Leukemic-phase mucosa-associated lymphoid tissue lymphoma

A 78-year-old man presenting with leukocytosis was admitted to our hospital. The patient was asymptomatic and showed no lymphadenopathy. Peripheral blood flow cytometry revealed a leukemic-phase B-cell lymphoma with medium-to-large abnormal cells with reticulum. Positron emission tomography/computed tomography revealed abnormal uptake in the right orbit, bone marrow, and spleen. We performed immunological staining and fluorescence in situ hybridization on tissues extracted from the right orbit and bone marrow, which led to the diagnosis of mucosa-associated lymphoid tissue (MALT) lymphoma. Polymerase chain reaction analysis of immunoglobulin heavy chain rearrangements in the right orbital mass and bone marrow suggested that they were identical clones. Based on these collective findings, the diagnosis of leukemic-phase MALT lymphoma was confirmed, with sites of involvement including the bone marrow, peripheral blood, right orbit, and spleen. This is a highly rare case of leukemic MALT lymphoma.

Development of a New Method for Simultaneous Quantitation of Plasma Concentrations of Voriconazole and Voriconazole N-Oxide Using Column-Switching LC-MS/MS and Its Application in Therapeutic Drug Monitoring

Background

Voriconazole therapy for fungal infections usually continues for several years and is often administered on an outpatient basis. Maintaining the voriconazole plasma concentration in the therapeutic range is highly important for effective therapy; however, it is difficult to obtain sufficient information to assess the voriconazole concentration in outpatients. Therefore, we developed a method to simultaneously measure the plasma concentrations of voriconazole and its major metabolite, voriconazole N-oxide, to obtain rapid results after outpatient blood collection and before medical consultation and to attain a better understanding of adherence and the drug-drug interactions of voriconazole.

Methods

Fifty microliters of patient plasma was deproteinized with methanol, injected into the liquid chromatography-tandem mass spectrometry system, and purified using an online column. Separation was achieved on an InertSustain C18 column (2.1 mm id × 50 mm, 2 μm) with a mobile phase of 30:70 (0.1% formic acid in water:methanol) at a flow rate of 0.2 mL/min. Detection was performed using electrospray ionization in positive ion multiple reaction monitoring mode.

Results

The analysis time was 4 min. The calibration curve was linear, in the range of 0.1 μg/mL to 20 μg/mL for voriconazole and 0.05 μg/mL to 10 μg/mL for voriconazole N-oxide, with a coefficient of determination at R2 > 0.999.

Conclusion

There is no need to dilute the patient's plasma even if the concentration of voriconazole is near the upper limit of measurement. Furthermore, the short measurement-time could immediately inform physicians of the patient's voriconazole concentration during ambulatory medical care. Simultaneous measurement of voriconazole and voriconazole N-oxide may also be useful for the immediate adjustment of voriconazole dosage in outpatients and would help us to understand adherence or drug-drug interactions in plasma voriconazole concentrations.

Chemopreventive effects and anti-tumorigenic mechanisms of Actinidia arguta, known as sarunashi in Japan toward 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK)- induced lung tumorigenesis in a/J mouse

BACKGROUND

Previously, we reported the inhibitory effect of Actinidia arguta juice, known as sarunashi juice (sar-j) in Japan, on mutagenesis, inflammation, and mouse skin tumorigenesis. The components of A. arguta responsible for the anti-mutagenic effects were identified to be water-soluble, heat-labile phenolic compounds. We proposed isoquercetin (isoQ) as a candidate anticarcinogenic component. In this study, we sought to investigate the chemopreventive effects of A. arguta juice and isoQ on 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK)-induced lung tumorigenesis in A/J mice, and identify the possible mechanisms underlying the anti-tumorigenic effects of A. arguta.

RESULTS

The number of tumor nodules per mouse lung in the group injected with NNK and administered A. arguta juice orally was significantly lower than that in the group injected with NNK only. Oral administration of isoQ also reduced the number of nodules in the mouse lungs. As expected, the mutagenicity of NNK and 1-methyl-3-nitro-1-nitrosoguanidine (MNNG) detected using S. typhimurium TA1535 decreased in the presence of sar-j. However, NNK and MNNG mutagenicity detected using S. typhimurium YG7108, a strain lacking the O⁶-methylguanine DNA methyltransferases (ogt_ST and ada_ST) did not decrease in the presence of sar-j suggesting that sar-j may mediate its antimutagenic effect by enhancing the DNA damage repair by ogt_ST and ada_ST. Phosphorylation of Akt, with or without epidermal growth factor stimulation, in A549 cells was significantly decreased following sar-j and isoQ treatment, indicating that components in sar-j including isoQ suppressed the PI3K/AKT signaling pathways.

