Impact of prestorage leucoreduction of autologous whole blood on length of hospital stay with a subgroup analysis in bilateral hip arthroplasty

BACKGROUND

Although prestorage leucoreduction (LR) of blood components for transfusion has gained favour around the world, evidence of its beneficial clinical effects is ambiguous.

STUDY DESIGN AND METHODS

To reveal whether leucocytes and/or platelets in transfused blood are related to transfusion-related adverse effects, a prospective randomized crossover study was performed on patients who donated autologous blood prior to elective surgery. Among 1487 primary enrolees, a total of 192 patients undergoing two-stage, bilateral total hip arthroplasty were randomized to receive autologous blood that was either prestorage leucoreduced, or not, for the first procedure. For the second procedure, each patient was crossed over to receive alternatively processed autologous blood. Length of hospital stay served as a primary end-point, with perioperative infectious/thrombotic complications, pre- and postoperative laboratory values, and body temperature serving as secondary endpoints.

RESULTS

No significant differences emerged between prestorage LR and non-LR cohorts in length of hospital stay, as well as perioperative infectious/thrombotic complications, postoperative body temperature and duration of fever. Postoperative laboratory values including white blood cell counts and C-reactive protein levels had no significant differences.

CONCLUSION

This study could not prove any superiority of prestorage LR over non-LR for autologous whole blood among patients who underwent total hip arthroplasty.

Total removal of huge chondrosarcoma of the skull base with facial nerve resection and reconstruction

Chondrosarcomas of the skull base are locally aggressive tumours, and radical surgical resection is often difficult because of involvement of important neural structures in the skull base. We report the successful total resection of a huge skull base chondrosarcoma extending both intra- and extracranially. The tumour involved the left mastoid process, entire petrous bone, jugular foramen, posterior fossa and the parapharyngeal space. Since the facial nerve in the fallopian canal was totally involved by the tumour, the nerve was sacrificed and reconstructed using a great auricular nerve graft. The removal of the tumour was radical and complete. The functional recovery of the reconstructed facial nerve was excellent. The patient has almost fully recovered from the other neurological symptoms and has been free of tumour recurrence for 4 years after surgery.

A lateral transzygomatic-transtemporal approach to the infratemporal fossa: technical note for mobilization of the second and third branches of the trigeminal nerve

This report describes an alternative approach to the infratemporal fossa lesions through a lateral zygomato-temporal craniotemy, which modifies the extradural temporopolar technique for cavernous sinus surgery. First, an L-shaped osteotomy of the zygoma from the frontozygomatic suture attaching the zygomatre arch and low positioned temporal cramotomy are made. Through this zygomato-temporal craniotomy and orbitotemporal drilling, leaving the lateral orbital rim and orbital roof intact, skeletonization of the foramens rotundum and ovale are carried out. The key element of this infratemporal exposure is the dissection and mobilization of the trigeminal nerve, trigeminal second branch rostrally, and the third branch caudally, which facilitates a wide exposure of the infratemporal fossa with preserving trigeminal function. The corridor between the mobilized trigeminal branches provides direct access to the lateral and medial pterygoid plate, internal maxillary artery, sphenoid and maxillary sinuses, maxilla and, finally, the parapharyngeal area. Our experiences have demonstrated that this lateral transzygomatic-transtemporal exposure is satisfactory for use with infratemporal fossa tumors. This approach has an advantage for cranial-base exposure with decreased risks of cosmetic deformity and of trigeminal nerve dysfunction.

Extended Transsphenoidal Approach with Sigma-shape Osteotomy of the Maxilla: Technical Note

The traditional sublabial transsphenoidal approach offers a limited operative field. This report describes a simple surgical technique to widen the sublabial transsphenoidal window to access the midline lesions from the planum sphenoidale to the lower clivus. This technique was developed on the basis of clinical experience and on data obtained by cadaveric dissection study. Following a sublabial incision and separation of the bilateral septal mucosa, a small Sigma-shape osteotomy of the maxilla, including the anterior nasal spine, was performed with a surgical saw. The width of the entrance to the nasal cavity ranged from 32 to 38 mm. Although the plexus of the anterior superior alveolar nerve was partially cut, our clinical experience revealed no significant sensory loss of the incisors after the Sigma-shape osteotomy. The nasal orests of the maxilla and palatine bone were drilled out, and the roof of the nasopharynx was then incised to expose the lower clival bone. Although extradural sellar or clival lesions were the focus of this approach, the intradural anatomical structures examined by cadaveric study were presented. The extended transsphenoidal approach with Sigma-shape osteotomy of the maxilla is a simple technique and provides widened access to the sellar and clival regions.

