[Long-Term Survival after Resection of Two Lung Metastases That Appeared Five Years after Pancreatic Cancer Surgery-A Case Report]

A woman in her 70s was diagnosed with cancer of pancreatic head. She underwent subtotal stomach-preserving pancreatoduodenectomy. Moderately differentiated adenocarcinoma, positive peripancreatic exfoliation surface, and R1 resection was diagnosed by histopathological examination. She underwent adjuvant chemotherapy(S-1), but 5 years and 6 months after the operation, a single nodule(16×9 mm)appeared on anterior segment of left lung. She underwent thoracoscopic left upper lobectomy on suspicion of primary lung cancer. Adenocarcinoma consistent with pancreatic cancer metastasis was diagnosed by histopathological examination. She didn't choose chemotherapy after second operation. 1 year and 1 month after the left pneumonectomy, a single nodule(11×10 mm)reappeared in lateral basal segment of right lung. Although it was difficult to diagnose whether it was primary or metastatic, she decided to undergo thoracoscopic partial lung resection. Histopathological examination revealed that the histology was similar to that of the previous lung lesion and was consistent with pancreatic cancer metastasis. After that, she also didn't choose chemotherapy. She has been alive for 7 years and 7 months after her first pancreatic cancer surgery without any new obvious recurrence.

Cellular cannibalism and consequent thrombocytopenia in a patient with bone marrow metastasis of malignant pleural mesothelioma: A case report

Cellular cannibalism is a tumor activity where a cell is engulfed by another cell. This process promotes tumor cell survival under unfavorable conditions. The current report describes an extremely rare case of thrombocytopenia resulting from cellular cannibalism in a patient with bone marrow metastasis due to malignant pleural mesothelioma (MPM). A 77-year-old male presented with hemothorax and thrombocytopenia. He was diagnosed with MPM of the sarcomatoid cell type. However, his disease progressed rapidly and he died 11 days after admission. Bone marrow aspiration revealed metastatic MPM cells that had engulfed other blood cells. Accordingly, the observed thrombocytopenia was attributed to cellular cannibalism by metastatic MPM tumor cells. To the best of our knowledge, this is the first reported case of thrombocytopenia due to cellular cannibalism in a patient with this type of malignancy (MPM). The results suggested that although MPM rarely metastasizes to the bone marrow, bone marrow aspiration could be useful in such cases.

[Mediastinal Giant Vagal Nerve Schwannoma;Report of a Case]

A 73-year-old man visited his family doctor with complaints of cough and breathlessness. Right pleural effusion was detected by chest X-ray. Computed tomography(CT) showed a huge mass 13×11 cm in the right mediastinum along with right pleural effusion and atelectasis of the right middle and lower lobes. Surgery was performed 4 days after admission. Although the tumor was huge, it could be successfully removed. The symptoms improved and the patient was discharged after 10 days of surgery. Pathological examination revealed vagal nerve schwannoma with no malignant features.

[Tumor-induced Hypophosphatemic Osteomalacia Caused by a Chest Wall Tumor]

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic disease characterized by hypophosphatemia and skeletal undermineralization. Overproduction of fibroblast growth factor 23( FGF23) from the responsible tumor is reported to be a causative factor. Removing the tumor is the only effective treatment for TIO, but identifying the tumor is sometimes difficult. A 43-year-old man complained of heel pain 4 years earlier, and the pain gradually expanded to the whole body. As a blood test showed the elevation of the serum FGF23 level and hypophosphatemia, he was diagnosed with FGF23-related hypophosphatemia. Chest computed tomography (CT) showed a 10-mm nodule in the right chest wall. Venous sampling for FGF23 revealed considerable elevation of the FGF23 level in the right subclavian vein. Therefore, a chest wall tumor was suspected as the tumor responsible for TIO, and surgical resection was performed. After surgery, hypophosphatemia improved within several days, and the FGF23 level also normalized.

The Dbl homology domain of BCR is not a simple spacer in P210BCR-ABL of the Philadelphia chromosome

The Dbl homology (DH) domain of BCR in P210BCR-ABL (P210/WT) has been thought to have a negative effect on the activation of BCR-ABL because P185BCR-ABL, in which this region is physically deleted, has stronger biochemical and biological activities. To study the role of the DH domain of BCR in the background of P210/WT, the region was replaced with homologous sequences derived from Dbl (P210/Dbl) or CDC24 (P210/CDC24) or with irrelevant sequences from LacZ (P210/LacZ) or luciferase (P210/Luci). Surprisingly, the abilities to transform Rat1 cells or mouse bone marrow cells and induce growth factor independence in interleukin 3-dependent mouse Ba/F3 cells were retained only in P210/Dbl. However, even P210/Dbl could not achieve the wild type level of surviving potential against genotoxins in Rat1 cells and in Ba/F3 cells. Activation of Akt correlated with the biological changes in Rat1 cells but did not correlate with the biological changes in Ba/F3 cells. The DH domain was not tyrosine-phosphorylated in vitro, nor could we find any differences in peptide mapping between in vitro phosphorylated P210/WT and P210/Dbl. Although functions of the DH domain remain to be discovered, we propose that the DH domain makes positive contributions to P210BCR-ABL.

A novel function of tissue factor pathway inhibitor-2 (TFPI-2) in human glioma invasion

Human tissue factor pathway inhibitor-2 (TFPI-2) is a Kunitz-type serine protease inhibitor that inhibits plasmin, trypsin, chymotrypsin, cathepsin G, and plasma kallikrein but not urokinase-type plasminogen activator, tissue plasminogen activator, or thrombin. Preliminary findings in our laboratory suggested that the expression of TFPI-2 is downregulated or lost during tumor progression in human gliomas. To investigate the role of TFPI-2 in the invasiveness of brain tumors, we stably transfected the human high-grade glioma cell line SNB19 and the human low-grade glioma cell line Hs683 with a vector capable of expressing a transcript complementary to the full-length TFPI-2 mRNA in either sense (0.7 kb) or antisense (1 kb) orientations. Parental cells and stably transfected cell lines were analysed for TFPI-2 protein by Western blotting and for TFPI-2 mRNA by Northern blotting. The levels of TFPI-2 protein and mRNA were higher in the sense clones (SNB19) and decreased in the antisense (Hs683) clones than in the corresponding parental and vector controls. In spheroid and matrigel invasion assays, the SNB19 parental cells were highly invasive, but the sense-transfected SNB-19 clones were much less invasive; the antisense-transfected Hs683 clones were more invasive than their parental and vector controls. After intracerebral injection in mice, the sense-transfected SNB19 clones were less able to form tumors than were their parental and vector controls, and the antisense-Hs683 clones but not the parental or vector controls formed small tumors. This is the first study to demonstrate that down- or upregulation of TFPI-2 plays a significant role in the invasive behavior of human gliomas.