CONCLUSIONS

Sar-j and isoQ reduced NNK-induced lung tumorigenesis. Sar-j targets both the initiation and growth/progression steps during carcinogenesis, specifically via anti-mutagenesis, stimulation of alkyl DNA adduct repair, and suppression of Akt-mediated growth signaling. IsoQ might contribute in part to the biological effects of sar-j via suppression of Akt phosphorylation, but it may not be the main active ingredient.

Clinical course of a Japanese patient with developmental delay linked to a small 6q16.1 deletion

There is only one report of patients with developmental delay due to a 6q16.1 deletion that does not contain the SIM1 gene. A 3-year-old female showed strabismus, cleft soft palate, hypotonia at birth, and global developmental delay. Exome sequencing detected a de novo 6q16.1 deletion (chr6: 99282717-100062596) (hg19). The following genes were included in this region: POU3F2, FBXL4, FAXC, COQ3, PNISR, USP45, TSTD3, CCNC, and PRDM13.

[Haploidentical stem cell transplantation for acute myeloid leukemia associated with adult-onset Shwachman-Diamond syndrome]

A 21-year-old man presented with bone marrow failure, short stature, fatty degeneration of the pancreas on CT images, and Shwachman-Bodian-Diamond syndrome (SBDS) gene abnormalities (exon 2: c.258+2T>C and deletion of exon 3). Thus, the patient was diagnosed with Shwachman-Diamond syndrome (SDS). In the clinical course, the patient developed acute myeloid leukemia (AML). Hematopoietic stem cell transplantation from the human-leukocytic-antigen-haploidentical father of the patient was performed. The patient was conditioned with 150 mg/m² fludarabine, 6.4 mg/kg busulfan, and 4 Gy total body irradiation. Graft-versus-host disease prophylaxis included tacrolimus, micophenolate mofetil, and posttransplant cyclophosphamide. Although the patient achieved a complete remission on day 21, AML relapsed on day 434 after the transplantation. He died of sepsis. The prognosis of patients with SDS and AML is poor. Adult-onset cases must be recognized, and transplantation should be performed during bone marrow failure.

Untreated Squamous Cell Lung Carcinoma May Contribute to the Occurrence of Hemophagocytic Syndrome

A 44-year-old man presented at our hospital to be evaluated for persistent fever and dyspnea. A chest computed tomography (CT) scan showed diffuse ground glass shadows and a left hilar tumor shadow. Upon further examination, he was found to have leukopenia, thrombocytopenia, and elevated lactate dehydrogenase and ferritin levels. He was diagnosed with both squamous cell lung carcinoma by a transbronchial lung biopsy and hemophagocytic syndrome by a bone marrow biopsy. After receiving treatment with dexamethasone and etoposide, the blood test abnormalities and performance status improved. Chemotherapy for lung cancer was initiated. He had a partial response after first-line chemotherapy and thereafter underwent left upper sleeve lobectomy.

Chemopreventive effects and anti-tumorigenic mechanisms of 2,6-dimethoxy-1,4-benzoquinone, a constituent of Vitis coignetiae Pulliat (crimson glory vine, known as yamabudo in Japan), toward 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK)-induced lung tumorigenesis in A/J mice

Previously, we isolated and identified anti-mutagenic and anti-inflammatory components from Vitis coignetiae (crimson glory vine, known as yamabudo in Japan) as 2,6-dimethoxy-1,4-benzoquinone (DBQ), fertaric acid and caftaric acid. We also reported that the oral intake of a partially purified fraction from yamabudo juice (yamabudo-fr) or DBQ affords significant protection against two-stage skin carcinogenesis in mice. In this study, we found that oral intake of yamabudo-fr or DBQ affords significant protection against a tobacco-specific nitrosamine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK)-induced mouse model of lung tumorigenesis. Furthermore, we investigated the anti-tumorigenic mechanisms of yamabudo juice and DBQ. NNK is known to be a DNA-methylating and alkylating agent; thus, we investigated the anti-tumorigenic mechanisms of yamabudo juice and DBQ in relation to DNA methylation. Pretreatment with yamabudo-fr or DBQ dose-dependently decreased formation of O⁶-methylguanine and N⁷-methylguanine in DNA of the A549 human lung epithelial-like cell line treated with a methylating agent, 1-methyl-3-nitro-1-nitrosoguanidine. Yamabudo juice and DBQ inhibited the mutagenicity of NNK in the Ames test using Salmonella typhimurium TA1535 but not S. typhimurium YG7108, an alkylguanine DNA alkyltransferase-deficient strain (same as TA1535 but Δada_st::Km^r, Δogt_st::Cm^r). Yamabudo juice and DBQ might accelerate the repair of DNA damage caused by NNK and reduce DNA damage to cells. We also investigated the effects of yamabudo juice and DBQ on signaling pathways in A549 cells. With or without epidermal growth factor stimulation, phosphorylation of Erk1/2, Akt and Stat3 in A549 cells was significantly decreased in the presence of yamabudo juice or DBQ, indicating that yamabudo juice and DBQ suppressed PI3K/AKT, MAPK/ERK and JAK/STAT3 signaling pathways. These results suggest that both initiation and growth/progression steps in carcinogenesis, especially anti-oxidant effects, stimulation of repair of alkyl DNA adducts and suppressed growth signaling pathways are potential anti-tumorigenic targets of yamabudo juice and DBQ in NNK-induced lung tumorigenesis.

