[A Case of Carcinomatosis of the Bone Marrow Due to Rectal Cancer]

A 33-year-old man was admitted due to dyschezia and melena. Colonoscopy revealed a circulating type 4 rectal tumor. Further examination revealed intestinal obstruction due to rectal cancer, paraaortic lymph node metastasis, and multiple bone metastases, and an ileus tube was transanally inserted for decompression. Bone scintigraphy revealed multiple abnormal uptake regions in the entire skeleton. We planned to perform primary tumor resection and postoperative adjuvant chemotherapy and radiotherapy administration. Peritoneal signs in the lower abdomen appeared after 6 days of tube insertion. Abdominal computed tomography demonstrated intestinal perforation, and emergency surgery was performed. During the surgery, tube penetration in the anterior abdominal wall was observed in the sigmoid colon proximal to the tumor. Postoperatively, the patient developed disseminated intravascular coagulation(DIC). The patient had multiple bone metastases and juvenile cells in peripheral blood figure analysis; therefore, we concluded that DIC was caused by carcinomatosis of the bone marrow. After an informed consent was obtained, FOLFOX4 with simultaneous DIC treatment was initiated, and DIC remission was observed. The patient was transferred to a different hospital near his home, but died 35 days postoperatively.

[Successful Control of Hyperammonemia with BRTO of a Splenorenal Shunt Induced by CAPOX Therapy]

Among portosystemic shunts, splenorenal shunts can cause increased portal pressure, which in turn can bring about hyperammonemia, resulting in hepatic encephalopathy. In recent years, it has been reported that oxaliplatin(OX), a key chemotherapy drug in colorectal cancer, can precipitate splenorenal shunts due to sinusoidal injury. We report a case of hyperammonemia post oxaliplatin therapy. A 72-year-old male patient who had undergone surgical resection for(RS)rectal cancer with hepatic metastasis had been receiving capecitabine plus OX(CAPOX)as adjuvant chemotherapy. During his 7th course of treatment, he visited the outpatient clinic with complaints of weakness, dysarthria, and urinary incontinence. Laboratory findings showed an elevated NH3 level (200 μg/dL), and subsequent abdominal computed tomography revealed a splenorenal shunt, which was attributed to OX. Balloon-occluded retrograde transvenous obliteration(BRTO)was then performed. The patient has been routinely followed up in the outpatient clinic and has had no recurrence of hyperammonemia or cancer 14 months after the procedure. In retrospect, the splenorenal shunt was present on his first visit, therefore, hyperammonemia could have been prevented at the time of commencement of chemotherapy. We report our case, along with the relevant literature.

A multicenter prospective registration study on laparoscopic pancreatectomy in Japan: report on the assessment of 1,429 patients

BACKGROUND

Prospective studies are needed to understand the safety and feasibility of laparoscopic pancreatectomy. The aim of the present study was to describe laparoscopic pancreatectomy currently undertaken in Japan, using a prospective registration system.

METHODS

Patient characteristics and planned operations were registered preoperatively, and then the performed operation and outcomes were reported using an online system. Collected data were also compared between institutions based on their level of experience. This study was registered with UMIN000022836.

RESULTS

Available data were obtained from 1,429 patients at 100 Japanese institutions, including 1,197 laparoscopic distal pancreatectomies (LDPs) and 232 laparoscopic pancreatoduodenectomies (LPDs). The rates of completion for planned operations were 92% for LDP and 91% for LPD. Postoperative complication rates after LDP and LPD were 17% and 30%, and 90-day mortality rates were 0.3% and 0.4%, respectively. Shorter operation time, less blood loss, and lower incidence of pancreatic fistula were observed in institutions experienced in LDP. A higher rate of pure laparoscopic procedure and shorter operation time were noted in institutions experienced with LPD.

CONCLUSION

LDPs and LPDs are performed safely in Japan, especially in experienced institutions. Our data could support the next challenges in the field of laparoscopic pancreatectomy.

[A Case of Long-Term Survival of a Patient with a Nodal Recurrence of Intrahepatic Cholangiocarcinoma Who Attained Complete Remission with S-1 Monotherapy]

An 82-year-old man was referred to our hospital after a hepatic tumor was identified on ultrasonography.Computed tomography(CT)revealed a hypovascular tumor measuring 3 cm in diameter in the lateral section.He was diagnosed as having intrahepatic cholangiocarcinoma(ICC), and a left hemihepatectomy was performed in November 2012. During the postoperative follow-up in August 2013, CT revealed swollen lymph nodes around the greater curvature of the stomach and upper edge of the pancreas.By using endoscopic ultrasonography fine-needle aspiration(EUS-FNA), lymph node metastases of the ICC was diagnosed.S -1 monotherapy was initiated instead of gemcitabine and cisplatin regimens because of renal dysfunction.In July 2014, CT revealed that both lymph nodes were shrinking, and in January 2015, S-1 administration was discontinued upon the patient's request.However, the patient survived for 4 years without S-1 administration, and no recurrent tumors were recognized on CT in November 2018.O ur diagnosis indicates complete remission.

Compact all-fiber pulsed coherent Doppler lidar system for wind sensing

A compact 1.5 microm all-fiber pulsed coherent Doppler lidar system for wind sensing, which includes the functions of variable pulse width and automatic polarization control has been developed. The system configuration is introduced and key components used in the system are explained. Theoretical performances of the system in wind sensing are estimated and compared with experimental results. The measurable range corresponding to the detection probability of >80% is approximately 1 km or more in the case of 150 m range resolution under the normal atmospheric conditions.

Randomized controlled trial of the effect of hysterectomy or LNG-IUS use on bone mineral density: a five-year follow-up

A 72-year-old female with scirrhous-type advanced gastric cancer was treated with TS-1/CDDP as neoadjuvant chemotherapy. TS-1 (80 mg/m(2)/day) was orally administered for 3 weeks and CDDP (60 mg/m(2)) was administered by intravenous drip on day 8. Partial response (PR) was obtained after the first course, and total gastrectomy was performed. The histological diagnosis revealed complete disappearance of cancer cells in the stomach and a few regional lymph node metastases (3/67). The patient has now been in good health without a recurrence for 1 year and 9 months after surgery.

