiodothyronine (T3). We evaluated the serum FT4 concentration by using both an equilibrium dialysis RIA kit (D-FT4) and a labeled-antibody kit (M-FT4) in two different groups of CRF patients, undergoing chronic hemodialysis (HD, n = 145) or not (non-HD, n = 30), and in a group of normal healthy subjects (n = 58). Thyroid peroxidase antibodies and thyroglobulin antibodies were not detected in any patient. Serum FT4 concentrations (mean +/- SD, pmol/L) by the D- and M-FT4 assays were, respectively, 21.5 +/- 4.6 and 16.6 +/- 2.0 in the healthy subjects, 17.8 +/- 4.3 and 13.9 +/- 3.6 in the non-HD patients, and 16.9 +/- 4.9 and 10.7 +/- 1.9 in the HD patients. By the D-FT4 assay, results for both CRF groups were significantly different from those for the healthy group (P <0.01), as were the results for each pair of groups by the M-FT4 assay (P <0.01). FT4 values were reported as being within the healthy reference range by D-FT4 in 73 of 113 HD subjects who had low T3 and low M-FT4 values. Serum FT4 concentrations measured by both assay kits showed a significant inverse correlation with the serum concentration of creatinine (P <0.01), but the serum concentrations of sex-hormone-binding globulin did not differ significantly among the three groups. Our results indicate that the low FT4 concentration measured by D-FT4 in patients with CRF, particularly those on HD, probably reflects the actual, mild nonthyroidal illness of renal failure.

Detection of p53 and bcl-2 protein in carcinoma of the renal pelvis and ureter including dysplasia

Ninety-four patients with transitional cell carcinoma (TCC) of the renal pelvis and ureter, including dysplastic lesions, were studied for p53 and bcl-2 protein expression by immunohistochemistry. Twenty-one patients were also studied for p53 gene mutations by direct sequencing and for bcl-2 gene rearrangement by Southern blot analysis. Overexpressed p53 protein was detected in 26 cases (27.7 per cent). bcl-2 immunostaining was observed in 21 tumours (22.3 per cent), including four cases with labelling for p53. Furthermore, the dysplastic lesions surrounding 19 p53-positive tumours also stained for p53. bcl-2 expression was also detected frequently in dysplastic lesions adjacent to 14 bcl-2-positive TCCs. Positive reactions of dysplastic lesions were also found adjacent to 37 bcl-2-negative tumours. p53 point mutation was detected in 6 of 21 cases. Five of the six cases were positive for p53 protein. blc-2 positivity was detected in 3 of 21 tumours, without bcl-2 gene rearrangements in the major breakpoint region. Overexpressed p53 protein was frequently detected in both high-grade (P < 0.05) and invasive tumours (P < 0.05). In three cases of p53-positive non-papillary invasive tumours, bcl-2 was found in non-invasive portions, but was not present in invasive areas. These findings suggest that overexpression (mutation) of p53 and/or bcl-2 protein may be early events in tumourigenesis and that p53 alterations in particular are essential for the maintenance of a malignant phenotype in tumour development.

[A case of crescentic glomerulonephritis with extensive hematuria resulting in severe anemia]

A 24-year-old woman was admitted to our hospital because of macroscopic hematuria with clotting. She had been well until two months before admission, when she experienced fever, arthralgia and lethargy and entered another hospital. Laboratory tests showed macroscopic hema-turia, anemia and mild renal dysfunction. Two weeks prior to admission, she had experienced an episode of macroscopic hematuria with clotting followed by severe anemia requiring blood transfusion. Because of the deterioration of her renal function, she was transferred to our hospital. Examinations to determine the source of bleeding from the urinary tract, including a renal arteriogram, were negative. Tests for c-anti-neutrophil cytoplasmic antigen (ANCA) and anti-glomerular basement membrane antibody gave negative results, whereas the test for p-ANCA was positive. Renal biopsy revealed crescentic glomerulonephritis with focal necrosis. Therefore, we diagnosed rapidly progressive glomerulonephritis (RPGN) due to ANCA-associated renal disease. As a result of methypre-dnisolone pulse treatment followed by oral steroid therapy, macroscopic hematuria disappeared with marked improvement of her renal function. We considered this patient to be a rare case of RPGN with blood loss through glomerular lesions resulting in severe anemia.

