Efficacy of microwave ablation versus radiofrequency ablation for hepatocellular carcinoma: a propensity score analysis

Purpose

To evaluate the efficacy and safety of radiofrequency ablation (RFA) and new-generation microwave ablation (MWA) for the treatment of hepatocellular carcinoma (HCC).

Methods

The propensity score matching method was applied to patients with HCC treated with MWA (93 patients) or RFA (156 patients) at a single institution from January 2014 to April 2020. The local tumor progression (LTP), intrahepatic distant recurrence (IDR), and recurrence-free survival (RFS) of the two matched therapies were analyzed using the Kaplan–Meier method. Cox proportional hazard models were used to identify risk factors for LTP and RFS. The therapeutic effects and complications of the two treatments were also compared.

Results

The LTP, IDR, and RFS of MWA and RFA were equivalent (LTP: hazard ratio [HR] = 0.87; 95% confidence interval [95% CI] 0.36- 2.07; P = 0.746, IDR: HR = 1.03; 95% CI 0.61–1.73; P = 0.890, RFS: HR = 1.15; 95% CI 0.69–1.91; P = 0.566). Para-vessel lesions was the only risk factor for LTP, whereas age, previous treatment, Albumin-Bilirubin score, and tumor diameter were risk factors for RFS. On the other hand, the ablation time per nodule (6.79 ± 2.73 and 9.21 ± 4.90 min; P = 0.008) and number of sessions per nodule required to achieve technical success (1.16 ± 0.39 and 1.34 ± 0.57; P = 0.009) were significantly lower in MWA than in RFA. The major complication rate of MWA and RFA was also equivalent.

Conclusion

MWA and RFA have similar therapeutic effects and safety, although MWA has advantages over RFA regarding efficacy, including shorter ablation time and fewer sessions required.

A giant Brunner gland hamartoma successfully treated by endoscopic excision followed by transanal retrieval: A case report

RATIONALE

Brunner gland hamartoma (BGH) is a rare tumor of the duodenum. Although BGH is a benign tumor, larger lesion with gastrointestinal symptoms requires tumor removal. We report a giant BGH, successfully treated by endoscopic excision followed by transanal retrieval.

PATIENT CONCERNS

A 38-year-old woman complained of severe anemia, tarry stool, and vomiting.

DIAGNOSES

Esophagogastroduodenoscopy (EGD) showed a pedunculated giant submucosal mass at the duodenal bulb.

INTERVENTIONS

We attempted to remove it because the lesion seemed to be responsible for patient's anemia and vomiting. The lesion had clear but bulky stalk. We carefully cut the stalk using needle-knife and IT knife2. We tried to retrieve specimen, but the mass could not pass through the pyloric ring because of its size. Then we tried to obtain the specimen from anus. Polyethylene glycol solution was administered to accelerate rapid excretion.

OUTCOMES

The mass was successfully removed and was histologically confirmed as a giant BGH, measuring 55 mm in size.

LESSONS

Reports about endoscopic resection of giant BGH are rare. Moreover, our case is the first report of transanal retrieval of resected specimen using polyethylene glycol solution. Endoscopic resection of BGH is less-invasive but can be more challenging if the mass is large. Our case provides useful option for endoscopic treatment of giant BGH.

Short term treatment results of local ablation with water-cooled microwave antenna for liver cancer: Comparison with radiofrequency ablation

The aim of the present study was to evaluate the efficacy and safety of the new-generation percutaneous microwave ablation (MWA) compared with the radiofrequency ablation (RFA) system for the treatment of hepatocellular carcinoma (HCC). A retrospective study was conducted from January 2014 to February 2019. A total of 44 patients and 52 nodules (mean tumor size, 17.2±4.9 mm) were treated with MWA, and 55 patients and 70 nodules (mean tumor size, 17.7±6.4 mm) were treated with RFA. After 4 days of treatment, the direct effects of ablation were assessed using dynamic CT, and after discharge, a follow-up dynamic CT scan was performed every 3-4 months. Treatment efficacy, complications and local recurrence were recorded. For MWA and RFA, the average number of CT sessions were 1.05±0.23 and 1.28±0.54, respectively, and the mean ablation times were 5.0±2.0 and 8.1±4.8 min. Following MWA and RFA, the ablation ranges that were evaluated with the axial images were 31.9±5.5 and 33.3±9.0 mm, respectively, in the long-axis diameter and 27.6±5.3 and 23.4±6.8 mm, respectively, in the short-axis diameter. The flatness ratios of the ablation regions were 0.13±0.09 and 0.29±0.14 (axial image) and 0.11±0.07 and 0.28±0.14 (coronal image), respectively. The rates of complete tumor necrosis were comparable. The complication rates were 13.6% (MWA) and 14.5% (RFA), which were not significantly different. The cumulative local recurrence rates were not significantly different between the two methods (one-year recurrence rate, MWA: 6.91%, RFA: 5.17%). MWA was therefore indicated to be an effective treatment for HCC in respect to session number, treatment time and spherical ablation.