[Leukemic cell kinetics of APL with a novel complex variant t (12;17;15)(p13;q21;q22)]

A 69-year-old woman with leukocytopenia and thrombocytopenia was referred to our hospital. Her bone marrow comprised 70.5% abnormal promyelocytes that were positive for myeloperoxidase/CD33/CD117 and CD13 (dim) and negative for CD2/CD34/CD56 and HLA-DR. Chromosome analysis of the bone marrow showed t (12;17;15) (p13;q21;q22), and fluorescence in situ hybridization revealed the PML-RARA fusion signal only on the derivative chromosome 15. The patient was diagnosed with acute promyelocytic leukemia (APL) with PML-RARA and was treated using all-trans retinoic acid (ATRA). In peripheral blood (PB), PML-RARA-positive polymorphonuclear cells (PMNs) appeared on the second week and became negative on the sixth week after treatment, whereas PML-RARA-negative PMNs started to increase in number on the sixth week. Molecular remission was confirmed on the 10th week. Quantitative evaluation of the differentiated leukemic cells of APL and recovered cells from normal hematopoiesis in PB can provide useful information for a safer induction therapy. No significant difference was noted in the kinetics of the leukemic cells under ATRA treatment as well as in the clinical features between our patient without RARA-PML and those with t (15;17), which is a cytogenetic evidence for the critical role of PML-RARA in the pathogenesis of APL.

92Transcatheter aortic valve implantation improves cerebral blood flow and cognitive function in elderly patients with aortic stenosis - Brain perfusion SPECT imaging study

Background

Cognitive impairment and depression are commonly noted in elderly frail patients with severe aortic stenosis (AS). However, their mechanisms and reversibility after treatment remain remain to be examined.

Purpose

In this study, we examined whether transcatheter aortic valve implantation (TAVI) increases cerebral blood flow (CBF) in cognitive/emotional brain areas, such as the hippocampus, in the elderly patients with severe AS.

Methods

We examined consecutive 15 right-handed patients with severe AS who were eligible for TAVI (median age 83.2 years, 12 (80%) women). We evaluated the following assessments both at baseline and 3 months after TAVI. Frailty was evaluated based on Fried scale, which consists of 5 items, including gait speed, cognitive function, weight loss, exhaustion, and inactivity. Frail and pre-frail were defined as greater than 3 and 1∼2 in the scale, respectively. Cognitive and emotional status were evaluated with Logical Memory (LM) II, Mini Mental State Examination (MMSE), and geriatric depression scale (GDS). Lower LM II (less than 4 points) and MMSE (less than 24 points) and higher GDS (more than 6 points) indicate worse memory, general cognitive function, and depressive symptoms, respectively. CBF images were recorded with 99mTc single-photon emission computed tomography and were analyzed using SPM12. Briefly, CBF images were firstly normalized to the standard Montreal Neurological Institute space. Then, a voxel-wise parametric analysis was conducted between normalized CBF images at baseline and those after TAVI (P<0.005 at each voxel). Continuous variables were presented as mean ± standard error (SE). Normality was assessed using the Shapiro-Wilk test. Continuous variables were compared with the use of paired t test. Linear mixed-model analysis was performed to evaluate changes in neuropsychological tests and CBF over time.

Results

In the present study, all patients were not robust but pre-frail (47.3%) or frail (53.7%). LM II score was significantly improved at 3 months after TAVI compared with baseline (baseline, 8.7 vs. 3 months, 13.8, P<0.01) (Figure A), whereas no significant changes in MMSE or GDS scores were noted (baseline, 24.6 vs. 3 months, 25.2 for MMSE; baseline, 4.3 vs. 3 months, 4.2 for GDS). Importantly, although no patients showed clinical symptoms or signs for transient ischemic attack or stroke after TAVI, CBF in the local regions, including the right hippocampus, was significantly increased after TAVI compared with baseline (P<0.005 at each voxel) (green arrowheads) (Figure B). Furthermore, CBF in the right hippocampus were positively correlated with LM II scores (P=0.017) (Figure C).

