Laparoscopic right posterior sectionectomy for a large hepatocellular carcinoma close to inferior vena cava

Approximately 20% of hepatocellular carcinomas (HCC) occur in noncirrhotic livers. Resection may be considered for patients with HCC, provided sufficient future liver remnant is available, regardless of the tumor size. Tumors located posteriorly near the right hepatic vein (RHV), or inferior vena cava can be managed through anterior or caudal approaches. RHV is typically conserved during right posterior sectionectomy. When a large posteriorly placed tumor causes chronic compression on RHV, the right anterior section drainage is redirected preferentially to the middle hepatic vein. The division of RHV in such instances does not cause congestion of segments 8 and 5. The technical complexity of laparoscopic right posterior sectionectomy arises from the large transection surface, positioned horizontally. We describe in this multimedia article, a case of large HCC in segments 6 and 7, which was successfully treated using laparoscopic anatomic right posterior sectionectomy.

Delayed presentation of a post-traumatic large right diaphragmatic hernia displacing liver and gallbladder - A case report

Blunt or penetrating trauma resulting in injury or rupture of the diaphragm is rare and constitutes about 1% to 3.9% of all thoraco-abdominal injuries. It is often regarded as a marker of severe trauma. Unfortunately about half of these injuries can be missed during the index admission. Contrast-enhanced computed tomography is the best modality to assess the extent, size of diaphragmatic defect and nature of hernial contents. Surgery is mandatory once the diagnosis is made to prevent future strangulation of hernial contents. Although technically challenging, laparoscopic reduction and mesh repair is feasible in expert hands. We report our experience with laparoscopic repair and mesh re-enforcement in a patient who had a large right diaphragmatic hernia with part of liver, gallbladder, small bowel and omentum within the right hemithorax secondary to a penetrating trauma he had incurred 29 years earlier.

GIST in Third Part of Duodenum Causing Partial Obstruction – Laparoscopic Management

Background: Gastrointestinal Stromal Tumor (GIST) arises from the interstitial cells of Cajal. Stomach is the most common site of GIST. The usual presentations of GIST are gastrointestinal bleeding and abdominal pain. GISTs in the duodenum are uncommon. Duodenal obstruction due to GIST is even more uncommon. Duodenal GISTs are usually detected on endoscopy, however they can be missed on routine endoscopy if they are located in the third part of duodenum. Computed Tomography (CT) of abdomen is useful in determining the exact size, location and extent of tumor. In the absence of metastases, surgical excision is the mainstay of treatment. Case Presentation: We present a case of a duodenal GIST in the 3rd part of duodenum, causing partial obstruction to the duodenal lumen and causing recurrent abdominal pain and vomiting. Although technically challenging, we successfully excised this lesion laparoscopically. Furthermore, as it was a pedunculated tumor arising from the posterior wall of the duodenum, we performed a novel technique of laparoscopic duodenotomy and stapling of pedunculated tumor at the base and primary closure, rather than the conventional technique of wedge or segmental resection. Conclusion: Third part of the duodenum is a difficult location to access surgically and excision of tumors in this location is usually performed by the open method because of the technical difficulties of laparoscopic surgery in this location. However, with adequate expertise and advanced laparoscopic skills, laparoscopic excision of tumors in the third part of duodenum can be accomplished with good post-operative outcomes.

The use of floating wire technique and intravascular ultrasound for precise aorto-ostial stenting

Background

Aorto-ostial interventions often lead to imprecise ostial demarcation, suboptimal stent implantation, and worse clinical outcomes when compared to non-ostial interventions. The floating wire technique (bumper or sepal wire technique) employs a second guidewire placed in the aortic root to both mark the ostium and prevent prolapse of the guide catheter past the target ostial lesion. Its use has been described in the literature and is used often in daily practice however, procedural and long-term clinical endpoints have not been assessed using the gold standard of post-implant IVUS to determine technical success. The aim of the study is therefore to objectively assess the rate of geographic miss using the floating wire technique as well as long-term clinical outcomes.