69 RELATION OF SPATIAL GENE EXPRESSION PATTERNS IN BOVINE EMBRYOS RECONSTRUCTED WITH SOMATIC CELLS TO BLASTOCYST DEVELOPMENT

Recently, enhanced development to full term was obtained with embryos reconstructed with bovine early G1 cells rather than with G0 cells (Kasinathan et al. 2001 Nat. Biotechnol. 19, 1176-1178; Urakawa et al. 2004 Theriogenology 62, 714-728). However, the reason why donor somatic cells at the early G1 phase are better for embryo reconstruction is unclear. In this study, we investigated the relation of spatial gene expression patterns at the 4- to 8-cell stage to blastocyst development of embryos reconstructed with early G1 cells. Bovine fibroblasts stably transfected with �-act/luc+/IRES/EGFP were used for embryo reconstruction. M phase cells were prepared as described by Urakawa et al. (2004). Early G1 cells were obtained from cultured M phase cells soon after the M phase cells divided. Quiescent cells (cultured in 0.4% serum for 7 days) were used as G0 cells for a control. The cells were electrofused with enucleated bovine oocytes matured in vitro, and activated with a calcium ionophore and cycloheximide. The reconstructed embryos were cultured until 60 hours post fusion (hpf), and zonae pellucidae of 4- to 8-cell embryos were removed by pronase. To determine gene expression, the LUC+ activity (luminescence) in the embryo blastomeres was detected with an imaging photon counter (Hamamatsu Photonics, Hamamatsu City, Shikuoka Prefecture, Japan) for 10 min. The embryos were categorized as being positive, mosaic, or negative depending on whether all, some or no blastomeres were luminescent, respectively. The embryos were cultured in mSOF medium individually until 168 hpf to assess development to the blastocyst stage. Blastocyst development of reconstructed embryos without detection of luminescence was also examined. Experiments were repeated three times, and the data were analyzed with Fisher's PLSD test following ANOVA. At 60 hpf, 75% (74/99) of embryos reconstructed with early G1 cells and 55% (46/83) of embryos with G0 cells developed to 4- to 8-cell stage embryos. The difference is significant (P < 0.05). The percentages of positive, mosaic, and negative embryos with G1 cells were 49, 35 and 16%, and blastocyst rates were 30, 11, and 0%, respectively. With G0 cells, the percentages were 32, 56, and 12%, and the blastocyst rates were 15, 4, and 0%, respectively. More positive embryos were obtained with early G1 cells than with G0 cells (P < 0.05). Blastocyst rates of the positive embryos with early G1 cells were the same as with G0 cells (P > 0.05). Blastocyst development of positive embryos was higher than that of mosaic and negative embryos in early G1 and G0 groups (P < 0.05). Without detection of luminescence, the blastocyst rates from the reconstructed embryos were 43% (35/81) and 16% (20/125) with early G1 and G0 cells, respectively (P < 0.05). These results suggest that the higher developmental capacity of embryos reconstructed with early G1 cells might be related to the appropriate spatial gene expression at the 4- to 8-cell stage. A part of this study was supported by a grant from the Wakayama Prefecture Collaboration of Regional Entities for the Advancement of Technological Excellence of the JST.

Abnormal muscle response monitoring during microvascular decompression for hemifacial spasm

BACKGROUND

Several studies have investigated the relation between intraoperative abnormal muscle response (AMR) findings and postoperative results in patients undergoing microvascular decompression (MVD) for hemifacial spasm (HFS). However, there is some debate over the reliability of AMR as an indicator of postoperative outcome. We investigated whether AMR findings obtained during MVD reflect postoperative outcome in patients with HFS.

METHOD

Subjects were 60 HFS patients who underwent AMR monitoring during MVD. AMR recordings were obtained from the mentalis muscle by electrical stimulation of the temporal branch of the facial nerve and from the orbicularis oculi muscles by stimulation of the marginal mandibular branch. Surgical outcome was compared with AMR findings at the completion of MVD. Mean follow-up was 61 months.

FINDINGS

HFS resolved completely in 50 patients in whom AMR disappeared intraoperatively and in 5 patients in whom the AMR amplitude was decreased at the end of MVD. Four patients showed HFS at the final follow-up examination despite cessation or decrease of AMR during surgery. In 1 patient, preoperative AMR waveforms persisted throughout MVD, but the postoperative outcome was excellent.

CONCLUSIONS

Our findings suggest that intraoperative cessation or decreased amplitude of AMR at the end of surgery indicates a high likelihood of postoperative relief of HFS. We believe that intraoperative AMR monitoring is useful in MVD surgery for HFS.

Magnetoencephalographic representation of the sensorimotor hand area in cases of intracerebral tumour

OBJECTIVE

To assess the clinical value of magnetoencephalography (MEG) in localising the primary hand motor area and evaluating cortical distortion of the sensorimotor cortices in patients with intracerebral tumour.

METHODS

10 normal volunteers (controls) and 14 patients with an intracerebral tumour located around the central region were studied. Somatosensory evoked magnetic fields (SEFs) following median nerve stimulation, and movement related cerebral magnetic fields (MRCFs) following index finger extension, were measured in all subjects and analysed by the equivalent current dipole (ECD) method to ascertain the neuronal sources of the primary sensory and motor components (N20m and MF, respectively). These ECD locations were defined as the primary hand sensory and motor areas and the positional relations between these two functional areas in controls and patients were investigated.

RESULTS

The standard range of ECD locations of MF to N20m was determined in controls. In 11 of the 14 patients, MRCFs could identify the primary motor hand area. ECD locations of MF were significantly closer to the N20m in the medial-lateral direction in patients than in controls. In patients with a tumour located below the sensorimotor hand area, relative ECD locations of MF to N20m moved anteriorly over the standard range determined in the control subjects. These MEG findings correlated well with radiological tumour locations. The mean estimated ECD strength of MF was significantly lower in patients than in controls.

CONCLUSIONS

MRCF was useful in localising the primary motor hand area in patients with intracerebral tumour. The relative ECD locations of MF to N20m describe the anatomical distortion of the sensorimotor cortex.

Functional posterior rhizotomy for severely disabled children with mixed type cerebral palsy

The authors evaluated the impact of functional posterior rhizotomy (FPR) for children with severely disabled mixed type cerebral palsy (CP). Three quadriplegic children at the age of 3, 4, and 10 years underwent FPR. They were classified as mixed type CP based on the clinical presentation of marked spasticity with dystonic posture. Preoperative Ashworth score of the lower extremity was 3.5, 4.5, 4.8 respectively. Two children showed prominent opisthotonus and all showed severe subluxation of the hip joint. Advanced scoliosis was associated in two children. FPR was performed from L2 to S1 in one child, L2 to S2 in one and L2 to S1/S2 in one based on the result of pudendal mapping. Rootlet cutting rate ranged from 66 to 75%. Postoperatively, Ashworth score dropped to 1.4, 1.2, 1.3, respectively. Functional improvement of the upper extremity and urination were confirmed in two children. Hip subluxation was reduced in one child and remained stable in two. A one-year follow-up review confirmed no relapse of spasticity among them. FPR achieved highly satisfactory surgical effects in children with severe mixed type CP. Although long-term follow-up is mandatory since there was a report of relapsed spasticity after FPR in this particular population of CP, FPR could be a choice of surgery in severely disabled children with mixed type CP.

