MR signal intensity changes in hepatic parenchyma with ductal dilation caused by intrahepatic cholangiocarcinoma

MR images of the liver in 13 patients with surgically proven intrahepatic cholangiocarcinoma were reviewed retrospectively and correlated to the histologic analysis of surgical specimens. We paid special attention to the peripheral liver tissue with ductal dilation but without tumorous involvement. High signal intensity was observed in the hepatic parenchyma with ductal dilation on T1-weighted spin-echo images (8 of 12) and spoiled gradient-recalled echo images (seven of seven), as compared with the contralateral hepatic lobe without duct dilation. The high signal intensity was not suppressed with fat saturation and showed enhancement after administration of contrast (11 of 12). Concurrent portal venous obstruction did not have significant effect on these findings (P < .05). Correlation with pathologic specimens suggested that this enhancement was associated with periportal fibrosis. The etiology of the high signal intensity on unenhanced spin echo or gradient-recalled T1-weighted image remains unclear. Radiologists should recognize these findings and should distinguish these from tumor involvement or the arterial buffer response caused by portal venous obstruction.

Splenectomy in biliary atresia patients with recurrent jaundice following partial splenic embolization

Splenectomy was performed for three patients with biliary atresia because of re-exacerbation of their jaundice following treatment by partial splenic embolization (PSE). The subjects' red blood cell count and hemoglobin, serum level of hepatic enzymes (glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, gamma-glutamyl transpeptidase, alkaline phosphatase, and lactic dehydrogenase), and total bilirubin (TB) were evaluated both before and after splenectomy in order to analyze the effects of splenectomy on these patients. The TB decreased significantly within 3 months after splenectomy in all three patients (13.0 +/- 1.6 mg/100 ml to 5.4 +/- 0.3 mg/100 ml, p < 0.05). The red blood cell count and hemoglobin increased gradually. There was a statistically significant correlation between the TB and the red blood cell count, and/or concentration of hemoglobin. The hepatic enzymes after splenectomy were not significantly different from those before splenectomy. The change in TB following splenectomy was essentially similar to that following PSE. These results suggested that the postoperative improvement in jaundice following splenectomy may not be due to improved hepatic function but merely a reflection of decreased red blood cell turnover. Splenectomy is a useful palliative procedure for jaundice in patients with biliary atresia for whom PSE is no longer effective.

Heterocyclic analogues of quinone methide: preparation and cytotoxicity of 3-oxo-3H-pyrazolo[1,5-a]indole derivatives

A series of 3-oxo-3H-pyrazolo[1,5-a]indole derivatives was prepared and characterized as heterocyclic analogues of quinone methide. These compounds showed some cytotoxicity to cancer cells, but were ineffective in an in vivo test against murine leukemia L1210.

MR imaging of hepatocellular carcinomas: effect of Cu and Fe contents on signal intensity

BACKGROUND

To elucidate the metallic factors contributing to the signal intensities of hepatocellular carcinoma (HCC) on T1-weighted magnetic resonance (MR) images and to determine whether or not changes in signal intensity contribute to the diagnosis of histological grading of HCC.

METHODS

In 35 patients immediately after surgery, the quantities of water, lipid, copper (Cu), iron (Fe), and manganese (Mn) were determined in HCCs and the surrounding hepatic parenchyma. The correlations among these findings, the histopathological findings, and the signal intensities of T1-weighted MR images were evaluated.

RESULTS

Among the 35 HCCs, 12 (34%) were of high intensity, 14 (40%) were isointense, and 9 (26%) were of low intensity on T1-weighted images versus the surrounding hepatic parenchyma. The paramagnetic ions, which contributed to the signal intensity patterns, were assumed to be Cu in HCCs (30.5 +/- 52.9 microg/g ww), and Fe in the livers (106.2 +/- 86.8 microg/g ww) and HCCs (87.7 +/- 49.1 microg/g ww). In 12 HCCs with high intensity, one was grade I, eight were grade II, and three were grade III according to Edmondson-Steiner's histopathological classification.