Figure 1

Conclusions

These results provide the first evidence that TAVI improves cerebral perfusion (especially that in the hippocampus) and cognitive functions in elderly patients with severe AS.

P889Clinical significance of four-dimensional flow magnetic resonance imaging measurement of turbulent kinetic energy for hypertrophic obstructive cardiomyopathy

Purpose

The aims of this study were to investigate the relationship between TKE value and echocardiographic findings, clinical symptoms and evaluate the usefulness of 4D flow MRI to distinguish hypertrophic obstructive cardiomyopathy (HOCM) from non-obstructive HCM (HNCM).

Methods

From April 2018 to January 2019, 18 hypertrophic obstructive cardiomyopathy (HOCM) and 14 non-obstructive HCM (HNCM) patients underwent 4D flow MRI. We investigated TKE value calculated by 4D flow MRI, echocardiographic findings; left ventricular pressure gradient (LVPG), mitral regurgitation (MR) and clinical symptom.

Results

HOCM was defined by the 30 mmHg or greater of LVPG (HOCM: 87.7±47.3 mmHg, HNCM; 5.8±7.8 mmHg, p<0.001). TKE value in HOCM patients was significantly higher than HNCM (14.2±4.7 mJ vs. 9.0±4.6 mJ, p<0.001). There was a significant positive linear relationship between TKE value and LVPG (r=0.488, p=0.046). There was no significant relationship between NYHA functional class and TKE value (p=0.47) or LVPG (p=0.11). ROC curve analysis showed that optimal cut off point of TKE value between HOCM and HNCM (sensitivity=95%, specificity=62%, AUC=0.798) was 9.270 mJ. Multiple linear regression showed that there was significant association between severity of MR and combination of TKE (p=0.015) or LVPG (p–=0.012). A representative case demonstrated the significant reduction of TKE value 1 week and 3 months after alcohol septal reduction compared with that obtained before the procedure (Figure)

Conclusion

Our findings suggest that 4D Flow MRI can effectively evaluate the energy dissipation associated with LV outflow tract obstruction and TKE value is useful for identifying HOCM. TKE value also can be the novel parameter of the severity of HOCM.

Correction to: Cell dynamics during differentiation therapy with all-trans retinoic acid in acute promyelocytic leukemia

In the original publication of the article, Table 2 was published incorrectly. The column names were swapped under the column heading "Prom (%)". The correct column names are PB and BM.

[MALT lymphoma with t (X;14) (p11.2;q32) developing during the course of cutaneous leukocytoclastic angitis]

A 73-year-old man with left parotid gland swelling over 2 months was referred to our hospital in March 201X. Purpura on the lower legs had been recurrent for >20 years. Biopsy of the parotid gland demonstrated diffuse infiltration of abnormal lymphocytes that were negative for CD10 and positive for CD19, CD20, and κ-chain. The Ki-67 positivity was <10%; lymphoepithelial lesions were observed. The patient was diagnosed with extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). Chromosome analysis revealed t (X;14) (p11.2;q32), and fluorescence in situ hybridization (FISH) of metaphase spreads showed three signals of the immunoglobulin heavy chain (IGH) gene on the derivative chromosomes X and 14, besides the normal chromosome 14. CT findings of parotid glands were suggestive of Sjogren syndrome, and biopsy of the purpura on the leg demonstrated leukocytoclastic vasculitis. In the literature, only seven patients with lymphoma and t (X;14) translocation have been reported. Of these, five patients had MALT lymphoma, one had nodal marginal zone lymphoma, and one had diffuse large B-cell lymphoma. In all patients, lymphoma evolved from previous autoimmune diseases. It is suggested that MALT lymphoma with the t (X;14) translocation forms a new entity of lymphoma.

Vessel wall enhancement in the diagnosis and management of primary angiitis of the central nervous system in children

We describe two cases of primary angiitis of the central nervous system in children (cPACNS) diagnosed by vessel wall contrast enhancement on magnetic resonance imaging (MRI). Both patients developed acute cerebral infarction after fever and malaise. In patient 1, a 7-month-old boy, MRI revealed extensive cerebral infarction in the right middle cerebral artery (MCA) area and stenosis at the M1 portion of the right MCA. Oral glucocorticoid therapy was initiated. Vessel wall enhancement was ameliorated 3months after onset, and stenosis was mostly restored. Patient 2, a 5-year-old boy, suffered from cerebral infarction in the left MCA area, and stenosis was identified in the left internal carotid artery, left MCA, and left posterior cerebral artery. Although vessel wall enhancement was reduced after glucocorticoid therapy, vessel wall enhancement of left MCA re-emerged, accompanied by increased erythrocyte sedimentation rate (ESR) and, decreased cerebral blood flow (CBF) in the affected hemisphere. Intravenous methylprednisolone therapy followed by oral glucocorticoid and mycophenolate mofetil resulted in resolution of these findings. Vessel wall enhancement is a promising finding in the diagnosis of cPACNS. Disease flares occur rarely in medium-to-large vessel cPACNS during dose tapering. Vessel wall enhancement, ESR, and CBF may be useful for the assessment of the activity of angiitis.