Inhibition of protein kinase C delta has negative effect on anchorage-independent growth of BCR-ABL-transformed Rat1 cells

The BCR-ABL oncoprotein transmits transformation signals mainly through pathways involving Ras, Myc and PI3 kinase. Here we report that inhibition of protein kinase C (PKC) delta had negative influence on anchorage-independent growth of Rat1 cells transformed by BCR-ABL. The effect was observed with delta isoform-specific inhibitor rottlerin, but not with Go6976 that inhibits only conventional isoforms. The kinase activity of delta isoform was found to be roughly two-fold higher in BCR-ABL-expressing Rat1 cells than that in mock. Although overexpression of wild type PKC delta did not enhance soft agar colony number by BCR-ABL-transformed Rat1 cells, that of dominant-negative delta isoform reduced it by approximately 40%.

Stable transfection of urokinase-type plasminogen activator antisense construct modulates invasion of human glioblastoma cells

The diffuse and extensive infiltration of malignant gliomas into the surrounding normal brain is believed to rely on modifications of the proteolysis of extracellular matrix components. A key molecule in regulating plasminogen-mediated extracellular proteolysis is the urokinase-type plasminogen activator (uPA). To investigate the role of uPA in the invasive process of brain tumors, we stably transfected a human glioblastoma cell line SNB19 with a vector capable of expressing an antisense transcript complementary to the 1020 bases at the 3' end of the uPA cDNA. Parental, vector-, and antisense construct-stably transfected cell lines were analyzed for uPA mRNA transcript by Northern blot analysis, for uPA enzyme activity by zymography, and for uPA protein levels by Western blotting. The levels of uPA mRNA, protein, and enzyme activities were significantly lower in antisense clones than in parental and vector controls. Radioreceptor binding studies demonstrated that uPA receptor levels remained the same in parental, vector-, and antisense-transfected cells. The antisense-transfected cells showed a markedly lower level of invasion in the Matrigel invasion assays, and their spheroids failed to invade the fetal rat brain aggregates in the coculture system. Green fluorescent protein (GFP) expressing parental and antisense transfectants was generated for detection in mouse brain tissue without any posttreatment. Intracerebral injection of antisense stable transfectants significantly reduced tumor formation compared with that in controls. Our results suggested that down-regulation of uPA expression may be a feasible approach to reducing the malignancy and invasiveness of glial tumors.

Down-regulation of cathepsin B expression impairs the invasive and tumorigenic potential of human glioblastoma cells

Increases in abundance of cathepsin B transcript and protein correlate with increases in tumor grade and alterations in subcellular localization and activity of cathepsin B. The enzyme is able to degrade the components of the extracellular matrix (ECM) and activate other proteases capable of degrading ECM. To investigate the role played by this protease in the invasion of brain tumor cells, we transfected SNB19 human glioblastoma cells with a plasmid containing cathepsin B cDNA in antisense orientation. Control cells were transfected with vector alone. Clones expressing antisense cathepsin B cDNA exhibited significant reductions in cathepsin B mRNA, enzyme activity and protein compared to controls. Matrigel Invasion assay showed that the antisense-transfected cells had a markedly diminished invasiveness compared with controls. When tumor spheroids containing antisense transfected SNB19 cells expressing reduced cathepsin B were co-cultured with fetal rat brain aggregates, invasion of fetal rat brain aggregates was significantly reduced. Green Fluorescent Protein (GFP) expressing parental cells and antisense transfectants were generated for detection in mouse brain tissue without any post-chemical treatment. Intracerebral injection of SNB19 stable antisense transfectants resulted in reduced tumor formation in nude mice. These results strongly support a role for cathepsin B in the invasiveness of human glioblastoma cells and suggest cathepsin B antisense may prove useful in cancer therapy.

Expression of tissue factor pathway inhibitor 2 inversely correlates during the progression of human gliomas

Protease inhibitors regulate a variety of physiological and pathological processes including angiogenesis, embryo implantation, intravascular fibrinolysis, wound healing, and tumor invasion. Tissue factor pathway inhibitor (TFPI) 2 is a Mr 32,000 Kunitz-type serine protease inhibitor that inhibits plasmin, trypsin, chymotrypsin, cathepsin G, and plasma kallikrein but not urokinase-type plasminogen activator, tissue plasminogen activator, or thrombin. In this study, we determined the relative amounts of TFPI-2 in low-, intermediate-, and high-grade human glioma cell lines and tumor tissue samples. TFPI-2 protein and mRNA levels (measured by Western and Northern blotting) were highest in low-grade glioma cells (Hs683), lower in anaplastic astrocytoma cells (SW1088 and SW1783), and undetectable in high-grade glioma cells (SNB19). Analysis of TFPI-2 protein in human normal brain and in glioma tumor tissues for TFPI-2 revealed the highest levels in normal brain, lesser amounts in low-grade gliomas and anaplastic astrocytomas, and undetectable amounts in glioblastomas. In situ hybridization of TFPI-2 mRNA with normal brain tissues revealed the greatest positivity in neurons, with moderate positivity in both glial and endothelial cells and moderate, little, or no TFPI-2 mRNA in low-grade glioma, anaplastic astrocytoma, and glioblastoma tumor tissue samples, respectively. We also found that recombinant TFPI-2 inhibited the invasiveness of SNB19 glioblastoma cells in a Matrigel assay in a dose-dependent manner. Collectively, these results suggest that TFPI-2 has a regulatory role in the invasiveness of gliomas in vitro and in vivo.