Attenuation of indomethacin-induced gastric mucosal injury by prophylactic administration of sake yeast-derived thioredoxin

BACKGROUND

Indomethacin is one of the group of nonsteroidal anti-inflammatory drugs, which often cause gastric mucosal injury as a side effect. Infiltration and activation of inflammatory cells, production of proinflammatory cytokines and chemokines, generation of reactive oxygen species, and activation of apoptotic signaling are involved in the pathogenesis of indomethacin-induced gastric injury. We examined whether sake yeast-derived thioredoxin (a small redox-active protein with anti-oxidative activity and various redox-regulating functions) reduced indomethacin-induced gastric injury.

METHODS

Gastric injury was produced by the intraperitoneal administration of indomethacin (40 mg/kg body weight) to C57BL/6 mice. Prior to the administration of indomethacin, the mice were offered food pellets containing non-genetically modified sake yeast-derived thioredoxin (thioredoxin 200 μg/g) for 3 days. Histological examinations, assessment of myeloperoxidase activity, and analysis of the gene expressions of proinflammatory cytokines and a chemokine (interleukin [IL]-1β, IL-6, and CXCL1) were statistically evaluated. Indomethacin cytotoxicity was determined by lactate dehydrogenase release from murine gastric epithelial GSM06 cells induced by 24-h treatment with 200 and 400 μM indomethacin after 1-h preincubation with 100 μg/ml sake yeast-derived thioredoxin.

RESULTS

Macroscopic (edema, hemorrhage, and ulcers) and histological (necrosis, submucosal edema, neutrophil infiltration) findings induced by indomethacin were significantly reduced by pretreatment with food pellets containing thioredoxin. Gastric myeloperoxidase activity and the gene expressions of proinflammatory cytokines (IL-1β and IL-6) were also significantly reduced by this pretreatment compared with findings in the mice not pretreated with thioredoxin-containing food pellets. The administration of sake yeast-derived thioredoxin significantly reduced indomethacin-induced cytotoxicity in GSM06 cells.

CONCLUSIONS

We conclude that oral administration of sake yeast-derived thioredoxin reduces indomethacin-induced gastric injury. Sake yeast-derived thioredoxin may have therapeutic potential against indomethacin-induced gastric injury.

The specific linker phosphorylation of Smad2/3 indicates epithelial stem cells in stomach; particularly increasing in mucosae of Helicobacter-associated gastritis

BACKGROUND

The gastric corpus and antrum are believed to contain epithelial stem cells in the isthmus. However, the lack of useful markers has hindered studies of their origin. We explored whether Smad2/3, phosphorylated at specific linker threonine residues (pSmad2/3L-Thr), could serve as a marker for stem cells.

METHODS

Stomachs, small intestines, and colons from Helicobacter felis-infected and noninfected C57BL/6 mice were examined. Double immunofluorescent staining of pSmad2/3L-Thr with Ki67, cytokeratin 8, or doublecortin and calcium/calmodulin-dependent protein kinase-like-1 (DCAMKL1) was performed, and pSmad2/3L-Thr immunostaining-positive cells were counted. After immunofluorescent staining, we stained the same sections with hematoxylin-eosin and observed these cells under a light microscope.

RESULTS

In infected mice, pSmad2/3L-Thr immunostaining-positive cells were significantly increased in the corpus and antrum compared with those of noninfected mice (p < 0.0001). The number of Ki67 immunostaining-positive cells in the corpus and antrum of infected mice was also much greater than in the noninfected mice. Although pSmad2/3L-Thr immunostaining-positive cells were detected among the Ki67 cells, immunohistochemical co-localization of pSmad2/3L-Thr with Ki67 was never observed. pSmad2/3L-Thr immunostaining-positive cells showed immunohistochemical co-localization with cytokeratin 8, but some of them showed co-localization or adjacent localization with DCAMKL1 immunostaining-positive cells. Under a light microscope, pSmad2/3L-Thr immunostaining-positive cells indicated undifferentiated morphological features and were confirmed in the isthmus. In small intestines and colons, pSmad2/3L-Thr immunostaining-positive cells were detected in specific epithelial cells around crypt bases, where the respective putative stem cells are thought to exist.

CONCLUSIONS

We have identified the significant expression of pSmad2/3L-Thr in specific epithelial cells of the murine stomach and have suggested these cells to be epithelial stem cells.

