Investigation of the local provocation test to PPP and IgA nephritis

We examined 24 cases with pustulosis palmaris et plantaris (PPP) and 13 cases with IgA nephritis. The provocation test was performed in 11 cases with PPP and 7 cases with IgA nephritis. According to Nosaka's criteria, as variables for assessing the provocation test, changes in WBC (white blood cell count), BT (temperature), ESR (erythrocyte sedimentation rate) and skin eruption or urinary findings (hematuria and proteinuria) were estimated. Analysis of the provocation test proved positive in 3 of 11 cases (27%) with PPP and in 5 of 7 cases (71%) with IgA nephritis. Improvement of PPP was found in 12 of 14 cases (86%) with tonsillectomy and in 5 of 10 cases (50%) without tonsillectomy. However, there was no significant relation between prognosis and results of provocation tests. Improvement of IgA nephritis was found in 6 of 10 cases (60%) with tonsillectomy and none of 3 cases (0%)) without tonsillectomy. Furthermore, the cases with positive reaction by the provocation test showed better prognosis than those with negative reaction. Our results suggest that in patients with IgA nephritis, the efficacy of tonsillectomy is better in patients with a positive reaction to the provocation test than in those with a negative reaction. However, this phenomenon was not observed in the patients with PPP. Improvement of symptoms in the patients undergoing tonsillectomy was found in the early time period after surgery as compared with that in the patients with conservative treatment.

[A new embolic material: super absorbent polymer (SAP) microsphere and its embolic effects]

SAP-Microsphere (sodium acrylic acid-vinyl alcohol copolymer) has the ability to absorb fluids within a few minutes and increase its diameter. Its diameter can also be calibrated. The diameters in ionic contrast material and human serum are 2.1 and 3.5 times larger, respectively, than the original size. It can pass through a microcatheter with an ionic contrast material, and swells at the occluding point into the desired size. It can be recognized under fluoroscopy due to its absorption of contrast material. A total of 10 rabbit kidney embolizations were done followed by resection in 1-14 weeks. Recanalization was absent in all cases. No adhesion to the perirenal tissue was found. Limited reactive change in endothelial cells was found at one week. No changes in the smooth muscle layer were found at any time during the study. Limited infiltration of neutrophil cells was found in perivascular tissue within a period of one week. SAP-Microspheres maintained their spherical shape during a 14-week period. Extensive fibrosis and calcification were found after 4 weeks. SAP-Microspheres are promising as an embolic agent to obtain satisfactory results of embolization therapy.

Intramural invasion of gastric cancer: evaluation by CT with water-filling method

OBJECTIVE

Our goal was to clarify the ability of CT to evaluate intramural invasion of gastric cancer.

MATERIALS AND METHODS

We reviewed bolus-enhanced CT images performed with orally administered 400-600 ml of water in 59 early gastric cancers and 22 advanced gastric cancers mimicking early gastric cancers macroscopically.

RESULTS

CT was able to reveal 49% of early gastric cancers and 68% of advanced gastric cancers mimicking early cancers. Twenty-seven gastric tumors were detected in two or three layered structure of wall. Morphologic features of early gastric cancers are strong enhancement without wall thickening and thickened inner layer with normal middle and outer layers. Morphologic features of early advanced gastric cancers are a thickened wall with disappeared middle and outer layers and transmural enhancement with wall thickening. If one of these features was used to predict whether the tumor was early or early advanced gastric cancer in detected cases, specificity was 93-100%, sensitivity was 7-72%, and positive predictive value was 80-100%.

CONCLUSION

We evaluated whether the wall pattern of gastric tumors on CT can provide useful information about intramural invasion.

[Pulmonary infection due to Mycobacterium szulgai associated with multiple bullous disease of the lung]

A 46-years-old male was admitted to our hospital because of productive cough and infiltrates on the chest roentogenogram. The patient had a history of left upper bullectomy ten years prior to the admission. The CT scan of the chest on admission showed infiltrats with cavitation in the left apex and multiple bullae in almost whole lung. Microscopical examination of smears of sputum and bronchoalveolar lavage fluid revealed acid-fast bacilli. They were identified as Mycobacterium szulgai by DNA-DNA hybridization method. The patient was treated with isoniazid, streptomycin and rifampicin. After treatment for about a month, the culture of sputum converted to negative for M. szulgai. After about three months hospitalization, the infiltrates decreased and the cavity wall became thin, and no recurrence sign has been observed after the discharge. There are a few case reports of pulmonary infection due to M. szulgai associated with bullous disease of the lung in Japan.

