Measurement of thickness of film deposited on the plasma-facing wall in the QUEST tokamak by colorimetry

After several experimental campaigns in the Kyushu University Experiment with Steady-state Spherical Tokamak (QUEST), the originally stainless steel plasma-facing wall (PFW) becomes completely covered with a deposited film composed of mixture materials, such as iron, chromium, carbon, and tungsten. In this work, an innovative colorimetry-based method was developed to measure the thickness of the deposited film on the actual QUEST wall. Because the optical constants of the deposited film on the PFW were position-dependent and the extinction coefficient k₁ was about 1.0-2.0, which made the probing light not penetrate through some thick deposited films, the colorimetry method developed can only provide a rough value range of thickness of the metal-containing film deposited on the actual PFW in QUEST. However, the use of colorimetry is of great benefit to large-area inspections and to radioactive materials in future fusion devices that will be strictly prohibited from being taken out of the limited area.

[Cranioplasty for isolated trigonocephaly with developmental disorder]

We reported 50 cases of mild to moderate trigonocephaly (most isolated type) treated by cranioplasty. All of them had clinical symptoms such as severe hyperactivity, speech delay, inability to communicate with others, self-mutilation (head banging), irritability, temper tantrum and mental retardation. Pre-operative CT scan and MRI showed no abnormal findings in the brain except for constricted frontal lobes. The 3 D-CT scan showed the most important diagnostic findings: a ridge of the metopic suture and narrow anterior fossa. TcECD SPECT was performed on 43 patients, and demonstrated in 31 cases some degree of decreased cerebral blood flow (CBF), mainly in the bilateral frontal lobes. Post-operatively, most patients improved to some degrees. The results were compared to those of trigonocephaly patients without cranioplasty. The operated group showed better improvement in the above clinical symptoms, especially, hyperactivity, indifference to others, understanding of verbal communication, self-mutilation, irritability and temper tantrum. The post-operative SPECT represented the increased CBF in 30 out of the 31 cases. MRI and CT scan revealed expanded frontal lobes. Thus, cranioplasty may alleviate the symptoms of patients with mild to moderate trigonocephaly and developmental disorders.

Four alkaloids, lucidine B, oxolucidine A, lucidine A, and lucidulinone from Lycopodium lucidulum

The structures of four alkaloids extracted from Lycopodium lucidulum (Lycopodiaceae) were established by X-ray and 2D NMR spectroscopic analyses. The dihydro-derivative of oxolucidine A, which was obtained by NaBH4 reduction of oxolucidine A, was treated with p-bromobenzoyl chloride to afford crystals, whose X-ray crystallographic analysis established the stereostructure, including the absolute configuration. The 2D NMR spectra of tetrahydrodeoxylucidine B were fully analyzed to establish the full structure of lucidine B, and the hitherto unknown stereochemistry at the C-14 position was established as beta-H. The structure of a new alkaloid, lucidulinone, was determined by spectroscopic analysis to be luciduline lactam.

[Vertigo and dizziness related to platelet aggregability]

Platelet aggregates were measured in 82 cases with vertigo and dizziness and 60 cases with additional symptom of headache (so-called cervical vertigo). Results showed that patients with vertigo and dizziness had increased aggregability and patients with cervical vertigo were within normal range (p < 0.0001). 53 cases of these with vertigo and dizziness were administrated platelet aggregation inhibitors (mainly ticlopidine). After 1 approximately 2 weeks, most of patients became symptom free, and at this time platelet aggregates of these patients were suppressed to within normal range. Then patients were followed with chronological measurements of platelet aggregates. During this time, aggregabilities were attempted to be kept within the normal range, thus dose of platelet aggregation inhibitor was controlled depending on the result of aggregability. Also patients were encouraged to show good drug compliance by being informed of sudden increasing aggregability. One patient experienced recurrence of vertigo after ceasing the medicine. This study demonstrates that platelet aggregation may increase in most of patients with not only vertigo but also dizziness in whom administration of a platelet aggregation inhibitor is effective. It also stresses that chronological measurements of platelet aggregations are important to control the dose of medication.

[Clinical study on poor-risk patients with non-seminomatous germ cell tumor]

Between 1988 and 1996, we treated 11 poor-risk patients with non-seminomatous germ cell tumors (NSGCT) at Nagoya University Hospital. "Poor-risk" was defined as i) advanced disease equal to or greater than class 7 of the Indiana University Classification (7 patients), ii) primary mediastinal extragonadal NSGCT (2), iii) tumor markers not normalized by the induction chemotherapy (1) or iv) primary retroperitoneal NSGCT with multiple lung metastases (1). Two patients with mediastinal tumors died during the chemotherapy. The minimal volume of fluid must be administered to patients with giant mediastinal tumors. The tumor marker normalized during the induction chemotherapy in only three patients. Three patients, whose tumor markers elevated during or one month after the induction chemotherapy, eventually died of cancer. The tumor markers in five of the seven patients which had not normalized during the induction chemotherapy, had decreased to the normal range during the salvage chemotherapy and two of the five subsequently achieved the status of "no evidence of disease" (NED). Six patients with and two without normalized tumor markers underwent retroperitoneal lymph nodes dissection and/or resection of residual tumors. Pathological examination of the resected tumors showed necrosis/fibrosis in five patients and two had elevated tumor markers immediately after the surgery and eventually died of the disease. Overall, eight (73%) of 11 poor-risk patients achieved a complete response but only five (45%) eventually achieved a NED status that was maintained (6.6 +/- 3.0 years). Our results were not satisfactory, and we believe that new strategies, such as early high-dose chemotherapy, are required for poor-risk patients, who are not likely to respond well to the induction chemotherapy.

