Significant gene expression of insulin-like growth factor II and proliferating cell nuclear antigen in a rapidly growing recurrent pituitary acth-secreting adenoma

BACKGROUND

We quantified the expression of various growth-related factors in an adrenocorticotropic hormone (ACTH)-secreting adenoma that had recurred very rapidly as invasive macroadenoma.

METHODS/RESULTS

A 43-year-old woman underwent successful transsphenoidal surgery for Cushing's disease. Seven years later, she was admitted to our ward for further endocrine examinations. In spite of a very high plasma ACTH level, the serum cortisol level was normal. Discrepancies between ACTH and cortisol levels were detected on the basis of diurnal rhythms, dexamethasone suppression tests, and corticotropin-releasing hormone test. The patient showed no clinical features of Cushing's disease. Magnetic resonance imaging of the pituitary showed an almost empty sella, and no microadenoma was found. These results, along with those of Sephadex column gel filtration and high-performance liquid chromatography of plasma-immunoreactive ACTH, suggested that the patient's residual corticotrophs secreted biologically inactive ACTH. Two years later, the patient suddenly developed diplopia and right abducens nerve palsy. She was slightly moonfaced and centrally obese. Her plasma ACTH and serum and urinary free cortisol levels were elevated, although discrepancies between ACTH and cortisol still existed. Magnetic resonance imaging revealed a large pituitary mass with suprasellar and cavernous sinus extensions. The tumor was excised, and the proopiomelanocortin gene and the expression of growth-related factors were analyzed. No mutations were found in the ACTH-coding region of the proopiomelanocortin gene. A significant expression of insulin-like growth factor II and proliferating cell nuclear antigen mRNAs was demonstrated. A high MIB-1 antibody labeling index was also detected in the adenoma tissue, suggesting high Ki-67 expression.

CONCLUSION

These growth- and proliferation-related factors might be involved in the rapid growth and aggressiveness of this patient's pituitary adenoma.

Primary yolk sac tumor in the spinal cord

A case of a primary yolk sac tumor of the spinal cord is reported. The patient was a 17-month-old Japanese girl, who was found to have an intramedullary mass at the upper thoracic level. The preoperative diagnosis was primary glioma, but histological examination of the surgical specimen revealed a yolk sac tumor. As there were no other lesions, the spinal cord lesion was considered to be the primary tumor. Based on our previous experience, we treated this patient with low-dose irradiation followed by combination chemotherapy with cisplatin, vinblastine and bleomycin. However, the effectiveness of this therapy was poor in this particular case, and the patient died of pyelonephritis with uncontrollable imbalance of serum electrolytes.

Cerebellopontine angle lymphoma: a case report and review of the literature

BACKGROUND

Although malignant lymphomas of the central nervous system have been reported to be increasing in frequency, cerebellopontine (CP) angle lymphoma is rare and only 13 cases have been reported previously in the literature.

CASE PRESENTATION

A 63-year-old woman had progressive dizziness and nausea for 2 months. Computed tomography scanning and magnetic resonance imaging (MRI) revealed a mass lesion in the left CP angle, that was compressing the lateral-dorsal aspect of the pons and the fourth ventricle. This tumor was avascular on angiography. The tumor was surgically removed through a left lateral suboccipital approach. It was considered to arise from the subarachnoid space of the CP angle cistern. For some reason, the histologic diagnosis was not definitively made, and therefore radiation therapy was not planned. The tumor recurred within 50 days after the tumor excision. Surgical excision of the recurrent tumor was performed again. The histologic diagnosis was B-cell type malignant lymphoma. Radiation therapy was performed. In the 27 months since irradiation, a recurrent tumor has not been detected on MRI.

CONCLUSIONS

Although erosion and expansion of the internal auditory canal suggest an acoustic neurinoma, CP angle lymphoma can, in rare circumstances, erode the internal auditory canal. There are three distinct patterns in which malignant lymphomas occupy the CP angle: (1) an extra-axial CP angle lymphoma, (2) an intra-axial lymphoma extending to the CP angle, and (3) a leptomeningeal lymphoma presenting as a CP angle lesion. Although malignant lymphomas rarely occupy the CP angle, it should be considered in the differential diagnosis of CP angle tumors. It is desirable to obtain a frozen section in all CP angle tumors during surgery to identify the tumor, because aggressive removal is not necessary, but radiation therapy should additionally be performed for malignant lymphomas.