p53 and human papillomavirus DNA in renal pelvic and ureteral carcinoma including dysplastic lesions

Ninety-eight cases of transitional-cell carcinoma (TCC) of the renal pelvis and ureter, including dysplastic lesions, were studied for tumor incorporation of human papillomavirus (HPV) type-16 and type-18 DNA by in situ hybridization (ISH) with DNA probes for each HPV viral type. Immunohistochemical analysis of p53 expression was also performed. Fresh tumor tissues from 26 patients were also studied for p53 mutations in exons 4 through 9 by direct sequencing and for HPV infection by polymerase chain reaction (PCR). Thirty-two tumors were positive for HPV DNAs, including 6 double-positive cases. Among these tumors, adjacent dysplastic lesions in 21 cases (66%) also revealed identical reactivity. Overexpressed p53 was detected in 26 cases. Expression of p53 was also detected in dysplastic lesions in 19 out of these 26 cases (73%). Three cases were positive for both HPV DNA and p53 antibody. p53 point mutation was detected in 7 of 26 cases, 6 of which were also positive for p53. HPV type-16 DNA was detected in 6 cases by PCR, 4 of which were also ISH-positive. Overexpressed p53 was frequently detected in invasive and non-papillary tumors (p < 0.01) and in high-grade tumors (p < 0.05). HPV infection was more common in non-invasive and papillary tumors (p < 0.05). These findings suggest that HPV infection or overexpression (mutation) of p53 may be an early event and be related to phenotypes of tumor-cell growth patterns and progression.

[Sex cord/stromal tumor of the testis: a case report]

We herein report a case of sex cord/stromal tumor of the testis. A 28-year-old man was admitted to our hospital with the chief complaint of painless swelling of the left scrotal contents. On examination, gynecomastia or swelling of superficial lymph nodes was not observed. With a diagnosis of left testicular tumor, left high orchiectomy was performed. Gross examination of the specimen demonstrated a mass measuring 20 x 18 x 14 mm within the testis. On the cut surface, the tumor was gray and was associated with focal hemorrhage and necrosis. The spermatic cord and epididymis were not involved by the tumor. Microscopically, the tumor demonstrated a mixed pattern consisting of, we thought, areas of Leydig-like cells as well as areas of Sertoli-like cells showing mild atypia. Without further treatment, the patient has remained free from the disease for over fifteen months since the operation. Fifty eight cases of sex cord/stromal tumor of the testis have been reported in the Japanese literature, but sex cord/stromal tumors, other than pure Leydig cell tumor or Sertoli cell tumor, are very rare. Only 4 cases have been reported including our case.

Case report: new sonographic finding in renal infarction

We observed a unique sonographic finding in a patient with right global renal infarction associated with an abdominal aortic dissection. Sonography in the acute phase revealed a highly echogenic and thickened perirenal fascia without demonstrable abnormality of the renal parenchyma. This finding may be helpful in the early diagnosis of renal infarction by routine sonography.

[Distribution of S-100 protein-positive dendritic cells inside the cancer nest and expression of HLA-DR antigen and blood group antigen on the cancer cell in transitional cell carcinoma of the urinary bladder--in relation to tumor progression and prognosis]

The distribution of S-100 protein positive dendritic cells (S100-DCs) inside the cancer nest and the expression of HLA-DR alpha antigen (HLA-DR) and blood group antigen (BGA) on cancer cells in 90 cases of transitional cell carcinoma (TCC) of the urinary bladder were immunohistochemically investigated in relation to the degree of malignancy and its prognosis. A dense infiltration of S100-DCs inside the cancer nest ("many", i.e. more than 10DCs/HPF) was detected in 47 (52%) out of 90 cases. The HLA-DR positive cancer cells (DR-CCs) were detected in 24 cases (27%), including in the 16 most dense cases ("many", i.e. more than 100DR-CCs/HPF). BGA positive cancer cells (BGA-CCs) were detected in 49 cases (54%) ("positive", i.e. more than 100BGA-CCs/HPF). In connection with the degree of malignancy and with the number of cases affected by S100-DCs infiltration. HLA-DR expression and BGA expression. A statistical analysis showed significant correlation between the number of cases affected by S100-DC and each clinicopathological factor including G, pT, ly, v, and showed also between that affected by BGA expression and each clinicopathological factor including G, pT, INF, but showed no significant correlation between that affected by HLA-DR and each clinicopathological factor. As regards the prognosis, the 10-year survival rates for all 90 cases were 60.4%. In the 10-year survival rate, S100-DCs "many'' (77.7%) and "few'' (39.0%), DR-CCs "many'' (85.7%) and "no'' (56.9%), DR-CCs "many'' and "few'' (43.8%), BGA-CCs "positive'' (74.3%) and BGA-CCs "negative'' (46.5%) were statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