Ictal magnetoencephalographic discharges from elementary visual hallucinations of status epilepticus

PURPOSE

To report the rare opportunity to study ictal magnetoencephalography (MEG) in a 26 year old man with simple partial status epilepticus that presented as elementary visual hallucinations (EVHs) in the right upper visual field.

METHODS

The patient described his EVHs as "snowing on TV," "flickering lights," and "rotating coloured balls" that continued for several days. MEG and simultaneous EEG were recorded twice: during an episode of EVHs (ictal recordings) and after EVHs were controlled by medications (interictal recordings).

RESULTS

During EVHs, MEG showed continuous periodic epileptiform discharges over the left posterior superior temporal region, while simultaneous EEG showed rhythmic theta waves and sporadic spikes over the left temporal region. The MEG discharge consisted of a three phase spike complex. Equivalent current dipoles (ECDs), modelled from spike complexes, localised in the left superior temporal area. After drug treatment controlled the EVHs, interictal MEG and EEG showed rare spikes over the same left temporal region. The average ictal ECD moment (mean (SD)) (128.7 (32.8 nAm)) was significantly weaker than the average interictal ECD moment (233.0 (63.9) nAm) (p<0.05).

CONCLUSIONS

The continuous, periodic, and clustered discharges seen on ictal MEG were the sources of EVH. The weaker ictal ECD sources were frequently not detected by scalp EEG, while the stronger interictal sources, presumably originating from an extensive interictal zone, were sufficiently large to be seen as EEG spikes.

Neuropsychological changes after surgical treatment for temporal lobe epilepsy

PURPOSE

The effect of unilateral temporal lobectomy on seizure frequency is well recognized, but little is known about the neuropsychological changes that occur after surgical treatment. We assessed neuropsychological status in 26 patients with an average age of 35 years before and after unilateral temporal lobectomy for medically intractable TLE.

METHODS

Neuropsychological examination to assess cognitive function, memory, attention, visuospatial analysis, language, and emotional functions was performed preoperatively and at 1 month and 1 year after the surgery.

RESULTS

At both 1 month and 1 year after the surgery, the patients had improved scores, compared with the preoperative scores, on the Wechsler Adult Intelligence Scale-Revised (WAIS-R: verbal IQ, performance IQ, and full-scale IQ), Wechsler Memory Scale-Revised (WMS-R: verbal, general, and delayed paired associates memory), and Raven Colored Progressive Matrices. In the Minnesota Multiphasic Personality Inventory (MMPI), significant decreases were observed at 1 year after the surgery in the scores for infrequency, hypochondriasis, psychasthenia, and schizophrenia. Patients in whom the seizures had been relieved postoperatively also had improved scores on the WAIS-R, WMS-R, and Raven Colored Progressive Matrices.

CONCLUSIONS

These data suggest that neuropsychological improvement postoperatively is influenced by the reduction in the frequency of seizures after surgery.

Surgical strategy and outcomes for epileptic patients with focal cortical dysplasia or dysembryoplastic neuroepithelial tumor

PURPOSE

The purpose of this study was to clarify and compare the influence of surgical strategy on relief from seizures in patients with focal cortical dysplasia (FCD) and those with dysembryoplastic neuroepithelial tumor (DNT).

METHODS

Six patients with FCD and five patients with DNT, all of whom underwent surgical resection for medically intractable epilepsy, were compared in terms of presurgical seizure types and frequency, location of lesions, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) with 99mTc-ECD, scalp electroencephalogram (EEG), and long-term video-EEG recording. Prolonged subdural recordings and intraoperative electrocorticograms (ECoG) were analyzed. The influences of surgical strategies on seizure outcomes were retrospectively analyzed.

RESULTS

In all the FCD patients, ictal SPECT revealed hyperperfusion in the regions where MRI showed FCD. Interictal epileptiform activity and ictal seizure onset on ECoG performed with subdural electrodes were localized on the FCD itself. In contrast, the tumors of all the DNT patients were depicted as hypoperfuse areas on interictal SPECT scans. Ictal SPECT in one DNT patient showed hyperperfusion in the area enclosing the tumor. Interictal spiking in all DNT patients and ictal seizure onset in two DNT patients were not in the lesions themselves but in an area enclosing the lesion. All but one patient with FCD who underwent total lesionectomy became seizure free. All DNT patients who underwent resection of the epileptogenic cortex associated with lesionectomy became seizure free or achieved a 90% reduction in seizures.

CONCLUSIONS

FCD has intrinsic epileptogenicity, whereas DNT is encompassed by epileptogenic cortical areas. Therefore, total lesionectomy is an essential strategy for FCD, whereas resection of the epileptic focus associated with lesionectomy of a DNT lesion is necessary to control seizures.

Expression and characterization of recombinant human antithrombin III in Pichia pastoris

Antithrombin III (ATIII) is a member of the serpin superfamily and a major regulator of the blood coagulation cascade. To express recombinant human ATIII (rATIII) in the methylotrophic yeast Pichia pastoris, we constructed an rATIII expression plasmid which contained the ATIII cDNA encoding mature protein region connected with the truncated mAOX2 promoter and the SUC2 secretion signal, introduced it into the P. pastoris genome, and screened for a single copy transformant. The secretion of rATIII from the transformant reached a level of 320 IU/L in the culture broth at 169 h. From the culture-supernatant, rATIII was purified to over 99% by heparin-affinity chromatography and other column chromatography methods. We characterized rATIII and compared it with human plasma-derived ATIII (pATIII). The purified rATIII possessed correct N-terminal amino acid sequence, and its molecular weight by SDS-PAGE of 56,000 Da was slightly different from the 58,000 Da of pATIII. Sequence and mass spectrometry analysis of BrCN fragments revealed that posttranslational modifications had occurred in rATIII. O-linked mannosylation was found at Ser 3 and Thr 9, and in some rATIII molecules, modification with O-linked mannosyl-mannose had probably occurred at Thr 386, close to the reactive center. Although the heparin-binding affinity of rATIII was 10-fold higher than that of pATIII, its inhibitory activity against thrombin was only half. As the conformation of rATIII and pATIII by circular dichroism spectroscopy was similar, O-glycosylation in the reactive center loop was assumed to be mainly responsible for the decreased inhibitory activity. pATIII can inactivate thrombin through formation of a stable thrombin-ATIII complex, but rATIII modified with O-glycosylation in the reactive center loop may act as a substrate rather than an inhibitor of thrombin.