Schizophrenic outpatient perceptions of psychiatric treatment and psychotic symptomatology: an investigation using structural equation modeling

Schizophrenic patient perceptions of treatment have clinical value and deserve detailed psychiatric investigation. The present study sought a model indicating statistically estimated cause-effect relationships of perceptions and psychotic symptomatology of outpatients with schizophrenia by applying a method of structural equation modeling. The perceptions included in this model were patient satisfaction with treatment, perceptions of their treating psychiatrists, and patient-role perception. Scores of Positive and Negative Syndrome Scale and poor insight measures were added to the model as possible influential factors. The constructed model revealed that the poor insight exerted a major influence on the patient-role perception that had small effects on the reliable therapist perception and the satisfaction. It was also shown that satisfaction was chiefly determined by the reliable therapist perception that was formed in the treatment relationship, rather independently of the other construct. These findings were valuable in terms of their implications for understanding the makeup of the perceptions and the strategy for interventions to improve them.

Improved nasal absorption of drugs using poly-L-arginine: effects of concentration and molecular weight of poly-L-arginine on the nasal absorption of fluorescein isothiocyanate-dextran in rats

The effects of the concentration and molecular weight of poly-L-arginine (poly-L-Arg) on the in vivo nasal absorption of fluorescein isothiocyanate-labeled dextran (MW, 4 kDa, FD-4) in rats were studied. When poly-L-Arg with a range of different molecular weights (MW, 8.9, 45.5 and 92.0 kDa) was applied intranasally at various concentrations, the bioavailability (F(0-9 h)) of FD-4 increased with the increasing concentration of poly-L-Arg. The enhanced absorption was also dependent on the molar concentration, in that the poly-L-Arg with a higher molecular weight increased F(0-9 h) at a lower molar concentration. In addition, for each applied concentration, the poly-L-Arg exhibited a molecular weight-dependence as far as the enhancement of FD-4 absorption was concerned. On the other hand, the maximum absorption rate (MAR) of FD-4, calculated by means of a deconvolution method, tended to reach a maximum plateau level at a lower applied concentration for the poly-L-Arg with the highest molecular weight, but this plateau level was almost the same for poly-L-Arg with molecular weights of 45.5 and 92.0 kDa. Moreover, the simulated absorption profiles of FD-4 indicate that the degree of enhancement (the level of MAR and the subsequent reduction in the absorption rate) was dependent on the molecular weight of poly-L-Arg, while the effect of poly-L-Arg was maintained for a longer period, depending on the applied concentration, although the MAR was relatively similar. These results indicate that the molecular weight of poly-L-Arg appears to affect both the enhancing efficiency (absorption rate) and the time-frame of this enhancing effect, whereas the concentrations of each poly-L-Arg system applied only have an effect on the time-frame. These effects may also be associated with the charge density of a poly-L-Arg molecule.

Improvement of patient attitude toward treatment among inpatients with schizophrenia and its related factors: controlled study of a psychological approach

A randomized controlled trial was conducted in an acute inpatient setting to test the effects of an intervention based on individual interviews, with the goal to improve patients' attitudes towards their psychiatric situation and understanding of illness and its treatment. In addition, the factors related to the improvement were explored. Fifty eligible male patients with DSM-IV schizophrenia recruited from consecutive admissions were allocated to two groups: weekly sessions plus routine inpatient treatment or routine inpatient treatment only. Assessment was conducted twice, before and after the maximum 8-week intervention period. The assessment included a self-report scale for measuring patients' psychological attitudes toward their treatment situation, scales of therapist perception and self-perception applying a semantic differential technique, and the Maudsley Personality Inventory (MPI), in addition to assessment of psychotic symptomatology. We found a modest but significant effect of the intervention on one domain of patient attitude: recognition of need for treatment. Trust of patients in their psychiatrist was a factor for improvement of the recognition domain. Neuroticism had some influence on the formation of personal relations in a psychiatric situation. This study lends support to the effectiveness of psychological treatment on patient attitude, and indicates some factors related to its development.

Perceptions of schizophrenic patients and their therapists: application of the semantic differential technique to evaluate the treatment relationship

This study is an attempt to evaluate the treatment relationship with schizophrenic patients by examining the patients' and their therapists' perceptions of themselves and each other, which are hypothesized to reflect features of the relationship. One hundred fifty-eight schizophrenic patients and 11 psychiatrists who maintained a supportive relationship with the patients as a therapist estimated their perceptions using the semantic differential (SD) technique with 17 adjective pairs. Eight composite scales with sufficient internal consistency were constructed from the estimations. The interrelationship among the perceptual elements, which was represented by correlation analysis of the composite scale scores, seemed consistent with our clinical experience. A factor-analytic study of the scales yielded 3 orthogonal factors that could be assumed to characterize the treatment relationship. The patient-therapist cooperation factor indicated the degree of trust between the two participants, supposedly the affective or relational aspect of the therapeutic alliance. The therapist passivity factor reflects the therapist's passive role-taking and the clinical stability of the patient. The patient strength factor was related to the condition-related and characterological strength of the patient. It is demonstrated that the estimations performed by patients and therapists are valid and useful for evaluation of the treatment relationship in the current status.