Experience with 24 cases of reconstructive anterior skull base surgery: classification and evaluation of postoperative facial appearance

This article details our experience with 24 cases of anterior skull base reconstruction after tumor resection. They were classified into four types according to the resected region. In 11 cases of type I resection, the orbital part of frontal bone and/or cribriform plate of ethmoid bone were resected. In two cases of type II resection, the orbital contents and partial orbital bone were resected with the addition of type I. In five cases of type III resection, the maxillary bone was resected with the addition of type II. In six cases of type IV resection, the zygomatic bone and/or facial skin were resected with the addition of type III. The tumor originating from intracranial region was 25% of this series and all of them belonged to type I. The tumor originating from extracranial region tumor was 75% and its resected region was more extensive. In type I and II resections, the cranial flap, radial forearm free flap, or a combination of the two was used for reconstruction. The rectus abdominis myocutaneous/muscle free flap was used for reconstruction of massive defects in type III and IV defects. Total incidence of postoperative complications was 16.7%. Donor site deformity of the cranial flap at the frontal and temporal region in types I and II resections and facial contour deformity in zygomatic region and defect of upper and/or lower palpebra in type IV resection were major problems with postoperative facial appearance. Although use of the rectus abdominis myocutaneous free flap combined with costal cartilages improved the midfacial contour, palpebral reconstruction remained an unsolved problem in reconstructive skull base surgery. The reconstructive goals in skull base surgery are not only to obtain safe and reliable skull base reconstruction but also to restore the facial appearance postoperatively.

Genetic mapping of genes for susceptibility to black spot disease in Japanese pears

Black spot disease, which is caused by the Japanese pear pathotype of Alternaria alternata (Fr.) Keissler, is one of the most harmful diseases in Japanese pear cultivation. We identified the exact positions and linkage groups (LGs) of the genes for susceptibility to black spot in the Japanese pear (Pyrus pyrifolia Nakai) cultivars 'Osa Nijisseiki' (gene Ani) and 'Nansui' (gene Ana). Segregation of susceptibility and resistance fitted the expected ratio of 1:1 in progeny of 'Nansui' but showed a slight distortion in progeny of 'Osa Nijisseiki'. We mapped the genes for susceptibility to black spot in both populations using a genome scanning approach. The simple sequence repeat (SSR) markers CH04h02 and CH03d02 showed tight linkage to Ani and Ana. Although Ani and Ana are derived from different sources, both genes are located at the top region of LG 11. Information about the positions of the susceptibility genes and the molecular markers linked to them will be useful for marker-assisted selection in pear breeding programs.

Second neoplasm and cerebrovascular disease in over five-year survivors with CNS germ cell tumor

9046

Background: Survivors of childhood and adolescent brain tumors are at risk for long-term effects of treatment (Tx). This study investigates details on second neoplasm and cerebrovascular disease of long-term survivors with CNS germ cell tumors (CNSGCTs). Methods: The authors reviewed clinical data on 203 institutional patients (pts) who had a CNSGCT and survived more than 5 years. Median age of initial Tx was 15.0 years and median follow-up period was 168 months (60–448 months). Results: Among these pts, 32 pts (15.4%) suffered from second neoplasm and/or cerebrovascular disease. Median age of 32 pts was 14.6 years at the initial Tx. Median interval to event was 151 months (24–456 months). The secondary events, therefore, occurred at the third decade of age. The second neoplasm included 8 cavernous angiomas, 7 GBMs, 3 meningiomas, 2 G-III glioma, 1 hemangiopericytoma, and 1 leukemia. Four cavernous angiomas caused a hematoma. The cerebrovascular disease included 14 steno-occlusive diseases of circle of Willis, 1 aneurysm, and 1 dural AVF. Four pts sufferred from both neoplasum and cerebrovascular disease. All 32 pts had previously received radiotherapy and 6 pts had undergone chemotherapy. Radiation field included whole ventricle system or whole brain involving basal cistern with the dose of more than 40 Gy, except for one who received 24 Gy followed by P-E chemotherapy. Eight of 32 pts died and 14 pts had additional sequelae due to these secondary events. Conclusions: The risk of lethal malignant neoplasm and disabling cerebarovascular disease after Tx for CNSGCTs is extremely large. Long-term follow-up system to monitor and prevent late sequelae should be established.

No significant financial relationships to disclose.