Noninvasive detection and prediction of bladder cancer by fluorescence in situ hybridization analysis of exfoliated urothelial cells in voided urine

OBJECTIVES

To investigate the clinical utility of fluorescence in situ hybridization (FISH) of voided urine in the detection of bladder cancer and the prediction of its recurrence.

METHODS

FISH with centromere-specific probes for chromosomes 9 and 17 was performed to evaluate the chromosomal alterations of exfoliated urothelial cells in voided urine obtained from 44 patients with bladder cancer and 20 controls. The analysis was also performed in 17 patients with bladder cancer after complete transurethral resection to prospectively determine whether FISH can predict tumor recurrence.

RESULTS

The sensitivity to detect bladder cancer by FISH analysis (85%) was significantly higher than that by urine cytologic examination (32%) and by the bladder tumor antigen test (64%) (P <0.0001 and P = 0.026, respectively). The specificity of FISH, cytologic analysis, and the bladder tumor antigen test was 95%, 100%, and 80%, respectively. Among the 17 patients tested after transurethral resection, 7 of 13 FISH-positive patients developed tumor recurrence within the 27-month follow-up period; none of 4 FISH-negative patients developed recurrence during the same period. The recurrence rate in patients with the loss of chromosome 17 was 100%, significantly higher than the 23% for patients without this alteration (P = 0.015).

CONCLUSIONS

These findings suggest that FISH analysis of exfoliated urothelial cells in voided urine can efficiently detect bladder cancer and predict its recurrence.

Neuropsychological outcome following pallidotomy and thalamotomy for Parkinson's disease

Cognitive and emotional outcomes were assessed after unilateral posteroventral pallidotomy (PVP) and ventral intermediate nucleus thalamotomy (Vim-Th) in patients suffering from idiopathic Parkinson's disease (PD). PVP was performed on 12 PD patients (8 men and 4 women, mean age 56.4 years, 6 left lesions and 6 right lesions) and Vim-Th was performed on 13 PD patients (5 men and 8 women, mean age 63.2 years, 6 left lesions and 7 right lesions). In both the PVP group and the Vim-Th group, the Hoehn and Yahr staging scores (p < 0.01) and the Unified Parkinson's Disease Rating Scale activities of daily living and motor scores (p < 0.001) improved significantly. No significant changes in cognitive function were observed 4 weeks after unilateral PVP or Vim-Th. PVP produced a significant decline in Hasegawa's Dementia Scale-Revised scores in immediate postoperative assessments (p < 0.05), which resolved 4 weeks after surgery. While the Minnesota Multiphasic Personality Inventory depression and social introversion scores improved significantly in the Vim-Th group (p < 0.01 and p < 0.05, respectively), the hypochondriasis and hypomania scores improved significantly in the PVP group (p < 0.01 and p < 0.05, respectively). We conclude that PVP and Vim-Th influence postoperative emotional status rather than postoperative cognitive status.

[Stereotaxy for parkinsonian tremor]

Thalamotomy with microelectrode recording is effective for the suppression of drug resistant tremor in patients with Parkinson's disease. In our series, thalamotomy was effective in 26 of 28 patients(93%). In one case of tremor recurrence, thalamic stimulation was effective for tremor control. Complications of thalamotomy were contralateral weakness in one case and subcortical hemorrhage in another case. Flexibility of thalamic stimulation and stimulation of the subthalamic nucleus(STN) for tremor control and complication avoidance makes them superior to thalamotomy. Surgical option is chosen between thalamotomy or/and thalamic stimulation, and bilateral thalamic or STN stimulation for symptoms, severity, and the patient's condition.

An oligoribonuclease gene in Streptomyces griseus

In Streptomyces griseus, A-factor (2-isocapryloyl-3R-hydroxymethyl-gamma-butyrolactone) serves as a microbial hormone that switches on many genes required for streptomycin production and morphological development. An open reading frame (Orf1) showing high sequence similarity to oligoribonucleases of various origins is present just downstream of adpA, one of the A-factor-dependent genes. Orf1 was named OrnA (oligoribonuclease A) because it showed 3'-to-5' exo-oligoribonuclease activity, releasing [(32)P]CMP from ApCpC[(32)P]pC used as a substrate. Reverse transcription-PCR and S1 nuclease mapping analyses revealed that ornA was transcribed from two promoters; one was a developmentally regulated, A-factor-dependent promoter in front of adpA, and the other was a constitutive promoter in front of the ornA coding sequence. Transcription of ornA was thus additively enhanced at the initiation stage for secondary metabolism and aerial mycelium formation. ornA-disrupted strains grew slowly and scarcely formed aerial mycelium. ornA homologues were distributed in a wide variety of Streptomyces species, including S. coelicolor A3(2), as determined by Southern hybridization analysis. Disruption of the ornA homologue in S. coelicolor A3(2) also caused phenotypes similar to those of the S. griseus DeltaornA strains. The OrnA oligoribonucleases in Streptomyces species are therefore not essential but play an important role in vegetative growth and in the initiation of differentiation.

Genetic identification of bilateral primary or metastatic nonpapillary renal cell carcinoma

OBJECTIVE

To clarify the clonality of bilateral tumours by genetic analysis of bilateral renal cell carcinomas (RCCs) using the VHL gene, which is inactivated in approximately 60% of RCCs and which plays a causal role in the development of most cases of nonpapillary RCC.

PATIENTS AND METHODS

The study included 20 patients; seven had von Hippel-Lindau disease, three had papillary RCC and 10 had nonpapillary RCC. Paraffin-embedded blocks of tumour tissue were obtained from two of the three patients with papillary RCC and from nine of 10 with nonpapillary disease; all three exons of VHL were examined by direct sequencing.

RESULTS

As reported previously, no VHL mutations were found in papillary tumours. However, in five of the nine nonpapillary cases, VHL mutations were identified in tumours on one or both sides. Three of the tumours had the same mutation on both sides, confirming a common origin. In the remaining two patients, the mutation status differed between the sides, confirming a bilateral primary origin. The former cases were characterized by a relatively large tumour on one side and multiple tumours on the other.

CONCLUSIONS

In nonpapillary RCC multiplicity may suggest a metastatic origin. Such genetic information will be useful in treating and following patients with bilateral renal tumours.

[Juvenile ischemic type of moyamoya disease: a case report]

Moyamoya disease is a rare, chronic cerebrovascular disorder characterized by progressive stenosis of the arteries composing the circle of Willis. The ischemic type of Moyamoya disease progresses insidiously. To prevent irreversible cerebral damage and psychomotor deterioration, early surgical treatment is considered indispensable. The patient may present with nonspecific symptoms and no specific abnormalities on brain MRI, and might be erroneously suspected as having psychosomatic disorder. The disease must be diagnosed as early as possible. Electroencephalography (EEG) is of little value in the diagnosis of the juvenile type of Moyamoya disease, except for the demonstration of "re-build up" after hyperventilation. Half of the children with Moyamoya disease have been demonstrated to exhibit "re-build up" after hyperventilation. Our patient showed normal background activities, no spike discharges and no slowing during hyperventilation. Nonetheless, we emphasize the appearance of irregular high voltage slow waves de novo after hyperventilation. The findings may be potentially useful for the screening of patients with the juvenile type of Moyamoya disease.