Methods

A single center retrospective study was conducted. Patients who underwent ostial lesion percutaneous coronary intervention (PCI) with the floating wire technique between January 2019 and September 2020 were identified. Procedural and clinical outcomes at 6 months follow up were investigated. The co-primary endpoints include 1) Geographic miss defined as inadequate ostial coverage by IVUS or excess stent protrusion on angiography and 2) Target lesion failure (TLF) at 6 months after PCI, defined as the composite of cardiovascular death, target-vessel myocardial infarction (MI), and target lesion revascularization.

Results

In total, 48 patients were identified. The average age was 71.7 years old, and 85.4% were male. Indication for PCI was acute coronary syndrome in about a third of patients. Twenty-six patients had left main ostial lesion, and 22 patients had right coronary artery ostial lesions. The average syntax score was 24.2. IVUS assessment was performed in 45 patients. Four (8.3%) patients had more than 2mm of excess stent proximal protrusion. Ostial miss occurred in 1 (2.2%) patient. Seven patients had loss to follow up. TLF, stroke, or major bleeding were not observed in any patients. One non-cardiovascular death, three type 2 MIs, and 1 type 4 MI were observed, which occurred in non-target vessels.

Conclusions

The floating wire technique was safe and efficient with low rates of geographic miss or adverse clinical outcomes. This is the first study to confirm precise aorto-ostial stent implantation using the floating wire technique with IVUS assessment.

Funding Acknowledgement

Type of funding sources: None. Floating Wire Technique for LM Stenting

Trace Element Zinc, a Nature's Gift to Fight Unprecedented Global Pandemic COVID-19

With the advent of twenty-first century, we are in cruel grip of a pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the associated illness being called as COVID-19. Since its outbreak in December 2019 in Wuhan, China, there are no medicines to cure the disease till date. Based on their experience, scientists say that developing a coronavirus vaccine could take at least a year. There are many steps in place before the vaccine comes for the distribution like its safety and cost-effectiveness, especially for the developing countries. In this scenario, the only way to prevent the disease is by following certain safety guidelines and to boost up the body's immune system. Zinc, a crucial trace element involved in several biological and metabolic processes, has been found to play a pivotal role in promoting and appropriately regulating the host defense mechanisms against viral infections. Zinc is naturally present in some foods, fortified in others and also available as dietary supplement. The current RDA (Recommended Daily Allowance) of zinc is 12 and 10 mg for males and females respectively. Zinc is the second most common trace mineral after iron in the cell. It is present in all organs and tissues in the body as it forms catalytic component of all 6 classes of enzymes encompassing almost 2000 enzymes in the body. Zinc is biologically essential for cellular processes, including growth and development, as well as DNA synthesis and RNA transcription. Zinc deficiency results in a number of metabolic changes besides a compromised immune system. In this review, the role of zinc in regulating the host defense and viral replication is being discussed with the main focus on COVID-19.

Giant De-Differentiated Liposarcoma of the Ascending Colon – A Rare Entity

Background: Liposarcoma is one of the common malignant mesenchymal tumors of the retroperitoneum and soft tissue of the extremities. Liposarcoma primarily arising from the colon is extremely rare. De-differentiated liposarcoma, a high grade variant has high local recurrence and distant metastatic potential. At present no standard treatment guidelines are established for the colonic liposarcoma in view of the rarity of the condition. Case Presentation: In this article we report a case of 46-year-old female who presented with a large right sided abdominal lump. On cross sectional imaging, she was found to have a large heterogenous exophytic mass arising from the ascending colon. Colonoscopy showed a submucosal lesion of the ascending colon with luminal narrowing. She underwent a right radical hemicolectomy. Histopathology of the resected specimen was reported as a de-differentiated liposarcoma arising from the ascending colon, which is an extremely rare occurrence. Patient made an uneventful recovery and is under follow-up. Conclusion: Liposarcoma is a rare disease of large intestine. It should be considered in the differential diagnosis when there is a large, submucosal colonic swelling with no lymph nodal or peritoneal disease. Complete surgical resection with clear margins is the standard of treatment. Evidence on the benefits of adjuvant chemotherapy and radiotherapy in improving survival in liposarcoma of colon is currently evolving.