[Beating heart surgery for the patient of severe mitral regurgitation with a episode of ventricular fibrillation; report of a case]

A 77-year-old female was admitted to our hospital with a diagnosis of severe mitral regurgitation. Cardiopulmonary revival was done by an emergent resuscitation for the ventricular fibrillation before admission. She had mild anoxic brain damage and brain magnetic resonance imaging (MRI) revealed severe brain atrophy. Chest X-ray showed severe cardiomegaly and congestion. Beating heart mitral valve replacement was planned for the prevention of reperfusion injury. A cardiopulmonary bypass was established by bicaval drainage and aortic return. The prolapse of anterior leaflet was recognized through transeptal approach after aortic clamp. We selected continuous infusion of antegrade cardioplegia for intraoperative coronary perfusion. Mitral valve replacement was done successfully. During intraoperation and postoperation, ventricular fibrillation did not occur. On-pump beating mitral valve replacement is a good procedure to prevent perioperative ventricular arrhythmia especially such the case with a decompressed myocardial function and with a preoperative episode of lethal ventricular arrhythmia necessary for cardiopulmonary resuscitation.

Genetic mapping of the pear scab resistance gene Vnk of Japanese pear cultivar Kinchaku

Pear scab (caused by Venturia nashicola) is one of the most harmful diseases of pears, especially Japanese and Chinese pear species. The molecular identification and early selection of resistant plants could greatly improve pear breeding. We have identified the position of the scab resistance gene, designated Vnk in an indigenous Japanese pear cultivar Kinchaku, within the pear genome by using simple sequence repeat (SSR) markers derived from pear and apple. The position of Vnk was identified in the central region of linkage group 1 of Kinchaku. Several amplified fragment length polymorphism (AFLP) markers linked to Vnk were obtained by bulked segregant analysis. Among them, the AFLP marker closest to Vnk was converted into a sequence tagged site (STS) marker. Four random amplified polymorphic DNA (RAPD) markers previously found to be loosely associated with Vnk (Iketani et al. 2001) were successfully converted into STS markers. Six markers (one SSR Hi02c07 and five STSs converted from AFLP and RAPD) showed tight linkages to Vnk, being mapped with distances ranging from 2.4 to 12.4 cM. The SSR CH-Vf2, which was isolated from a BAC clone of the contig containing the apple scab gene Vf, was mapped at the bottom of linkage group 1 in Kinchaku, suggesting that the Vnk and Vf loci are located in different genomic regions of the same homologous linkage group.

[Multi-vessel dissection; report of a case]

We report an extremely rare case of multi-vessel dissection including left carotid artery, ascending aorta and thoracoabdominal aorta independently. A 65-year-old man suffered from cerebral infarction due to left carotid artery dissection. Five days later, he complained of severe back pain and was diagnosed as acute DeBakey type IIIb aortic dissection. He had been treated medically. One month later, computed tomography (CT) scan demonstrated DeBakey type II as well as type IIIb aortic dissections. The ascending aorta was replaced on August 8, 2001. Then replacement of the descending thoracic aorta with reconstruction of the eighth and tenth intercostal arteries was performed on September 26, 2001. The left carotid artery dissection has been treated medically.

Blalock-Taussig shunt for a neonatal case of Ebstein's anomaly with unobstructed right ventricular outflow tract

A neonate with Ebstein's anomaly presented with severe cyanosis because of massive right-to-left shunt through an atrial septal defect and reduced blood flow through an unobstructed right ventricular outflow tract. This atypical patient underwent a right modified Blalock-Taussig shunt, which resolved the respiratory.

Clinical study of urine NMP 22 (nuclear matrix protein 22) as a tumor marker in urinary epithelial cancer

The prognosis of urinary epithelial cancer is still poor, and early detection of this cancer is strongly desirable. The sensitivity of conventional urinary cytology is not satisfactory enough. It is hoped that a specific tumor marker will be established. In recent years, it has been reported that urine NMP 22 is very useful and that urine BFP is also relatively useful. We have now determined urine NMP22 and BFP and studied their clinical usefulness as a tumor marker. Using patients diagnosed with histologically confirmed urinary epithelial cancer as the subjects, we retrospectively studied the usefulness of NMP 22, BFP and cytology mainly with regard to the sensitivity (positivity rate), and also in relation to atypia, degree of infiltration and clinical course.

MRI in methotrexate-related leukoencephalopathy: Disseminated necrotising leukoencephalopathy in comparison with mild leukoencephalopathy

We report two fatal cases of methotrexate (MTX)-induced disseminated necrotising leukoencephalopathy (DNL) in which MRI was repeated from the onset. Initial T2-weighted images showed multiple areas of high signal, mainly in deep cerebral white matter, which on follow-up, spread and coalesced to involve the entire white matter. Small irregular low-signal foci on T2-weighted images were seen within the high-signal lesions. Multiple areas of contrast enhancement corresponded to these low-signal foci. The condition of both patients deteriorated and they died. We compared their MRI findings with those of seven patients with mild MTX-related leukoencephalopathy, six of whom were asymptomatic; one had transient neurological symptoms. They showed no contrast enhancement, but rather mild-to-moderate diffuse high signal in deep white matter, which later disappeared. These findings suggest that multiple low-signal foci on T2-weighted images with contrast enhancement may be characteristic of DNL, and that contrast-enhanced imaging is useful to differentiate this condition from mild leukoencephalopathy.