Ganglioglioma with a tanycytic ependymoma as the glial component

We studied a cystic ganglioglioma (GG) located in the right frontal lobe of the brain. Interestingly, the fibrillary spindle glial cells were often arranged in a fascicular pattern, and the generally uniform, round-to-oval delicate nuclei appeared to resemble those of ependymoma; and the neoplastic neurons often contained neurofibrillary tangles (NFTs). The glial component was positive for glial fibrillary acidic protein and occasionally contained granular or microvesicular structures positive for epithelial membrane antigen. Ultrastructural investigation revealed that the glial cells were ependymal in nature; intracytoplasmic lumina and intercellular microrosettes lined with cilia and microvilli, as well as long zonulae adherentes, were evident. In addition, chromogranin A-positive granular staining, neurosecretory-granule-like structures, and parallel arrays of microtubules were sometimes associated with the blood vessels. We considered the present case to be an unusual example of GG with an ependymoma, more precisely a tanycytic ependymoma, as the glial component; to our knowledge, the existence of ependymoma as the main glial component of this particular tumor has not been described before. The occurrence of NFTs, which has been reported in several cases of GG, was an additional, unusual feature.

[Epilepsy surgery for focal cortical dysplasia and dysembryoplastic neuroepithelial tumor]

We studied six patients with focal cortical dysplasia (CD) and four patients with dysembryoplastic neuroepithelial tumor (DNT) who had surgical resection for medically intractable epilepsy. In all CD patients, ictal single photon emission computed tomography (SPECT) using 99mTc-ECD revealed hyperperfusion in the regions where magnetic resonance (MR) imaging showed CD abnormalities. Interictal epileptiform activity and ictal seizure onset on electrocorticography using subdural strip or grid electrodes were demonstrated in the CD itself. In contrast, in all DNT patients, interictal SPECT disclosed hypoperfusion in the area of the lesions. Ictal SPECT in one DNT patient disclosed hyperperfusion in the superior area of the region where MR imaging showed cystic abnormalities. Interictal spiking in all DNT patients and ictal seizure onset in two DNT patients were demonstrated not in the lesions themselves but in the distinct zone from the region of the tumor-involved brain. All CD patients who underwent lesionectomy became seizure-free with a mean follow-up period of 33.5 months. All DNT patients who underwent lesionectomy and resection of the epileptogenic cortex became seizure-free or had their seizure significantly reduced a mean follow-up period of 41.5 months. We conclude that CDs have intrinsic epileptogenicity, while DNTs have epileptogenicity not intrinsically but in encompassed cortical surface areas.

Thalamic potentials evoked by motor point stimulation

We studied thalamic potentials elicited by stimulation of the extensor digitorum communis muscle motor point during stereotactic surgery for movement disorders. In 6 patients with Parkinson's disease and 1 with cerebral palsy, muscle afferent-evoked thalamic potentials (METPs) were recorded in the ventral intermediate (Vim) nucleus. METPs consisted of three peaks with an average latency of 11.02 +/- 0.80 ms for initial positive peak (PI), 13.04 +/- 0.58 ms for negative (N), and 14.30 +/- 0.87 ms for later positive peak (PII). These METPs were different from those evoked by median nerve stimulation. No peaks corresponding to the N20 component of the somatosensory evoked potential were recorded from C3 or C4 scalp electrodes. The METP amplitudes in the ventrolateral (VL) nucleus were markedly lower than those in the Vim nucleus. These findings suggest that METPs in the Vim nucleus are responses that occur via the fast conducting group Ia afferent fibers rather than somatosensory afferent fibers.

The A-factor regulatory cascade leading to streptomycin biosynthesis in Streptomyces griseus : identification of a target gene of the A-factor receptor

In Streptomyces griseus, A-factor (2-isocapryloyl-3R-hydroxymethyl-gamma-butyrolactone) at an extremely low concentration triggers streptomycin biosynthesis and cell differentiation by binding a repressor-type receptor protein (ArpA) and dissociating it from DNA. An A-factor-responsive transcriptional activator (AdpA) able to bind the promoter of strR, a pathway-specific regulatory gene responsible for transcription of other streptomycin biosynthetic genes, was purified to homogeneity and adpA was cloned by PCR on the basis of amino acid sequences of purified AdpA. adpA encoding a 405-amino-acid protein containing a helix-turn-helix DNA-binding motif at the central region showed sequence similarity to transcriptional regulators in the AraC/XylS family. The -35 and -10 regions of the adpA promoter were found to be a target of ArpA; ArpA bound the promoter region in the absence of A-factor and exogenous addition of A-factor to the DNA-ArpA complex immediately released ArpA from the DNA. Consistent with this, S1 nuclease mapping showed that adpA was transcribed only in the presence of A-factor and strR was transcribed only in the presence of intact adpA. Furthermore, adpA disruptants produced no streptomycin and overexpression of adpA caused the wild-type S. griseus strain to produce streptomycin at an earlier growth stage in a larger amount. On the basis of these findings, we propose here a model to demonstrate how A-factor triggers streptomycin biosynthesis at a late exponential growth stage.

Contractile responses to alpha1-adrenoceptor agonists in isolated human male and female urethra

OBJECTIVE

To investigate the contractile responses mediated through alpha1-adrenoceptors in human urethra and to evaluate the effectiveness of NS-49 [(R)-(-)-3'-(2-amino-1-hydroxyethyl)-4'-fluoromethanesulphonanilide++ + hydrochloride], a novel alpha1-adrenoceptor agonist, against contraction of the human urethra.

MATERIALS AND METHODS

The contractile responses were assessed in 10 male prostatic urethrae and six female urethrae. Antagonism was evaluated in the urethra using phenylephrine, a nonselective alpha1-adrenoceptor agonist, cumulatively applied > 20 min after applying 0.1 micromol/L prazosin or 0.1 micromol/L 5-methylurapidil, a selective alpha1A-adrenoceptor antagonist. Agonism was determined in both male and female urethrae to obtain the concentration-response curve for the agonist.