Combination chemotherapy (cisplatin, vinblastin) and low-dose irradiation in the treatment of pineal parenchymal cell tumors

Pineal parenchymal cell tumors (PPCTs) with or without metastasis into the lumbar region by way of the cerebrospinal fluid were treated successfully with combination chemotherapy using cisplatin, vinblastin, and bleomycin (PVB) or cisplatin and vinblastin (PV) and low-dose irradiation (25 approximately 30 Gy). Our series included a case of pineoblastoma, two cases of mixed pinocytoma/pineoblastoma, and a case of pineocytoma, compared to which the data held by the All Japan Brain Tumor Registry (AJBTR) included information on 47 cases pineocytoma and 20 of pineoblastoma. All our patients have survived, with scores of 90% or over on Karnofsky's performance scale, for 2-12 years of follow-up so far; however, the 5-year survival rates of the patients recorded by AJBTR were 83% for pineocytoma treated with radiation and 43% without radiation; and 42% for pineoblastoma treated with radiation and 50% without radiation. Incomplete or varied chemotherapeutic regimens used in different medical centers to treat PPCTs precluded an evaluation such as was made by AJBTR. Our results suggested that combination chemotherapy with low-dose back-up radiotherapy may be the treatment of choice for primary or recurrent disease with or without dissemination in PPCTs.

A case of Rathke's cleft cyst with apoplexy

We report a case of Rathke's cleft cyst associated with cholesterin granuloma in an 8-year-old girl with apoplexy. She was admitted to our hospital in April 1996 because of repeated headache and deep ophthalmic pain, without any visual disturbance. Computed tomography (CT) of the pituitary demonstrated an intrasellar isodense mass extending to the suprasellar cistern. Magnetic resonance imaging (MRI) showed a high-intensity mass on both T1- and T2-weighted images. The preoperative diagnosis of this lesion was Rathke's cleft cyst associated with a craniopharyngioma and/or hemorrhage. Transsphenoidal microsurgery was performed, and a bloody coffee-like serous and mucinous-yellowish substance was evacuated. Curettage of the wall removed the yellowish hard mass and soft membranous tissue. Histological examination of this tumor revealed a Rathke's cleft cyst with cholesterin granuloma.

The distribution fields of sensory neurons in the human thalamus

Thalamic neurons were identified by activity related to passive joint movement, active joint movement, tapping stimulation, and light touch stimulation during surgery to treat movement disorders. The neurons were classified into three types: movement-related neurons, tapping-related neurons, or superficial sensory neurons. Tapping-related neurons had characteristics of lemniscal sensory neurons and occupied the border area of movement-related neurons and superficial sensory neurons. Tapping-related neurons showed a laminar distribution 1.0-1.5 mm in width in the anterodorsal region of the nucleus ventrocaudalis. Results suggest that the distribution pattern of tapping-related neurons in the human thalamus is consistent with the functional distribution pattern found in the monkey thalamus.

Induction of specific cytotoxic T lymphocytes against autologous brain tumor by crossreactive allo-tumor cell stimulation

Cytotoxic T lymphocytes (CTL) against autologous malignant brain tumor were generated in peripheral blood lymphoid cells (PBL) prepared from a patient with a malignant brain tumor by stimulation of the cultured PBL for 7 days with attenuated crossreactive malignant melanoma (MM2) cells pretreated with mitomycin C. The crossreactive MM2 cells were effective for antigen stimulation for CTL induction in place of autologous glioblastoma cells, which are difficult to expand in culture. The optimal ratio between nylon wool-passed T lymphocytes and nylon wool-adherent accessory cells to induce CTL in the patient's PBL was found to be 25 to 1. In vitro-activated CTLs induced by MM2 were cytotoxic not only to MM2, but also to the autologous tumor cells in an HLA class I-restricted manner, and their surface phenotype was found to be CD3+ and CD8+. CTL therapy using cross-reactive allogeneic tumor cells as the stimulator could be clinically valuable to treat malignant brain tumors.

Survival probability, delayed mortality, and relationship between short-term outcome and long-term survival after aneurysmal subarachnoid hemorrhage

The long-term survival probability, causes of delayed mortality, and relationship between short-term outcome and long-term survival after aneurysmal subarachnoid hemorrhage were retrospectively studied in 106 patients followed up for longer than 5 years. The Kaplan-Meier cumulative survival probabilities at 1 month, 6 months, and 5 years were 85.9%, 79.2%, and 66.8%, respectively. Six months after the onset, 41 patients made a good recovery (GR) and 34 were moderately disabled (MD). On the last follow-up day, 64 had good outcome (GR or MD) and eight had died. In contrast, there were nine patients with poor 6-month outcome (severe disability or vegetative state), seven of whom died within 5 years. Five of these seven patients had experienced intraventricular hemorrhage (IVH) on admission. A total of 15 patients died beyond 6 months, five died of complications related to shunts. Six-month outcome is a predictor of long-term survival and delayed mortality. Improved long-term survival requires the development of better management for IVH, improved 6-month outcome, and careful follow-up of patients who undergo shunting.