High-risk human papillomavirus infections and overexpression of p53 protein as prognostic indicators in transitional cell carcinoma of the urinary bladder

Ninety Japanese patients with transitional cell carcinoma of the urinary bladder were investigated for tumor incorporation of DNA for high-risk human papillomavirus (HPV) types 16, 18, and 33 by in situ hybridization with biotinylated DNA probes. In addition, immunohistochemical analysis of p53 protein expression was performed with an antibody to p53 protein. Twenty-eight tumors were positive for HPV DNA, and multiple HPV infection was detected in 17 cases. Positive nuclear staining of cancer cells by the antibody to p53 protein was detected in 32 cases. DNA for HPV 16, 18, and/or 33 and the overexpression of p53 protein were simultaneously observed in 6 tumors by using a mirror section method. The overexpression of p53 protein was frequently detected in invasive and nonpapillary tumors (P < 0.05) and in high grade tumors (P < 0.05). In contrast, HPV infection was more common in noninvasive and papillary tumors (P < 0.01). The patients with tumors positive for HPV DNA and/or p53 antibody had a significantly worse survival rate (P < 0.05). These results suggest that HPV infection or overexpression of p53 protein may be related to tumor behavior and may indicate a relatively poor prognosis in patients with transitional cell carcinoma.

[Postoperative results of ligation of crura penis for impotence with corporal veno-occlusive insufficiency]

We performed ligation of the crura penis for 34 impotents with corporal veno-occlusive insufficiency without arterial insufficiency and neural dysfunction from October 1987 to April 1991. Ages ranged from 24 to 72 (52.6 +/- 12.7) years old and follow up period was from 1 to 41 (17.7 +/- 12.6) months. For six patients ligation of the crura only was performed, for 22 ligation of the crura and deep dorsal vein (DDV) as well was performed at the same time, and for 6 crural ligation was performed after ligation of DDV. These operations required less than one hour and there were no severe complications. The postoperative results at 1 month were as follows: Excellent (sufficient spontaneous erection was recovered); 18, Improved (complete erection with intracavernous papaverine injection was achieved); 13, and Failure; 3. Erectile function was maintained only in 50% of the 18 pts. graded excellent. Ninety percent of the 31 patients graded either excellent or improved could maintain erectile function after 40 months with papaverine injection. Venous surgeries could not be a primary treatment for correcting the outflow abnormalities (of the veins). So it is conceivable that failure or recurrence could occur during a long follow up period. We concluded that crural ligation was acceptable as the first line treatment for erectile dysfunction due to corporal veno-occlusive insufficiency because of its relative non-invasiveness compared to other venous surgeries.

Immunohistochemical and ultrastructural studies of intraluminal crystalloids in human prostatic carcinomas

Intraluminal crystalloids (ICr) observed in 19 cases of incidental or invasive human prostatic carcinoma (PCa) and in a case of benign prostatic hyperplasia were examined extensively by immunohistochemistry and electron microscopy. They were brilliantly eosinophilic with haematoxylin and eosin, manifesting needle-like, triangular, rectangular, hexagonal and irregular lump-like in shape. They were strongly positive, dark blue, with phosphotungstic acid -haematoxylin (PTAH) stain in all cases examined. Among the human antibodies tested, epithelial membrane antigen (EMA) gave specifically positive immunostainability with ICr in all cases. Annual ring-like lamellar or concentric structures were detected by electron microscopy. Positive staining of ICr with PTAH and anti-EMA antibody is very useful as a diagnostic marker for PCa in human prostatic tissues.