Intravesical bacillus Calmette-Guérin (Tokyo 172 strain) therapy for carcinoma in situ of the bladder

To evaluate the clinical response to intravesical instillation therapy with bacillus Calmette-Guérin (BCG) Tokyo 172 strain for carcinoma in situ (CIS) of the bladder and subsequent patient prognosis, we reviewed data for 30 patients treated between 1985 and 1994. Median follow-up was 56 months. The CIS cases comprised two groups: primary (19 patients) and subsequent to development of a gross neoplasm (11 patients). Either 40 mg (n = 20) or 80 mg (n = 10) doses of BCG were instilled weekly for 8 weeks. This intravesical therapy resulted in apparent eradication of tumour cells in 25 of the 30 patients for a complete response (CR) rate of 83%, with no difference found between primary and secondary groups. Tumours later recurred in 6 of the 25 patients (24%) and disease progression was found in only 3 (12%). In contrast, progression occurred in 3 of 5 patients (60%) for which a complete response was not achieved with intravesical BCG therapy. The difference between these two groups was significant (p = 0.04). Total cystectomy was performed in 2 of 25 CR patients (8%) first and in 4 of the 5 unresponsive (80%), the statistical difference being highly significant (p = 0.003). The 5-year survival rate was 96% for the study subjects as a whole. In conclusion, CIS unresponsive to BCG therapy should be treated with immediate total cystectomy while cases demonstrating a complete response should be followed up for a long period.

Quantitative evaluation of the IL-1 beta and IL-1 receptor antagonist obtained from BALF macrophages in patients with interstitial lung diseases

Our previous reports demonstrated the concomitant release of IL-1 beta and IL-1 inhibitory activity in the culture supernatants of BALF macrophages in both healthy subjects and patients with interstitial lung diseases. IL-1 inhibitory activities decreased in healthy smokers (HS), and patients with sarcoidosis (Sar), or idiopathic pulmonary fibrosis (IPF), compared with those in healthy nonsmokers (HNS), though an increase in IL-1 beta release was not detected. IL-1 inhibitory activity was mainly characterized as IL-1 receptor antagonist (IL-1ra). In this study, we confirmed a decrease in IL-1ra in terms of the amounts of protein (enzyme-linked immunoassay) and gene transcripts (reverse transcriptase polymerase chain reaction followed by high performance liquid chromatography). Imbalance between IL-1ra and IL-1 beta was expressed as a molar ratio of IL-1ra/IL-1 beta protein: (Sar; 4.20 +/- 2.06, IPF; 4.26 +/- 3.41, HS; 3.44 +/- 3.09 versus NS 8.33 +/- 2.77: P < 0.001). These results were similar in terms of the amounts of gene transcripts. In conclusion, the imbalance of IL-1 beta and IL-1ra production was confirmed at three levels: biological activity, amounts of protein, and gene transcript obtained from BALF macrophages in chronic inflammatory processes in the lungs.

M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) for poor prognosis patients with urothelial tumors and effect of dose intensity

The effects of the M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) regimen, which has been reported to improve the outcome of patients with urothelial cancers, were studied on 41 patients treated at our hospital. The patients were divided into adjuvant (24 patients), neoadjuvant (5 patients), and salvage (12 patients) groups. We investigated the dose intensity, the cause-specific survival, response rate and toxicities in the three groups. Although 36 patients received > or = 95% of the initial doses projected, the mean dose intensity (+/-standard deviation) in the adjuvant, neoadjuvant, and the salvage groups was 77 (+/-11), 73 (+/-4), and 74 (+/-12)%, respectively. The five-year cause-specific survival in the adjuvant group was 69% (95% confidence limit: 50-88%). Only 2 of the 5 patients (40%) in the neoadjuvant group survived 23 months after the initiation of the treatment, and all patients in the salvage group died of cancer or treatment-related toxicity within 33 months. The median survival was 38 months in the adjuvant group, 21 months in the neoadjuvant group, and 7 months in the salvage group. A dose intensity > or = 75% did not improve survival in any group. The overall response rate was 33% in 15 patients with evaluable lesions. A complete response was noted in 1 patient and a partial response was noted in 1 patients. Two patients died of treatment-related complications. Nausea and vomiting were observed in all patients. Leukopenia, thrombocytopenia and anemia > or = WHO grade 3 were observed in 25 (61%), 4 (10%), and 7 (17%) patients, respectively. Thrombocytopenia, anemia, and pyrexia > or = grade 3 were seen relatively more often in the patients receiving a dose intensity < 75%. Stomatitis > or = grade 3 appeared to be more frequent in the patients receiving a dose intensity > or = 75%. Adjuvant M-VAC might be beneficial, while its efficacy was limited in the neoadjuvant and salvage settings. Although dose intensity is considered to be important, it did not appear to be related to survival, the response rate, or the toxicity of M-VAC.

A case of intraperitoneal testicular cancer with ascites

We report an initial case of intraperitoneal testicular cancer with ascites. Although the cytology of aspirated ascites revealed no tumor cells, the beta-HCG and AFP values were high. Preoperative cisplatin-based combination chemotherapy was used without any pathological diagnosis. Following 2 cycles of chemotherapy, the beta-HCG and AFP values normalized. Furthermore, no ascites was observed on CT scan. Although an accurate histological diagnosis was not established before treatment, it was thought that the ascites originated from the disseminated testicular cancer cells in the peritoneum.

Angiomyolipoma of the kidney with extension into the inferior vena cava

Renal angiomyolipoma is a benign, nonaggressive hamartoma which rarely invades the vascular system. A case of angiomyolipoma of the right kidney with extension into the inferior vena cava, detected by ultrasonography, computed tomography (CT scanning), and magnetic resonance imaging (MRI) is presented. This tumor was found incidentally in a 31-year-old female who underwent CT scanning for unrelated abdominal problems. To our knowledge, only eight cases of angiomyolipoma with caval involvement have been reported in the world medical literature.