[Studies on mucociliary transport in patients with pulmonary atypical mycobacteriosis--by aerosol inhalation cine-scintigraphy]

Mucociliary transport (MCT) was studied in 22 patients with atypical mycobacteriosis (Group I : 16 with M. avium-intracellulare complex (MAC), Group II : 6 with M. kansasii) by aerosol inhalation cine-scintigraphy. In most of the patients, the MCT was abnormally slow both in the main bronchus and in the trachea, while in healthy controls the transport of the inhaled aerosol in the bronchus and the trachea were rapid and smooth. In both groups, the tracheal MCT was impaired in two thirds of the patients, while the MCT in the main bronchus was impaired in all except one in Group I and in two-thirds in Group II. The results indicate that the grade of bronchial impairment was higher in MAC than in M. kansasii infections. In atypical mycobacteriosis, especially in MAC infections, such impairment of MCT could be closely related to the disruption of local defence mechanisms in the airways.

Portal vein thrombosis associated with active ulcerative colitis: percutaneous transhepatic recanalization

A patient with severe ulcerative colitis developed portal vein thrombosis. Intraportal infusion of plasminogen activators through a percutaneous transhepatic catheter produced an effective thrombolysis without increasing rectal bleeding. This is the first report in which portal vein thrombosis associated with active ulcerative colitis was treated successfully.

[Studies on production of interleukin-1 beta (IL-1 beta) and granulocyte. Macrophage-colony stimulating factor (GM-CSF) by peripheral blood monocytes from patients with Mycobacterium avium-intracellulare complex (MAC) infection]

Production of Interleukin-1 beta (IL-1 beta) and granulocyte macrophage-colony stimulating factor (GM-CSF) by peripheral blood monocytes (PBMs) from patients with Mycobacterium avium-intracellulare complex (MAC) infection was assessed and the relationship with their clinical course was analyzed. PBMs were obtained from MAC-infected patients in their active stage as well as in the inactive stage and the healthy controls. Spontaneous release of IL-1 beta by PBMs from patients in the active stage was higher than those by the cells in the inactive stage or the healthy controls. On the other hand, spontaneous GM-CSF release by PBMs from patients in the active stage was higher than the healthy controls. When PBMs were stimulated with MAC-derived purified protein derivatives (PPD-B), increased production of both IL-1 beta and GM-CSF were obtained for PBMs in their active stage. While these enhanced production upon stimulation with PPD-B related to the persistent infection with MAC, the increased IL-1 beta production correlated with the exhausted nutritional state. Both IL-1 beta and GM-CSF produced by PBMs seemed to be closely related with the clinical course of human MAC infection.

Evidence of cellular supplies to the endolymphatic sac from the systemic circulation

Donor T lymphocytes injected into the host systemic circulation were observed to infiltrate into the host endolymphatic sac in mice. These findings suggest that the endolymphatic sac, a major immune organ in the inner ear, is supplied with immunocompetent cells from the systemic circulation. This concept is consistent with clinical reports that inner ear disorders accompany certain systemic autoimmune diseases. Bone marrow transplantation to replace autoreactive immunocompetent cells with normal cells should be considered as a potential therapy for inner ear autoimmune diseases and an alternative to conventional treatments.