Fluorescence localization of anti-pregnant rat kidney antibody and lectin binding analysis in exencephalic rat embryos

We sought to determine the distribution of anti-pregnant rat kidney serum (ARKS) in fetuses that subsequently developed a form of neural tube defect (NTD). We produced exencephaly in rat embryos by injecting a rabbit anti-pregnant rat kidney serum into the peritoneal cavity of pregnant Wistar rats on day 7 of gestation; 71.1% (27/38) of the rat embryos developed this anomaly. Fluorescence immunohistochemical studies were performed to localize ARKS binding in the embryos. We also investigated the binding of two lectins, concanavalin A (ConA) and wheat germ agglutinin (WGA), to glycoconjugates on neuroepithelium during the process of neurulation in rat embryos injected with normal rabbit serum (NRS) and ARKS. We found for the first time that ARKS directly affected the neural tube during neurulation. Intense fluorescence was observed on the luminal side of the neuroepithelium in the intercellular region and on the basement membrane of the neural tube in embryos on day 9 of gestation (GD9). In GD21 embryos there was much more intense fluorescence in the extracellular matrix and the ependymal lining cells of the ventricles than in controls. The binding of the two lectins on the cell surface of the neuroepithelium during neurulation was different in rat embryos injected with ARKS than in normal embryos injected with NRS. These results support the idea that simple nonclosure and overgrowth constitute the mechanism of NTD. However, the lectinbinding data suggest that dysraphic states may be induced by cell-to-cell adhesive molecular failure.

Supra- and infratentorial multiple cavernous angiomas in an infant: report with MR evaluation of an unusual case

A rare case of multiple cavernous angiomas with repeated hemorrhages in a 9-month-old male infant is presented, together with sequential computed tomography (CT) and magnetic resonance (MR) images. The infant underwent hematoma evacuation for left cerebellar hemorrhage and his postoperative course was uneventful. The multiple cavernous angiomas receded gradually without any treatment except the hematoma evacuation. Two years following presentation, he continues to do well. To the authors' knowledge, this is the first report of multiple cavernous angiomas with brain stem involvement in an infant.

Role of cytokines, tyrosine kinase, and protein kinase C on production of superoxide and induction of scavenging enzymes in human leukocytes

We investigated the effects of proximal modulators of cytokines, tyrosine kinase (TK), and protein kinase C (PKC) on reactive oxygen species (ROS) generation and the induction of scavenging enzymes, superoxide dismutase (SOD), catalase, and glutathione peroxidase (GSH-Px) of human neutrophils and lymphocytes, by using IL1-alpha, TNF-alpha, and IFN-gamma and neutralizing antibodies to these cytokines. Inhibitors of TK (ST638 and herbimycin) or PKC (H-7, calphostin, and staurosporine) were also used. The results revealed that both (O2)- generation stimulated by five different agents (opsonized zymosan, A23187, PAF, PMA, and fMLP) and the inductions of all three scavenging enzymes were potentiated by priming with TNF-alpha. In contrast, both (O2)- generation and enzyme induction were attenuated by priming with IL1-alpha, with the exception of PMA-stimulated (O2)- generation. IFN-gamma decreased (O2)- generation but increased scavenging enzyme induction. Antibodies to all three cytokines and all the TK and PKC inhibitors decreased (O2)- stimulated by most agents, but markedly enhanced (O2)- levels stimulated by PAF. Induction of all three enzymes was enhanced equally by low concentrations of each of the three anticytokine antibodies, while each of the TK or PKC inhibitors decreased induction of SOD and GSH-Px and increased catalase induction. These results suggest that both ROS generation and scavenging enzyme induction are controlled in complex ways by the actions of these three proximal mediators. This supports our hypothesis that disturbances in the regulation of early events of cell activation can lead to oxidative tissue injury.

Immunohistochemical study of medulloblastoma with a monoclonal antibody against human copper and zinc-superoxide dismutase

Superoxide dismutase (SOD) expression in tumor tissues was investigated in 10 cases of medulloblastoma by immunohistochemistry, using a monoclonal antibody against human copper and zinc-superoxide dismutase. Abundant SOD was expressed in tumors from patients with poor outcomes and little SOD in patients with good outcomes. These results suggest that resistance to adjuvant therapy depends on the amount of SOD in tumor tissues. The effects of adjuvant therapies for medulloblastomas depend on the production of free oxygen radicals, so if tumor cells contain a free radical scavenger such as SOD, the effects of adjuvant therapy may be reduced. Measurement of SOD in tumor tissues may be useful as a prognostic indicator for medulloblastoma.