Growth of human tumor xenografts on chorioallantoic membrane of chick embryo

We evaluated the success rates of transplantation and growth conditions of 33 human tumor xenografts transplanted on the chorioallantoic membrane of chick embryos. Eleven out of 14 renal cell carcinomas (78.6%), 7 out of 9 urothelial carcinomas (77.8%), 2 out of 3 testicular tumors (66.7%), an adenocarcinoma of the colon and an adenocarcinoma of the ovary but none of the 5 prostatic carcinomas were transplanted successfully. Histologically, carcinoma cells survived on the chorioallantoic membrane forming organoids the structure of which was well preserved. Several regions of the grafts frequently became necrotized. However, the viability of carcinoma nests was not influenced by the inflammatory changes surrounding necrotic tissues. Renal cell carcinomas survived diffusely with prominent angiogenesis. Immunostaining with anti-bromodeoxyuridine (BrdU) and Ki-67 monoclonal antibodies demonstrated a strong correlation between the %BrdU labeling index of the cancer cells on the chorioallantoic membrane and %Ki-67 index of the original tumors. No difference in %BrdU indexes was found between small and large cancer nests. Growth conditions remained constant for 8 days after inoculation. The growth potential of cancer nests surviving on the chorioallantoic membrane, which was identical to that of the original carcinomas, appeared to be unchanged during incubation. However, it might be difficult to exploit the chorioallantoic membrane for anticancer chemosensitivity tests except for renal cell carcinoma since few cancer cell nests were produced in spite of the high transplantation success rates.

Surgical treatment of renal cell carcinoma metastases: prognostic significance

Between January 1980 and March 1993, 166 patients with renal cell carcinoma were treated at Nagoya University Hospital. Among them 16 (9.6%) underwent surgical removal of 21 metastatic lesions: 12 patients had distant metastases at diagnosis and the other 4 demonstrated new distant metastases during their clinical course after nephrectomy. The metastatic lesions involved the brain in 6 patients, bone in 4, lung in 2, contralateral adrenal glands in 2, soft tissues in 2, lymph nodes in 2, pleura in 1, pancreas in 1, and contralateral renal pelvis in 1. All of the 16 patients underwent nephrectomy and 15 of them (93%) received interferon-alpha therapy. Patients with lesions which were completely resected had significantly longer survival than those with lesions which were palliatively treated and those with metastatic lesions at other sites (p = 0.02). Improvement of performance status was observed in 5 of 6 (83%) patients undergoing palliative surgical treatment. The present study suggests that surgical removal of metastatic lesions prolongs survival in a limited number of renal cell carcinoma patients and that it improves performance status in those symptoms related to metastasis.

Clinicopathological characteristics of small renal cell carcinomas

To clarify the clinicopathological characteristics of small renal cell carcinomas (RCCs) the authors reviewed data for 154 RCC patients treated between January 1980 and September 1992. Of 20 patients with tumours of 3 cm or less in diameter, 12 (60%) had no related symptoms: 6 (30%) were found during routine physical check-ups and 6 (30%) were incidentally detected during examinations for diseases other than RCC. The remaining 8 (40%) patients demonstrated indicative symptoms. Most small tumours showed expansive growth and nuclear atypia was minimal or moderate. In all 20 cases, the lesions of 3 cm or less were confined to the kidney (pT1 to pT2b) and no lymph node metastasis was found. Only one (5%) had a distant metastasis, and venous involvement was also microscopically observed in only one patient (5%). The 5-year survival rates were 95% for patients with tumours of 3 cm or smaller, 74% for those of 3.1 to 5 cm, and 68% for those of greater than 5 cm. These findings revealed small RCC to demonstrate biologically less malignant behaviour. Early detection of such small lesions by ultrasonography should therefore improve the overall survival of patients with RCC.

TNF alpha mRNA, but not IL-1 beta, is differentially expressed in lung macrophages of patients with active pulmonary sarcoidosis

In pulmonary sarcoidosis or experimental granuloma formation, interleukin-1 beta (IL-1 beta) or tumor necrosis factor alpha (TNF alpha) seem to play important roles during the inflammatory process. In order to examine whether IL-1 beta or TNF alpha mRNA expression in lung macrophages relates to disease activity or clinical course, ten cases with pulmonary sarcoidosis were divided into two groups: five cases with disease duration of more than 10 years (14.6 +/- 4.4 yrs; group A), and 5 cases with a duration of less than 3 years (1.7 +/- 1.1 yrs; group B). All cases showed both abnormal chest X-rays and elevated serum angiotensin converting enzyme activities. We compared these ten cases with 12 healthy subjects (6 nonsmokers: NS and 6 current smokers: S), and 5 cases with idiopathic pulmonary fibrosis (IPF) as disease control. Lavage macrophages were purified using the rosette forming method followed by plastic adhesion for one hour. Thereafter, RNA was extracted according to the AGPC method and amplified by the reverse transcription-polymerase chain reaction (RT-PCR). The results showed that IL-1 beta mRNA was detected in all samples studied, but TNF alpha mRNA expression was different among the groups: 5/5 (100%) in group A, 1/5 (20%) in group B, 5/5 (100%) in IPF, and 12/12 (100%) in healthy subjects. A constitutive expression was seen in healthy controls. On the other hand, no detection of TNF alpha mRNA was shown in pulmonary sarcoidosis. This fact may relate to a spontaneous regression of inflammation in sarcoidosis, as a substantial number of cases in group B may in time regress spontaneously.