Genetic linkage maps constructed by using an interspecific cross between Japanese and European pears

Genetic linkage maps of the European pear ( Pyrus communis L.) cultivar 'Bartlett' and the Japanese pear ( Pyrus pyrifolia Nakai) cultivar 'Housui' were constructed based on AFLPs, SSRs from pear, apple and Prunus, isozymes and phenotypic traits by using their F(1) progenies. The map of the female parent Bartlett consisted of 226 loci including 175 AFLPs, 49 SSRs, one isozyme and one S locus on 18 linkage groups over a total length of 949 cM, while that for 'Housui' contained 154 loci including 106 AFLPs, 42 SSRs, two phenotypic traits and the other four markers on 17 linkage groups encompassing a genetic distance of 926 cM. These maps were partially aligned using 20 codominant markers which showed segregating alleles in both parents. Compared with the reports of apple genetic maps, these pear maps were not saturated but were near saturation. Distorted segregation was observed in two and one regions of the genome of Bartlett and Housui, respectively. The position of 14 SSRs originating from apple could be successfully determined in pear maps, which enabled us to compare the two maps. Some SSRs developed from Prunus (peach, cherry) were also mapped. The relationships between pear and the other species belonging to the Rosaceae were discussed based on the position of SSRs.

[Pericardiectomy for post-coronary artery bypass grafting constrictive pericarditis; strategy for safe and complete pericardiectomy]

Surgery for constrictive pericarditis after coronary artery bypass grafting (CABG) needs complete pericardiectomy without injury to bypass grafts. We performed pericardiectomy for post-CABG constrictive pericarditis 15 months after the first surgery. Preoperative multislice helical 3-dimensional computed tomography (CT) clearly demonstrated the patent bypass grafts and anatomical relationship between grafts and surrounding organs. Among surgical approaches, we chose bilateral thoracotomy to avoid injury to the bypass grafts and to obtain a good surgical exposure, especially for pericardiectomy of the left side of the heart. Additionally, with the use of intraoperative doppler ultrasound blood flowmetry, we could safely achieve complete pericardiectomy. We conclude that the combined application of 3-dimensional CT, bilateral thoracotomy and doppler ultrasound blood flowmetry was a supreme strategy for the operation of constrictive pericarditis after CABG.

Ultrafiltration of the priming blood before cardiopulmonary bypass attenuates inflammatory response and improves postoperative clinical course in pediatric patients

The priming solution using in cardiopulmonary bypass (CPB) for infants undergoing cardiac surgery includes considerable amounts of stored blood. Our objective was to test the hypothesis that ultrafiltration (UF) of the stored blood before CPB reduces the unfavorable effects of stored blood and the production of inflammatory cytokines. Fifty pediatric patients with congenital heart defects took part in this study. The patients were randomly divided into two groups: the UF (27 pediatric patients who received UF) and control (23 pediatric patients who did not receive UF) groups. UF was performed with a polysulphone ultrafiltrator before CPB. Blood samples were collected immediately before, during, and 1 h after CPB. The levels of cytokines (TNF-alpha, IL-1beta, IL-8), NH3, and bradykinin were determined. The serum concentrations of NH3 and bradykinin decreased significantly after UF. Compared with the control group, the UF group had significantly lower cytokine production. Water balance in UF group was better than that of control group. The UF group received significantly less inotropic support and shorter duration of ventilator support and ICU stay. We conclude that removal of bradykinin and a decrease in the levels of NH3, potassium, and pH play a significant role in reducing water retention and postoperative lung injury. UF of the blood used to prime the circuit for CPB is a safe and efficient method for use in open heart surgery in small pediatric patients.