Biosynthesis and characterization of the brain-specific membrane protein DPPX, a dipeptidyl peptidase IV-related protein

Dipeptidyl peptidase IV-related protein (DPPX) was found to be preferentially expressed in the brain tissue. We isolated two rat cDNA clones encoding DPPX-S and DPPX-L from a brain cDNA library, of which DPPX-L had a longer sequence at the NH2 terminus. The biosynthesis of DPPXs was examined in both in vitro and in vivo systems. In the cell-free translation system, DPPX-S and DPPX-L were synthesized as 93-kDa and 97-kDa forms, respectively, which are in good agreement with the molecular masses estimated from their primary structure. In COS-1 cells transfected with the cDNAs, DPPX-S and DPPX-L were initially synthesized as 113-kDa and 117-kDa forms, respectively, with high-mannose type oligosaccharides, which were then converted to 115-kDa and 120-kDa forms, mostly with the complex-type sugar chains. Immunofluorescence-microscopic observations confirmed that both DPPXs were expressed on the cell surface. DPPXs were found to have no enzyme activity of DPPIV, even when they were mutated to have the consensus active-site sequence Gly-X-Ser-X-Gly for serine proteases. Immunoblot analysis of samples prepared from various rat tissues demonstrated that DPPX-S, but not DPPX-L, was detectable only in the brain tissue. These results indicate that, of the two isoforms, DPPX-S is preferentially expressed in the brain tissue as the surface glycoprotein without protease activity, although its function remains unknown at present.

Selective suppression of matrix metalloproteinase-9 in human glioblastoma cells by antisense gene transfer impairs glioblastoma cell invasion

Increased expression of matrix metalloproteinases (MMPs) has been associated with human glioblastoma tumor progression. In this study, we sought to down-regulate MMP-9 expression by stably transfecting a high-grade glioblastoma cell line with a plasmid vector capable of expressing an antisense transcript complementary to a 528-bp segment at the 5' end of human MMP-9 cDNA. Stable transfectants were obtained through selection with G418. Of the clones transfected with vector, sense, and antisense constructs, Northern blotting, Western blotting, and gelatin zymography showed that MMP-9 expression was significantly reduced only in the antisense-transfected cells. A Matrigel invasion assay revealed marked reductions in invasiveness for the antisense clones relative to the parental, vector, and sense clones. Cocultures of tumor spheroids and fetal rat brain aggregates showed that the antisense-transfected stable clones showed no invasion of the rat brain aggregates; in contrast, 90% of the parental, vector, and sense clones invaded the rat brain aggregates. Intracerebral injection of antisense stable transfectants in nude mice produced no tumors or very small tumors, but intracerebral injection of parental or vector clones did produce tumors. These results suggest that MMP-9 expression is essential for the invasiveness of glioblastoma cells.

Non-tumorous enhancement caused by cholecystic venous inflow shown on biphasic CT hepatic arteriography: comparison with hepatocellular carcinoma

The haemodynamics in non-tumorous abnormalities on CT arterial portography (CTAP) owing to cholecystic venous direct inflow to the liver were compared with the haemodynamics in hepatocellular carcinoma. 53 patients who simultaneously underwent CTAP and CT during hepatic arteriography (CTHA) to detect hepatocellular carcinoma had the late phase added to CTHA. Changes in size, shape and pattern of 47 non-tumorous enhancement abnormalities on the liver around the gall bladder or in the dorsum of segment IV between the early and late phases on biphasic CTHA as well as of 60 tumorous lesions were determined. Enhancement on biphasic CTHA was seen in all 47 lesions with a non-tumorous portal defect (early phase alone, n=8; late phase alone, n = 3; both, n = 36). In these 47 lesions, the size and the shape of enhancement changed in 63.8% and 51.1%, respectively, between the early and late phases on CTHA; the pattern of enhancement did not change in 72.3%. On the other hand, the size of enhancement on biphasic CTHA changed in only 16.7% of 60 tumours, and the shape in only 5%, although the enhancement pattern changed in a large proportion (80%). In conclusion, owing to the difference in haemodynamics, non-tumorous abnormalities caused by cholecystic venous inflow and tumours are clearly delineated on biphasic CTHA. Thus, adding the late phase to previous single phase CTHA (i.e. performing biphasic CTHA) is useful in differentiating the two entities.

Downregulation of the urokinase-type plasminogen activator receptor through inhibition of translation by antisense oligonucleotide suppresses invasion of human glioblastoma cells

We previously showed that downregulation of the urokinase-type plasminogen activator receptor (uPAR) in the SNB19 human glioblastoma cell line by the stable transfection of a plasmid expressing a 300 bp antisense sequence to the 5' end of the uPAR gene produced a decrease in the amount of target mRNA. In a more recent study, we found that adenovirus-mediated transduction (Ad-uPAR) of the same uPAR antisense gene construct in SNB19 cells also downregulated uPAR protein levels. We report here that Ad-uPAR-transfected SNB19 cells produced the same amounts of target uPAR mRNA but significantly less protein by in vitro translation and by in situ [35S] labeling compared to Ad-CMV vector-transfected and mock-transfected cells. This antisense construct also inhibited glioblastoma cell invasion confirming previous results. We conclude that downregulation of uPAR by this antisense gene construct results from inhibition of protein translation.