RESULTS

Phenylephrine caused both male and female urethrae to contract, and showed high potency and efficacy. Prazosin antagonized these contractions with low affinity (apparent pKB of 8.30 in male urethrae). 5-Methylurapidil, also antagonized the contractions with low affinity (apparent pKB of 7.88 in male urethrae). Noradrenaline and phenylephrine caused both male and female urethrae to contract, with high potency and efficacy. A novel and selective alpha1A-and alpha1L-adrenoceptor agonist, NS-49, induced contractile responses with high potency and moderate efficacy, whereas methoxamine induced contractions with low potency and moderate efficacy. Norephedrine was a very weak contractile agonist.

CONCLUSION

In the human urethra, phenylephrine-induced contractions were mediated through alpha1L-adrenoceptors and not through alpha1A-adrenoceptors. Contractions of the human urethra induced by NS-49 were also mediated mainly through alpha1L-adrenoceptors, with high potency and moderate efficacy. NS-49 may therefore be useful for the treatment of urinary stress incontinence, with minimal side-effects because it has subtype selectivity.

Multiple pulmonary metastasis of prostatic carcinoma with little or no bone or lymph node metastasis. Report of two cases and review of the literature

We describe 2 cases of prostatic carcinoma with pulmonary metastasis. In the first case there was no lymph node or bone metastasis, and in the second case there was only one bony metastatic lesion. Presentation, etiology and management are discussed.

Increased renal retention of 99mTc-methylene diphosphonate after nephron-sparing surgery

Nephron-sparing surgery has become established as an effective treatment for localized renal cell carcinoma when preservation of renal function is necessary. The surgery usually requires temporary renal artery occlusion and may induce ischemic renal damage. In this study, we retrospectively evaluated renal activity on bone scintigraphy after nephron-sparing surgery.

METHODS

Eleven patients who underwent nephron-sparing surgery for renal cell carcinoma and had a normal contralateral kidney were studied. A total of 12 bone scintigraphy images with 99mTc-labeled methylene diphosphonate were obtained within 1 y after surgery in these patients to assess skeletal metastasis. Activity in the spared renal parenchyma was compared visually with that in the contralateral normal kidney.

RESULTS

The tumor was successfully resected in every patient, and no clinically significant complications occurred. Activity in the spared renal parenchyma was elevated in six of seven examinations performed within 21 d after surgery. In three examinations, the increase in renal activity was heterogeneous, being relatively prominent near the surgical margin. Increased renal activity was not observed on five examinations performed 3 mo or more after surgery.

CONCLUSION

Renal retention of bone-seeking agents is elevated in the early period after nephron-sparing surgery, probably as a result of ischemic insult during the surgical procedure. Bone scintigraphy may aid in evaluating the presence and degree of ischemic damage of the spared renal parenchyma.

Patients with temporal lobe epilepsy show an increase in brain-derived neurotrophic factor protein and its correlation with neuropeptide Y

Model studies on animal seizures have proposed potential involvement of the neurotrophins, BDNF and NGF, in human epilepsy. However, their biological significance in this disease itself remains to be evaluated. Here we demonstrate that patients with intractable temporal lobe epilepsy show a marked increase in protein levels of BDNF (2.6-fold, p<0.01) but not other neurotrophins. Moreover, the specific BDNF increase was significantly correlated with contents of neuropeptide Y. Thus, these results indicate the activity-dependent expression of BDNF in human subjects and its potential contribution to the pathophysiology of human epilepsy via neuropeptide Y.

Surgical treatment of renal cell carcinoma associated with Budd-Chiari syndrome: report of four cases and review of the literature

AIMS

Renal cell carcinoma is sometimes associated with inferior vena caval tumour thrombus, but occlusion of hepatic veins by the tumour thrombus causing liver dysfunction, the so-called Budd Chiari syndrome, is relatively uncommon. There are only a few reports in the literature which discuss this condition.

METHODS

Four cases admitted to our hospital over a 7-year period and eight cases reported in detail in the English and the Japanese literature were included in this study. They are classified into two groups: mild/silent, without liver failure, and severe, with liver failure.

RESULTS

Five patients were classified as mild/silent and seven as severe. Clinical manifestations were mild in the former cases and acute in the latter. Surgery was performed in four of the former cases but only in one case of the latter cases.

CONCLUSIONS

In mild cases, surgical treatment seems to avoid imminent hepatic failure effectively and should be performed as soon as possible. In such cases Budd Chiari syndrome in itself does not affect the prognosis. In severe cases, however, surgical treatment is very difficult and risky due to the existing hepatic failure.

Distribution of alpha1-adrenoceptor subtype mRNAs in human renal cortex

OBJECTIVE

To determine the quantity and distribution of alpha1-adrenoceptor subtype mRNAs in human renal cortex.

MATERIALS AND METHODS

Specimens of renal cortex tissue were obtained at the time of radical nephrectomy or total nephroureterectomy from 46 patients (mean age 59.0 years, sd 14.7) with renal cell carcinoma, renal pelvic or ureteric tumour. Using the reverse-transcriptase polymerase chain reaction (RT-PCR), the RNase protection assay and in situ hybridization, the presentation, quantity and distribution of alpha1-adrenoceptor subtype mRNAs were determined.

RESULTS

Expression of the three alpha1-adrenoceptor subtype mRNAs (alpha1a, alpha1b and alpha1d) was confirmed in the arteries of the renal cortex (arciform, interlobular, arteriole), but among the three subtypes, the alpha1b was less apparent by in situ hybridization. Intense alpha1-mRNA staining was apparent especially in the smooth muscle of arterial walls. In both proximal and distal renal tubules, each of the alpha1-mRNAs was less marked in cytoplasm than in the arteries. In the glomeruli weak staining was detected in the endothelium but there was no obvious staining in the veins. RT-PCR showed all three subtypes of alpha1-adrenoceptor. The RNase protection assay showed that the predominant alpha1-adrenoceptor subtype mRNA in human renal cortex was alpha1a. However, the abundance of alpha1a-mRNA in human kidney was much less than in the prostate.

CONCLUSION

Three alpha1-adrenoceptor subtype mRNAs were recognized in human renal cortex and detected particularly in the smooth muscle of the arteries. There was more alpha1a-adrenoceptor subtype in human renal cortex than the other subtypes. It is not known how each subtype operates against adrenergic stimulation; further studies are needed to examine receptor density or receptor function.

The alpha1L-adrenoceptor subtype in the lower urinary tract: a comparison of human urethra and prostate

OBJECTIVE

To identify the alpha1-adrenoceptor subtypes present in the human urethra, by comparing the affinity of prazosin for alpha1-adrenoceptors in the rabbit, dog and human prostatic urethra, and in the dog and human prostate.