CONCLUSIONS

Signal intensity and signal intensity patterns alone cannot be signs of low-grade malignancy because of the Fe in livers and in HCCs.

Continuous brachial plexus infusion of butorphanol-mepivacaine mixtures for analgesia after upper extremity surgery

We have recently reported that continuous administration of butorphanol into the brachial plexus neurovascular sheath provided superior analgesia compared with that obtained with continuous i.v. administration. Furthermore, we found that analgesia was most pronounced when a mixture of mepivacaine and butorphanol was given and that butorphanol alone ranked next. In this study, we increased the dose of butorphanol, compared with that used in our previous reports, and an initial bolus dose of butorphanol was administered into the brachial plexus neurovascular sheath just after surgery had ended. Thereafter, postoperative pain relief was estimated. In patients undergoing upper extremity surgery with continuous axillary brachial plexus block, group A received a bolus of 1 ml of physiological saline with 1.5% mepivacaine, 10 ml into the brachial plexus sheath followed by a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/ 72 h. Group B was given a bolus of butorphanol 1 mg (1 ml) with 1.5% mepivacaine, 10 ml into the brachial plexus sheath and a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/72 h. After operation, VAS scores did not differ between the two groups. The time to first use of supplementary analgesia did not differ significantly between the two groups and there were no significant differences in the number of patients who required supplementary analgesia. These results indicate that continuous butorphanol 2 mg day-1 with 0.5% mepivacaine provided sufficient postoperative analgesia after upper limb surgery.

The effect of current direction induced by transcranial magnetic stimulation on the corticospinal excitability in human brain

Evoked spinal cord potentials (ESCPs) from the cervical epidural space and motor evoked potentials (MEPs) from the hand muscles were recorded simultaneously in 6 subjects following transcranial magnetic stimulation in two different coil orientations on motor cortex. The onset latency of the MEPs was approximately 1 ms shorter when the induced current flowed in a latero-medial direction (L-M stimulation) on the motor cortex as compared to a postero-anterior direction (P-A stimulation). Hence, L-M stimulation elicited an earlier component of the ESCPs than that induced by P-A stimulation. During general anesthesia with Sevoflurane, only the first component of the ESCPs could be elicited routinely following L-M stimulation. In contrast, all components of the ESCPs were dramatically attenuated following P-A stimulation. Moreover, first component latency of the ESCPs induced by L-M stimulation was almost the same as that induced by transcranial anodal electrical stimulation. These results suggest that if the induced current following transcranial magnetic stimulation flows in a latero-medial direction on motor cortex, it preferentially stimulates the corticospinal tract non-synaptically (producing a D-wave). However, if the induced current flows in a postero-anterior direction, it preferentially stimulates the corticospinal tract trans-synaptically (producing I-waves). Therefore, the direction of magnetically induced current is crucial in determining corticospinal excitability in the human brain.

Clinical evaluation of orthodontic treatment after surgical repositioning or transplantation of teeth

Fourteen impacted teeth in thirteen patients aged 9 to 17 years were either repositioned or transplanted, followed by postoperative orthodontic treatment. Successful results were achieved in twelve of the teeth. In one tooth, ankylosis of the root prevented a successful outcome, and deficient bone healing of the alveolar process led to an unsuccessful result in a second tooth.

Anatomy and etiology of extrahepatic portal vein obstruction in children leading to bleeding esophageal varices

BACKGROUND

The cause of extrahepatic portal vein obstruction in childhood is unknown. We investigated the anatomical features of extra hepatic portal vein obstruction to clarify its cause.

STUDY DESIGN

We studied portal venous anatomy in 10 patients with extrahepatic portal vein obstruction without hepatic disturbances ranging in age from 1 to 7 years (mean age, 4.2 years) using ultrasonography, portal venography, cholangio-computed tomography, and magnetic resonance imaging.