[The correlation of immunohistochemical expression of human manganase-superoxide dismutase and outcome of the patients with medulloblastomas]

There in no clear indicator for making a prognosis in patients with medulloblastoma. The effects of adjuvant therapy on the tumor are exerted through free radicals that emerge in the cytoplasm of tumor cells following chemotherapy and/or radiotherapy. Thus, free radical scavengers, such as superoxide dismutase (SOD), in tumor cells may antagonize the effects of adjuvant therapy. In order to determine whether there is a correlation between SOD levels and the prognosis of medulloblastoma patients, SOD expression in tumor tissue was investigated immunohistochemically in eleven cases of medulloblastoma by using a polyclonal antibody against human manganase SOD. Abundant SOD was expressed in the tumors of patients with poor outcomes whereas there was little SOD expression in patients with good outcomes. This suggests that resistance to adjuvant therapy depends on the level of SOD in tumor tissue. The effect of adjuvant therapy on medulloblastoma depends on the production of oxygen free radicals. Thus, if the tumor cells contain free radical scavengers, such a SOD, the effects of adjuvant therapy may be reduced. Measurement of SOD in tumor tissue is useful as a prognostic indicator in medulloblastoma.

[A case of myogenic intractable pain due to thalamic hemorrhage relieved by Vim-Vo thalamotomy]

A 58-year-old female patient with myogenic intractable pain due to thalamic hemorrhage which was relieved by stereotactic Vim-Vo thalamotomy was reported. She had an intractable pain, involuntary movement and deep sensory disturbance in her right arm. We performed stereotactic Vim-Vo thalamotomy using electrophysiological technique to relieve her involuntary movement and myogenic intractable pain. The electrophysiological recordings suggested the followings: (1) The destructive lesion by thalamic hemorrhage was located on from posterior border of Vim nucleus to the upper half of Vc nucleus. (2) Most of Vim neurons remained as intact state. (3) Thalamic electrical activities were relatively enhanced in the Vim nucleus. From these data, we can deduce that the deep sensory inputs reach the border area of Vim nucleus and Vc nucleus in the human thalamus. IMP-SPECT scans were performed before and after the operation. IMP-SPECT scan before operation showed us the contra-lateral cerebellar low perfusional state (crossed cerebellar diaschisis). This crossed cerebellar diaschisis disappeared after the operation. This result suggested that the interaction of cerebellum and Vim nucleus was very close. The above mentioned speculation was more compatible to Jones & Hirai's new parcellation of the human thalamus than to Hassler's.

Classification of hydrocephalus and outcome of treatment

PURPOSE

Retrospective analysis in cooperative study of hydrocephalus at institutions of members of the Research Committee on Intractable Hydrocephalus sponsored by the Ministry of Health and Welfare of Japan was performed to determine the functional prognosis for all types of hydrocephalus and thus to clarify the outcome.

METHODS

In preparation of this study, we have proposed the definition, clinical classification and diagnostic criteria of hydrocephalus. We have classified non-tumoral hydrocephalus into eight types based on its etiology and the time of onset. To establish the diagnosis in each type of hydrocephalus, we have set up inclusion and exclusion criteria, as well as supplementary criteria which are useful for its diagnosis.

RESULTS

Analysis of the 1450 cases of hydrocephalus of various etiologies stored in the data base obtained from the study for each type of hydrocephalus revealed that following types and conditions were associated with a neurologic deficit: (1) early fetal hydrocephalus, (2) overt neonatal hydrocephalus, (3) hydrocephalus associated with such severe brain malformations as hydranencephaly, holoprosencephaly and lissencephaly, (4) hydrocephalus associated with severe brain damage, (5) hydrocephalus associated with epilepsy, (6) hydrocephalus shunted late after detection, and (7) hydrocephalus complicated by a shunting operation.

CONCLUSION

The postnatal functional outcome was significantly poor in fetal hydrocephalus diagnosed in the early gestation. Childhood onset hydrocephalus showed a poorer outcome than adult hydrocephalus.

Scalp hair loss caused by octreotide in a patient with acromegaly: a case report

We used octreotide to treat a woman with acromegaly and observed pituitary adenoma shrinkage after 5 months. Diffuse scalp hair loss occurred after 5 months, resulting in the discontinuation of treatment. After the cessation of octreotide, the hair loss stopped and hair growth resumed. Since bromocriptine did not effectively decrease the GH level of the patient, we decided to perform transsphenoidal surgery. After resection of the pituitary adenoma, her GH and IGF-1 levels were normalized. Although octreotide-induced scalp hair loss has not been well recognized, we should pay more attention to this side effect.

[Immunohistochemical study on the expression of copper and zinc-superoxide dismutase (Cu, Zn-SOD) in human adenohypophysis and pituitary adenomas]

A location of copper and zinc- superoxide dismutase (Cu, Zn-SOD) in adenohypophysis and pituitary adenomas was examined with immunohistochemical technique. Pituitary adenomas include thirteen functioning, five nonfunctioning; functioning adenomas consist seven prolactinomas, four growth hormone (GH) secreting, two adrenocorticotropic hormone (ACTH) secreting adenomas. Three specimens of normal adenohypophysis were used for control study. The Cu, Zn-SOD was localized diffusely in the cytoplasm of normal adenohypophyseal cells and the tumor cells. Sometimes immunoreactive products of Cu, Zn-SOD revealed in the cytoplasm of endothelial cell, neutrophil, macrophage and the cell membrane of erythrocyte in the vessels. The content of Cu, Zn-SOD in normal adenohypophyseal cells and pituitary adenomas was markedly higher in normal cells than adenoma cells. No significant difference of the SOD content was observed not only in non-functioning adenoma but also in functioning adenoma cells including PRL, GH and ACTH cells.