[Results of treatment for advanced non-seminomatous germ cell tumors of the testis based on Indiana University classification]

From 1980 to 1990, we treated 45 patients with non-seminomatous germ cell tumors of greater than or equal to stage II according to the Japanese general rule for clinical and pathological studies on testicular tumors. The patients were divided into 2 groups based on the Indiana University Classification: 26 good risk patients (score < or = 6) and 19 poor risk patients (score > or = 7). The clinical results, the % dose intensity of Cisplatin and half-lives of tumor makers were analyzed in the two groups. The per cent dose intensity of Cisplatin of the induction chemotherapy was 61 +/- 24% in 1980-1985 and 87 +/- 18% in 1986-1990. The NED rate improved from 66.7% (10/15) to 81.8% (9/11) in the good risk patients and from 33.3% (3/9) to 50.0% (5/10) in the poor risk patients between the above two periods. When the % dose intensity of Cisplatin exceeded 80%, the NED rate increased from 66.7% (10/15) to 90.0% (9/10) in good risk patients and from 33.3% (2/6) to 45.5% (5/11) in poor risk patients. The NED rate was only 25.0% (4/16) in the poor risk patients whose residual tumors were not resected. The half-lives of AFP and beta-HCG from the latter part of the first course to the second course were 6.8 +/- 1.9 days and 4.4 +/- 1.4 days, respectively, in the patients with a good prognosis, while they were 6.5 +/- 1.5 days and 4.4 +/- 2.9 days, respectively, in with a poor prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

A randomized trial of early intravesical instillation of epirubicin in superficial bladder cancer. The Nagoya University Urological Oncology Group

A total of 135 patients with superficial bladder cancer diagnosed as totally resectable were entered into a randomized multicenter trial to investigate the efficacy of early intravesical epirubicin instillation after resection in comparison with transurethral resection (TUR) alone. Epirubicin (40 mg/40 ml saline) was given within 24 h of TUR and once during the 1st week, weekly for 4 weeks and then monthly for 11 months. In all, 122 patients (90.4%) were eligible and 119 (88.1%) were evaluable. The interval to initial recurrence was significantly longer (P = 0.02) in the epirubicin group (36 months; 95% confidence interval, 32-40 months) than in the group receiving TUR alone (28 months; 95% confidence interval, 24-32 months). The recurrence rate per year in the epirubicin group was less than that in the TUR-alone group (0.13 versus 0.29 annual recurrences). Disease progression was observed in only one patient in the epirubicin-instillation group. The main toxicity encountered was bladder irritation (13.8%). These results demonstrate that early intravesical epirubicin instillation is efficacious in preventing local recurrence.

Evaluation of testicular germ cell tumor proliferation using DNA flow cytometry and nucleolar organizer silver staining

We studied 41 testicular germ cell tumors (TGCT) using DNA flow cytometry and argyrophilic (silver staining) nucleolar organizer region (Ag-NOR) quantitation to evaluate the proliferative characteristics of TGCT and the significance of those analytical techniques. In nonseminomatous germ cell tumor (NSGCT), the percentage of S + G2M phase cells (%S + G2M) in DNA aneuploid tumor was higher than in DNA of diploid tumors. Likewise, in NSGCT the aneuploid Ag-NOR sites per nucleus (Ag-NOR count) were significantly higher in DNA aneuploid than in DNA diploid tumors. There was also a significant linear correlation between % S + G2M phase cells and the Ag-NOR count in TGCT. However, the DNA ploidy pattern and the % S + G2M phase cells, and Ag-NOR counts, did not correlate significantly with the patient survival rate or clinical stage. In conclusion, our study suggests that Ag-NOR enumeration is an effective technique for assessing cellular proliferative activity that is somewhat less expensive than DNA flow cytometry.

[Quantitative evaluation of gene expression of IL-1 beta and IL-1 receptor antagonist (IL-1ra) from alveolar macrophages in idiopathic pulmonary fibrosis (IPF) and sarcoidosis]

Our previous studies demonstrated the concomitant release of IL-1 and IL-1ra in the culture supernatants of alveolar macrophages in both healthy subjects and patients with interstitial lung diseases. IL-1ra was decreased in healthy smokers (HS), IPF, and sarcoidosis, compared to healthy nonsmokers (HNS), although an increase in IL-1 release could not be detected. In this study, we examined whether such findings could be found at the gene level, or reflect posttranscriptional regulation in patients with IPF (n = 8), sarcoidosis (n = 7), healthy smokers (n = 6) and healthy nonsmokers (n = 5). The expression of IL-1 beta, IL-1ra and a house keeping gene (glucose 6 phosphate dehydrogenase: G6PD) was investigated using reverse transcription polymerase chain reaction (RT-PCR). After RT-PCR, analysis and quantification of PCR products were performed by high-performance liquid chromatography. We used 26 cycle for IL-1 beta and IL-ra mRNA and 29 for G6PD, because amplification of mRNA was in the exponential phase on that cycles, respectively. The results were expressed as the ratio of each mRNA to G6PD mRNA. IL-1ra/G6PD ratio in patients with IPF and sarcoidosis, was lower than that in HNS. On the other hand, IL-1 beta/G6PD ratio was similar in all groups. IL-1ra/IL-1 beta ratio was decreased in patients with IPF and sarcoidosis, compared to HNS. These results suggest that decreased expression of IL-1ra gene may contribute to the development of chronic low grade inflammation of the lung.

[Two cases of continent cystoileostomy using nipple valve method]

We performed continent cystoileostomy in which the technique of Kock's efferent nipple was utilized, on two female patients with urethral cancer and vulvar cancer. We recommend continent cystoileostomy for the patient who needs urethrectomy but whose bladder function can be preserved.

Minocycline instillation for lymphorrhea after extraperitoneal pelvic lymphadenectomy. OFF

We managed four cases of lymphorrhea after extraperitoneal pelvic lymphadenectomy by means of minocycline instillation into the cavity around the drainage tube. Two patients had concomitantly undergone cystectomy and one prostatectomy via the extraperitoneal approach. In all four cases, the lymphorrhea markedly subsided, which dramatically shortened the duration of drainage. No side effects occurred. These findings indicate that minocycline instillation is an efficacious treatment for lymphorrhea.