Awareness of being a patient and its relevance to insight into illness in patients with schizophrenia

This article presents the development of the Awareness of Being a Patient Scale (ABPS), a 25-item self-report scale to measure the awareness of schizophrenic patients. Awareness is defined in terms of a patient's psychological attitude toward the psychiatric situation, and is to be evaluated from the standpoint of Parsons' sick-role concept by assessing the recognition of the need for treatment and acceptance of the treatment situation. It is hypothesized that awareness is a factor in the motivation to receive treatment. Closely related to the awareness is the insight into illness, a clinical construct comprising a patient's understanding of psychotic illness and symptoms. There also seems to be an overlap between them. However, the difference is that awareness principally pertains to a patient's perspective, not addressing the precise understanding of illness and symptoms, while the frame of reference in assessing insight is from the viewpoint of psychiatry. In examining properties of the ABPS, it is demonstrated that the ABPS has satisfactory reliability, favorable concurrent validity, and significant value in discriminating between long-term stable outpatients and recently admitted and long-term hospitalized patients. This study indicates that the awareness of being a patient has clinical importance and the ABPS is an efficient means of measuring such awareness.

P300 and disability of daily life in schizophrenia

1. The relationship between the P300 component of event-related potentials and disability of daily life was examined in schizophrenia. The subjects were 26 chronic schizophrenic patients. 2. Disability of daily life was assessed by using the Life Assessment Scale for Mental Illness (LASMI). 3. Auditory event-related potentials were recorded during a standard oddball task. 3. P300 amplitude correlated negatively with general psychopathology scale of PANSS (r = -0.416) and Work of LASMI (r = -0.417). P300 latency did not correlate with any of PANSS or LASMI score. 4. These results indicate that P300 amplitude can be an index for disability of daily life in schizophrenia.

Interrater reliability of the Japanese version of the Positive and Negative Syndrome Scale and the appraisal of its training effect

The purpose of the present study is to test interrater reliability of the Japanese version of the Positive and Negative Syndrome Scale (PANSS) and to examine factors possibly affecting the reliability. The study group conducted the PANSS rating on 20 patients with DSM-IV schizophrenia. For the analysis of interrater reliability, intraclass correlation coefficient (ICC) was calculated. The ICC for individual items of the PANSS ranged from 0.26 to 0.92, and those for the positive, negative, and general psychopathology subscales were 0.85, 0.83 and 0.75, respectively. The Cronbach's alpha coefficient for the subscales were 0.84, 0.87 and 0.76, respectively. The interrater reliability and the internal consistency were satisfactory and similar to those obtained in the antecedent studies. No salient training effect was found in a sequential analysis of the concordance rate. It is concluded that the Japanese version of the PANSS is a reliable and efficient tool for comprehensive assessment of the schizophrenic syndrome.

Unique expression of HRF20 (CD59) in human nervous tissue

Damage to autologous tissue by complement is limited by several widely distributed membrane-associated glycoproteins which restrict the action of the complement in homologous species. These include decay accelerating factor (DAF), membrane cofactor protein (MCP) and 20 kDa homologous restriction factor (HRF20,CD59). Using immunohistochemical techniques, we examined the localization of these proteins in the central nervous system (CNS) and peripheral nervous system (PNS) using non-neurological human nervous tissue since some complement components have been demonstrated to be synthesized in the CNS. There was no evidence of parenchymal staining by anti-DAF or anti-MCP antibodies in either type of tissue except for the staining of the endothelium in capillaries. On the other hand, anti-HRF20 antibody clearly stained myelinated axons in the CNS as well as Schwann cells in the PNS. In addition, we detected positive staining by anti-DAF antibody in the PNS of a Paroxysmal nocturnal hemoglobinuria (PNH) patient who is genetically deficient in HRF20.

A case of Fabry's disease with granulomatous interstitial nephritis

A 15-year-old boy with proteinuria and hematuria is reviewed in this study. He was first found to have urinary abnormalities at the age of 13 years, and his renal function was exacerbated for a short duration. Renal biopsy was performed to make a histological diagnosis and to establish adequate therapy. Light microscopy showed marked tubulointerstitial inflammation with granulomatous changes, and electron microscopy revealed that numerous osmiophilic inclusions were present in podocytes, mesangial cells, and endothelial cells of the glomeruli and in epithelial cells of the tubules. The alpha-galactosidase activity of lymphocytes from the patient was measured, and the results of this assay indicated that the patient's lymphocytes had a low level of alpha-galactosidase activity. Therefore, the patient was diagnosed as having Fabry's disease with renal dysfunction. This study demonstrated that the onset age of renal insufficiency in Fabry's disease may be earlier than that described previously, and that when granulomatous interstitial nephritis is developed, renal function may deteriorate progressively.