Suppressive effect of soluble factor(s) derived from Prevotella loescheii ATCC 15930 on proliferation of human lymphocytes

Soluble sonic extracts of Prevotella loescheii caused a dose-dependent inhibition of human peripheral blood lymphocyte proliferation by mitogen and of the proliferation of a leukemic cell line, BALL-1, when assessed by DNA synthesis (3H-thymidine incorporation). RNA (3H-uridine incorporation) and protein (3H-leucine incorporation) synthesis were similarly altered after exposure to the extract. There was no effect on cell viability as measured by either trypan blue exclusion or extracellular release of the cytoplasmic enzyme lactate dehydrogenase. Preliminary characterization indicates the suppressive factor(s) derived from P. loescheii to be a protein since it is heat-labile and trypsin-sensitive. The factor eluted in a peak on a high-pressure liquid chromatography gel filtration corresponding to a molecular weight of approximately 32,000. Since black-pigmented anaerobic rods have been implicated in the pathogenesis of periodontal disease, the data suggest that P. loescheii contributes to the disease process by suppressing lymphocyte function.

Calcium phosphate cements: study of the beta-tricalcium phosphate--monocalcium phosphate system

The possibility of making cements based on beta-tricalcium phosphate (beta-TCP), a promising bone graft material, was investigated. Upon admixture with water, beta-TCP/monocalcium phosphate monohydrate (MCPM) mixtures were found to set and harden like conventional hydraulic cements. Beta-TCP powders with larger particle size, obtained by sintering at higher temperatures, increased the ultimate strength of the cement. Results show that setting occurs after dissolution of MCPM, as a result of the precipitation of dicalcium phosphate dihydrate (DCPD) in the paste. The ultimate tensile strength of the hardened cement is proportional to the amount of DCPD formed. Upon ageing above 40 degrees C, DCPD transforms progressively into anhydrous dicalcium phosphate (DCP), thereby decreasing the strength. Ageing of the pastes in 100% r.h. results in a decay of the mechanical properties. This can be ascribed to an intergranular dissolution of the beta-TCP aggregates as a result of the pH lowering brought about by the MCPM to DCPD conversion.

A simplified aluminum stain in paraffin sections of bone from hemodialysis patients

A new simplified method has been devised for staining aluminum and has been tested in paraffin sections of bone from 60 patients who have undergone hemodialysis. Iliac crest bone fragments were fixed in 20% phosphate-buffered formalin for less than a day and demineralized at room temperature in 10% phosphate-buffered formalin containing 5% formic acid for only 2 to 3 hr. Four-micron paraffin sections, accompanied by positive controls, were stained with Maloney's aluminum stain, the Berlin blue reaction for iron, dylon or Congo red for amyloid and von Kossa's reaction for calcium. Aluminum and iron were demonstrated particularly at the mineralizing front of bony tissues; aluminum in 52 cases, iron in 45. Dylon staining also gave positive results in 52 cases. It is important in determining whether aluminum deposition is present that the von Kossa reaction remains positive even after demineralization. This method may be more useful for demonstrating aluminum in bony tissues than the complicated and time-consuming resin-embedding method currently used.

[Renal cell carcinoma in the solitary kidney]

We have treated surgically 5 patients with renal cell carcinoma in the solitary kidney. The cause of renal absence was nephrectomy for renal stones, in 2 patients and renal tuberculosis, renal cyst and renal hypoplasia in 1 patient each. Four of the 5 patients died. One of the 4 patients died 5 days after surgery due to gastrointestinal bleeding, 1 due to metastasis, 1 due to gastric cancer and one due to hemodialysis complications. Surgical management of renal cell carcinoma of solitary kidney is discussed.

Adaptive changes of H+ and/or bicarbonate transport in chronic metabolic acidosis: its quantitative evaluation by using isolated perfused kidney

We have recently improved the technique of the isolated perfused rat kidney by addition of amino acids to the perfusion solution. Utilizing this improved preparation, we examined to what extent chronic acid-base status can alter H+ and/or bicarbonate transport in the whole kidney and the effect of acetazolamide (10(-4) M) on this process. Kidneys from rats that had been drinking tap water (control), 1.5% NH4Cl (acidotic), or 1.5% NaHCO3 (alkalotic) were perfused with a solution of identical pH and PCO2. During the control period, the fractional bicarbonate reabsorption was higher in acidotic rats than in control rats by 1.0% and urine pH was lower than those in control. On the other hand, the two parameters were not different between control and alkalotic rats. Acetazolamide increased urine pH and decreased the fractional bicarbonate reabsorption in all, but these parameters in acidotic and alkalotic rats were not different compared with those in control. We conclude that adaptive changes of H+ and/or bicarbonate transport in chronic metabolic acidosis corresponds to about 1.0% as fractional bicarbonate reabsorption by the isolated perfused kidney and is largely carbonic anhydrase dependent.