[Production of tumor necrosis factor alpha and interleukin-6 by peripheral monocytes from patients with atypical mycobacteriosis--relationship to clinical activity]

The production of tumor necrosis factor alpha (TNF alpha) and of interleukin-6 (IL-6) by peripheral blood monocytes (PBMs) from patients infected with Mycobacterium avium intracellular complex (MAC) were assessed. Spontaneous release of both TNF alpha and IL-6 were greater during the active stage than during the inactive stage and in healthy controls. When the cells were stimulated with MAC-derived purified protein derivative B (PPD-B). TNF alpha production by PBMs in the active stage increased and IL-6 production by cells in both the active and inactive stages decreased. Moreover, the in vitro increase in TNF alpha production after stimulation in the active stage seemed to be related to the persistent MAC infection, which resulted in an exhaustion of nutrition. These results suggest that the ability of PBMs to produce TNF alpha and IL-6 in vitro is closely related to the clinical stage of MAC infection.

[Spinal anesthesia for patients with progressive muscular dystrophy]

Spinal anesthesia was applied on 8 occasions to 7 patients with progressive muscular dystrophy (PMD) undergoing orthopedic lower limb surgery. No postoperative complication occurred in all patients. During the operations, however, two patients were subjected to high spinal anesthesia, which caused ventilatory suppression in one patient and bronchial asthma attack in another. Both respiratory complications were easily managed by ventilatory assistance with endotracheal intubation or by administration of bronchodilator, respectively. High spinal anesthesia should be avoided in applying spinal anesthesia to patients with PMD.

Transarterial embolization of an extrahepatic portal vein aneurysm with arterioportal fistula

We successfully performed transcatheter arterial embolization of an extrahepatic arterioportal fistula with a portal vein aneurysm. The fistula was considered secondary to cholecystectomy for cholecystolithiasis 5 years earlier. After occlusion of the fistula with platinum coils, the aneurysmal cavity thrombosed.

Cervical invasion of endometrial carcinoma--evaluation by parasagittal MR imaging

Twenty-seven consecutive patients were examined by T2-(1,800/70 ms) and postcontrast T1-weighted (600/15) spin echo (SE) or dynamic (200/15) SE MR imaging to determine the usefulness of parasagittal MR imaging in assessing cervical invasion of endometrial carcinoma. The images were obtained in a direction parallel to the longitudinal axis of the uterus (parasagittal). The cervical epithelium, being hyperintense on the late phase dynamic and postcontrast T1-weighted SE images, had disappeared partially or totally in all 4 patients with cervical invasion. The enhanced cervical epithelium was completely seen in one patient with the tumor protruding into the cervical canal in a polyp-like form without cervical epithelial invasion. The same was also seen in the 22 patients with the tumor remaining in the corpus cavity. The enhanced parasagittal MR images facilitated the evaluation of the extent of the endometrial carcinoma.

Hepatocellular carcinoma: efficacy of transcatheter oily chemoembolization in relation to macroscopic and microscopic patterns of tumor growth among 100 patients with partial hepatectomy

PURPOSE

To evaluate the efficacy of transcatheter oily chemoembolization (TOCE) for hepatocellular carcinoma (HCC) on the basis of microscopic and macroscopic findings postembolization.

METHODS

HCCs ranging in size from 0.5 to 13 cm (mean 3.6 cm) were obtained from partial hepatectomies of 100 consecutive patients who had undergone TOCE between 20 and 246 days (mean 59.5 days) prior to surgery. The efficacy of TOCE was assessed on the basis of the necrotic to live cell ratio of the tumors. The microscopic pattern of tumor growth was grouped into expanding type (complete capsule formation) and replacing type (incomplete or no capsule). There were five types of macroscopic groupings: single nodule, single nodule with extranodular growth (SNE), contiguous and noncontiguous multinodular, and massive growth type.

RESULTS

Among 79 cases with the expanding type, 29 (37%) had 100% HCC necrosis, but none with 100% necrosis were in the replacing type. By macroscopic grouping, the efficacy of TOCE decreased from the single nodule type (50% of patients had 100% necrosis) to the SNE type (21%), and the other types (9%).

CONCLUSION

TOCE appears to be most efficacious for HCC with the expanding growth pattern and HCC forming single nodules. Poor results are to be expected in HCC of replacing growth type and multinodular or massive growth types.