Effect of levetiracetam in acute encephalitis with refractory, repetitive partial seizures during acute and chronic phase

AIM

To clarify the effect of levetiracetam (LEV) for acute and chronic seizure control in acute encephalitis with refractory, repetitive partial seizures (AERRPS).

METHODS

We retrospectively reviewed the clinical course of six AERRPS cases treated with LEV, and explored the acute phase termination by withdrawal from barbiturate-induced coma under artificial ventilation, and the reduction in seizure frequency during the chronic phase. LEV was administrated orally or via nasogastric tubes as an add-on agent during acute (n=3; age 8-10 years) and chronic (n=3; age 19-30 years) AERRPS.

RESULTS

In the acute phase, administration of LEV (50-60 mg/kg/d) in combination with phenobarbital (n=3; peak 57.9-76.1 μg/ml) and potassium bromide (n=2; 30-36 mg/kg/d)) resulted in successful reduction of intravenous barbiturate dosage and withdrawal from artificial ventilation. In the chronic phase, seizure frequency reduced by >75% for 5-18 months with LEV 750-1500 mg/d.

CONCLUSION

LEV may affect seizure control in AERRPS, particularly during the chronic phase, through its unique action of inhibition of excitatory neurotransmitter release. The regimen of oral barbiturate, potassium bromide and LEV would be worth for trial during the acute phase of AERRPS.

Japanese strategies to maximize heart and lung availabilities: experience from 100 consecutive brain-dead donors

OBJECTIVE

Because the donor shortage is extremely severe in Japan because of a strict organ transplantation law, special strategies have been established to maximize heart and lung transplantations (HTs and LTs, respectively). We reviewed 100 consecutive brain-dead donors to evaluate our strategies to identify and manage heart and lung donors.

METHODS

We retrospectively reviewed all 100 consecutive brain-dead donors procured since the law was issued in 1997. There were 56 mens and the overall mean donor age was 43.5 years. The causes of death were cerebrovascular disease (n = 62), head trauma (n = 20), and asphyxia (n = 16): Since November 2002, special transplant management doctors were sent to donor hospitals to assess cardiac and lung functions, seeking to identify transplant opportunities. They stabilized donor hemodynamics and lung function by administering antidiuretic hormone intravenously and performing bronchofibroscopy for pulmonary toilet.

RESULTS

Seventy-nine HTs, 1 heart-lung transplantations, and 78 LTs (46 single and 32 bilateral) were performed. By applying these strategies organs per donor were increased from 4.5 to 6.8. Among heart donors, 61/80 were marginal: high inotrope requirement (n = 29), cardiopulmonary resuscitation (n = 28), and/or >55 years old (n = 20). None of the 80 HT recipients died of primary graft failure (PGF). Patient survival rate at 10 years after HT was 95.4%. Among lung donors, 48/65 were marginal: pneumonia (n = 41), chest trauma (n = 4), and >55 years old (n = 9). Only 2/78 LT recipients died of PGF. Patient survival rate at 3 years after LT was 72.2%. After inducing frequent pulmonary toilet, lung procurement and patient survival rates increased significantly after LT.

CONCLUSIONS

Although the number of cases was still small, the availability of organs has been greater and the outcomes of HT/LT acceptable.

Donor evaluation and management system (medical consultant system) in Japan: experience from 200 consecutive brain-dead organ donation

PURPOSE

As the donor shortage is extremely severe in Japan because of a strict Organ Transplantation Act, special strategies must be established to maximize organ transplant opportunities. The purpose of this study was to evaluate our strategies to identify and manage 200 consecutive brain-dead organ donors.

METHODS AND MATERIALS

We retrospectively reviewed the 200 donors procured since the Organ Transplantation Act was issued in 1997, including 118 males, a mean overall age of 45.1 years and cause of death being cerebrovascular disease (n = 119), head trauma (n = 37), and asphyxia (n = 44). DONOR EVALUATION AND MANAGEMENT SYSTEM: Since November in 2002, special transplant management doctors ("medical consultants") were sent to donor hospitals to assess organ function and identify transplantable organs. They also provided intensive care to stabilize hemodynamics and improve cardiac and lung functions by administering antidiuretic hormone intravenously and providing bronchofiberscopic pulmonary toilet.