Roles of the functional loss of p53 and other genes in astrocytoma tumorigenesis and progression

Loss of function of the p53 tumor suppressor gene due to mutation occurs early in astrocytoma tumorigenesis in about 30-40% of cases. This is believed to confer a growth advantage to the cells, allowing them to clonally expand due to loss of the p53-controlled G1 checkpoint and apoptosis. Genetic instability due to the impaired ability of p53 to mediate DNA damage repair further facilitates the acquisition of new genetic abnormalities, leading to malignant progression of an astrocytoma into anaplastic astrocytoma. This is reflected by a high rate of p53 mutation (60-70%) in anaplastic astrocytomas. The cell cycle control gets further compromised in astrocytoma by alterations in one of the G1/S transition control genes, either loss of the p16/CDKN2 or RB genes or amplification of the cyclin D gene. The final progression process leading to glioblastoma multiforme seems to need additional genetic abnormalities in the long arm of chromosome 10; one of which is deletion and/or functional loss of the PTEN/MMAC1 gene. Glioblastomas also occur as primary (de novo) lesions in patients of older age, without p53 gene loss but with amplification of the epidermal growth factor receptor (EGFR) genes. In contrast to the secondary glioblastomas that evolve from astrocytoma cells with p53 mutations in younger patients, primary glioblastomas seem to be resistant to radiation therapy and thus show a poorer prognosis. The evaluation and design of therapeutic modalities aimed at preventing malignant progression of astrocytomas and glioblastomas should now be based on stratifying patients with astrocytic tumors according to their genetic diagnosis.

MR imaging of the brain in lymphomatoid granulomatosis

BACKGROUND AND PURPOSE

Clinical diagnosis of lymphomatoid granulomatosis (LG) of the brain, in patients without skin or chest lesions, usually is difficult because of the nonspecific neurologic manifestations, laboratory data, and CT appearance. Our aim was to characterize the MR appearance of LG of the brain.

METHODS

We retrospectively reviewed the MR images in four patients (35 to 72 years old) with histologically confirmed LG of the brain.

RESULTS

On T2-weighted images, we noted diffuse hyperintense lesions in the cerebral white matter bilaterally (n = 3), in the brain stem and cerebellar hemisphere (n = 1), and patchy hyperintense lesions the brain stem (n = 2). On contrast-enhanced T1-weighted images, we observed multiple punctate or linear enhancements residing along the perivascular space (n = 4), nodular enhancements (n = 2), ringlike enhancements (n = 1), and a large, enhanced mass (n = 1). All patients had multifocal lesions.

CONCLUSION

Although the MR appearance of LG of the brain varies, multiple punctate or linear enhancements that reside along the perivascular space suggest LG.

JC virus large T protein transforms rodent cells but is not involved in human medulloblastoma

JC virus (JCV) together with Simian virus 40 (SV40) and BK virus (BKV), belong to the polyomavirus group and these viruses are neuro-oncogenic to rodents by expression of large T antigen (LT), which binds to cellular p53 and pRB thus reducing the anticancer potential of the cell. The function of LT has not been clarified because small t antigen (st) is transcribed from the same start codon as the overlapping reading frame of LT, and is translated as a different protein with the same N-terminal residues (1-81 amino acids) by a splice-site variant of mRNA. To elucidate the function of LT without st, we constructed plasmids that express LT only by deleting the splicing region including the C-terminus of st, and consequently stable cell lines were established that express only JCLT, SV40LT and BKLT. The growth rates of these cells were examined in colonies on soft agar and it was found that LT alone has a transforming capacity; the order of efficiency being SV40LT, BKLT and JCLT. In addition, to verify the involvement of JCV in human medulloblastoma, eight cases of medulloblastoma, six cases of frozen material and five cases of paraffin-embedded tissues which included three cases of frozen tissues, were examined. PCR assay, genomic Southern blotting, and in situ hybridization were applied to detect the JCV genome, and LT and st were examined by immunohistochemistry; the results were compared with JCV-infected tissues as a positive control. All methods failed to detect not only JCV genome but also LT protein in medulloblastoma and it was concluded that JCV LT has transforming activities in rodent cells, but is not related to human medulloblastoma.

A clinical study of urine basic fetoprotein and urine polyamine as tumor markers in epithelial cancer of the urinary tract

BACKGROUND

The reliability of a new screening test for epithelial cancer of the urinary tract was evaluated and the results were compared with those obtained employing urinary cytology in routine use.

METHODS

The subjects consisted of 187 cases selected randomly from among the patients who attended Toho University Ohashi Hospital during a period of 1 year from January 1998. The values for urine basic fetoprotein (BFP) and polyamine and urinary cytology were examined.

RESULTS

Urine BFP is considered useful for screening and monitoring urinary tract epithelial cancer as is urinary cytology. Urine BFP showed a statistically significant difference (P < 0.05) for G1 compared with urinary cytology and a significantly high level compared with urinary cytology as to the positive rate in the low stage group (P < 0.05). The positive rate of urine BFP was high in patients with urinary tract infection.

CONCLUSION

Determining urine BFP, when combined with urinary cytology, is considered very useful for diagnosing patients with urinary tract epithelial cancer. This study suggests the possibility of urine BFP being superior to urinary cytology for screening early cancer and also as an indicator for observations on the clinical course.