Immunohistochemical demonstration of membrane cofactor protein (MCP) of complement in normal and diseased kidney tissues

The immunohistochemically stained membrane cofactor protein of complement (MCP/CD46), one of the complement regulatory proteins, was up-regulated in some diseased kidney tissues. MCP in diseased kidneys was strongly concentrated along the glomerular capillary walls as well as in the mesangial regions, while MCP in normal kidneys was weakly detected in all glomerular structural cells and in the epithelial cells of tubules. Since the enhanced staining was noted in those areas where depositions of C3b/C3c occurred, ongoing complement reaction might be responsible for the up-regulation of MCP expression. MCP expression may be up-regulated by complement fragments generated during complement activation in glomerulonephritis. Furthermore, anti-MCP staining was stronger in intensity in patients with moderate to massive proteinuria, indicating that up-regulation of MCP expression could be directly correlated to the kidney damage.

[Clinical assessments on pre-treatment prognostic factors in 138 patients with advanced prostatic carcinoma (stage D2)]

We investigated the prognostic factors in 138 patients with stage D2 prostatic cancer by univariate and multivariate analyses. Analysis was restricted to 8 pre-treatment parameters, that is, age, general condition (PS), pain, number of metastases on bone scan, acid phosphatase value, Gleason's primary pattern, secondary pattern, and nucleoli grading. In addition, 4 therapeutic modalities except routine endocrine therapy, that is, castration, oral administration of estramustine phosphate, of 5-fluorouracil (5-FU) or its analogue, and combination chemotherapy, during the whole treatment period were included in the analysis. Univariate analysis (Kaplan-Meier method) showed only PS to be a significant prognostic factor. Multivariate analysis (Cox's proportional hazard model) revealed that PS, Gleason's primary pattern, oral administration of 5-FU or its analogue and combination chemotherapy were significant prognostic factors. However, patients treated by combination chemotherapy had poorer prognosis and chi 2 values of combination chemotherapy was the highest among the four parameters cited above. These results suggested that the 8 pre-treatment parameters examined in this study were not sufficient for predicting the prognosis of each patient.

Myofibroblastic pseudotumor mimicking epididymal sarcoma. A clinicopathologic study of three cases

The clinical and pathologic features of three cases of epididymal pseudotumor are described with emphasis on its differential diagnosis and histopathogenesis. The first lesion was found histologically worrisome in the region of ductus epididymis by a torsioned testis in an 8-month-old boy, although the lesion was clinically indistinctive, and grossly not remarked. Histodiagnostic difficulties are encountered because this lesion forms numerous infiltrative spindle cells in haphazard arrangement. Ultrastructurally, the cell components of this lesion are predominantly myofibroblasts, intermediate cells between fibroblasts and myocytes. Similar epididymal lesions with the same cell components were identified in the two other infantile cases on the review of 36 consecutive orchiectomy specimens all obtained for testicular torsion. These three boys were found to present with a relatively gradual clinical course of the testicular torsion. It is suggested that myofibroblastic proliferation in the epididymal location histologically reminiscent of sarcomas occurs under ischemic circumstances.

Paroxysmal nocturnal hemoglobinuria due to hereditary nucleotide deletion in the HRF20 (CD59) gene

HRF20 (CD59) is a membrane glycoprotein which protects cells from the membrane attack reaction of homologous complement. A patient who is completely deficient in HRF20 expression and is suffering from paroxysmal nocturnal hemoglobinuria (PNH) was studied. His parents are cousins and both have decreased HRF20 expression, suggesting that the deficiency is genetic. We established a cultured cell line (NCU1) which is HRF20 deficient from the patient's lymphocytes by Epstein-Barr-virus (EBV) infection. Northern blot analysis revealed HRF20 mRNA signals, indicating that HRF20 mRNA were transcribed. HRF20 cDNA was amplified by the polymerase chain reaction (PCR) method. Sequencing of the cDNA from the NCU1 showed two single-base deletions at amino acid 16 and 96 from the N terminus of the mature protein. Deletion in the genomic DNA of peripheral blood lymphocytes was confirmed by the DNA sequence of an HRF20 open reading frame containing amino acid 16. Furthermore, the patient's parents and sister possessed both intact and deleted genomic HRF20 DNA while his brother's DNA was intact. These findings demonstrate that the HRF20 deficiency was genomic in origin, and that complete deletion was brought about by a homozygous abnormality in the HRF20 gene. The base deletion caused a codon frame shift resulting in failure to produce intact HRF20 protein in the patient.