RESULTS

The extrahepatic portal vein was not obliterated, but it crossed over the common bile duct from the left to the right side at the cranial level of the pancreas and ran in a cranial direction along the right side of the common bile duct or coiled itself around the bile duct. Thus, the extrahepatic portal vein formed a tortuous eta-shape.

CONCLUSIONS

The portal vein was not obstructed in patients with extrahepatic portal vein obstruction but formed a characteristic eta-shape by coiling itself around the common bile duct, suggesting that extrahepatic portal vein obstruction has an embryological cause.

Soluble complement receptor type 1 inhibited the systemic organ injury caused by acid instillation into a lung

BACKGROUND

Acid aspiration into one lung causes contralateral lung injury and systemic organ injury; this injury is thought to be mediated by the sequestration of activated neutrophils. Recombinant human soluble complement receptor 1 (sCR1) inhibits both the classical and alternative complement pathways; this study investigated the role of the complement system in unilateral acid lung injury by measuring the effects of administering sCR1 before or immediately after acid instillation.

METHODS

Anesthetized rats (n = 18 in each group) underwent tracheostomy and insertion of a cannula into the anterior segment of the left lung. Then either 0.1 ml 0.1 N hydrochloric acid (HCl group) or 0.1 ml pH 7.4 phosphate buffered-saline (PBS group) was instilled. Fifteen minutes before (pre-sCR1 group) or 15 min after (post-sCR1 group) the acid was instilled, 10 mg/kg sCR1 was administered intravenously. Four hours after the acid instillation, rats were killed. In an additional 4 rats in each group, blood and bronchoalveolar lavage fluids obtained 1 h after the instillation of either acid or PBS were analyzed for tumor necrosis factor-alpha activity.

RESULTS

The instillation of acid led to an increased wet-to-dry ratio of 5.2 +/- 0.1 in the acid-instilled lungs compared with their contralateral lungs (4.7 +/- 0.06). These values were greater than the values of 4.6 +/- 0.2 and 4.5 +/- 0.03 in the PBS-instilled lungs and their contralateral lungs, respectively (P < 0.05). The administration of sCR1 before or immediately after the instillation of acid did not attenuate the increase in the wet-to-dry ratio of the acid-instilled lungs. However, the small but consistent increase in the wet-to-dry ratio of the contralateral lungs was attenuated by the sCR1 infusions (P < 0.05). The instillation of acid increased the protein concentration in the bronchoalveolar lavage fluids from the injured lungs (1,000 +/- 206 micrograms/ml) compared with the protein concentration measured in the bronchoalveolar lavage fluids from their contralateral lungs (254 +/- 55 micrograms/ml). The administration of sCR1 before or immediately after the instillation of acid did not decrease the protein concentration in the bronchoalveolar lavage fluids from the acid-instilled lungs. The myeloperoxidase activity was increased in the acid-instilled lung, in their contralateral lung, and in the small intestines of the animals. The infusions of sCR1 before or immediately after the administration of acid led to significant decreases in the myeloperoxidase activities measured in the lungs and the intestines of the treated animals. Plasma tumor necrosis factor-alpha activity was only increased (2.7 +/- 1.1 U/ml) in the animals that had received acid instillations. The infusions of sCR1, administered either before or immediately after the acid instillations, significantly decreased the measured tumor necrosis factor-alpha activity in the plasma (0.5 +/- 0.6 and 1.0 +/- 0.7 U/ml, respectively).

CONCLUSIONS

The results suggest that the complement system plays an important role in the pathogenesis of the injury of the contralateral lung and of the small intestine after unilateral instillation of acid to the lung. Further investigation is warranted to determine the clinical utility of antiinflammatory agents in acid-induced lung injury.