A case of spontaneous recanalization following renal infarction

A 30-year-old-male was admitted to our hospital with a tentative diagnosis of appendicitis. We found no signs of peritonitis, and therefore suspected urinary tract calculi. Intravenous pyelography revealed his right kidney to be nonfunctional, while retrograde pyelography was normal. Angiography revealed right renal infarction. Renovascular hypertension was present, and treatment with captopril was prescribed. Two years later without medication he had normal blood pressure and plasma renin activity. Intravenous pyelography revealed a right kidney functioning well, and digital subtraction angiography (DSA) revealed spontaneous recanalization of his right renal artery.

Metastasis of renal cell carcinoma to the contralateral renal pelvis

Extremely rarely renal cell carcinoma metastasizes to the contralateral renal pelvis or ureter. The present report concerns a case where a metastatic tumor could be successfully removed from the left renal pelvis 3 years after right nephrectomy for the primary tumor. A review of the literature revealed this to be only the fourth such case documented.

[Complications of Kock continent reservoir. Report of 103 cases]

We installed a Kock continent reservoir in 103 patients after radical cystectomy or pelvic exenteration between Feb. 1986 and Dec. 1989. They consisted of 81 male and 22 female patients. Patients' age ranged from 30 to 78 years with the average being 63 years. Their original diseases were bladder cancer (96 patients), prostatic cancer (2), sigmoid colon cancer (2) and others (3), The Kock reservoir was made by the procedure described by D. G. Skinner et al. The mean operation time for reservoir creation was 220 minutes. In 99 patients with a Kock reservoir for more than 3 months, the capacity of the reservoir was 200-900 ml with the average being 490 ml and the frequency of self-catheterization was 4 to 6 times a day. Early complications occurred within 3 months in 27 (26%) patients. Complications directly related to the reservoir were urine leakage (5 patients), intestine reservoir fistula formation (3) and necrosis of the reservoir (1). Late complications occurred after 3 months in 25 (25%) patients. They consisted of difficulty of catheterization (9 patients), ureteral reflux from reservoir (2), hydronephrosis (8), abscess (4), metabolic acidosis (2) and others. The results indicated that this procedure is an appropriate urinary diversion since the quality of life in the patients with a Kock reservoir is better. However, after this procedure surgical complications were not infrequent. Therefore, this procedure should be performed in selected patients.

Immune responses and serum levels of cytokines in adult T-cell leukemia patients and human T-cell leukemia virus type-I carriers

To find predictive parameters for development and progression of adult T-cell leukemia (ATL) in human T-cell leukemia virus type-I (HTLV-I) carriers, we investigated cellular immune responses such as mitogenic responses and natural killer activity of the peripheral blood mononuclear cells (PBMC). And serum or plasma levels of cytokines, including tumor-necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma) and immunosuppressive acidic protein (IAP), were also measured in patients with ATL, healthy HTLV-I carriers and healthy HTLV-I non-carriers as controls. Results are as follows: (1) increased spontaneous proliferation and decreased mitogenic responses of PBMC already existed in HTLV-I carriers; (2) IAP was significantly higher in patients with acute/lymphoma type ATL than in those with chronic/smoldering type, HTLV-I carriers and HTLV-I non-carriers. These results suggest that spontaneous proliferation or mitogenic responses and IAP may be useful parameters for the development and progression of ATL from the carriers. Since HTLV-I carriers already have various grades of immunosuppression, we should seriously try to prevent further HTLV-I transmission.

[A pathogenesis of chronic subdural hematoma; it's relationship to subdural membrane]

Our report concerns 112 cases of chronic subdural hematoma (CSH). M:F ratio is 3.5:1. (Fig. 1). The etiology of CSH is as follows; mild head injury (71 pts.), post-craniotomy (3 pts.), post-V-P shunt (1 pt.) and unknown (37 pts.). All patients are diagnosed by CT scan. Twenty patients were followed up after the subdural space was expressed as low density on CT (Fig.2). 14 of these were found to have extremely thin subdural fluid collection without compression of the brain. Cisternography by using radioisotope and/or metrizamide was carried out in seven patients in whom the subdural fluid collection was found on CT, and in five of whom the dye flowing into the subdural space was retained for 24-48 hours (Fig. 3 a). For treatment, burr holes and irrigation of the hematoma was carried out and then a drain was inserted into the subdural space. The inner membrane of the chronic subdural hematoma was looked at in 19 patients during surgery. All but one showed the inner membrane totally covering the brain surface. However, in one patient the inner membrane didn't entirely cover the brain surface, suggesting that this was the condition just before the entire encapsulation of the hematoma (Fig. 4 b). It used to be considered that a blood clot in the subdural space is needed to develop a chronic subdural hematoma. However, since the introduction of CT scan, there have been many reports suggesting that chronic subdural hematoma has developed from subdural fluid collection without apparent evidence of blood clot after head injury. Therefore, it has been controversial whether the blood clot is absolutely essential to develop into the chronic subdural hematoma or not.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bladder replacement by entero-cystoplasty after radical cystectomy for bladder cancer--the urethral Kock pouch]

From September 1989 to March 1990, 6 male patients with invasive bladder cancer, 49 to 70 years old in age, underwent bladder replacement with the ileum (the urethral Kock pouch) after radical cystectomy. Follow up ranged between 3 and 9 months. Urodynamic evaluation showed the ileal bladder to be a low pressure reservoir with a capacity that increased to more than 250 ml. The ileal bladder was emptied by straining without significant residual urine in all patients except one who was performing intermittent self-catheterization. All patients were continent in the daytime. However, all patients required pads at night because of occasional loss of a little urine. Excretory urograms revealed excellent upper tract function. The procedure is suitable whenever the urethra can be preserved after cystectomy for cancer.