Follicular neoplasms of the thyroid. Total circumferential evaluation of the fibrous capsule

Fourteen encapsulated follicular neoplasms were extensively dissected without tangential sectioning to represent the circumference of the entire capsule on sequential histologic sections. A thorough evaluation of these sections divided the 14 cases into five benign adenomas, seven encapsulated carcinomas with only intracapsular angioinvasion, and two minimally invasive carcinomas with focal capsular invasion. Among these nine early-stage follicular carcinomas it was found that angioinvasion occurred multicentrically in at least seven and showed a geographically even distribution. Angioinvasion was found far more often than capsular invasion on the circumference of all nine early-stage carcinomas. Multiple sections produced by this extensive dissection aided the disclosure of minute but convincing findings of angioinvasion. Also, a fibrous capsule as thick as 3.8 mm at its maximum thickness as well as an irregular interface between the capsule and parenchyma were often found to be characteristic of these early-stage carcinomas. Thus, upon comparison with 38 previous cases of similarly localized follicular neoplasms, in which randomly sampled histologic sections yielded diagnoses of benign adenoma (21 cases) and encapsulated or minimally invasive carcinoma (17 cases), extensive circumferential evaluation of the capsule is considered to allow not only effective distinction of follicular neoplasm with slight invasive capability from benign adenoma but also adequate assessment of invasive foci with application of strict criteria. Despite the similarity of clinical prognosis among all the above adenomas and early-stage carcinomas, given the limited follow-up period, an extensive examination method introduced herein is practically useful and necessary for identification of malignancy in encapsulated follicular neoplasms.

Suppression of immunoglobulin production of lymphocytes by intravenous immunoglobulin

The proliferative responses and the immunoglobulin production of peripheral blood mononuclear cells to pokeweed mitogen were dose-dependently suppressed by sulfonated intravenous immunoglobulin (IVIG), polyethylene glycol-treated IVIG, pH 4-treated IVIG, or human gamma-globulin, but they were not or only slightly suppressed by human serum albumin or pepsin-treated IVIG. Moreover, the suppression of immunoglobulin production by sulfonated IVIG, polyethylene glycol-treated IVIG, or pH 4-treated IVIG was seen in the cases in which B cells preincubated with IVIGs were cocultured with T cells and monocytes preincubated with or without IVIGs and in the cases in which monocytes preincubated with IVIGs were cocultured with T cells and B cells preincubated with or without IVIGs. However, in the cases in which only T cells were preincubated with IVIGs, immunoglobulin production was not suppressed. The suppression of the monocyte function by IVIGs tended to be less than the suppression of the B-cell function by IVIGs. Moreover, the suppression by IVIGs was blocked by anti-human IgG Fc. Our results suggest that IVIGs suppress the immunoglobulin production of lymphocytes through suppression of the B-cell function and the antigen presenting-cell function by attachment of IVIGs to Fc receptors of B-cell membranes and antigen presenting-cell membranes.

Prostate mucinous adenocarcinoma with signet ring cell

Carcinoma exhibiting signet ring cell appearance in the prostatic gland is rare. An example of this rare tumor is presented herein.

Immunohistochemical demonstration of complement components in formalin-fixed and paraffin-embedded renal tissues

Although there are many articles describing the detection of complement components in formalin-fixed and paraffin-embedded renal tissues, it is still difficult to obtain reproducible results. The authors determined the optimal conditions for detecting complement components in routine paraffin sections by the avidin-biotin-peroxidase complex method and concluded that proteolytic digestion of the deparaffinized sections was crucial to detect complement and to preserve tissue structures. The optimal proteolytic digestion was a 15-minute incubation at 37 degrees C in trypsin solution, 0.5 mg/ml, pH 7.6. Under these conditions, all of the complement components so far studied (C1q, C1s, C4, C3c, C3b, C5, C6, C9, and properdin) were detected without significant destruction of tissue structures in 52 renal biopsy specimens from patients with various forms of glomerulonephritis. Immunohistochemistry using the avidin-biotin-peroxidase complex method was equivalent to indirect immunofluorescence and superior to direct immunofluorescence in utility and was useful in the diagnosis of glomerular diseases.

Congenital neuroblastoma presenting as a paratesticular tumor

A 1-month-old male newborn was operated upon for a scrotal tumor that was localized outside of the testis. Histological diagnosis was neuroblastoma. Although neuroblastoma often may present as metastatic disease when first seen, this case is unique in that an undetected adrenal neuroblastoma presented as a paratesticular tumor immediately after birth.

Pulmonary reaction to an aspirated balanced liquid diet in a cancer patient

A 60-year-old man with pharyngeal carcinoma developed spontaneous pneumothorax. A biopsied lung tissue revealed an extensive granulomatous reaction to some yellow material. Because of the patient's frequent aspirations of the liquid diet which was mixed with an artificial lemon flavor, it is considered that the aspirated material provoked the pulmonary reaction and possibly the pneumothorax. An energy dispersive X-ray analysis of the biopsied lung tissue aided in excluding the possibility of the pulmonary reaction and the yellow material being of ubiquitous pneumoconiotic origin.