Venous malformation in the posterior fossa: guidelines for treatment

Venous malformations in the posterior fossa are relatively rare. Although the introduction of CT and MRI has made them easier to detect, their treatment is still controversial. Based on our experience with six patients and a review of the literature, we have tried to establish guidelines for their treatment. Since they have a benign natural course and may provide venous drainage in the posterior fossa, venous malformation found incidentally, unruptured venous malformation with nonhaemorrhagic complications, and those accompanied by small intracerebellar haematoma of less than 2 cm in diameter due to their rupture, should be treated conservatively unless they are associated with a coexistent malformation. Venous malformation with intracerebellar haematoma larger than 3 cm or reexpansion of the haematoma due to rebleeding should be treated surgically by evacuation of the haematoma. Resection of venous malformations in the posterior fossa should be restricted to cases in which the malformation is small and does not serve as a functional venous drainage route. Radiation therapy, including the "gamma-knife", may be a treatment of choice in the future.

Management of a broken atrial catheter migrated into the heart: a rare complication of ventriculoatrial shunt--case report

A 21-year-old male, who had undergone a ventriculoatrial shunt for hydrocephalus 5 years previously, became stuporous. A roentgenogram revealed that the distal segment of the broken atrial catheter had migrated and become lodged in the heart. Because the fragment had not adhered to the myocardium, it was easily retrieved by the transvenous approach with a retriever catheter. If the migrated catheter does not adhere to the myocardium, transvenous catheter retrieval is absolutely necessary. If, however, the migrated catheter adheres to the myocardium, an open thoracotomy would be required for retrieval, or the alternative of warfarin administration without retrieval may be the treatment of choice, as long as other problems do not occur.

[Application of intravascular ultrasound imaging to carotid artery]

Although conventional angiography is utilized to assess the extent and severity of carotid artery disease, it yields only a silhouette of the vessel lumen. Intravascular ultrasound imaging (IUI), which has been developed for imaging the coronary artery, can supplement angiography by providing a tomographic perspective of the vessel wall structure. Therefore, we applied IUI (4.3F, 30MHz) to the carotid artery to evaluate the extent of arteriosclerosis, and we were successful in imaging the perspective of the carotid artery. Our results suggest that IUI is a useful device to evaluate the extent of atherosclerosis of the carotid artery.

Immunohistochemical localization of superoxide dismutase in congenital hydrocephalic rat brain

The effects of active oxygen species in the development of congenital hydrocephalus have been investigated. Superoxide dismutase (SOD) is one of the scavengers of active oxygen species and there have been many recent reports on the relationship between neurological disorders by active oxygen species following reperfusion for ischemic brain and SOD. In this study, the localization of Cu-SOD and Zn-SOD in WIC-Hyd congenitally hydrocephalic rat brains was identified by the enzyme unlabeled antibody method. We examined the localization of SOD in the choroid plexus, hippocampus, and ependymal cells of the lateral ventricle and aqueduct of WIC-Hyd rats. SOD was hardly observed in the choroid plexus and faintly localized in the hippocampus and ependymal cells of the congenitally hydrocephalic brain, but was observed equally in the cytoplasm of the choroid plexus, hippocampus, and ependymal cells in control animals. In the hippocampus, less SOD was found in hydrocephalic rats than in controls. The SOD was slightly observed in the CA1 pyramidal cells in hydrocephalic rats. In the lateral ventricle and aqueductal ependyma, less SOD was found in hydrocephalic than in controls rats. The amount of Cu, Zn-SOD in the congenitally hydrocephalic rat brain was less than in the control, especially in the choroid plexus. Therefore, we suspect that the production of SOD is congenitally reduced in the congenitally hydrocephalic rat brain, and this may promote the impairment of the function of choroid plexus and cilia due to increased active oxygen species. The reduction of SOD in the choroid plexus, hippocampus and ependymal cells of ventricles or aqueduct may promote the development of hydrocephalus in the congenitally hydrocephalic rat.

[Predictive factors for in-hospital mortality and delayed mortality following aneurysmal subarachnoid hemorrhage]

It is important to detect predictive factors for in-hospital and delayed mortality of patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysm. Forty-eight patients with initial bleeding of aneurysmal SAH were referred to our hospital from January 1982 to December 1985. In-hospital mortality was 16.7% (8 to 48), and 15% (6) of forty patients died later during the follow-up period. Using the Kaplan-Meier method we were able to conclude that, cumulatively, there was 70.8% probability that much patients would survive for 10 years. We analysed predictive factors of in-hospital and delayed mortality retrospectively. The most significant predictive factor for in-hospital mortality was SAH grading on admission, and for delayed mortality (29.2%) age on admission was the best predictive factor. In fact, two patients died with cardiac event during the follow-up period. This result suggests that, although the SAH grading on admission was the second most significant factor for delayed mortality, patients who survived in the acute phase had a survival probability similar to those in a normal control group.