[A case of bladder transitional cell carcinoma with sigmoidovesical fistula due to diverticulitis]

We present a case of bladder transitional cell carcinoma with sigmoidovesical fistula due to diverticulitis. The patient was a 65-year-old male who had been suffering from recurrent abdominal pain with high fever for the past 6 months. He noticed pneumaturia and cloudy urine several times. He visited a doctor complaining of macroscopic hematuria and high fever, and was treated under the diagnosis of acute prostatitis. In our University Hospital cystoscopy showed a papillary bladder tumor. Pathological study of the tumor revealed transitional cell carcinoma, grade II, noninvasive type. Multiple diverticulosis of sigmoid colon was identified with barium enema examination. We performed transurethral resection of the bladder tumor. Three weeks later, the sigmoidovesical fistula was treated by primary resection of the sigmoid colon and wedge resection of the bladder including fistula.

[Statistical analysis of tumors of the renal pelvis and the ureter--determinants of prognostic significance]

Sixty-two patients with epithelial tumors of the renal pelvis and the ureter were studied with respect to 16 clinicopathological factors and their relationship to the patients survival. The cumulative survival curves are depicted by the Kaplan-Meier method and the statistical difference in the survival rates were detected in 11 factors, age, tumor number, multicentricity, tumor size, histological tumor type, stage, grade, growth pattern, infiltration pattern, lymphatic invasion and venous invasion. Cox's proportional hazard model was applied to evaluate the contribution of these 11 factors to survival. With the univariate analysis, lymphatic invasion showed the greatest hazard ratio followed by growth pattern, stage, venous invasion, age, and grade in this order. Stepwise selection of these factors based on the relative magnitude of their contribution to the survival with Cox's proportional hazard model revealed the most important factor for survival as the lymphatic invasion (hazard ratio 5.29), followed by growth pattern (hazard ratio 2.89). In conclusion, patients with tumor lymphatic invasion and tumor of non-papillary growth pattern showed poor prognosis, and adjuvant chemotherapy should be performed on them to improve their survival.

Retroperitoneal schwannoma mimicking lymph node metastasis of seminoma

We report a case of retroperitoneal schwannoma mimicking lymph node metastasis. A 32-year-old man presented with an intrascrotal mass, and underwent radical orchiectomy. Histological examination revealed a typical seminoma of the testis. Systemic work-up for staging demonstrated a retroperitoneal mass, which was located in the supra-hilar inter-aortocaval region. Under the diagnosis of retroperitoneal metastasis of the seminoma, he underwent three courses of cisplatin, vinblastine, and bleomycin (PVB) therapy. Persistence of the tumor after the chemotherapy led to retroperitoneal lymphadenectomy, histological examination then revealing a benign schwannoma. The location of the tumor and its unresponsiveness to chemotherapy might be useful indicators for differentiating lymph node metastasis of seminoma from primary tumors of other origin.

[A case of metastasis of lung cancer to renal cell carcinoma]

A 62-year-old male was admitted with abnormal shadow in chest X-P. CT and other examinations were done, and he was diagnosed left renal cell carcinoma with metastatic lung cancer. He rejected operation and was discharged. We gave him alpha-interferon injection every day. About 5 months later, he complained of fever and dyspnea, and was admitted. On the 10th day after admission, he died suddenly with massive hemoptysis. This hemoptysis was from the pulmonary artery, which was surrounded by tumors and ruptured into the trachea. Pathological diagnosis was double cancer, such a case is very rare with a primary lung cancer (oat cell carcinoma) which has metastasized into a renal cell carcinoma (common type, clear cell subtype).

Ciliated epithelial cell cluster in Rathke's cleft cyst--report of two cases

The authors report two cases of symptomatic Rathke's cleft cyst. Cytological examination of the cyst contents identified clusters of ciliated epithelial cells. Rathke's cleft cyst is normally defined by mucoid fluid in the cyst cavity and cyst wall biopsy. However, intraoperative cytology was found useful in diagnosis and deciding operative strategy.

[Grand mal like attack by interferon injection in case of renal cell carcinoma]

We performed a radical nephrectomy for renal cell carcinoma on a 60-year-old female. We began to give alpha-interferon (natural type), she had an attack of tonic clonic convulsion (like grand mal attack). There were no abnormal findings in head computed tomography, nor hematologic tests. We ascribed the attack to interferon, and stopped giving it. Because there was an abnormal wave in EEG, she was given an anti-convulsant per os. One month later, the electroencephalogram became normal and she showed no neurological symptoms nor findings.

[Statistical study of tumors of the renal pelvis and ureter]

We reviewed data from 62 patients with epithelial tumors of the renal pelvis and ureter who were hospitalized and treated at Nagoya University Hospital between July, 1970 and June, 1988. Of the 62 patients, 50 were males and 12 were females, the ratio being 4.2:1. The mean age was 62.1 years, the ages ranging from 41 to 87 years. The peak incidence of tumors was marked in the sixth decade for the males and in the seventh decade for the females. Eighty-two percent of the patients were 50 years of age or older. Smoking habits were noted in 76.0 percent of the males and in 16.7 percent of the females. Asymptomatic macrohematuria, found in 43 patients, was the most frequent symptom. Ninety percent of the 62 tumors were transitional cell carcinoma. Twenty-five patients (40.3%) had concomitant bladder cancer, which was previously diagnosed in 3, simultaneously found in 9, and subsequently developed in 16. Twenty-nine patients had tumors localized in the renal pelvis and eighteen in the ureter; the remaining fifteen had tumors localized in two or three organs, including the renal pelvis, ureter and bladder. Histological grades of ureteral tumors were significantly higher than those of renal pelvic tumors. The sensitivity of urinary cytology was 57.8 percent. High-grade tumors had higher sensitivity than low-grade tumors. Larger tumors (greater than 3 cm in diameter) were significantly associated with high-stage tumors, whereas no apparent correlation was found between tumor size and histological grade. Nonpapillary growth of tumor and vascular invasion were significantly related with high-stage and high-grade tumors; diffuse pattern of tumor infiltration was associated with high-stage tumors.