A novel role for the urokinase-type plasminogen activator receptor in apoptosis of malignant gliomas

Glioblastomas express more urokinase-type plasminogen activator receptor (uPAR) than do low-grade gliomas and normal brain tissue. We previously showed that downregulation of uPAR through the transfection of SNB19 cells with an antisense cDNA construct corresponding to 300 bp of the 5' end of the human uPAR gene inhibited tumor cell invasion in vitro and tumor formation in vivo. Here we sought to determine whether uPAR is necessary for cell survival and whether the inhibition of tumor formation in nude mice is due to apoptosis of intracerebrally injected SNB19 cells. Apoptosis measured by DNA fragmentation were higher in the brains of animals injected with the antisense stable transfectants than in those injected with the parental cells. Moreover, the increase in apoptotic cell death in vitro was associated with increased expression of apoptotic protein BAX in antisense clones compared to controls. To our knowledge, this is the first report of uPAR playing a novel role in cell survival in human gliomas.

Neuroendoscopic approach to tectal tumors: a consecutive series

OBJECT

The authors report a consecutive series of 10 patients who presented with signs and symptoms caused by tectal tumors. Clinical findings, radiographic features, neuroendoscopic management strategies, and histological findings are reported and discussed.

METHODS

Since January 1990, 11 neuroendoscopic procedures were performed in 10 patients who harbored tectal tumors. The patients were followed for an average of 5 years (range 2 months-11 years), and a retrospective study was conducted in which case notes, radiological findings, operative notes, and histopathological findings were assessed. Magnetic resonance (MR) imaging was performed, and the images were used to classify patients into three groups: those with hypertrophy of the tectum in whom isointensity appeared on T1-weighted images (Group 1); those with a tectal tumor occupying the cerebral aqueduct in whom decreased signal intensity appeared on T1-weighted images, as well as no enhancement after gadolinium administration (Group 2); and those with a tectal tumor in whom mixed signal intensity and conspicuous evidence of contrast enhancement appeared on T1-weighted images (Group 3). The results of histological examination were consistent with MR imaging features: in Group 1, glial tissue or gliosis; in Group 2, benign astrocytoma; and in Group 3, malignant astrocytoma. Cerebrospinal fluid diversion was the only surgical treatment that provided relief from obstructive hydrocephalus. One patient in Group 3 underwent radiotherapy and subsequent partial tumor removal under neuroendoscopic guidance. Thereafter, the tumor remained in decline. All patients had normal intellectual status after undergoing surgery in which a neuroendoscope was used.

CONCLUSIONS

Neuroendoscopic procedures can provide histological diagnosis, define the tumor-midbrain interrelationship, and be highly effective in treating obstructive hydrocephalus and in removing tectal tumors. This procedure may receive clinical application as a new management strategy for tectal glioma.

Erythropoietic protoporphyria with fatal liver failure

A 33-year-old woman with a history of photosensitivity, persistent abdominal pain, and liver dysfunction was admitted to our department because of abdominal pain and progression of liver dysfunction. On admission, levels of protoporphyrin and coproporphyrin within erythrocytes were markedly increased. Autofluorescent erythrocytes were also detected, leading to a diagnosis of erythropoietic protoporphyria. A liver biopsy specimen revealed cirrhosis with dark brown granules filling hepatocytes, bile canaliculi, and bile ductules. Transfusion of washed erythrocytes, hemodialysis, and administration of cholestyramine and beta-carotene transiently improved levels of porphyrins and liver function. The patient died of rupture of esophageal varices followed by multiple organ failure. However, the treatments were believed to have extended survival.

Concurrent three dimensional neuroendoscopy: initial descriptions of application to clinical practice

Applications of endoscopic technique neurosurgery are becoming increasingly popular as greater evidence of the safety and efficacy of these techniques is reported. Nevertheless, significant technical limitations need to be solved before neuroendoscopy can achieve widespread popularity. One limitation is the surgeon's difficulties in becoming anatomically oriented in a two-dimensional (2-D) environment. The lack of appropriate visual cues to orient oneself in three-dimensional (3-D) space makes relatively simple anatomical regions difficult to navigate. The authors describe an endoscopy system that allows for stereoscopic visualization during minimally invasive procedures and that acts as an adjunct to conventional open craniotomies. Four cases are described in which stereoendoscopy was used as either a primary means of visualization or as an adjunct to the operating microscope in conventional open neurosurgical procedures. The authors believe that stereoendoscopic vision is a significant advance in endoscope technology and will play a large role in the popularization of minimally invasive techniques in neurosurgery.

[alpha-thalassemia accompanied with Gilbert's syndrome]

A 15-year-old boy was admitted to our hospital because of microcytic hypochromic erythrocytosis and hyperbilirubinemia in October 1996. The laboratory findings were RBC: 597 x 10(4)/microliter, Hb: 13.1 g/dl, Ht: 40.8%, MCV: 70fl, MCH: 22pg, total bilirubin: 3.2 mg/dl (indirect: 2.2 mg/dl), s-Fe: 99 micrograms/dl, and ferritin: 25 ng/ml. Routine liver function tests were normal. There were no findings of hemolysis except for an increase in serum indirect bilirubin and reticulocytes. Decreased erythrocyte osmotic fragility was observed. The patient's mother and sister also showed microcytic hypochromic erythrocytosis. PCR analysis of genomic DNA from this patient, his mother, and his sister confirmed the diagnosis of the alpha-thalassemia trait. However, the bilirubin-UDP-glucuronosyltransferase 1 (B-UGT 1) gene mutation and the findings of the fasting test indicated the simultaneous presence of Gilbert's syndrome. The association of these two diseases in the same patient appears to be rare, especially in Japan because of the low incidence of thalassemia in this country. We concluded that the hyperbilirubinemia was caused by decreased bilirubin clearance, not by increased erythrocyte destruction.

Leiomyosarcoma of the inferior vena cava. Resection and reconstruction of the renal vein using the gonadal vein

We succeeded in surgically resecting a leiomyosarcoma of the inferior vena cava (IVC), which originated at the confluent portion of the right renal vein (RRV), together with the IVC and RRV, and also were able to preserve the right kidney by reconstructing the RRV with end-to-end anastomosis using the right gonadal vein. A good blood flow of the reconstructed RRV was thereafter confirmed by color Doppler ultrasonography, and the renal function was also satisfactory. This new procedure, a reconstruction of the RRV using the gonadal vein, has not been previously reported, but is considered to be an easy and effective method which enables the surgeon to preserve the normal right kidney.