Primary adenocarcinoma of the small intestine with emphasis on microvillous differentiation

A detailed ultrastructural study was made of 12 primary adenocarcinomas of the small intestine. A comparative analysis of microvilli identified three characteristic features in various proportions on the apical tumor cell surface. These were; 1) "long rootlets," which are long intravillous filamentous cores penetrating into the cytoplasm and identical to those observed in colonic adenocarcinoma; 2) a regular arrangement of uniform microvilli similar to the brush border of normal intestinal epithelium; and 3) sparse rudimentary microvillous structures. Because of the rarity of adenocarcinoma in the small intestine no previous study defined these ultrastructural characteristics. The results of the present study suggest that the diverse ultrastructural findings may be related to different stages of tumor cell maturation and that the neoplastic state may increase the variation and range of microvillous differentiation regardless of capacity of mucin secretion by the tumor cells. For diagnostic purposes, brush borders as well as two other microvillous features may serve to identify adenocarcinoma of mucosal origin of the small intestine, if an ultrastructural study discloses these three features.

Effect of prostacyclin analog on pulmonary edema in isolated heart-lung autoperfusion model

Pulmonary edema and impaired gas exchange function are worrisome early complications of heart-lung transplantation. The present study was designed to determine the effect of a new prostacyclin analog, OP-41483, on these complications with the use of a heart-lung autoperfusion model. Twenty-four mongrel puppies (4 to 6 kg) were evenly divided into four groups according to the oxygen content of inspired air (group 1, 95%; group 2, 60%) and the use of an intravenous drip of OP-41483 (0.1 microgram/kg/min) (group 3, 95% + OP; group 4, 60% + OP). During the course of these experiments, systolic pressure and cardiac output were maintained constant at 100 mm Hg and 40 ml/kg/min, respectively. Pulmonary arterial pressure was almost constant in each group throughout the experiment. Arterial oxygen tension (Pao2) was significantly decreased in groups 1 (410 +/- 49 to 237 +/- 38 mm Hg, p less than 0.01) and 2 (368 +/- 44 to 243 +/- 26 mm Hg, p less than 0.01) over the 5-hour autoperfusion period but was maintained at a high level in groups 3 (488 +/- 70 to 447 +/- 39 mm Hg) and 4 (431 +/- 33 to 430 +/- 35 mm Hg). Pathologic findings (perivascular edema and capillary dilatation) were significant in group 1 but less marked in group 2. However, no abnormal pathologic changes were observed in groups 3 or 4. These data demonstrated that OP-41483 was effective in preventing functional and pathologic pulmonary disturbances at a dosage (0.1 microgram/kg/min) that is reported to induce no undesirable hemodynamic effect.

Primary leiomyosarcoma in the breast

The case is presented of a 62-year-old woman having a well-circumscribed, painless breast lump which led to the discovery of pure mammary leiomyosarcoma. There are only a few documented cases of primary leiomyosarcoma in the breast, and a brief review of the literature on the diagnostic findings and histogenesis of a smooth muscle malignant neoplasm in this site is, therefore, provided. As far as the histogenesis is concerned, ultrastructural features of the present case suggest a tumor of pluripotent mesenchymal cell nature rather than of vascular smooth muscle cell origin.

Ultrastructural diagnosis of melanoma from an endoscopic biopsy

A 56-year-old male with abdominal symptoms and hypoalbuminemia was found to have multiple polypoid lesions on an upper gastrointestinal series, suggesting intestinal involvement by lymphoma. An endoscopic biopsy was interpreted by light microscopy as poorly differentiated adenocarcinoma. Study of the endoscopic biopsy by electron microscopy revealed epithelial features including intracytoplasmic acini, but the presence of premelanosomes in the tumor cells established the diagnosis of malignant melanoma.

Focal adrenocortical cytomegaly observed in two adult cases

Two adult cases of incidental adrenal focal cytomegaly are presented. Neither of the patients involved had congenital malformations or symptoms attributable to adrenocortical dysfunction. In both, the histologic pattern was a cluster of giant cells resembling adrenal cytomegaly of the fetus or neonate. Similar to that in pediatric adrenal cytomegaly, the ultrastructure of these cells in adults suggests both cellular hyperactivity and exhaustion.