[Minimally invasive stereotactic functional surgery using an intravenous anesthetic propofol and applying Image Fusion and AtlasPlan]

Image-guided stereotactic surgery of the ventralis intermedius nucleus of the thalamus, globus pallidus, and subthalamic nucleus is a prevailing modality as a treatment of movement disorders. This technical note describes a method of minimally-invasive stereotactic functional surgery for patients with parkinsonian symptom or various tremors. Patients were administered propofol, an intravenous anesthetic, during placement of a burr hole and a stereotactic frame, but not the period when the patients were necessary to be awake. The intravenous anesthesia was very beneficial to relieve local pain and mental stress of the patients. Radionics ImageFusion and AtlasPlan were used for defining the target localization without an intraoperative ventriculography. ImageFusion efficiently fused high-resolution MR images on CT images. AtlasPlan accurately corrected the localization of the tentative target point after measurements from the midpoint of the anterior commissure-posterior commissure line on the modified MRI, and enabled us to reduce the degree of an intraoperative correction to fix a final target. Stereotactic functional surgery has been thought to be less-invasive, however further modifications of surgical procedure and intraoperative medication can make this type of surgery much more less-invasive.

Alternative EWS-FLI1 fusion gene and MIC2 expression in peripheral and central primitive neuroectodermal tumors

Primitive neuroectodermal tumors (PNET) occur either in the central nervous system (CNS; central PNET, cPNET) or in the peripheral sites (peripheral PNET, pPNET). Recent molecular approaches have been defining a new concept of PNET, that is, the pPNET including Ewing's sarcoma (ES) which expresses MIC2 glycoprotein and shows the specific chimeric gene of EWS-FLI1. The expression of MIC2 and the genetic rearrangement of EWS-FLI1 are considered to be highly specific to the pPNET/ES. This study examined the expression of MIC2 and EWS-FLI1 gene by means of immunohistochemistry and reverse transcriptase-polymerase chain reaction (RT-PCR) on various small round cell tumors originating in the CNS or non-CNS organs. All peripheral PNET tested expressed MIC2 and were positive for EWS-FLI1 (11/11). In contrast, all cPNET and other blastic CNS tumors were negative for MIC2: medulloblastoma (0/3), cerebral PNET (0/2), spinal PNET (0/2), glioblastoma (0/2), retinoblastoma (0/3), and pineoblastoma (0/2). These MIC2-negative tumors were also negative for the chimeric gene product of EWS-FLI1. Interestingly, one PNET originating in the intracranial dura mater was positive for both MIC2 and EWS-FLI1 fusion gene. The results indicate that cPNET lacks any genetic or protein markers, except for a meningeal PNET which falls into the same phenotypic spectrum of pPNET.

Penile schwannoma

Schwannoma of the penis is extremely rare. A 65-year-old man presented with a subcutaneous tumor of penile shaft without any other symptoms. Histopathologic examination of the excised tumor revealed benign schwannoma. No recurrence has been observed over the 6 months since the surgery.

[Production and clinical application of fibrin sealant with high concentrated fibrin (fibrin patch)]

OBJECT

The sealing properties of fibrin sealant with high concentrated fibrin (fibrin patch) were examined.

MATERIAL AND METHODS

A commercial fibrin sealant (Bolheal) produced from pooled human plasma was utilized for this study. The fibrin sealant made of fibrinogen and thrombin solutions mixed in a volume ratio 5:1 was applied as the fibrin sealant with high concentrated fibrin (fibrin patch). The burst pressure of the fibrin clots of either 1:1 or 5:1 mixing ratio, which sealed the small holes, was measured by a water-leak preventing model. The tensile strength of the fibrin patch was measured by the breaking pressure of the fibrin clot. The burst pressure of the fibrin patch, which sealed the dural defect with a diameter of 15 mm, was compared with that of expanded polytetrafluoroethylene (ePTFE).

RESULTS

The burst pressure was elevated from 287 +/- 23.1 to 445 +/- 30.5 mmHg by changing the mixing ratio from 1:1 to 5:1. The breaking pressure of the fibrin patch showed 131 +/- 25.4 mmHg and that of the patch mixed at the ratio of 1:1 showed 46.6 +/- 9.9 mmHg. The result of dural repair with the fibrin patch revealed higher sealing effectiveness than that of ePTFE. The burst pressure averaged 70.5 +/- 21.4 mmHg in the fibrin patch samples and 51.4 +/- 13 mmHg in the ePTFE samples.

CONCLUSION

The fibrin patch revealed higher performance as a sealant and has the potential to be a candidate for acceptance as the new dural repair material.