Expression and distribution of CC chemokine macrophage inflammatory protein-1 alpha/LD78 in the human brain

Macrophage inflammatory protein (MIP)-1 alpha, also known as LD78, is a member of a family of chemokines which recruit leukocytes to sites of inflammation. We have shown by Northern blot analyses that MIP-1 alpha mRNA is expressed in several human tissues, including brain. To explore MIP-1 alpha distribution in brain tissue, we immunohistochemically examined brain tissues from 13 neuropsychiatric patients. Glial cells in the white matter of brain tissues from four patients with schizophrenia and one with manic depressive illness were MIP-1 alpha positive. Glial cells in the cortex from these patients were negative, except in one patient with schizophrenia in whom neurones as well as glial cells in the cortex stained positively for MIP-1 alpha. In situ hybridization showed that MIP-1 alpha mRNA was expressed in both neurones as well as glial cells in this patient. These results suggest a heterogeneous distribution of MIP-1 alpha in human brain.

[A case of internal supravesical hernia]

We report a case of internal supravesical hernia. A 74-year-old male with complaint of abdominal pain underwent an operation for small intestinal obstruction due to its incarceration into the internal supravesical hernia. Retrospectively, the preoperative abdominal CT film showed the relation of the incarcerated intestine, the urinary bladder, and the middle umbilical ligament. This is the first case of the internal supravesical hernia in which the preoperative CT had taken and it will contribute to the preoperative correct diagnosis in the future.

Fibromuscular dysplasia of the visceral arteries

Fibromuscular dysplasia (FMD) commonly involves the renal and carotid arteries. However, visceral arterial involvement is rare. We report a 39-yr-old male who developed ischemic bowel disease twice (once in the jejunal artery and once in the sigmoid artery) as a result of FMD. First ischemic change occurred in the sigmoid colon with manifestation of melena and abdominal pain, and the second occurred in the jejunum, with severe abdominal pain and intestinal stenosis. Angiography revealed the "string of beads" appearance, characteristic of FMD, in those two arteries responsible for the ischemic lesions. Fasting therapy with intravenous hyperalimentation improved both lesions, but secondary stenosis caused by ischemia occurred in the jejunum. Surgical resection of the stenotic jejunum was required. Although the abnormal arteries that had been imaged as a "string of beads" on angiography were not resected, the postoperative course has been uneventful and satisfactory.

Duplication of the gallbladder with advanced adenocarcinoma: diagnostic value of MRI and angiography

We present a very rare case of duplicated gallbladder in which the accessory gallbladder was involved by advanced adenocarcinoma with stones. In this case, MRI was the most useful modality in revealing the cystic formation of the accessory gallbladder with packed stones beside the main gallbladder. Additionally, celiac angiography demonstrated the unusual form of the intrahepatic artery which enveloped the cystic tumor, that might be a diagnostic characteristic of accessory gallbladder.

The radiographic restoration of the ventricular system after third ventriculostomy

Ten adult patients were treated by third ventriculostomy for idiopathic aqueductal stenosis. Idiopathic aqueductal stenosis was diagnosed according to MR imaging; aqueductal stenosis secondary to tumor, hemorrhage, and/or infection was excluded. Following a third ventriculostomy under a flexible neuroendoscope, all patients were reviewed at 1, 3, 6, 12, and 24 months, and MR images with ventricular measurements were repeated for evaluation of the radiographic restoration of the ventricular system. The ventricular structures arranged in order of restoration were the size of the III ventricle, the upward deviation of the brain stem, and the size of the lateral ventricle in response to third ventriculostomy. The restoration of the whole ventricle steadied within two years. Our results contribute new information regarding restoration of the ventricular system under aqueductal stenosis and produce evidence that third ventriculostomy is a reasonable treatment based upon the patient's physiological condition.

Right or left trisegment portal vein embolization before hepatic trisegmentectomy for hilar bile duct carcinoma

BACKGROUND

Percutaneous transhepatic embolization of the right portal vein plus the left medial portal branch (R3-PE) and the left portal vein plus the right anterior portal branch (L3-PE) is not well described.

METHODS

Four patients with far advanced carcinoma of the hepatic hilus underwent R3-PE (n = 1) or L3-PE (n = 3) as preoperative management for right hepatic trisegmentectomy or left hepatic trisegmentectomy. The portal vein embolization was performed with the ipsilateral approach through the right anterior portal branch.

RESULTS

In all patients the embolizations were successful without complications. Volumetric study with computed tomography showed sufficient hypertrophy of the nonembolized hepatic segments. Three of the four patients eventually underwent trisegmentectomy. The postoperative courses in two of the patients were uneventful. The remaining patient suffered from posthepatectomy liver failure but recovered.

CONCLUSIONS

R3-PE or L3-PE is advisable as preoperative management for trisegmentectomy and appears effective for increasing the safety of the operation. This embolization is achievable only through the ipsilateral approach.

Changes in hepatic lobe volume in biliary tract cancer patients after right portal vein embolization

Changes in lobar volume of the liver and in total hepatic function were studied in 19 patients with biliary tract cancer who underwent right portal vein embolization as preoperative management for extensive liver resection. Computed tomography (CT) was performed to estimate liver volume before and approximately 11 days after embolization. An indocyanine green (ICG) test was performed before and 11 to 13 days after embolization. The calculated volume of the right lobe decreased from 761 +/- 181 cm3 to 625 +/- 110 cm3 11 days after embolization (P < .0001), whereas the volume of the left lobe increased from 420 +/- 94 cm3 to 555 +/- 110 cm3 (P < .0001). Thus, portal embolization produced a gain in left lobe volume of 136 +/- 62 cm3 and an almost equivalent loss in right lobe volume. The hypertrophy ratio of the left lobe, expressed as percentage of postembolization volume of the left lobe to preembolization size, of the 5 patients with diabetes mellitus (DM) was lower than that of the 14 patients without diabetes (116.7 +/- 6.3% vs. 140.4 +/- 18.4%; P < .005). The ICG disappearance rate in 16 patients improved from 0.163 +/- 0.034 to 0.177 +/- 0.027 (P < .05). The improvement was especially evident in 9 of 14 post-jaundice patients, although the rate decreased slightly in 2 patients without jaundice. We conclude that right portal vein embolization can produce a compensatory hypertrophy of the left lobe within 11 days without seriously affecting hepatic function. In diabetic patients, however, a longer interval between embolization and operation may be needed to achieve sufficient hypertrophy of the left lobe.