Metastatic Extraskeletal Mesenchymal Chondrosarcoma of the Pancreas: Report of an Unusual Case with Review of Literature

Extraskeletal mesenchymal chondrosarcoma (ESMC) metastasizing to the pancreas in isolation is a rare occurrence. We report a 49-year-old gentleman who had undergone excision of an ESMC of the thigh in 2009 and presented with sudden onset abdominal pain and icterus in 2019. Radiological imaging revealed calcified mass of the pancreas with multiple nodules with extension into the adipose tissue. Distal pancreatectomy was performed and the pathology revealed a bimorphic tumor composed of undifferentiated round blue cells with abrupt transition to hyaline cartilage, typical of mesenchymal chondrosarcoma. To the best of our knowledge, there are only seven prior cases of metastatic ESMC of the pancreas in the English literature. Surgical intervention appears to be the preferred modality of treatment for metastatic pancreatic tumors. These patients may have long latency period before metastasizing and seem to have a good survival period post excision.

Laparoscopic resection of duodenal carcinoid: A feasible method: Single institute case series

Background

Duodenal carcinoids (neuroendocrine tumour) are rare tumour, but recently, increase in incidence has been noted. Various techniques for excision of tumour have been described in literature, but very few case reports and case series have mentioned about laparoscopic management of carcinoid tumour. We describe a case series of seven cases of duodenal non-periampullary carcinoids which was managed by laparoscopic method.

Aims

The aim of the study was to check feasibility of laparoscopic management of duodenal carcinoid and technique of surgery.

Settings and Design

This study design was a case series and prospective data were retrospectively collected.

Materials and Methods

A total of 7 patients were operated for carcinoid tumour of duodenum mainly involving first part by laparoscopic method from February 2016 to January 2017. All patients were followed up for minimum 1-year period and various pre-operative, intra-operative findings and post-operative outcome were noted.

Results

Out of seven patients, 6 patient were managed by laparoscopic duodenotomy and transduodenal excision whereas one patient required duodenectomy of first part. Mean operative time was 99 min, mean intraoperative blood loss was 55.7, mean hospital stay was 99.7 and no recurrence in a 1-year follow-up.

Conclusions

Laparoscopic excision of carcinoid tumour is safe, technically reproducible and feasible method.

A Case Series on Superior Mesenteric Artery Syndrome Surgical Management, Single Institution Experience

Compression of duodenum by Superior Mesenteric Artery (SMA) causing proximal intestinal obstruction is an uncommon condition. Treatment of this condition involves conservative management initially followed by surgical management in those patients who have persistent symptoms. This case series evaluates surgical management and outcome of six patients after one year, who presented with SMA syndrome and describes a brief review of literature. Three patients underwent open duodenojejunostomy and the rest three underwent laparoscopic duodenojejunostomy. All patients had uneventful postoperative recovery. Postoperative requirement of analgesics was less in laparoscopic group versus open group. All the three patients in laparoscopic group could be mobilised out of bed on the day of the surgery itself. Mean duration of hospital stay was seven days for open surgery group and three days for the laparoscopy group. Outcome in terms of resolution of abdomen pain and vomiting was similar in both the groups. Four patients were asymptomatic after one year of follow up. A high index of clinical suspicion is needed for the diagnosis of SMA syndrome. Laparoscopic approach is feasible, safe, less morbid and effective as compared to open surgery. In the presence of facilities and surgical expertise, laparoscopic duodenojejunostomy should be considered the procedure of choice for SMA syndrome. Majority of patients remain symptom free at one year follow up.