[A case of post-biopsy arterio-venous fistula in a renal allograft]

We report here a case of post-biopsy arterio-venous fistula in a renal allograft which was successfully embolized. Percutaneous needle biopsy of renal allograft is performed when the cause of deteriorating renal function is clinically difficult to diagnose, and the pathological diagnosis obtained by it determines the therapy. An easy and safe biopsy encourages the clinician, but some complications occur after the procedure. Arterio-venous fistula is one of the complications after percutaneous needle biopsy of renal allograft. Color-coded ultrasonography is effective to find it, and transarterial embolization should be tried first to treat it.

Contrast-enhanced MR imaging of intrahepatic cholangiocarcinoma: pathologic correlation study

The authors describe the enhanced magnetic resonance (MR) imaging appearance of intrahepatic cholangiocarcinoma. The MR images of eight patients with intrahepatic cholangiocarcinoma who underwent MR examination within 3 weeks before partial hepatectomy were retrospectively studied. The MR images, including a dynamic study, were compared directly with pathologic and histologic findings. The peripheral region of the medullary subtype of cholangiocarcinoma, with many tumor cells, showed greater enhancement relative to liver parenchyma in the early phase. The peripheral region of the scirrhous subtype, with fewer tumor cells showed less enhancement in the early phase. In one patient, the thin rim of the medullary tumor showed less enhancement in the late phase, and this rim corresponded to the peripheral region of the medullary tumor with many tumor cells. The central region of tumors with a large amount of fibrous tissue showed prolonged enhancement in the late and delayed phases. The thin rim of liver parenchyma around the tumor showed less enhancement in the early phase and greater enhancement in the late phase; this rim corresponded to congestive liver parenchyma with dilated sinusoids. Intrahepatic cholangiocarcinoma shows various enhancement patterns, which depend on both the histologic subtype and the degree and distribution of fibrosis within the tumor.

[Diagnostic value of tissue polypeptide antigen in pleural effusions with malignant pleural mesothelioma]

There are no known tumor makers of malignant pleural mesothelioma. We measured the concentration of TPA in the pleural effusions from patients with malignant pleural mesothelioma and from patients with other pleural diseases, evaluate its clinical usefulness. The concentration of TPA was more than 7,000 U/l (mean: 18,600 +/- 9,867 U/l, n = 5) in all patients with malignant pleural mesothelioma, but it was less than 4,000 U/l in those with benign asbestos pleurisy and other benign pleural effusion (benign asbestos pleurisy 1,598 +/- 570, n = 5: p < 0.01, tuberculous pleurisy 1.37 +/- 759, n = 11: p < 0.01, others 2,497 +/- 2,152 n = 3: p < 0.05). The concentration of TPA in the pleural effusions was not significantly different between malignant pleural mesothelioma and lung cancer (12,287 +/- 17,070 U/l). However, in all patients with lung cancer and high TPA concentrations, cytologically malignant cells were detected in the pleural effusions. TPA was high in all five patients with malignant pleural mesothelioma, but cytologically malignant cells were detected in only one patient. Only in malignant pleural mesothelioma (not in other benign disease or in lung cancer) was the concentration of TPA more than 4,000 U/l, and no evidence of malignancy was obtained by cytological methods. These findings suggest that assessing TPA in the pleural effusion might contribute to the diagnosis of malignant pleural mesothelioma.

Infralabyrinthine approach to vestibular neurectomy in Menière's disease

The infralabyrinthine approach to vestibular neurectomy was performed in 9 patients with unilateral Menière's disease. According to the AAOO (1972) criteria, 7 of 9 cases were graded as class B and the remaining 2 cases as class C. Otherwise, according to the AAO-HNS (1985) criteria, 6 patients who could be followed over 2 years were all graded as 'complete' at the vertigo control. The compensation of the spontaneous vestibular signs was rapid in the first 2 postoperative weeks, though an occasional imbalance on movement persisted even 3 years after the operation. No specific caloric reaction was elicited in any patient after warm or cold water irrigation of the operated side in any postoperative period. There have been no serious complications except a delayed facial palsy that appeared in one case one week after surgery. This approach offers access to the vestibular nerve with minimal risk and morbidity.