[Rupture of intracranial aneurysm due to intravascular metastasis of choriocarcinoma. Case report]

A 55-year-old female was admitted to the Juntendo Izunagaoka Hospital, because of sudden onset of motor aphasia and right hemiparesis. Neurological examination on admission revealed drowsy state, bilateral papilledema, motor aphasia, and right hemiparesis. Computed tomography showed a subcortical hematoma in the left frontoparietal region associated with perifocal edema. Left carotid angiography revealed a fusiform aneurysm at a peripheral branch of the central artery. There was no tumor stain on cerebral angiograms. A combination procedure was carried out during emergency surgery, including evacuation of the intracerebral hematoma and removal of the thrombus-like material from the aneurysmal cavity followed by wrapping the aneurysm with fascia. Histological examination of the thrombus-like material demonstrated that it was a neoplastic embolus of choriocarcinoma. Serum (2600 mIU/ml) and urinary (7200 mIU/ml) human chorionic gonadotropin levels were elevated. The features of neoplastic aneurysm due to choriocarcinoma are reviewed and discussed.

[Clinical study of urinary cytology in bladder tumors--analysis of factors related with positivity of urinary cytology]

To clarify the clinical and pathological determinants affecting the sensitivity of urinary cytology, we reviewed cytological findings from 119 patients with bladder cancer who were initially treated between January 1982 and March 1988. Cytological specimens obtained from voided urine were stained by the Giemsa and Papanicolaou techniques, and were classified into three categories of malignant cells: positive, suspicious, and negative. Of 311 specimens examined, 114 (37%) were positive, 81 (26%) were suspicious, and the remaining 116 (37%) were negative. The overall positive rate, or sensitivity, was 50% (60 out of 119 patients). The sensitivities were 7% for patients with grade 1 tumors, 42% for grade 2 tumors, and 97% for grade 3 tumors. Univariate analysis by logistic regression analysis revealed that grade, stage, histological pattern of growth, size and number of tumors, and patient age were significantly related with the positivity of voided urinary cytology. The logistic regression model, as a multivariate analysis, demonstrated that grade was the most important determinant affecting the positive cytologic finding, followed by number of tumors with statistical significance. We conclude that the lower sensitivity in conventional urinary cytology for low-grade tumors necessitates new adjuncts, including immunocytochemistry and flow cytometry, to lower the false-negative rate.

[Statistical evaluation of determinants of progression of superficial bladder cancer by proportional hazards model]

To evaluate clinical and pathological factors present at the initial consultation which affect disease progression, we reviewed data from 223 patients with superficial bladder cancer (pTa and pT1) who were initially treated at Nagoya University Hospital between January 1973 and December 1987. The factors included in the present analysis were age, sex, symptoms, interval between initial symptoms and first consultation, location of tumor, size, number, endoscopic shape, histological pattern of growth, grade and stage. The median duration of the follow-up after initial treatment was 46 months. Of the 223 patients, 17 died: 8 (3.6%) of bladder cancer and the remaining 9 (4.0%) of unrelated causes. Disease progression developed in 12 patients (5.4%): muscle invasion of the bladder wall in 11 and lung metastasis in one. The interval between initial treatment and progression ranged from 4 to 108 months, with a median of 11.5 months. Of the 12 patients, 9 (75%) had disease progression within 2 years. Progression was significantly associated with poor prognosis (p less than 0.001): the 5-year actuarial survival rates were 47.1% and 92.8% in patients with and without progression, respectively. Univariate analysis by Cox's proportional hazards model demonstrated that characteristics such as irritative bladder symptoms, higher-grade tumors, invasion into lamina propria, and nonpapillary growth seen at initial consultation were significantly related to disease progression. Cox's proportional hazards model produced hazard ratios of 10.2 in irritative bladder symptoms (yes vs. no), 6.3 in histological grade (grade 3 vs. grades 0-2), 4.9 in stage (pT1 vs. pTa), and 4.7 in pattern of growth (papillary vs. nonpapillary).(ABSTRACT TRUNCATED AT 250 WORDS)

[Adult T-cell leukemia with massive melena due to marked gastrointestinal involvement]

A 60-year-old man born in Okinawa was admitted to our hospital because of epigastralgia. Physical examination revealed general lymphadenopathy, mild hepatomegaly and skin eruption. The peripheral blood leukocyte count was 168,600/microliters, with 93% abnormal lymphocytes showing convoluted or lobulated nuclei. Anti HTLV-1 antibody was positive with titer of 1: 1280 (PA). Leukemic cells had typical ATL cells' surface markers (OKT3; 97.2%, T4; 93.3%, T8; 2.8%, OKIA1; 39.6%, IL-2R; 41.8%) and complete monoclonal HTLV-1 provirus DNA. Endoscopic examination with biopsy revealed massive involvement of ATL cells into gastric mucosa. In the course of the treatment, he had extremely massive melena, and was saved by emergency operation. Multiple ulcers were found in the resected colon. Histological examination showed the marked infiltration of the ATL cells into the mucous or submucous membrane. Thereafter, he was treated well with ALG (Anti Lymphocyte Globulin), until hypercalcemia occurred. He died of acute renal failure after hypercalcemia.

[An autopsy case of AIDS with disseminated cytomegalovirus infection and neurological disturbance]

We report a case of acquired immunodeficiency syndrome (AIDS) complicated by disseminated CMV infection and neurological disturbance. A 21 years old male with hemophilia A was diagnosed as having AIDS in Feb. 1986 because of interstitial pneumonia and esophageal candidiasis. Since Jan. 1987 he had complained of hypesthesia in the legs. On Mar. 14 he was admitted due to diarrhea. The laboratory data revealed that WBC was 4,000/microliters including 29% of lymphocytes, 1.6% of OKT4+-, 71.6% of OKT8+-lymphocytes, T4/T8 ratio 0.02 and positive HIV antibody and HTLV-1 antibody. After the admission, sensory disturbance exacerbated to complicate paraplegia. He developed acute hepatitis associated with leukopenia, thrombocytopenia, pneumonia and melena, and eventually died on May 29. The autopsy findings disclosed CMV infection in the lungs, colons, and adrenal glands, suggesting that the primary cause of death was adrenal insufficiency. Degeneration of cerebro-spinal nerve cells and peripheral neuritis were thought to result from direct HIV infection to the nervous system.