A Rare Case of Intestinal Malrotation and Volvulus of Jejunum with Coexisting Carcinoid Tumour of Appendix

Malrotation of the midgut is generally regarded as a paediatric pathology. It is rare in adults. Patients may present with symptoms of acute bowel obstruction or chronic abdominal pain. Barium study, Contrast Enhanced Computed Tomography (CECT), Magnetic Resonance Imaging (MRI), diagnostic laparoscopy and sometimes explorative laparotomy are used for diagnosis. Ladd's procedure through the open approach has been the treatment of choice for complete malrotation of midgut, however there are reports on successful outcome for both complete and incomplete malrotation after laparoscopic approach as well. We report a case of a 25-year-old female who presented with a history of severe pain in abdomen for one week. CECT abdomen showed incomplete malrotation and volvulus in midgut. Laparoscopic detorsion of bowel loops, adhesiolysis, caecopexy and appendectomy was done. Patient's symptoms subsided immediately after surgery. Histological analysis of the appendix specimen showed small appendiceal carcinoid, which was purely incidental. At three months follow up, patient was symptom free.

A Rare SOL of the Liver: Diagnostic and Management Dilemma

Aetiology and clinical presentation of space occupying lesions (SOL) of liver are varied. It can be solid, cystic or heterogenous. Usually liver abscess presents as a symptomatic cystic SOL in a sick patient. Here, we are reporting a case of giant liver abscess presenting as simple benign cyst with corroborative image findings of simple cyst. He had significant co-morbid illness and jaundice on clinical evaluation. Liver abscess was not a differential diagnosis from clinical history. None of the haematological and biochemical parameters were suggestive of liver abscess. It was an intra-operative surprise to find such a huge liver abscess with 2 liters of pus, which was drained. We report this case because of its unusual presentation and associated findings.

Transfascial suture in laparoscopic ventral hernia repair; friend or foe?

'Suture hernia' is fairly a new and rare type of ventral hernia. It occurs at the site of transfascial suture, following laparoscopic ventral hernia repair (LVHR). Employment of transfascial sutures in LVHR is still debatable in contrast to tackers. Prevention of mesh migration and significant post-operative pain are the pros and cons with the use of transfascial sutures, respectively. We report an unusual case of suture hernia or transfascial hernia, which can further intensify this dispute, but at the same time will provide insight for future consensus.

Amyand's hernia: Our experience in the laparoscopic era

Amyand's hernia is a rare presentation of inguinal hernia, in which the appendix is present within the hernia sac. This entity is a diagnostic challenge due to its rarity and vague clinical presentation. A laparoscopic approach can confirm the diagnosis as well as serve as a therapeutic tool. When the appendix is not inflamed within the inguinal hernia sac, then appendicectomy is not always necessary. Our case series emphasize the same presumption as three patient of Amyand's hernia underwent laparoscopic transabdominal preperitoneal hernioplasty without appendicectomy. The aim of this paper is to review the literature with regards to Amyand's hernia and provide new insight in its diagnosis and treatment.

A curious discourse of Krukenberg tumor: a case report

Krukenberg tumor is usually but not always a bilateral involvement of ovaries from metastatic deposit from adenocarcinoma of stomach and rarely from other gastrointestinal (GI) and non GI organs. The route of metastatsis of this rare condition is still not proven. It is still uncertain whether surgical resection of ovarian metastases and/or primary tumor could improve the outcome. We report even a rare presentation of this rare disease entity.

3D Laparoscopy - Help or Hype; Initial Experience of A Tertiary Health Centre

INTRODUCTION

To evaluate the advantages of 3D laparoscopy and compare its significance with conventional 2D laparoscopy during various operative procedures.

METHODS

During present study, two groups were formed. Group A included patients who were operated using 3D laparoscopic imaging and Group B consisted of operated patients by 2D laparoscopy. Operative performance of both the groups was compared in terms of operative time and quality of imaging.