[Three months angiographic follow-up after successful percutaneous transluminal angioplasty]

Percutaneous Transluminal Angioplasty (PTA) is applied to supra-aortic arteries. Although first follow-up angiography after coronary angioplasty is usually undergone three or four months later, there are few reports of follow-up angiography after PTA of supraaortic arteries. Because of this, we performed follow-up angiography three months after successful PTA on eight cases of stenosis in seven patients. Although no symptom due to restenosis occurred, it was shown to have occurred in one of four cases of internal carotid arterial stenosis. It was a case of ostial stenosis of a left common carotid artery. Restenosis occurred in neither two cases of subclavian arterial stenosis, nor in a case of left middle cerebral arterial stenosis. The overall restenosis rate was 25%. We suspect that it is important to perform a follow-up angiography after angioplasty of supra-aortic arteries, and our result suggests that the restenosis might occur before three months after PTA as well as after coronary angioplasty.

Successful combination chemotherapy (cisplatin, vinblastine, and bleomycin) with small-dose irradiation in the treatment of pineoblastoma metastasized into spinal cord: case report

A case of successful combination chemotherapy using cisplatin, vinblastine, and bleomycin (PVB) therapy with small-dose irradiation (25 Gy) to treat a pineoblastoma that metastasized into the lumbar region through the cerebrospinal fluid is presented. Pain in the lower extremities and urinary incontinence with paraplegia improved during irradiation of the spinal cord after two courses of PVB therapy administered during a period of 6 weeks. The patient is presently attending school normally and has a score of 100% on the Karnofsky performance scale 4 years after therapy. These results suggest that combination chemotherapy with small-dose back-up radiotherapy may be one of the treatments of choice for recurrent or disseminated pineoblastoma.

Cerebral paragonimiasis--report of five cases

Five cases of cerebral paragonimiasis presenting with hemianopsia, convulsion, and gait disturbance are discussed. The cases were all in the chronic stage. The intradermal paragonimiasis reaction, complement fixation, and Ouchterlony tests were not useful for diagnosis. Computed tomography demonstrated calcifications in all cases in sites consistent with the foci of symptoms. Surgical treatment in two cases failed to improve symptoms.

Intracranial lipomas: current perspectives in their diagnosis and treatment

Intracranial lipomas are very rare lesions, which are probably congenital. Though they can occur anywhere in the intracranial space, a high proportion of cases tend to be ++located around the midline. They are usually asymptomatic. When symptoms do occur, they are frequently the result of co-existing general clinical conditions. Lipomas used to be reported mainly as incidental findings at autopsy, but advances in neuroimaging techniques have greatly improved the likelihood of their being discovered during life. Surgical extirpation is not necessary in the majority of patients, many of whom show remarkable clinical improvement following shunt procedures for obstructive hydrocephalus (when present) as well as vigorous treatment of co-existing conditions.

[Ossifying fibroma in the cranial vault. Case report]

Ossifying fibroma is relatively common in the maxilla, but rare in the cranial vault. A 10-year-old girl was referred for painful swelling of the left temporal region. On admission, she presented no abnormal physical and neurological findings except for the painful swelling. Plain skull X-ray films showed a radiolucent lesion of the left temporal bone about 4 cm in diameter, with a hyperostotic area of the parietal side. Computed tomography scan using bone window level also showed an abnormal density lesion in the same site. Curettage of this tumor was performed from a cosmetic point of view and at the family's petition. Histological examination showed vascular fibrous tissue in which lamellar bone was surrounded by osteoblasts.

Intracranial lipomas

Intracranial lipomas are very rare, probably congenital lesions. Though they can occur anywhere in the intracranial space, a good proportion of cases tend to be located around the midline. Review of the literature as well as our own three cases--which forms the basis of this article--shows that they are mostly asymptomatic. When symptoms occur, they are frequently the result of coexisting general clinical conditions. Lipomas used to be reported mainly as incidental findings at autopsy. Advances in neuro-imaging techniques have vastly improved the likelihood of their being discovered during life. At present however, significant increase in the reported incidence of these tumours is yet to be seen. Surgical extirpation of the tumour is not considered necessary in the majority of patients, many of whom show remarkable clinical improvement following shunt procedures for obstructive hydrocephalus as well as treatment of coexisting conditions such as epilepsy.