Fractionated stereotactic radiotherapy for vestibular schwannoma (VS): comparison between cystic-type and solid-type VS

PURPOSE

To compare the effectiveness and complications of fractionated stereotactic radiotherapy (SRT) for cystic-type vestibular schwannoma (VS) with those of solid-type VS.

METHODS AND MATERIALS

In 65 patients treated with fractionated SRT between 1991 and 1999, 20 were diagnosed with cystic VS, in which at least one-third of the tumor volume was a cystic component on magnetic resonance imaging (MRI), and 45 were diagnosed with solid VS. Thirty-six Gy to 50 Gy in 20-25 fractions was administered to the isocenter and approximately 80% of the periphery of the tumor. All cystic and solid components were included in the gross tumor volume. The mean follow-up period was 37 months, ranging from 6 to 97 months.

RESULTS

The actuarial 3-year rate of no episode of enlargement greater than 2.0 mm was 55% for cystic-type and 75% for solid-type VS; the difference was statistically significant (p = 0.023). The actuarial 3-year tumor-reduction (reduction in tumor size greater than 2.0 mm) rates were 93% and 31%, respectively (p = 0.0006). The overall actuarial tumor control rate (no tumor growth greater than 2. 0 mm after 2 years or no requirement of salvage surgery) was 92% at 5 years in 44 patients with a follow-up period of 2 or more years. There was no difference in the class hearing preservation rate between cystic VS and solid VS. No permanent trigeminal or facial nerve palsy was observed in either group.

CONCLUSION

Transient tumor enlargement occurs in cystic VS more frequently than in solid-type VS, but the subsequent tumor-reduction rate in cystic VS is better.

Minimally invasive surgical exposure of the extreme high cervical internal carotid artery: anatomical study

The purpose of this study is to investigate a minimally invasive access to a high cervical lesion involving the internal carotid artery. Using 13 fixed cadaveric preparations, we sought to design a surgical approach that would cause minimal involvement of the surrounding structures and maximal exposure to the extreme high cervical area. This technique preserves the function and integrity of the mandible, sternocleidomastoid, posterior belly of digastric and styloid process muscles. The method uses retraction and mobilisation of those muscles, as well as decompression of the facial from the stylomastoid foramen. The internal carotid artery is exposed up to the entry point into the carotid canal. The cranial nerves IX, X, XI and XII are kept in sight up to the jugular foramen. This approach creates a wide corridor into the deep high cervical and inferior cranial base area and can be utilised for high cervical carotid lesions and tumours related to the artery.

Asymptomatic schwannoma of the oculomotor nerve: case report

Intracranial oculomotor schwannoma without neurofibromatosis is rare and is usually symptomatic. Only one case of asymptomatic oculomotor schwannoma has been previously reported. We present a case of intracranial oculomotor schwannoma which caused no signs or symptoms. Microsurgical resection of this tumour resulted in oculomotor palsy. We reviewed 7 reported cases and the findings indicated that radical removal of the tumour invariably caused or worsened the oculomotor palsy. The reason why the tumour caused no symptoms in this case was unclear. However, improvements in diagnostic methods such as magnetic resonance imaging (MRI) may increase the detection of such asymptomatic cases. Indications for surgical treatment should be established.

[Two cases of the epidermoid on the petrous bone]

Epidermoids known as cholesteatomas, are congenital benign tumors and originate in the embryonic ectoderm. They account for 1.3% of all intracranial tumors. They are often found in the cerebellopontine angle and the paraseller region, but rarely in the petrous portion of the temporal bone. Epidermoids of the petrous bone tend to slowly present progressive facial palsy and hearing disturbance. In this article, two cases of epidermoids involving the petrous bone are reported. A 55-year-old male presented left facial palsy, left hearing disturbance and decreased gustation in the left side of the tongue. MRI revealed a non-enhanced mass on the petrous portion of the left temporal bone, and bone-window CT showed bone destruction in the same region (Case 1). A 71-year-old female was aware of left facial palsy and left hearing loss for 15 years. MRI showed a non-enhanced mass on the petrous bone, and bone-window CT demonstrated extensive bone erosion of the petrous bone and the middle cranial fossa (Case 2). In both cases, total removal was performed via the middle cranial fossa approach. Both tumors existed extradurally and had pressed against the genicurate ganglion of the facial nerve. The facial palsy of the former case recovered 12 months after surgery. We discuss the problems of diagnosis and treatment of epidermoids of the petrous bone.