RESULTS

We obtained 146 heart, 1 heart-lung, and 154 lung (87 single and 67 bilateral), 175 liver (28 splitted liver), 142 pancreas (114 pancreas-kidney), 253 kidney and 12 small bowel grafts. Organs procured from 1 donor increased from 4.5 to 6.8 after applying these strategies.

CONCLUSIONS

Although the number of cases was still small, the availability of organs and outcomes of transplantation have been acceptable.

[Atheromatous aorta: clinical pitfall in cardiovascular surgery]

A highly atheromatous aorta has been reported to bring about devastating complications such as endorgan ischemia with or without aortic manipulation. One of the complications has been perioperative stroke known that almost the halves suffered have been dead even in recent era. The other of the devastating complications has been called cholesterol crystal embolization or blue toe syndrome, meaning scattered embolization by small cholesterol crystals towards splanchnic organs or lower extremities respectively, which has also known to be critical. Nowadays, new devices have encouraged cardiovascular clinician to have a plan for a safe cardiovascular intervention including aortic manipulation even with highly atheromatous aorta. Before the manipulation, modern powerful modalities such as transesophageal echocardiography, epiaortic ultrasonography and computed tomography (CT), have already become common based on many evidences. During operation, evolving techniques and technologies such as off-pump coronary artery bypass grafting (OPCAB) and axillary artery cannulation both of which are aorta non-touch techniques, which are technically demanding, has proved to reduce perioperative stroke recently even though severe complications still occur in lower percentages.

[Is emergency aortic root replacement combined with arch replacement safe?]

BACKGROUND

Aortic root replacement (ARR) combined with aortic arch replacement (AAR) is an invasive procedure even in elective cases. Nevertheless, such combined operations are often mandatory in acute type A aortic dissection. We examined whether emergency operation might have further incremental risks compared with elective surgery in this type of operations.

METHODS

Forty-six cases of ARR combined with AAR were divided into 2 groups, the emergency (EM) group and the elective (EL) group. The EM group consisted of 10 cases of acute type A aortic dissection, whereas the EL group of 36:23 of chronic aortic dissection and 13 of true aneurysm.

RESULTS

There were no statistical differences between the 2 groups in the durations of aortic crossclamp, selective cerebral perfusion and cardiopulmonary bypass. The incidences in the EM and EL groups were as follows:in-hospital death; 0 vs 3( 8%), respiratory failure; 4 (40%) vs 14 (39%), renal failure; 0 vs 6 (17%), IABP requirement; 1 (10%) vs 3 (8%), and cerebral infarction; 0 vs 1 (3%), respectively.

CONCLUSION

Early surgical results of emergency ARR combined with AAR were almost equal to those in elective surgery.

Disruption of Tacc3 function leads to in vivo tumor regression

The formation of the bipolar spindle is responsible for accurate chromosomal segregation during mitosis. The dynamic instability of microtubules has an important role in this process, and has been shown to be an effective target for cancer chemotherapy. Several agents that target non-microtubule mitotic proteins, including the motor protein Eg5, Aurora kinases and Polo-like kinases, are currently being developed as chemotherapeutic drugs. However, because the efficacies of these drugs remain elusive, new molecular targets that have essential roles in tumor cells are desired. Here, we provide in vivo evidence that transforming acidic coiled-coil-3 (Tacc3) is a potential target for cancer chemotherapy. Using MRI, we showed that Tacc3 loss led to the regression of mouse thymic lymphoma in vivo, which was accompanied by massive apoptosis. By contrast, normal tissues, including the thymus, showed no overt abnormalities, despite high Tacc3 expression. in vitro analysis indicated that Tacc3 depletion induced multi-polar spindle formation, which led to mitotic arrest, followed by apoptosis. Similar responses have been observed in Burkitt's lymphoma and T-ALL. These results show that Tacc3 is a vulnerable component of the spindle assembly in lymphoma cells and is a promising cancer chemotherapy target.

[Aortic root surgery in patients with previous aortic root or valve operations]

OBJECTIVES

To assess the operative indication, risk factors, procedures, and outcomes of aortic root surgery in patients with previous aortic root or valve surgery.

PATIENTS AND METHODS

Between 1995 and 2007, aortic root surgery was performed in 137 patients. Thirty-five of those, who had previous root replacement, root remodeling or aortic valve surgery, were evaluated retrospectively.