A variant of early gastric carcinoma. Histologic and histochemical studies of early signet ring cell carcinomas discovered beneath preserved surface epithelium

Gastric carcinomas hidden beneath flat and intact mucosal surface epithelium are rarely discovered. Such a tumor in the early stage is at best diagnosed as an incidental finding, so that the diagnosis is probably always a surprise to the clinician. Six such cases of early gastric carcinoma were presented. Four were intramucosal lesions and the remaining two were invasive with submucosal extension. All the tumors are composed purely of signet-ring cells (diffuse-type by Lauren's classification). Histologic examination of the six cases revealed that certain features, which are not characteristically observed in ordinary signet-ring cell carcinomas, were commonly recognized. These included compact nests of uniform signet-ring cells sharing a common cytoplasmic wall, lack of desmoplastic stromal response, and intracytoplasmic mucin predominantly composed of neutral mucopolysaccharide. These six tumors are considered to be an incipient stage of signet-ring cell carcinoma. The findings also suggest a close histogenetic relationship between these tumors and the mucous neck cells in the basal region of gastric glands. The grossly unremarkable mucosal surface and histologically innocuous appearance associated with this form of tumor are emphasized for diagnosis.

Primary squamous cell carcinoma with its spindle cell variant in the endometrium. A case report and review of literature

A case of squamous cell carcinoma of the endometrium in a 72-year-old woman is presented. A review of the previous 28 cases of endometrial squamous cell carcinoma (ESCC) that are adequately substantiated in the literature revealed several misconceptions about this rare tumor: the association with pyometra is not as frequent; the lesion does occur in premenopausal women; squamous metaplasia of the endometrium is not always coexistent; and malignant transformation of squamous metaplasia to ESCC has never been convincingly demonstrated. In the current case, a focal sarcomatoid spindle-cell tumor was associated with typical ESCC; however, light and electron microscopic examinations provided convincing evidence that the tumor was composed solely of ESCC. Ultrastructure of the spindle-cell tumor revealed it to be essentially identical to that of a spindle-cell variant of squamous cell carcinoma reported previously.

An 18-year history of a corticotropin-secreting spindle cell carcinoid in the lung

A unique case is reported demonstrating latency and slow growth of a spindle-cell carcinoid in the lung. Seventeen years after bilateral adrenalectomy, performed for Cushing's syndrome, a patient presented with a newly developed lung tumor. The tumor demonstrated spindle cell histology, neurosecretory granules typical for carcinoid, and a positive immunoreactivity for corticotropin. After the removal of the lung tumor, the high serum corticotropin level returned to normal.

Peri-articular reactions to microscopic erosion of silicone-polymer implants. Light- and scanning electron-microscopic studies with energy-dispersive x-ray analysis

Two patients are described who underwent implantation of silicone-polymer prostheses: one for an arthroplasty of the left great toe after a bunionectomy, and another for replacement of fractured trapezoid bone of the left wrist. Each patient developed unexplained severe pain at the sites of surgery at 3 and 7 months postoperatively. On removal of the implants and adjacent tissues, there was a microscopic foreign-body reaction to amorphous material in the subsynovial connective tissue. Although both prostheses were grossly intact, scanning electron microscopy revealed multiple erosions on their surfaces. Energy-dispersive x-ray analysis of foreign material in the paraffin-embedded sections revealed a peak for silicon. These two cases indicate that clinically significant pathological reaction may occur as early as 3 months after silicone-polymer implantation and that energy-dispersive x-ray analysis of excised tissue is a useful and specific diagnostic procedure.

Concurrent occurrence of adenocarcinoma and carcinoid tumor in the stomach: a composite tumor or collision tumors?

A morphologic curiosity is presented in a polypoid gastric tumor combined with adenocarcinoma and carcinoid tumor. It is likely that those two represent a composite tumor; however, the authors think it is more likely that they are two concurrent, independent collided tumors.

Granular cell tumor: unusual cause for mucocele of gallbladder

A small granular cell tumor of the cystic bile duct is presented. A review of the literature revealed that all previously reported granular cell tumors in the biliary ducts affected women. Among them, 13 cystic bile duct tumors were exclusively small and slow-growing benign lesions. All had been operated on for gallstone disease, but in 10 cases no stone was actually found. Although such a small tumor might be easily overlooked grossly, histological diagnosis is relatively easy if differentiated from a reactive smooth muscle granular lesion.

A family study of an extremely rare Rh-Hr variant (-D-/-D-) in two generations

A rare variant (-D-/-D-) in two generations due to consanguineous marriage was reported. The propositus (T.M., 27 years of age) delivered her second baby who suffered from severe jaundice. She had agglutinin of titer 1:64 in saline and 1:1,024 in Coomb's test against red cells of her husband (CDe/cDE). Family study revealed that T.M.'s father and his two siblings were grouped as -D-/-D-. Each of the siblings (both females, 53 and 46 years of age) had three children who were delivered normally without hemolytic disease. No agglutinin concerning the Rh-Hr system was detected in the sera of the siblings.