MATERIALS AND METHODS

The study comprised samples of human prostate and prostatic urethra, obtained by open prostatectomy of patients with benign prostatic hyperplasia, and of the proximal urethra and prostate from male Beagle dogs and rabbits. Specimens were homogenized, filtered and pelleted by centrifugation. Nonspecific binding was determined in the presence of 1 mmol/L prazosin when assessing [3H]YM-617 (tamsulosin) binding, and 10 mmol/L phentolamine when assessing [3H]prazosin binding. Specific binding was defined as the difference between total binding and nonspecific binding.

RESULTS

The dissociation constant for [3H]prazosin in the human prostate (0.088 nmol/L) was less than that in the rabbit urethra (0.299 nmol/L), dog urethra (0.604 nmol/L), dog prostate (0.482 nmol/L) and human urethra (0.254 nmol/L). The affinity of prazosin was also investigated by determining the potency of the inhibition of [3H]YM-617 binding. The affinity of prazosin for alpha1-adrenoceptors in the human urethra (Ki, 2.5 nmol/L) was lower than its affinity for alpha1-adrenoceptors in the human prostate (Ki, 0.25 nmol/L) and all of the cloned subtypes (Ki, 0.26-0.44 nmol/L).

CONCLUSION

The alpha1L-adrenoceptor subtype is more prominent in the human, rabbit and dog urethra and dog prostate than in the human prostate.

[Surgical or medical castration with LH-RH analogue for prostatic cancer]

Since the discovery by Huggins and Hodges that androgen deprivation therapy is effective for prostatic cancer, surgical castration or the administration of exogenous estrogen has been the mainstay of treatment for advanced prostatic cancer. However, surgical castration is refused by some patients because of psychological impact and estrogen therapy is reported to be associated with significant morbidity and mortality. The chronic administration of superactive analogue of LHRH has been shown to suppress markedly gonadal steroidogenesis. Medical castration with LHRH analogue has been demonstrated to be safe and effective in patients with advanced prostatic cancer. But the traditional surgical castration still remains as another powerful option, because it is more excellent in the points of compliance and cost-benefit than a monthly injection of expensive LH-RH analogue.

[Stereotaxy during intravenous anesthesia with propofol]

A series of 30 patients, who underwent stereotactic surgery for movement disorder under intravenous propofol anesthesia between March, 1995 and December, 1997, was retrospectively reviewed. In 28 patients with Parkinson's disease including seven juvenile cases of parkinsonism, the postoperative motor and ADL scores on the Unified Parkinson's Disease Rating Scale significantly improved. In the other two patients, one of whom had severe posttraumatic tremor and the other had cerebral palsy, the stereotactic surgery produced considerable alleviation of their symptoms. We evaluated and discussed the usefulness of intravenous propofol anesthesia in stereotaxy. Except for one patient who had an allergic reaction against propofol, none of the patients complained of intraoperative pain postoperatively. Wake-up tests were performed to record neural noise levels in 26 cases. This recording was performed under propofol anesthesia in two cases with advanced Parkinson's disease and one with cerebral palsy. In these patients, neural noise levels were recorded and were useful for identifying the target. Although the tremor disappeared under propofol anesthesia in 17 patients presenting with moderate or severe tremor, it was presented again after discontinuation of propofol. Wake-up test, therefore, made a good evaluation of Vim thalamotomy for tremor. In juvenile parkinsonian patients, three presented with dopa-induced dyskinesia (DID) during propofol infusion. In two of them, the DID emerged immediately after posteroventral pallidotomy and continued 4 or 10 hours after stereotaxy. These findings suggest that propofol possibly has an anti-parkinsonian effect. Intravenous propofol anesthesia is a useful method to use with stereotactic surgery for movement disorders.

Granulocyte colony-stimulating factor induces neutrophil sequestration in rabbit lungs

The effects of intravenous injection of recombinant human granulocyte colony-stimulating factor (rhG-CSF) on circulating neutrophil numbers, pulmonary vascular permeability, and morphologic changes in the lung were examined in rabbits. Intravenous injection of rhG-CSF caused a rapid, profound neutropenia due to neutrophil sequestration primarily within capillaries but also in larger microvessels of the lungs. Examination of neutrophil deformability using microfilters revealed that granulocyte colony-stimulating factor (G-CSF) treatment caused a rapid stiffening of neutrophils through the polymerization of F-actin but not microtubule assembly. The expression of CD11b, CD11c, and CD18 on human neutrophils after G-CSF treatment increased, but CD11a did not. Intravenous injection of rhG-CSF did not induce neutrophil emigration or albumin leakage into alveolar space, wet/dry lung weight ratios were unchanged, and no pathologic changes in lung histology were observed. These studies indicate that injection of rhG-CSF caused a rapid neutropenia and neutrophil sequestration in the lungs that is likely to be mediated through a G-CSF-induced decrease in neutrophil deformability, although neutrophil-endothelial cell adhesion may also play a role. However, this G-CSF-induced neutrophil sequestration did not induce a massive lung injury.

Trigeminal neuralgia caused by the vertebral artery associated with primitive trigeminal artery and agenesis of the internal carotid artery

A 69-year-old female presented with trigeminal neuralgia caused by tortuous vertebrobasilar artery associated with primitive trigeminal artery (PTA) and agenesis of the ipsilateral internal carotid artery (ICA). Left vertebral angiography showed marked elongation of the left vertebral artery and filling of the left ICA via the PTA. Bone window computed tomography suggested agenesis of the left ICA. Intraoperative findings showed that the vertebrobasilar junction had compressed the root entry zone of the trigeminal nerve. The neuralgia improved immediately after microvascular decompression. There has been no recurrence for 20 months. Trigeminal neuralgia may be caused by a tortuous vertebrobasilar system due to hemodynamic stress associated with PTA and agenesis of the ICA.

Co-expression of hepatocyte growth factor and its receptor in human prostate cancer

Hepatocyte growth factor acts differently depending on the organs or tumours involved. It may be produced simultaneously with its receptor, c-Met, in several types of malignant tumour cells and may exercise an autocrine regulation. To analyse the effect of hepatocyte growth factor in human prostate cancer, we conducted immunohistochemistry, in situ hybridization and the reverse transcriptase polymerase chain reaction. The first two techniques revealed the growth factor in prostate cancer cells, and the polymerase chain reaction confirmed this expression. c-Met is expressed in prostate cancer cells, but not in interstitial cells. Hepatocyte growth factor is expressed in interstitial cells, especially in hormone-treated cancer tissue, indicating that the growth factor pathway changes with the hormonal status. Low-grade tumours expressed c-Met at the plasma membrane. Higher grade tumours tended to express it in the cytoplasm, suggesting that the role of c-Met as the hepatocyte growth factor receptor was blocked in higher grade tumours. The relationship between the growth factor and its receptor is thus influenced by hormonal status and differentiation in prostate cancer and is not explained simply in terms of autocrine or paracrine action.