RESULTS

Indications for redo surgery included lesions at coronary artery reconstruction site after root procedures, aneurysmal formation or dissection of sinus Valsalva after aortic valve procedures, and prosthetic material infection. Two cases with prior graft infection died of sepsis, and one case with extended aortic dissection died of esophageal bleeding. Hospital mortalities were, hence, 8.6% in redo cases, which was comparable to 5.0% in primary root surgery cases. Multivariate risk factor analysis of root surgery revealed that preceding infective aortic root lesion was the only significant independent risk factor for postoperative mortality, whereas redo procedure per se was not a significant risk.

CONCLUSIONS

Redo aortic root surgery can be performed with a reasonably low operative risk. Graft infection in patients with previous aortic root surgery remains a challenging lesion.

Efficacy of perfusion cooling of the epidural space and cerebrospinal fluid drainage during repair of extent I and II thoracoabdominal aneurysm

AIM

The aim of this study was to evaluate spinal cord injury and mortality resulting from repair of extent I and II thoracoabdominal aneurysm. The authors compared patients operated under mild hypothermia with or without epidural perfusion cooling (EPC) and cerebrospinal fluid drainage (CSFD).

METHODS

From 1988 to 2007, 116 patients underwent replacement of the thoracoabdominal aorta; the procedure was performed in 38 patients with the aid of mild hypothermia alone (group A), and in 78 patients with the aid of EPC, mild hypothermia and CSFD (group B). Two catheters for epidural perfusion cooling were inserted in group B, in which one catheter was inserted into the epidural space to infuse chilled saline, and the other was inserted into the subdural space to drain the cerebrospinal fluid and to measure temperature and pressure. There were no significant differences in mean age, etiology of aortic disease, and aneurysm extent between the two groups.

RESULTS

There were no significant differences in cardiopulmonary bypass time, the lowest nasopharyngeal temperature and operation time between the two study groups. The incidence of spinal cord injury in group A (16.2%) was significantly higher than in group B (3.8%, P=0.03). Hospital mortality in groups A and B was 10.5% and 2.6%, respectively (P=0.08). There was no significant difference in postoperative complications between the two study groups.

CONCLUSION

The combination of EPC and CSFD was effective in lowering the incidence of postoperative spinal cord injury in the repair of extent I and II thoracoabdominal aortic aneurysm.

Functional results of intersphincteric resection for low rectal cancer

BACKGROUND

Intersphincteric resection (ISR) is the ultimate sphincter-preserving operation for very low rectal cancer. The aim of this study was to assess defaecatory function after ISR in relation to the degree of resection of the internal anal sphincter.

METHODS

Between 2001 and 2003, 35 consecutive patients with low rectal cancer had curative ISR, categorized as total, subtotal or partial resection of the internal anal sphincter. Defaecatory function was assessed in terms of frequency of bowel movements and continence. Sphincter function was evaluated by manometric study and anorectal sensation testing before surgery and 3, 6 and 12 months afterwards.

RESULTS

Defaecatory function was satisfactory after ISR; 34 of 35 patients were grossly continent. The maximum resting anal canal pressure fell after all three procedures. Patients who had total ISR had reduced anal canal sensation at 3 months, but this had improved by 12 months after surgery.

CONCLUSION

These functional results suggest that ISR should be considered as an alternative to abdominoperineal resection for low rectal cancer. However, as the outcome for continence is worse after total ISR than subtotal or partial ISR, the indication for total ISR should strictly take into account the preoperative sphincter function.

Anti-prolactin (PRL) autoantibody-binding sites (epitopes) on PRL molecule in macroprolactinemia

Macroprolactinemia, in which serum prolactin (PRL) mainly consists of PRL with a molecular mass greater than 100 kDa, has been demonstrated to be associated with hyperprolactinemia. We previously reported that anti-PRL autoantibody is the major cause of macroprolactinemia. In this study, the autoantibody-binding sites (epitopes) on the PRL molecule were examined using deletion mutant PRL. The sera from 159 patients with hyperprolactinemia were screened for macroprolactinemia using the polyethylene glycol method and 18 patients (11%) were diagnosed with macroprolactinemia. The sera from these patients were incubated with glutathione S-transferase-human prolactin (hPRL) fragment fusion proteins immobilized on glutathione sepharose and the amounts of bound immunoglobulin G (IgG) were measured using ELISA. IgG was bound to full-length hPRL1-199 in significantly greater amounts in sera from 14 of 18 patients with macroprolactinemia than in controls. hPRL, but not PRL of other species such as bovine, porcine, rat, or human GH, dose-dependently displaced the binding, suggesting that these patients had hPRL-specific autoantibodies. Deletion of 34 amino acid residues from N-and/or C-terminals significantly reduced the binding and N- or C-terminal fragment alone showed partial but significant binding, suggesting that the major epitopes recognized by anti-PRL autoantibodies are located in both N- and C-terminal residues of the PRL molecule.