Earlobe crease and coronary heart disease in Japanese

To evaluate whether a significant statistical correlation exists between earlobe crease (EC) and coronary heart disease (CHD), 1000 Japanese adult patients (573 males, 427 females) were examined for the presence or absence of EC, clinical or angiographic evidence of CHD, and the following coronary risk factors: male sex, age over 50 years, obesity, hypertension, diabetes mellitus, cigarette smoking, and hyperlipidemia. Patients were divided into two groups according to clinical evidence of CHD: 237 patients with angina pectoris and/or myocardial infarction (CHD+ group); 720 patients without evidence of CHD (CHD- group). Coronary angiography was performed on 200 patients from this sample population; these patients were also divided into two groups: 119 patients with greater than 50% luminal narrowing of at least one major coronary artery (stenosis+ group); 81 patients with no significant atherosclerotic changes in the coronary arteries (stenosis- group). EC was present in 58 of 237 CHD+ patients (24.5%) but in only 35 of 720 CHD- patients (4.8%; P less than 0.001); it was present in 31 of 199 stenosis+ patients (26.1%) but in only 3 of 81 stenosis- patients (3.7%; P less than 0.01). EC was also found to correlate significantly with some coronary risk factors; the correlations between the presence of EC and the presence of CHD and coronary risk factors were investigated by multivariate analysis. In a multivariate setting, the existence of CHD and an age of over 50 years was significantly related to the presence of EC. To investigate the relationship between EC and advancing age, all patients were separated into age-groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced extraction of I-propranolol by perfused rat liver in the presence of uremic blood

Previous in vivo studies have shown that the presystemic clearance of p.o.-administered levo-isomer of propranolol is inhibited in rats with uranyl nitrate-induced acute renal failure. A series of steady-state single-pass rat liver perfusion studies were performed to explore the probable mechanism of the observed metabolic inhibition. When livers from normal rats were perfused with blood perfusate prepared from normal donor animals, a high extraction ratio (Eh) of 0.974 +/- 0.005 (mean +/- S.D.) was observed at an influent I-propranolol concentration of 400 ng/ml, i.e., only 2.6% of drug entering the liver escaped single-pass extraction. The extraction of I-propranolol was significantly lower (i.e., Eh = 0.906 +/- 0.017) when livers isolated from uranyl nitrate-induced renal failure rats were perfused with uremic blood; such that there was an approximate 3-fold increase in the amount of drug escaping single-pass extraction (i.e., from 2.6 to 9.4%). This difference in hepatic extraction is quantitatively consistent with the increase in p.o. systemic availability of I-propranolol observed in our previous in vivo study with the uranyl nitrate-induced renal failure rat model. When livers from normal rats were cross-perfused with uremic blood, extraction of I-propranolol was depressed to almost the same level (i.e., Eh = 0.927 +/- 0.009) as when livers from renal failure animals were perfused with uremic blood. In contrast, livers from renal failure rats cross-perfused with normal blood exhibited comparable extraction for I-propranolol (Eh = 0.970 +/- 0.010) as normal livers perfused with normal blood.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics of l-propranolol during repetitive dosing in normal and uranyl nitrate-induced renal failure rats

The effect of experimental renal failure on the intravenous and oral pharmacokinetics of l-propranolol was studied in rats. Renal failure was induced by a single intravenous injection of uranyl nitrate (5 mg/kg). Pharmacokinetic studies were carried out on the fifth day after injection of the renal toxin (renal failure group) or saline (control group). Serum concentration time course of l-propranolol was characterized after a single intravenous or oral dose as well as after five consecutive doses of the drug given at 3-hr intervals. During repetitive intravenous drug administration, steady state was reached by the second dose, i.e., within 6 hr after initiation of repetitive dosing. No significant difference in the serum concentration time course of l-propranolol was observed between control and renal failure animals. In both groups the AUC over the steady-state dosing interval was on the average 21-27% higher than the AUC after a single dose, indicating a slight decrease in the systemic clearance of l-propranolol during repetitive intravenous drug administration. An approximately two- to three-fold higher serum l-propranolol concentration was observed in renal failure animals as compared to the normal controls after both single or repetitive oral dosing. The apparent reduction in oral clearance probably reflected an inhibition of the hepatic first-pass metabolism of l-propranolol in the renal failure rat. An unexpectedly high and protracted accumulation of serum l-propranolol concentration was observed during repetitive oral drug administration. Continuing accumulation was still evident after the fifth oral dose, i.e., a period of 15 hr or approximately 10 half-lives. The mean AUC over the last dosing interval was 32.0 and 17.8 times higher than the predicted steady-state estimate based on single oral dose data for control and renal failure rats, respectively. The substantial reduction in the oral clearance during repetitive drug administration may be due to an auto-inhibition of l-propranolol metabolism.