The long-term suppressive effect of prior activation of synaptic inputs by low-frequency stimulation on induction of long-term potentiation in CA1 neurons of guinea pig hippocampal slices

We have investigated the effects of prior activation of afferent inputs by a train of low-frequency stimulation (LFS) on the induction of long-term potentiation (LTP) induced by high-frequency stimulation (tetanus, 100 Hz, 100 pulses) in CA1 neurons of guinea pig hippocampal slices. The parameters of the LFS were altered systematically: the frequency (1 or 5 Hz); the number of pulses (80, 200 or 1000); and the time lag from the LFS to the tetanus (20, 60 or 100 min). Conditioning effects of the LFS on the induction of LTP were evaluated in terms of the slope of the field excitatory postsynaptic potential (S-EPSP) and the amplitude of the population spike (A-PS). LTP could reliably be induced by 100 Hz tetanic stimulation delivered to a naive slice. In contrast, the attempt to induce LTP 60 min after LFS of 200 or 1000 pulses at 1 Hz resulted only in short-term potentiation while the LFS itself produced no significant change in the responses. The suppressive effect on LTP was significantly reduced for 1 Hz LFS with a smaller number of pulses (80 pulses), or a shorter (20 min) or longer (100 min) time lag from the LFS to the tetanus, or with LFS at a higher frequency (5 Hz). When the LFS of 1000 pulses at 1 Hz was delivered in the presence of the N-methyl-D-aspartate (NMDA) receptor antagonist AP5 (D,L-4-amino-5-phosphonovalerate, 50 microM), which was washed out after the end of the LFS, the tetanus given 60 min after application of the LFS produced stable LTP, indicating the involvement of NMDA receptor/channels in the mechanisms of this particular form of synaptic plasticity-long-term suppression of LTP.

Unilateral anomalous left common carotid artery; a case report

An anomaly of the left common carotid artery was observed in a Japanese male cadaver during an anatomy class at the Saitama Medical School in 1995. The superior thyroid, lingual and facial arteries arose from the common carotid artery, and the posterior auricular, maxillary and superficial temporal arteries arose from the common carotid artery by a common trunk. The occipital and ascending pharyngeal arteries arose from the internal carotid artery. The left carotid body (glomus caroticum) was observed to be slightly below the lingual artery, behind the common carotid artery, and it was located at the level of the intervertebral disk between C2 and C3 or at the same level as the right carotid body. The carotid body was richly innervated by a branch of the glossopharyngeal nerve and by a plexus of sympathetic fibers from the vagus and glossopharyngeal nerves. We assumed that the artery above the level of the carotid body was the internal carotid artery; there was no specific external carotid artery and all branches of the external carotid artery arose from the internal carotid artery.

A case of advanced gastric cancer complicated by severe toxicity induced by a combination of tegafur, uracil and mitomycin C, and associated with abnormal pharmacokinetics

A 60-year-old female patient with gastric cancer and lymph node and liver metastases was treated with a combination of tegafur and uracil (UFT) (375 mg/m2/day) and mitomycin C (MMC) (5 mg/m2 once weekly). On day 15, when diarrhea appeared, chemotherapy was stopped immediately. On day 21, the WBC decreased to 900/microl and high fever developed. Despite treatment with granulocyte colony-stimulating factor and antibiotics, leukopenia persisted and the patient went into septic shock on day 26. On day 34, WBC increased to 5,400/microl and she recovered, with reduction in the size of the lymph node and liver metastases. Pharmacokinetic examination after intravenous injection of low-dose MMC (0.5 mg/m2) showed a markedly high peak plasma concentration (PPC), a large area under the time-versus-concentration curve (AUC) and reduced clearance. Similarly, oral administration of UFT (tegafur 300 mg/body) produced a relatively higher PPC and a larger AUC of 5-fluorouracil (FU). The activity of dihydropyrimidine dehydrogenase, the rate-limiting enzyme in the metabolism of FU, in peripheral mononuclear cells was within the normal range (0.265 nmol/min/mg). MMC is believed to have played a large part in inducing the severe toxicity observed in this patient. Physicians should be aware of the possibility of severe toxicity during treatment with UFT and MMC, although details of its incidence and mechanism are unclear.