Changes in hepatic lobe volume in biliary tract cancer patients after right portal vein embolization

Changes in lobar volume of the liver and in total hepatic function were studied in 19 patients with biliary tract cancer who underwent right portal vein embolization as preoperative management for extensive liver resection. Computed tomography (CT) was performed to estimate liver volume before and approximately 11 days after embolization. An indocyanine green (ICG) test was performed before and 11 to 13 days after embolization. The calculated volume of the right lobe decreased from 761 +/- 181 cm3 to 625 +/- 110 cm3 11 days after embolization (P < .0001), whereas the volume of the left lobe increased from 420 +/- 94 cm3 to 555 +/- 110 cm3 (P < .0001). Thus, portal embolization produced a gain in left lobe volume of 136 +/- 62 cm3 and an almost equivalent loss in right lobe volume. The hypertrophy ratio of the left lobe, expressed as percentage of postembolization volume of the left lobe to preembolization size, of the 5 patients with diabetes mellitus (DM) was lower than that of the 14 patients without diabetes (116.7 +/- 6.3% vs. 140.4 +/- 18.4%; P < .005). The ICG disappearance rate in 16 patients improved from 0.163 +/- 0.034 to 0.177 +/- 0.027 (P < .05). The improvement was especially evident in 9 of 14 post-jaundice patients, although the rate decreased slightly in 2 patients without jaundice. We conclude that right portal vein embolization can produce a compensatory hypertrophy of the left lobe within 11 days without seriously affecting hepatic function. In diabetic patients, however, a longer interval between embolization and operation may be needed to achieve sufficient hypertrophy of the left lobe.

[Effect of biapenem (L-627) on fecal flora in gnotobiotic mice and children]

Biapenem (L-627), a novel injectable carbapenem antibiotic, was studied with regard to its effect on mice inoculated with four types of bacteria and on the intestinal flora of pediatric patients. L-627 was given i.m., 40 mg/kg once daily for 5 consecutive days, to mice inoculated enterically with four types of bacteria (Escherichia coli, Enterococcus faecalis, Bacteroides fragilis, and Bifidobacterium breve). Except for a mild decrease in E. coli, there were no major fluctuations in viable bacterial counts in the feces during the treatment. Five children with bacterial infections (3 boys and 2 girls; ages: 1 month to 7 years and 7 months; body weights 4.62-21.8 kg) were given L-627 at 6.0 to 11.7 mg/kg 3 times daily for 7 to 11 days. Among aerobes, although Enterobacteriaceae such as E. coli tended to decrease remarkably in all patients, there was no major change in Enterococcus. Consequently, total aerobe counts did not change significantly in any patient. Among anaerobes, Bifidobacterium, Bacteroides, and Eubacterium, which are the predominant organisms in infants, decreased remarkably in some patients. One of the patients showed a marked decrease in total anaerobe count associated with a change in fecal characteristics (diarrhea). Glucose nonfermenting Gram-negative bacilli or fungi did not become predominant organisms in any patient. Recovery from these changes in the intestinal flora was noted promptly after terminating L-627 treatment. L-627 was detected in the feces of 4 patients during treatment. The fecal concentration ranged from 0.24 to 2.22 micrograms/g. Clostridium difficile was not detected in any patient. Although C. difficile D-1 antigen was observed in 2 patients, it bore no relationship to fecal properties. The results indicated that L-627 had relatively few effects on the intestinal flora compared to other new beta-lactam antibiotics.

[Histological observations of hydroxyapatite thermal decomposition product injected into the femur of ovariectomized rats]

Hydroxyapatite thermal decomposition product is a mixture of alpha-tricalcium phosphate and tetracalcium phosphate, which is hardened by mixing with water in vitro. This decomposition product mixed with water solution (HAp cement) was injected into the femur of 24 Wistar strain rats at 36 weeks after ovariectomy at 8 weeks of age. Age-matched rats were used as a control. The diaphysis of the femur was observed histologically at 4, 8 and 12 weeks after injection. At 4 weeks after the injection, new bone formation was seen only around the HAp cement in the control group, while new bone formation was observed in direct contact with the HAp cement in both the ovariectomized and the control groups after 8 weeks. In histomorphometrical analysis, the area of new bone bonded to the HAp cement and the ratio of the length of the HAp cement-bone interface to the circumference of the HAp cement increased with time in both groups. However the area and the ratio were significantly smaller in the ovariectomized group than in the control group.

Doppler analysis of hepatic blood flow predicts liver dysfunction after major hepatectomy

In 17 consecutive patients who underwent major hepatic resection, 9 of whom with combined resection of the gastrointestinal tract or the pancreatic head (or both), postoperative hepatic blood flow was investigated. In this study, the patients were classified into two groups according to their postoperative serum total bilirubin level: Group A comprised 7 patients with the level higher than 7 mg/dl for more than 1 week postoperatively, and group B comprised 10 patients who did not meet this criterion. For 2 weeks after surgery, the portal blood flow velocity, the hepatic artery resistive index (RI) calculated from the changes in Doppler frequency shifts, and the hepatic venous blood flow velocity were measured intermittently using color Doppler ultrasonography. Liver volume was assessed by computed tomography to provide the restoration. Significant differences in portal blood flow velocity and hepatic artery RI were noted between the two groups from the third postoperative day. In group A the portal blood flow velocity decreased below the preoperative value, and the hepatic artery RI increased above 0.75. In contrast, group B showed high portal blood flow velocity and low hepatic artery RI. In both groups the RI correlated significantly with the total bilirubin level (r = 0.74; p < 0.0001), and the growth rate of the remnant liver was proportional to the mean postoperative portal blood flow velocity (r = 0.70; p = 0.016). We concluded that measurement of the portal blood flow velocity and hepatic artery RI can be useful for predicting postoperative liver dysfunction and liver regeneration after major hepatic resection.