Development of a compact, highly efficient, totally implantable motor-driven assist pump system

We have developed a compact, highly efficient, totally implantable assist pump system, which consists of a motor-driven assist pump and a transcutaneous energy and optical information transmission system. The motor-driven assist pump consists of a.d.c. brushless motor and a specially designed miniature ball screw. A magnetic coupling mechanism between the blood pump and an actuator provides active blood filling via mild suction force. The controller consists of a PID follow-up controller using an 8-bit one-chip microcomputer. The volume of the pump is 350 ml, and its controller is 210 ml. Pump outflow of 5.8 L/min was obtained against a mean after-load of 100 mm Hg. The pump showed a high efficiency rate and good durability. An efficiency rate of 19-21% (pump output/motor input) was obtained during 87 days of continuous pumping. No mechanical trouble occurred for an accumulated period of 6 months.

Transthoracic percutaneous ethanol injection into the liver

RATIONALE AND OBJECTIVES

The feasibility of the new transthoracic approach of percutaneous ethanol injection through the lower lung to the subphrenic region of the liver was evaluated in normal rats.

METHODS

Fourteen normal rats received percutaneous ethanol injection. A 22-gauge fine needle was inserted into the liver via the thoracic cage and through the lower lung parenchyma under computed tomographic (CT) guidance. After ethanol (0.1-0.2 mL) was injected, three follow-up CT scans were performed: immediately after, 1 day after, and 1 week after the initial injection. All animals were killed 1 week after injection to evaluate macroscopic changes of the diaphragm and pleura.

RESULTS

No major complications were observed. Minor complications were observed in six rats; these included one pneumothorax (7%) and five band-like and streaky shadows (presumably pulmonary hemorrhages) (35%) on the CT scan obtained immediately after the procedure. However, all complications had disappeared spontaneously in the follow-up CT scan obtained 1 day after the procedure. At autopsy, no pleural changes were seen.

CONCLUSIONS

This study demonstrates that percutaneous ethanol injection through the lower lung parenchyma is achievable. Although this study was performed only in normal rats, the transthoracic approach can be a complementary method of ultrasound-guided percutaneous ethanol injection for tumors in the subphrenic region of the liver. Further study will be needed in abnormal livers and then in human subjects to verify the safety and efficacy of this procedure.

MR imaging of mixed hepatocellular and cholangiocellular carcinoma

Two patients with mixed hepatocellular and cholangiocellular carcinoma underwent partial hepatectomy after magnetic resonance (MR) imaging. Correlation is made with the histopathologic manifestations. In both cases the tumors showed relative low signal intensities on T1-weighted spin-echo (SE) images and high signal intensities on T2-weighted SE images. Dynamic MR imaging showed the enhancement from the periphery of the tumor to the inner area gradually and the enhancement continued into the delayed phase. With both cases fibrosis was marked in the inner area of the tumor compared to the peripheral area. The extent and degree of fibrotic tissue is considered to reflect the enhancement on dynamic MR imaging.

[Doses of epirubicin used in oily chemoembolization of hepatocellular carcinoma]

Epirubicin (EPIR), an anticancer agent, has recently been used with increasing frequency in transcatheter oily chemoembolization (TOCE) of hepatocellular carcinoma. We conducted a dose-finding study of EPIR with regard to its safety. One hundred thirty-four patients were divided into five groups according to the EPIR doses (mg/m2), Group A (< 30 mg/m2), Group B (> or = 30 - < 40 mg/m2), Group C (> or = 40 - < 50 mg/m2), Group D (> or = 50 - < 60 mg/m2), and Group E (> or = 60 mg/m2). The number of leukocytes decreased at 2 weeks but recovered at 4 weeks with no significant differences among the groups. However, there were significantly fewer leukocytes in Group E than in Groups A to D. There were no significant differences among the groups in either the number of erythrocytes or platelets. The number of platelets tended to remain at increased levels even at 4 weeks. Liver function as represented by GOT, GPT, LDH, and total bilirubin was not aggravated, but tended to improve. GOT and LDH in Groups D and E, in particular, improved significantly at 4 weeks, probably because of the antitumor effect of TOCE. These results suggest that EPIR can be administered up to 50 mg/m2 for TOCE.