Family study of acute intermittent porphyria and hereditary coproporphyria in Niigata and Akita Prefectures, Japan

Simple screening tests, urinary porphobilinogen (PBG) for acute intermittent porphyria (AIP) and fecal coproporphyrin for hereditary coproporphyria (HCP), were performed in a family study of AIP and HCP. Urinary PBG was positive in 93 of 211 members of 10 AIP families, but was negative in 568 of 572 controls. Fecal coproporphyrin was positive in 54 of 108 members of 10 HCP families, but was negative in 188 controls. A dominant inheritance was assumed by a chi-square test and Weinberg segregation ratio. Worsening factors around puberty were suggested by the onset age and cumulative percentage of genetically loaded cases. Sex-related expression of symptoms was also inferred by a higher incidence of both porphyrias in females than in males. Fitness and penetrance of both porphyrias were good. An l-triiodothyronine loading test was the most useful for the detection of masked carriers of AIP. In conclusion, AIP and HCP in Japan show a dominant inheritance with sex-related metabolic and clinical manifestations.

Complete excision of the intrapancreatic portion of choledochal cysts

BACKGROUND

Cyst excision is the treatment for patients with choledochal cysts. In general, many authors recommend intramural dissection between the outer and inner layers of the cyst or partial excision leaving part of the cyst in the pancreas to avoid pancreatic injury. However, because there are few large series with long-term follow-up periods, it remains unclear how much of the intrapancreatic portion of the cyst should be resected and what resection technique should be used.

STUDY DESIGN

During an 18-year period, 104 patients underwent excision of choledochal cysts at our hospitals. Twelve patients had partial excision of the cyst above the pancreas, and 17 had intramural dissection of the intrapancreatic portion. Seventy-five patients underwent complete excision of the intrapancreatic portion of the cyst by our new technique, in which the outer plane of the epicholedochal plexus is dissected, exposing the narrow distal segment connecting the cyst to the pancreatic duct. Our new technique was compared retrospectively with the other two techniques.

RESULTS

With our technique, the intrapancreatic cyst could be excised completely in 75 patients without any complications. Blood loss was significantly decreased when our technique was used compared to intramural excision. A pancreatic fistula occurred after intramural excision in one patient, and pancreatic stones formed several years after partial excision and intramural excision in three patients who proved to have residual cystic material in the pancreas.

CONCLUSIONS

Our operative technique is safe and effective for the complete excision of the intrapancreatic portion of a choledochal cyst.

[Intralobar pulmonary sequestration associated with asymptomatic aspergillosis: a case report]

One case of intralobar pulmonary sequestration associated with asymptomatic aspergillosis are reported. A 39-year-old woman was admitted to our hospital because of abnormal shadow in the right lower lobe detected on mass miniature chest X-ray. The patient had been asymptomatic, and an aortogram showed an anomalous artery originating from abdominal aorta and entering the abnormal shadow suggesting sequestration. The right S10 segmentectomy was done. With bacterial culture of fluid in the specimen and on microscopic investigation this proved to be an intralobar pulmonary sequestration infected with Aspergillus. This case shows the necessity of prompt resection of intralobar pulmonary sequestration, even if asymptomatic.

Primary malignant lymphoma in the porta hepatis: a case report

A case of primary lymphoma in the porta hepatis is presented here. Cholangiography, angiography, ultrasonography and computed tomography suggested the presence of a mass in the porta hepatis, but all these failed to demonstrate the tumor clearly. Magnetic resonance imaging was very useful in defining the characteristics of the tumor and in delineating its extent, though it was not specifically diagnostic.