Significance of the BTA test in bladder cancer: a multicenter trial. BTA Study Group Japan

BACKGROUND

The BTA test is a latex agglutination assay for the qualitative detection in the urine of analytes that are associated with bladder tumor. We compared the results of the BTA test with those of voided urine cytology (VUC) in patients with bladder cancer.

METHODS

A multicenter trial was performed at 6 institutions. A total of 132 patients with histologically diagnosed bladder cancer were enrolled. Urine samples were split for BTA and VUC testing.

RESULTS

The sensitivities of the BTA test and VUC were 57.6% and 37.9%, respectively; this difference was significant (P < 0.001). The BTA test had much higher sensitivity for small, solitary, superficial tumors than did VUC.

CONCLUSION

The BTA test is simple to perform, gives rapid results, and is far more sensitive than VUC for detection of bladder cancer. The BTA test has the potential to become an additional tool for detecting bladder cancer.

Hemifacial spasm resulting from facial nerve compression near the internal acoustic meatus--case report

A 61-year-old female presented with a rare case of hemifacial spasm (HFS) resulting from facial nerve compression near the internal acoustic meatus. She underwent a first surgery for microvascular decompression at the root entry zone of the facial nerve, but this did not achieve resolution of the HFS. During the second surgery, the meatal loop of the anterior inferior cerebellar artery (AICA) was found to be the offending artery near the internal acoustic meatus. When the AICA was dissected and separated from the facial nerve, abnormal muscle responses of the mentalis muscle due to electrical stimulation of the zygomatic branch of the facial nerve were abolished. Following surgery the patient was completely free of the HFS.

[Retrograde radical cystectomy. Advantages of our "vesico-rectal tunnel" method]

BACKGROUND

The facilitation of dissecting the vesical pedicles and undisturbed preservation of the membranous urethra were investigated during radical cystectomy using the retrograde technique.

METHODS

First, just as with radical prostatectomy, the prostate and the rectum were separated by blunt digital dissection. After the deep dorsal vein complex and the urethra were cut, the bladder and the rectum were also separated in a retrograde manner towards the Denonvillier's fascia. Then the peritoneum was opened and its lowest part was incised above the cul-de-sac. A tunnel was made beginning at the cut-end of the urethra to the cul-de-sac. Consequently, the bladder was lifted up by hand inserted this "vesico-rectal tunnel" and the bilateral remaining lateral pedicles were ligated and transsected without difficulty.

RESULTS

Fourteen patients underwent radical cystectomy using this technique. Among them, the average operating time and blood loss in 4 patients received retrograde radical cystectomy accompanied with ileal conduit were 5 hours 15 minutes and 1606 ml, respectively. These in 9 patients received retrograde radical cystectomy followed by bowel orthotopic urinary reservoir were 7 hours and 6 minutes and 1086 ml, respectively. Another patient received ureterocutaneoustomy.

CONCLUSION

Creating a "vesico-rectal tunnel" during radical cystectomy primarily by the retrograde extraperitoneal technique can afford to preserve the urethral sphincter and to ligate the pedicles easily. This method is fundamentally familiar to us because retrograde radical prostatectomy is now widely adopted and it may help to reduce the operating time even when there is a shortage of manpower.

Short-latency somatosensory evoked potentials in patients with brain stem tumor: study of N20 and N18 potentials

Short-latency somatosensory evoked potentials (SSEPs) elicited by median nerve stimulation were studied in 17 patients with brain stem tumor. A total of 35 SSEP records were obtained and classified into five groups: 13 in Group I, central conduction time (CCT) < 7.56 msec (within the normal limits); eight in Group II, CCT > or = 7.56 msec; nine in Group III, N20 potential was abolished; four in Group IV, N20 and N18 potentials were abolished; and one in Group V, N20, N18, and P14 potentials were abolished. These SSEP groups were correlated with the size and location of the brain stem tumor on magnetic resonance images. N20 potentials were unchanged in latency in patients with small localized gadolinium (Gd)-enhanced lesions. In contrast, the N20 potentials were abolished in patients with tumors extending to the dorsal pons and the upper medulla oblongata. The extent of nonenhanced low-intensity lesion did not correlate with the changes of the N20 potentials. The degree of the impairment of the N20 potentials reflected the severity of the clinical symptoms. The N20 potential can evaluate brain stem dysfunction caused by brain stem tumor. The N18 potentials were abolished in four patients, in whom the tumor extension (one Gd-enhanced lesion, three low-intensity lesions) involved not only the pons but also the medulla oblongata. Therefore, the N18 potentials are probably generated from the medulla oblongata.

Comparison of the results of bilateral total knee arthroplasty with and without patellar replacement for rheumatoid arthritis. A follow-up note

Simultaneous bilateral total knee arthroplasty was performed in twenty-six patients who had rheumatoid arthritis, and a patellar replacement was performed concurrently in one randomly selected knee in each patient. A lateral retinacular release was performed in all knees. The patients were followed for at least six years (mean, 6.6 years; range, 6.0 to 7.5 years), and the postoperative status of the patients was evaluated with the knee score of The Hospital for Special Surgery. Pain on standing and on ascending or descending stairs as well as tenderness of the patellofemoral joint also were assessed. The over-all score and the individual scores for pain, function, range of motion, muscle strength, flexion contracture, and instability were not significantly different between the knees that had had a patellar replacement and those that had not. However, pain on standing and on ascending or descending stairs as well as tenderness of the patellofemoral joint were only noted in knees that had not had a patellar replacement. These findings suggest that, in order to diminish pain on standing and on using stairs, replacement of the patella during total knee arthroplasty is preferable for patients who have rheumatoid arthritis.

Temporal lobe lesion demonstrating features of dysembryoplastic neuroepithelial tumor and ganglioglioma: a transitional form?

We report an unusual multimodular glioneuronal lesion found in a temporal lobe from a 17-year-old boy with complex partial seizure. Histologically, this lesion was located within the cortex of the middle temporal gyrus and consisted of multinodular foci and the surrounding cortical dysplasia, resembling dysembryoplastic neuroepithelial tumor (DNT). However, it was quite different in the following respects from usual DNT: 1 nodule found in the subpial area consisted entirely of mature atypical neuronal cells separated by a reticulin fiber network connecting to the pia mater and the area around and between the above nodule, whereas another neighboring nodule, which contained many oligodondroglia-like round cells as well as occasional neuronal cells and fibrillary astrocytic cells, showed scattered neuronal cells in the well-differentiated fibrillary astrocytic stroma, the histological features being those of ganglioglioma (GG). We consider that the present case is a good example of the transitional form between DNT and GG. At 25 months following total lesion extirpation, the patient is healthy and free from seizures.