[The studies of melatonin values in the cerebrospinal fluid of hydrocephalic patients]

The changes in daytime levels of melatonin (MLT) in the cerebrospinal fluid (CSF) of twenty seven hydrocephalic patients were studied by the high-performance liquid chromatography (HPLC) method. Patients comprised three with congenital hydrocephalus (spina bifida 1, Chiari type II malformation 2), four post-meningitic hydrocephalus, fifteen brain tumors (chiasmal germinoma 3; malignant glioma of frontal 3, and temporal lobes 1; germinoma 1, teratoma 2, yolk sac tumor 1, epidermoid 1 in pineal region) and five cases of normal pressure hydrocephalus. CSF was collected between 0930 and 1030 h through puncture of the flushing device of shunt system or the lateral ventricle. The lowest value of MLT detected by HPLC was 15 pg/ml. Melatonin values were higher in patients aged under 10 years than over 20 years in the absence of meningitis or tumor in the pineal region. Even at ages over 15 years, higher CSF MLT values were obtained in the patients with meningitis or tumors in the pineal region. These results suggest that the inflammation or invasion of tumor into the pineal gland may stimulate the secretion of MLT by the pineal gland. However, lower MLT values were obtained in all patients over 40 years old. For these reasons, if one may use the changes of MLT values in CSF as a tumor marker or for determination of the treatment modality, time of CSF collection, age of patient, location or character of the tumor and presence of meningitis should be given due consideration. Also, the presence or absence of the rhythmical changes of melatonin values in a day following circadian rhythm are very important in determination of the treatment modality.

[A case of recurrent medulloblastoma treated by combination therapy with cisplatinum and tetrahydropyranyladriamycin (PP therapy)]

PP therapy, combination therapy with Cis-platinum (CDDP) and tetrahydropyranyladriamycin (THP-ADR), were performed on a case of recurrent medulloblastoma. CDDP and THP-ADR involve agents difficult to pass the blood brain barrier (BBB), but can pass BBB on the metastatic lesion. PP therapy is considered to be one of the most effective agents for the treatment of recurrent malignant brain tumor.

Central nervous system bioaminergic responses to mechanical trauma. An experimental study

Changes in biogenic amines in the brain and spinal cord following penetrating injury were studied in male Wistar rats using high-performance liquid chromatography with electrochemical detection. Rapid increase in hemispheric concentration of these substances was noted beginning shortly after trauma. This trend continued until they were about three to four times control levels by about 24 to 48 hours postinjury. In the spinal cord, however, there was an initial sharp reduction in regional concentrations 2 hours postinjury followed by a slow rise thereafter. By 48 hours postinjury, levels of norepinephrine, dopamine, and serotonin of the cords of injured animals were still less than those of nontraumatized controls. This variation in the central nervous system bioaminergic response with the level of injury raises questions as to its precise role in neurological damage following mechanical insult.

Bilateral aseptic femoral head necrosis associated with steroid therapy for prolactinoma--case report

The authors report a recent case of prolactin-secreting pituitary adenoma in a young male who had earlier received treatment for infertility. Following partial adenomectomy, he was placed on postoperative steroid substitution among other treatments, but developed femoral head necrosis several months later. Hormone studies at the time showed significant findings, including an elevated serum cortisol level. The authors conclude that this complication resulted from prolonged steroid therapy and offer suggestions as to how a similar situation may be avoided.

[Gonadotropin, as a tumor marker, in body fluid and tumor tissues of germ cell tumors]

The value of gonadotropin in the body fluids of germ cell tumor patients is its usefulness as a tumor marker. It is also used for differential diagnosis and/or judgement of therapeutic effects. In order to clarify the most effective value of gonadotropin as a tumor marker in the body fluids, we compared the value in serum, liquor and urine with one another. The liquor contained highest (1650 IU/l) value of gonadotropin in the primary intracranial germ cell tumors, mostly in choriocarcinoma. But the gonadotropin value was highest (3050 IU/l) in the serum of secondary intracranial choriocarcinoma. Chiasmal germ cell tumor, except choriocarcinoma, which does frequently secrete gonadotropin (alpha, beta) showed moderate or very high values in the liquor. However, pineal germ cell tumors rarely secrete gonadotropin and sometimes mild high value are obtained in the serum without gonadotropin secretion immunohistochemically. In such cases, the gonadotropin may be increased by indirect mechanism of gonadotropin-secretion following pineal disorder. In most of such cases, the gonadotropin was not human chorionic gonadotropin (HCG) but lutein hormone (LH). Because alpha-subunit of such gonadotropin has the same structure, their antibodies show immunologic cross reaction. So, a count of beta-subunit gonadotropin in the serum or liquor is the best way for differential diagnosis or judgement of therapeutic effects. From our results, it is considered that the tumor secretes HCG if the serum beta-HCG value was higher than 30 IU/l, and that it doesn't secrete HCG if beta-HCG value was lower than 10 IU/l or non calculable. The mild increased HCG may be caused by hypothalamo-diencephalic disorder such as pineal tumor.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pituitary adenoma calcification]