[A surgical case report of ossified left atrial myxoma]

A 68-year-old female has developed dyspnea on effort for 5 years. On admission, a grade 2/6 apical systolic regurgitant murmur was noted. Chest X-ray examination showed moderate cardiac enlargement. Echocardiogram showed a highly echoic mass with acoustic shadow in the left atrium which was attached to the interatrial septum. A partial herniation of the tumor through the mitral annulus in diastolic phase and moderate mitral regurgitation was noted. Ultra fast computed tomography of the chest revealed a left atrial mass with high density area. At operation the mass was excised with atrial septum through the right atriotomy. Microscopic findings showed the myxoma with bone and bone marrow formation.

Human herpesvirus-6 (HHV-6)-associated hemophagocytic syndrome

Virus-associated hemophagocytic syndrome (VAHS) is characterized by histiocytic proliferation and phagocytosis triggered by virus infections. Viruses in the herpes group, especially the Epstein-Barr virus (EBV), are well known to cause VAHS; however, the relationship between this syndrome and human herpesvirus-6 (HHV-6) infection has rarely been reported. In this study, we describe a 23-month-old girl who exhibited typical manifestations of VAHS associated with HHV-6 infection. To the best of our knowledge, this case is the fifth reported case in the English literature.

[Abnormality of HDL subfractions in cholesteryl ester transfer protein deficiency]

High-density lipoprotein (HDL) in cholesteryl ester transfer protein (CETP) deficiency is deficient in reverse cholesterol transport although HDL-cholesterol levels markedly increase in such patients. This may be responsible for the abnormal metabolism of pre beta 1-HDL, the initial acceptor of cell-derived cholesterol. To answer this question, we determined HDL subfraction levels in 8 CETP deficiency and 21 normolipidemic subjects. We also measured the rate of decrease in pre beta 1-HDL level by LCAT activity during the incubation at 37 degrees C for 90 min. We found that HDL2b was 2.4 times higher in CETP deficiency than in control [52.2 +/- 14.3, vs. 21.5 +/- 9.8% of plasma apoA-I(%AI), p < 0.005] while HDL2a and HDL3 were significantly lower in the former than in the latter (HDL2a; 25.5 +/- 8.0 vs. 40.4 +/- 6.5% AI, p < 0.005) (HDL3; 10.0 +/- 6.8 vs. 28.3 +/- 5.9% AI, p < 0.005). There were no significant differences in pre beta 1-HDL level between 2 groups (4.9 +/- 3.0 vs. 4.5 +/- 2.3% AI, NS). However, the rate of decrease in pre beta 1-HDL was significantly less in CETP deficiency than in control (-33.2 +/- 22.9 vs. -73.7 +/- 12.2%, p < 0.005). In conclusion, the metabolism of pre beta 1-HDL is delayed in CETP deficiency. It is suggested that the esterification of cell-derived cholesterol removed by pre beta 1-HDL may be deficient in CETP deficiency.

Radiologically identifiable intratumoral portal vein in intrahepatic cholangiomas: a diagnostic pitfall

BACKGROUND

Although intratumoral patent portal vein (ITPV) is one of the characteristic features of benign hepatic lesions, ITPVs can be demonstrated in malignant tumors. We present the spectrum of MR and CT findings of ITPV identified in intrahepatic cholangiomas with pathological correlations.

METHODS

The ultrasound, CT and/or MRI findings of pathologically-confirmed intrahepatic cholangiomas were reviewed and correlated with surgical specimen or autopsy findings.

RESULTS

Intratumoral patent vessels were radiographically-demonstrated in 5 patients with intrahepatic cholangiomas. All intratumoral vessels were secondary or tertiary order portal vein branches. Some wall thickening was identified on pathological examinations.

CONCLUSION

The radiological demonstration of intratumoral portal vein is not a specific sign of benignity. In the case of a hepatic tumor with a patent portal tract, cholangioma should be considered, as well as benign tumors or lymphoma.