[Influence of S-1108 on intestinal bacterial flora]

The effect of S-1108, a new oral cephem antibiotic, on intestinal bacterial flora was studied in tetra-contaminated mice and pediatric patients. S-1108 in a fine granular form was administered at a dose of 15 mg/kg once a day for 5 consecutive days to mice infected with Escherichia coli, Enterococcus faecalis, Bacteroides fragilis and Bifidobacterium breve. The viable fecal bacterial cell count of each of these 4 species of bacteria was slightly reduced in 5 days after the start of the drug administration. Five boys (weighing 12.0 to 42.0 kg) with bacterial infections were entered into this pediatric study. Their ages ranged from 2 years 4 months to 9 years 3 months. S-1108 (fine granules) was administered at a dose of 2.3 to 6.0 mg/kg, 3 times a day for 5 to 11 days. Cell counts of primary aerobes, anaerobes and total anaerobic cells decreased markedly in three patients, but in the remaining two patients the total number of aerobic and anaerobic cells did not change appreciably. Glucose-nonfermentating Gram-negative rods did not become predominant during the period of S-1108 administration. Candida became predominant in the three patients in whom the other bacteria had markedly decreased. Counts of predominant aerobic and anaerobic bacteria decreased markedly during the regimen in 3 out of 5 cases. S-1006 was detected in stools of the 3 cases at concentrations ranging from 235 to 516 micrograms/g during the administration of S-1108. Intestinal bacteria that produce beta-lactamase were not present in the feces of any of the patients. Based on these results, S-1108 (fine granules) appears to have relatively little effect on intestinal bacterial flora similarly to other new oral cephems. Because of individual differences, however, the drug may be excreted in the feces at high concentrations, and this would result in changes in intestinal bacterial flora. Therefore, attention must be given to fecal drug concentrations.

An observation of the third ventricle under flexible fiberoptic ventriculoscope: normal structure

The third ventricle, which is deeply seated in the center of the brain, is one of the most inaccessible regions from which to obtain information before surgery. A new flexible fiberoptic endoscope for examination of the ventricles is presented herein. The main advantages of this new device over existing fiberoptic instruments are the extended flexibility of the tip and its small diameter. Using this endoscope, one can observe the third ventricle in situ in patients with hydrocephalus associated with various lesions. The neural and vascular structures in the inner wall of the third ventricle are also illustrated.

[The influence of cefprozil on intestinal bacterial flora]

Cefprozil (CFPZ, BMY-28100), a new oral cephalosporin antibiotic, was studied for its effect on the intestinal bacterial flora in pediatric patients. The subjects were children admitted for infections (2 males and 2 females, 9 months to 6 years 3 months old, weighed 4.3 to 19.0 kg). CFPZ granule was orally administered at a dose between 10.0 to 11.6 mg/kg, 3 doses daily, over 4 to 14 days. The feces from these children were collected before, during and after administration, and bacteria were identified and counted. CFPZ concentration, beta-lactamase activity were also assayed. Bacterial flora in feces during CFPZ administration showed some variance, but no significant change was observed in main aerobes and anaerobes. And in no case, glucose nonfermentative Gram-negative bacilli or fungi were found dominant. beta-Lactamase activity was positive in the feces in all cases. CFPZ concentrations were not detectable in feces before, during and after administration. The above results suggest that CFPZ is a drug with little influence on the intestinal bacterial flora in children.

[Effect of meropenem on fecal flora in children]

Meropenem (MEPM, SM-7338), a novel parenteral carbapenem antibiotic, was examined for its effect on intestinal flora in children. Seven children with infectious diseases (3 male and 4 female children of age's ranging from 4 months to 8 years and 9 months weighing from 7.3 to 23.0 kg) were treated with MEPM at doses ranging 10.3 to 40.5 mg/kg 3 or 4 times a day for 6 to 12 days. Before, during and after the treatment, identities and numbers of various bacteria contained in 1 g of feces were determined and fecal beta-lactamase activity and Clostridium difficile D-1 antigen were also assayed. Changes in fecal flora during MEPM treatment was somewhat different depending on cases. Regarding Enterobacteriaceae among aerobes, all of 7 cases exhibited moderate or pronounced reductions in Escherichia coli. Some of the cases exhibited the tendency to increase in Klebsiella oxytoca. Enterobacter cloacae and Citrobacter freundii. E. coli which was reduced during the treatment increased rapidly after the treatment in 5 out of 7 cases, and the initial bacterial counts were restored. Diverse strains were observed within the genus Enterococcus, while the overall bacterial counts of this genus exhibited the tendency to increase during the treatment. As a result, no significant change in total aerobe count was observed in any case except 1 case where Enterococcus count was somewhat reduced. Among anaerobes, major bacteria such as Bacteroides, Bifidobacterium, Eubacterium and Peptococcaceae exhibited tendencies to decrease in some cases during the antibiotic treatment. Two infants and 1 child exhibited significant decreases in total anaerobe counts. In most of the cases, such changes in major anaerobes were transient and bacterial counts recovered to their initial values rapidly after completion of the treatment. In no cases, glucose non-fermentative Gram-negative bacilli or fungus became predominant. Although C. difficile D-1 antigen was observed in 4 cases, its changes had no relationship with characteristics of feces. C. difficile was not detected in any of the cases. MEPM was detected in feces in 4 cases being treatment, in concentrations ranging from 0.35 to 66.0 micrograms/g. Fecal MEPM levels were very low except in 1 case in which beta-lactamase was negative. From these results, effects of MEPM on intestinal flora in children were relatively minor compared to other new beta-lactam drugs. However, a care should be taken to minimize diarrhea and bacterial turnover when a prolonged use of the antibiotic, was practiced because of potential significant effects on intestinal flora.