[A case of temporal lobe epidermoid cyst]

A case of temporal lobe epidermoid cyst was reported. More than 5 ml of cerebrospinal fluid was aspirated during the operation. This cerebrospinal fluid among the anatomical interstices of the tumor was considered to be rather responsible for the low density in the CT scan.

[Multivariate evaluation of survival factors and postoperative adjuvant chemotherapy in patients with bladder cancer treated by radical cystectomy]

Multivariate analysis by Cox's proportional hazard model was performed on 71 bladder cancer patients treated by radical cystectomy to clarify factors affecting survival and to evaluate the efficacy of postoperative adjuvant chemotherapy. Clinicopathologic data included in the analysis were age, sex, interval from onset of symptoms to first consultation, prior tumor history, year of operation and tumor characteristics: size, number, growth pattern, stage, grade, mode of infiltration, lymphatic invasion, lymph-node metastasis and lymphocyte infiltration around tumors. Analysis revealed that stage is the most statistically significant factor for survival (p less than 0.0001); followed by year of operation (p less than 0.05) and lymph node metastasis (p less than 0.1). The above three determinants yielded hazard ratios of 16.6 for stage (pT3a-pT4 vs. pTis-pT2), 2.7 for year of operation (1978-1982 vs. 1983-1987) and 2.4 for lymph node metastasis (positive vs. negative). Postoperative adjuvant chemotherapy consisting of cisplatin, peplomycin and mitomycin C (PPM therapy) seemed to improve survival, when the influence of the major prognostic factors were adjusted by the proportional hazards model. The authors conclude that stage and lymph node metastasis should be considered when postoperative adjuvant treatment is selected for patients with bladder cancer treated by radical cystectomy, and that further prospective randomized trials are mandatory to confirm the efficacy of postoperative adjuvant PPM therapy suggested by the present retrospective multivariate analysis.

[A study of postoperative adjuvant chemotherapy of advanced urinary epithelial cancer]

The effect of postoperative adjuvant chemotherapy was studied in 22 cases of advanced urinary epithelial cancer. Vincristine, mitomycin C and bleomycin (VMB) was administered in combination to 9 prophase cases from December, 1980 to March, 1982 and cis-dichlorodiamine platinum, peplomycin and mitomycin C (PPM) in combination to 13 anaphase cases from April, 1982 to November, 1984. The site was renal pelvic cancer in 3 cases, cancer of the ureter in 3 cases, cancer of the bladder in 13 cases, cancer of the pelvis, ureter, and bladder in 1 case, and recurrence of pelvic cancer following bladder cancer in 2 cases. The degree of invasion was pTa in 2 cases, pT1 in 1 case, pT2 in 1 case, pT3 in 11 cases and pT4 in 5 cases. Lymph node metastasis had occurred in 9 cases, no metastasis in 8 cases and it was unclear in the remaining 6 cases. The mean observation period was 16.5 months; 10 patients were alive without any tumors, one patient was alive with a tumor, 11 patients died of cancer, and one patient died intercurrently. The mean postoperative survival period in the mortality cases was 14.5 months. According to the classified type of chemotherapy received, there were 3 out of 9 cases (33.3%) who survived without tumors after receiving VMP and 7 out of 13 cases (53.8%) in the PPM group who survived without tumors. Although a simple comparison cannot be made, it appears that PPM therapy is superior. No severe side-effects were observed.

[Assessment of obstructive nephropathy using diuretic 99mTc-DTPA renogram and 99mTc-DMSA renoscintigraphy]

99mTc-DMSA and diuretic 99mTc-DTPA renoscintigraphy were performed on 51 kidneys suspected of obstructive nephropathy based on excretory urography to evaluate the residual renal function and the degree of urinary flow impairment respectively. We classified the response to diuretics into 6 patterns: I. normal, IIa. severely damaged renal function, IIb. slow RI excretion without urinary tract visualization (pattern II had no response to furosemide), IIIa. rapid elimination of tracer from the obstructed upper tract, IIIb. slow elimination, and IV. gradual tracer accumulation in the pelvicalyceal system with fairly well preserved renal function but no response. Hydronephrosis varied according to pattern type, in the ascending order of I, IIIa, IIIb and IV (p less than 0.05). Degree of hydronephrosis was inversely related to 99mTc-DMSA uptake, but without statistical significance. 99mTc-DMSA uptake was lower for pattern III as a whole (IIIa + (IIIb) than for pattern I (p less than 0.005), but there was no difference between IIIa and IIIb. Pattern IIa exhibited a significantly lower uptake than any of the other groups. (p less than 0.005) In contrast to previous views, we believe that pattern IIIa indicates a mild obstruction of urinary flow and impaired renal function. Consequently, assessment of obstructive nephropathy should not be based only on urodynamic study but also on differential renal function test.

[A case of giant vesical diverticulum with malignant neoplasm]

We experienced a case of giant vesical diverticulum with a malignant neoplasm in which the preoperative diagnosis was difficult. It simultaneously occurred with a vesical tumor. The patient, a 68-year-old man, visited our hospital complaining of pollakisuria, nycturia and microscopic hematuria. He had urinary retention and his vesical urine volume was 1,450 ml. X-ray examination and ultrasound examination revealed a giant vesical diverticulum and moderate hypertrophy of the prostate. A vesical tumor was suspected. Cystometrogram revealed a flaccid pattern with vesical capacity over 900 ml. Diverticulectomy and resection for a vesical tumor were performed. A malignant neoplasm in the vesical diverticulum was found during the operation. Transurethral resection of the prostate was performed after two months. There has been no evidence of recurrence for 3 years postoperatively.