Application of advances in molecular biology to the treatment of brain tumors

Recent advances in molecular biology have substantially improved our understanding of the molecular genetics of primary brain neoplasms. Soon each histopathologic category of glioma will be further divided into subgroups according to similar genetic background, gene expression profile, and similarity of biologic responses to radiotherapy or chemotherapy. Identification of key molecules that are specifically altered in neoplastic cells will provide candidate molecular targets for tumor treatment. Novel therapeutic tools for targeting tumor cells, such as viral vectors for gene therapy, have been created. In the near future, the accumulation of new knowledge in brain tumor biology and genetics, combined with rational drug design, will revolutionize the treatment of malignant gliomas, which are among the most lethal human cancers.

Spinal intramedullary ependymomas: surgical results and immunohistochemical analysis of tumour proliferation activity

This study analysed the outcome of 35 consecutive patients with intramedullary ependymoma who underwent a radical surgical resection between 1983 and 1996. The median age of patients was 47 years. Tumour location was cervical in 22 patients, cerviothoracic in eight and thoraco lumber in five. The proliferative activity of 24 spinal and 14 intracranial ependymomas were determined by MIB-1 immunolabelling. Total removal of tumour was achieved in 26 patients and subtotal removal was performed in nine patients of whom six received postsurgical radiation therapy. Twenty-nine patients out of 35 could be followed over 3 years (follow-up periods: 168-36 months: mean 70). Moreover many patients could be followed over 4 years. In 27 of those 29 patients, the neurological symptom was stabilized or improved. The proliferation indices of spinal ependymomas were significantly lower than those of intracranial ependymomas. Tumour regrowth occurred only in a young patient 29 months after a subtotal removal of the tumour which was not treated with irradiation and showed a high proliferation index on the second operation.

Surgical approaches for the treatment of aneurysms on the P2 segment of the posterior cerebral artery

OBJECTIVE

The P2 segment of the posterior cerebral artery has remained a challenging region to expose surgically. We establish a surgical strategy for P2-segment aneurysms.

METHODS

Each segment of the posterior cerebral artery was classified according to Zeal and Rhoton's classification. Fourteen of 18 P2-segment aneurysms were surgically treated. The patient's outcome, the aneurysm location, and the surgical procedures were evaluated. A cadaveric study was performed to clarify the surgical view obtained via three different surgical approaches.

RESULTS

Nine aneurysms were clipped, two were trapped, one was coated, and one was excised with parent artery reconstruction. Cerebral revascularization techniques were used for three patients. The pterional approach exposed the anterior half of the P2a segment. The subtemporal approach revealed the P2a segment, but its exposure was restricted by its localization in the ambient cistern. Via the occipital interhemispheric transtentorial approach, the P2p segment was visible and could be manipulated. When the posterior half of P2a segment was high on a coronal view of magnetic resonance imaging, it was extremely hard to access via any approach.

CONCLUSION

A surgical strategy for the P2 aneurysm can be planned with accurate prediction of the aneurysm location. When the localization of an aneurysm on the posterior half of P2a segment is high, a resection of brain tissue may be required.

Deep brain stimulation of subthalamic area for severe proximal tremor

Proximal tremors are often refractory to nucleus ventrointermedius thalami thalamotomy. Subthalamotomy has been suggested to be effective for treatment of tremor, although this procedure is associated with considerable adverse effects, and has rarely been considered a suitable treatment modality. The authors demonstrate the efficacy and safety of subthalamic deep brain stimulation in two patients, one with a severe, refractory proximal essential tremor and one with tremor with dystonia.

Topography of the vestibulocochlear nerve

OBJECTIVE

The terms superior vestibular nerve and inferior vestibular nerve have been used in the field of neurosurgery to indicate anatomically the two respective vestibular components of the vestibulocochlear nerve. To reappraise the aptness of this terminology, fascicular patterns and the anatomic relationship of the vestibular and cochlear components were examined.

METHODS

Twenty vestibulocochlear nerve specimens were obtained from cadavers. The nerves were excised, with care taken to sustain their spatial relationships, then embedded in paraffin blocks and cross sectioned in 10-microm-thick slices. Serial cross sections were stained and examined with a light microscope.

RESULTS

The vestibular component was separated into two parts only at the lateral fundus of the internal auditory canal, lateral to the vestibular ganglion. In the internal auditory canal of all specimens, the vestibular component was represented by numerous fascicles. Around the porus acusticus, the fascicular pattern among the specimens was diverse: 13 of the 20 specimens were still polyfascicular, 4 specimens consisted of two large, distinct fascicles, and, in the remaining 3 specimens, a portion of the vestibular fascicles had fused with the cochlear component. Near the root entry zone, all vestibular fascicles fused and merged with the cochlear nerve to form a single trunk.

CONCLUSION

There was no evidence to support the anatomic correctness of specifying the superior and inferior vestibular nerves, except in the lateral fundus of the internal auditory canal.