[The influence of cefdinir on the intestinal bacterial flora]

The influence of cefdinir (CFDN), a new oral cephalosporin, on the intestinal bacterial flora was studied in tetra-contaminated mice and in pediatric patients. CFDN in fine granules was administered at a dose of 10 mg/kg once a day for 5 consecutive days to mice contaminated with 4 different species of organism: Escherichia coli, Enterococcus faecalis, Bacteroides fragilis and Bifidobacterium breve. No remarkable changes were observed in the fecal viable cell counts except that decreases in E. coli counts were observed on the day 3 to 5 after starting administration. The subjects in pediatric study were 7 children with infections, 3 boys and 4 girls, with their ages from 6 months to 12 years 7 months. Their body weights ranged from 5.5 to 29.2 kg. CFDN fine granules was administered at each dose of 3.0 mg/kg to 3.7 mg/kg, 3 times a day for 4 to 14 days. During the administration of CFDN, some variations were observed in the pattern of changes in the fecal bacterial flora between subjects. Although Enterobacteriaceae and total counts of anaerobes were markedly decreased in 2 cases, total counts of aerobes were unchanged in the 2 cases, whereas main aerobes and anaerobes except enterococci hardly varied in the other cases. There was no case in which glucose non-fermenting Gram-negative rods and fungi became predominant species continually. Although Clostridium difficile and C. difficile D-1 antigens were detected in 1 and 4 cases, respectively, no relationship was found between the number of C. difficile and the characteristics of the feces. With regard to the drug sensitivities of bacteria isolated from feces before and after administration of CFDN, higher levels of resistance were found in some bacteria such as Enterococcus and Bacteroides during or after administration than before administration. CFDN was detected in fecal samples from 2 cases during administration with concentrations ranging between 0.99-254 micrograms/g. High value of CFDN was found in a case with low beta-lactamase activity in feces, in which marked decrease of Enterobacteriaceae and total counts of anaerobes was observed. The above results suggest that CFDN is considered to be a drug with relatively small influence on the intestinal bacterial flora. But as high concentrations of drugs were detected in feces under some circumstances, our attention will be required. Particular care is also required for the occurrence of diarrhea and microbial replacement during continuous, long-term administration of the drug.

[Pharmacokinetics and clinical efficacy of flomoxef in neonates]

Clinical pharmacology and efficacy of flomoxef (FMOX) in neonates were investigated. And the following results were obtained. 1. Mean serum concentrations of FMOX at 30 minutes after administration were 24.3 micrograms/ml, 47.6 micrograms/ml, and 85.8 micrograms/ml at doses of 10 mg/kg, 20 mg/kg, and 40 mg/kg administered, respectively. 2. Mean serum half-lives of FMOX were 3.4 hours in 0-3 day-old neonates, and 2.6 hours in 4 day-old or older subjects. 3. A dose response was evident among different dose groups given 10 mg/kg, 20 mg/kg, and 40 mg/kg. 4. Urinary recovery rates of FMOX in the first 6 hours after administration ranged between 12.8 and 51.1%. 5. FMOX was effective in 7 out of 8 cases in which causative pathogens were identified. 6. Diarrhea was observed in 1 case as a side effect of the drug, but the symptom was relieved soon after the completion of the treatment. There was no case in which any abnormal laboratory results were observed. 7. FMOX has a broad spectrum of activities against Gram-positive and Gram-negative aerobes and anaerobes. It is stable against most of beta-lactamases. It was demonstrated to be highly effective in our study, and yet without any serious side effects. FMOX is therefore considered to be one of the useful agents of the first choice for the treatment of bacterial infections such as sepsis and urinary tract infections in neonates and infants.

Preliminary Study on Auxiliary Value of Serum Basic Fetoprotein in Diagnosing Lung Cancer

To characterize basic fetoprotein (BFP) as a new tumor marker, we measured serum levels of BFP and 5 other tumor markers (CA19-9, CEA, NSE, SCC, and TPA) concomitantly in 65 patients with lung cancer, 57 patients with benign pulmonary disease, and 40 healthy volunteers. The sensitivity of BFP was 43%, the specificity 82% and the accuracy 61%. The positivity increased in relation to stage of the disease. There was no correlation between positivity of BFP and histologic type. On the whole, BFP appeared to be analogous to TPA in terms of broad spectrum and to have an auxiliary value in diagnosing lung cancer.

[Influence of cefodizime on intestinal bacterial flora]

Effects of cefodizime (CDZM), a new injectable cephem antibiotic, on the intestinal bacterial flora were studied in tetra-contaminated mice and in pediatric patients. CDZM was intramuscularly administered at a dose of 100 mg/kg once a day for 5 consecutive days to mice contaminated with 4 different species of organisms: Escherichia coli, Enterococcus faecalis, Bacteroides fragilis and Bifidobacterium breve. For 3 species except E. faecalis, bacterial populations in feces were markedly reduced after the start of the treatment. Subjects in the pediatric study were 5 children with bacterial infections (4 boys and 1 girl) at ages from 7 months to 9 years 6 months and with their body weights ranging from 7.6 kg to 51.1 kg. CDZM was intravenously administered at a dose of 9.7 mg/kg to 23.0 mg/kg 4 times a day for 5 to 15 days. Although some variations in the fecal bacterial flora were noticed among these subjects during the treatment, populations of main aerobes and anaerobes such as Enterobacteriaceae, Enterococcus, Bacteroides, Bifidobacterium and Eubacterium decreased markedly in most cases. Glucose non-fermenting Gram-negative rods and fungi tended to increase during or after the administration of CDZM, and they were the most predominant species in some cases. Although these changes tended to return to predosing states after the cessation of the treatment with CDZM, attention must be paid to possible occurrences of diarrhea, superinfection or bleeding tendency when treatment with the drug is continued for long periods of time. Fecal concentrations of CDZM considered to be closely related to the changes of the intestinal bacterial flora showed pretty high values in all cases.