Three hundred and eighteen cases of functioning and non-functioning pituitary adenoma were examined by histological, immunocytochemical and electronmicroscopic technique. Fourty-four of them (13.8%) showed evidence of calcospherites in the tumor tissues. A high incidence of calcospherite is found in functioning adenoma, but not in non-functioning adenoma. Calcification was seen most frequently in cases of prolactinoma (23), GH secreting (7), or GH + PRL tumor (2) and less in adrenocorticotropic hormone secreting adenoma (2) and follicle stimulating hormone secreting adenoma (1). Prolactin and growth hormone might be involved in the control of calcium metabolism. This is because, following adenomectomy in patients with prolactinoma or GH-secreting adenoma with hypercalcemia, there is normalization of serum PRL and GH with reduction in serum calcium. Calcospherite is produced in all of metastatic calcification, arterial calcification, dystrophic calcification and calcinosis. In cases of non-functioning adenoma however, the mechanism is believed to by dystrophic calcification.

[A recurrent case of TSH-PRL secreting microadenoma following hypothyroidism]

A thirty-seven-year-old housewife whose chief complaints were recurrence of galactorrhea and amenorrhea three years after having a selective adenomectomy. Hormonal examination done as a result of the continuation of the endocrinism revealed a hyperprolactinemia and high level of TRH due to hypothyroidism. Serum prolactin responded to neither TSH stimulation nor L-Dopa suppression tests. In addition, serum TSH did not react to TRH test. Contrast enhancement CT showed an intrasellar enhancing mass the size of which was less than 1 cm in diameter. A unilateral septal transsphenoidal operation was performed; and a soft white-yellowish mass 7 X 5 X 5 mm in size was found in the left inferolateral aspect of the pituitary gland. Histological studies of frozen sections of this revealed it to be a pituitary adenoma, with the border between tumor and normal tissue being quite distinct. Immunocytochemical diagnosis further confirmed it to be both PRL and TSH producing adenoma. Electron microscopy showed more than three different hormone-producing cells. The PRL cells contained large, and the TSH cells had small hormone granules; but some tumor cells contained secretory granules of both sizes suggesting production of both PRL and TSH in the cytoplasm. It is necessary in the management of patients like this, during the post-operative period, to adequately institute a thyroid hormone replacement therapy so as to prevent recurrence.

Large intramedullary lipoma of the cervical cord and posterior fossa. Case report

A large intramedullary lipoma of the cervical cord extending into the posterior fossa is reported in a 7-year-old boy. Magnetic resonance imaging was very useful for delineation of the anatomy of the lipoma as an aid in planning the operation.

Brain tumors in childhood: statistical analysis of cases from the Brain Tumor Registry of Japan

This paper attempts to summarize and statistically analyze 2,361 pediatric brain tumors out of a total of 20,192 human brain tumors from about 250 institutes in Japan during the period 1969-1978 in order to obtain an idea of their incidence and results of treatment. This report uses the classification and nomenclature adopted by UICC (Unio Internationalis Contra Cancrum) in 1965. Survival rate was computed as relative survival rate by the method reported by Cutler in 1964 [3]. Interestingly, germinomas (7.8%) are still frequent tumors in Japan. Astrocytoma (19.7%), medulloblastoma (16.6%), craniopharyngioma (12.5%), germinoma (7.8%) and ependymoma (6.6%) occurred in that order of frequency. Five-year survival rate of medulloblastoma was 35.7% in subtotal and 55.3% in "total" removal. Radiotherapy was an effective therapeutic adjunct for the treatment of medulloblastoma. The germinoma prognosis was good, with a 5-year survival rate of 42.4% without and 69.1% with radiation therapy, revealing radiotherapy as a statistically significant treatment. Radiotherapy, with or without shunt, is thus the treatment of choice. The survival rate of patients with craniopharyngiomas was also high, with a 5-year survival of approximately 75% in partial and 76.3% in total removal. Most of the craniopharyngiomas were treated by partial removal of the tumor, with or without radiotherapy. Patients treated with radiotherapy survived a little longer than patients without.

Cystic prolactinoma: a variant of "transitional cell tumor" of the pituitary

Pituitary tumors with features of both Rathke's cleft cysts and adenohypophysial adenomas are extremely rare and have been termed "transitional cel tumors." The ultrastructural features of one of these tumors has been reported, demonstrating cells with features transitional between those of adenohypophysial cells and Rathke's cleft cells, along with other cells with the distinctive features of either cell type. We report a case of a prolactin-secreting "transitional cell tumor" with similar light-microscopic and ultrastructural features. Additionally, the transitional cells in our case exhibited abundant intracellular mucin production. This represents a variant of "transitional cell tumor" of the pituitary gland.