Repair of congenital ascending aortic aneurysm

We report a case of congenital ascending aortic aneurysm associated with double-outlet right ventricle that has been successfully repaired by graft replacement and extracardiac total cavo-pulmonary connection.

[Emergent coronary artery bypass grafting using percutaneous cardiopulmonary support in a patient with a quadricuspid aortic valve; report of a case]

A 63-year-old man was admitted to our hospital for acute myocardial infarction. A cardiac catheter study showed 3 vessels coronary disease. He was treated by percutaneous coronary intervention for a left anterior descending arterial (LAD) lesion. Unfortunately, cardiac tamponade following stenting for LAD was complicated. A percutaneous cardiopulmonary support system was commenced along with an emergent coronary artery bypass grafting to the LAD and obtuse marginal branch. A quadricuspid aortic valve was discovered by an aortotomy and identified as Hurwitz-Roberts classification type b. Blood from the left coronary main trunk had already stopped. Intraaortic balloon pumping was instituted while weaning from the cardiopulmonary bypass. The patient's postoperative course was uneventful and all bypass grafts were sufficient. He was well 1 year after the operation.

[Spinal cord protection during most or all of descending thoracic or thoracoabdominal aneurysm repair]

OBJECTIVES

The purpose of this study is to evaluate usefulness of perfusion cooling for regional spinal cord hypothermia during most or all of thoracic or thoracoabdominal aneurysm repair.

METHODS

From 1987 to 2003, 103 patients underwent most or all of thoracic or thoracoabdominal aneurysm repair. Forty-eight patients underwent operation using distal aortic perfusion, mild hypothermia and segment sequential repair (group MH). Fifty-five patients underwent the same operation as group MH except epidural perfusion cooling and drainage of cerebrospinal fluid (CSF) [group EC & CSFD]. The aorta was replaced sequentially in segment and several paris of intercostal and lumbar arteries were reconstructed in 2 groups.

RESULTS

Cardiopulmonary bypass time of group MH and group EC & CSFD was averaged 235 and 241 minutes, respectively. The lowest CSF temperature in group EC & CSFD was averaged 24.7 degrees C, and the difference between nasopharyngeal and CSF temperature was averaged 6.4 degrees C. The rate of spinal cord injury of group MH and EC & CSFD was 10.4% and 3.6%, respectively. Hospital mortality of group MH and EC & CSFD was 8.3% and 5.5%, respectively. The incidence of spinal cord injury and hospital mortality of group EC & CSFD were decreased compared to them of group MH.

CONCLUSION

We conclude that the perfusion cooling of epidural space and CSF drainage are effective method in reducing postoperative spinal cord injury.

Dieulafoy's lesion of the esophagus correctly diagnosed and successfully treated by the endoscopic injection of N-butyl-2-cyanoacrylate

Dieulafoy's lesion is an arterial malformation in the subumucosal layer of the gastrointestinal tract that can cause massive bleeding. The esophagus is not a common location for this lesion. We present here a first report of Dieulafoy's lesion of the esophagus correctly diagnosed and successfully treated by the endoscopic injection of N-butyl-2-cyanoacrylate.

Matrix metalloproteinase-7 and matrix metalloproteinase-9 are associated with unfavourable prognosis in superficial oesophageal cancer

If oesophageal carcinoma is detected in the superficial stage, the prognosis is better than for advanced oesophageal carcinoma. But the factors which predict the prognosis and treatment policy remain unclear. Matrix metalloproteinase-7 (MMP-7) and matrix metalloproteinase-9 (MMP-9) have been reported to have close associations with tumour invasion and metastasis. In this study, we retrospectively studied the relations between MMP-7 and MMP-9 expression in immunohistochemistry, clinicopathologic factors, and prognosis in 55 superficial oesophageal carcinomas. MMP-7 and MMP-9 expression occurred in 23.6% and 47.3% of the patients, respectively. MMP-7 expression was significantly correlated with the presence of nodal metastasis (P=0.004). MMP-9 expression was significantly correlated with the depth of tumour invasion (P=0.004), lymphatic permeation (P=0.001), nodal metastasis (P=0.049), and pathologic differentiation grade (P=0.003). By the log-rank test, MMP-7 expression and MMP-9 expression on the invasive front were related to the prognosis. In multivariate analysis, MMP-9 expression on the invasive front was an independent prognostic indicator. The combined expression of MMP-7 and MMP-9 may be a good marker for the degree of malignancy of oesophageal cancer and for the presence of lymphatic metastasis.

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.