Alterations in serum protein binding and pharmacokinetics of l-propranolol in the rat elicited by the presence of an indwelling venous catheter

Preliminary investigations in the rat revealed some unexpected alterations in the pharmacokinetics of l-propranolol when single dose studies were performed on two separate occasions 7 days apart. The apparent volume of distribution of l-propranolol was found to be consistently lower on the second study day. Also, the systemic availability of orally administered propranolol (6 mg/kg) increased from 4.1 to 7.8% from the 1st to the 2nd study day, indicating a decrease in the presystemic clearance of the drug. These changes were associated with a 50 to 60% decrease in the serum unbound fraction of l-propranolol between the 2 study days. Further investigations revealed that the time-dependent increase in the serum protein binding of l-propranolol was elicited by the presence of an indwelling venous catheter which was surgically implanted for the purpose of blood sampling. In contrast, a slight decrease in the serum protein binding of an acidic drug, phenytoin, was observed after catheter implantation. These changes in serum drug protein binding were readily reversed when the indwelling catheter was removed. The total serum protein concentration was not affected by catheter implantation. Fractionation of serum proteins by electrophoresis revealed an increase in alpha 1- and gamma-globulin fractions, a slight decrease in serum albumin and no change in beta- and alpha 2-globulin fractions. Competitive protein binding studies with tris(2-butoxyethyl)phosphate, a specific ligand to alpha 1-acid glycoprotein (AAG), indicate that the increase in serum l-propranolol binding was largely due to an elevation in serum AAG. These observations also explain the opposite effect of catheterization on the serum protein binding of phenytoin, which is bound largely to serum albumin.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of experimental renal failure on the disposition kinetics of l-propranolol in rats

The effect of uranyl nitrate-induced renal failure on the pharmacokinetics of the levo-isomer of propranolol in rats was investigated. The serum clearance of an i.v. dose of propranolol (1.5 mg/kg) in normal animals approached hepatic blood flow, suggesting that the systemic clearance of the drug is rate-limited by blood flow to the liver. Extensive first-pass metabolism was observed after oral administration of l-propranolol was only 7%. Renal failure had no apparent effect on the distribution and elimination of i.v. administered l-propranolol. In contrast, the area under the serum drug concentration time curve after oral administration was increased from 6.95 to 19.3 micrograms X min/ml, which corresponded to a 2.5-fold increase in the systemic availability of l-propranolol (from 7 to 18%). The gastrointestinal absorption of l-propranolol, as assessed by comparing the urinary recovery of radioactivity after i.v. and oral administration of l-[3H]propranolol, was complete in normal animals. Hence, an increase in the extent of absorption of l-propranolol in renal failure cannot be offered as a cause of increased systemic availability. Neither the in vitro nor the in vivo serum protein binding of l-propranolol differed between renal failure and control animals. The intrinsic metabolic clearance of unbound l-propranolol in renal failure rats is estimated to be about 60% lower than that in control rats. These results suggest that the previously reported increase in propranolol serum concentration after oral administration of the drug to uremic patients is due to decreased presystemic biotransformation of the drug.

Vitamin D-mediated decrease of Ca2+-pump activity in the rat parotid gland

In vitro activities of Ca2+-ATPase and 45Ca2+ uptake in microsomes, which were prepared from vitamin D-deficient rat parotid glands, were decreased in parallel by the oral administration of vitamin D3 as compared with those of control animals (r = 0.83). In vivo 45Ca2+ uptake in the parotid glands of vitamin D-deficient rats was also decreased by the oral administration of vitamin D3.