RESULTS

Operative time interval for various procedures was significantly less in Group A as compared to Group B. Also, imaging quality was far superior with use of 3D imaging system especially in terms of depth perception.

CONCLUSION

Advantages of 3D laparoscopy are well appreciated during operative procedures as previously documented by other studies in training models.

Laparoscopic necrosectomy in acute necrotizing pancreatitis: Our experience

CONTEXT:

Pancreatic necrosis is a local complication of acute pancreatitis. The development of secondary infection in pancreatic necrosis is associated with increased mortality. Pancreatic necrosectomy is the mainstay of invasive management.

AIMS:

Surgical approach has significantly changed in the last several years with the advent of enhanced imaging techniques and minimally invasive surgery. However, there have been only a few case series related to laparoscopic approach, reported in literature to date. Herein, we present our experience with laparoscopic management of pancreatic necrosis in 28 patients.

MATERIALS AND METHODS:

A retrospective study of 28 cases [20 men, 8 women] was carried out in our institution. The medical record of these patients including history, clinical examination, investigations, and operative notes were reviewed. The mean age was 47.8 years [range, 23-70 years]. Twenty-one patients were managed by transgastrocolic, four patients by transgastric, two patients by intra-cavitary, and one patient by transmesocolic approach.

RESULTS:

The mean operating time was 100.8 min [range, 60-120 min]. The duration of hospital stay after the procedure was 10-18 days. Two cases were converted to open (7.1%) because of extensive dense adhesions. Pancreatic fistula was the most common complication (n = 8; 28.6%) followed by recollection (n = 3; 10.7%) and wound infection (n = 3; 10.7%). One patient [3.6%] died in postoperative period.

CONCLUSIONS:

Laparoscopic pancreatic necrosectomy is a promising and safe approach with all the benefits of minimally invasive surgery and is found to have reduced incidence of major complications and mortality.

Laparoscopic management of a large duodenal lipoma presented as gastric outlet obstruction

Laparoscopic excision of duodenal lipoma may be an effective alternative when endoscopic excision is not feasible.

Lipoma of the duodenum is a rare tumor, with fewer than 230 cases reported to date. A majority of these tumors were managed by endoscopic and open surgical intervention, with published data on one case that was managed by total laparoscopy. We report a case of a 43-year-old woman with signs and symptoms of gastric outlet obstruction who was diagnosed as having a large duodenal lipoma that was managed successfully with laparoscopic excision.

Laparoscopic completion cholecystectomy: a retrospective study of 40 cases

INTRODUCTION

Throughout the world, laparoscopic cholecystectomy is a widely accepted surgical treatment for both acute and chronic cholecystitis. It provides total relief of pre-surgical symptoms in up to 85% of patients. However, about 5% of patients may experience severe episodes of upper abdominal pain similar to those that they had prior to cholecystectomy; this is known as post-cholecystectomy syndrome. Gallbladder remnant with calculi is one of the causative factors. However, there have been only a few case series related to this reported in literature to date. Herein, we present our experience with laparoscopic management of gallbladder remnant with calculi in 40 cases.

METHODS

A retrospective study of 40 cases was carried out in our institution. All patients underwent open cholecystectomy at other centres, and their cases were managed by laparoscopic completion cholecystectomy.

RESULTS

The mean operating time was 102.4 min (range, 60-120 min). The duration of hospital stay was 2-4 days. Two cases were converted to open surgery because of extensive dense adhesions. One case had minor a common bile duct injury, and another had port-site infection. There were no cases of mortality.

CONCLUSION

Gallbladder remnant containing stones may be the cause of otherwise unexplained postcholecystectomy pain. Completion cholecystectomy offers a definitive treatment for any residual gallbladder remnant and can be performed laparoscopically.

Percutaneous drainage of gastric remnant dilatation after laparoscopic Roux-en-Y gastric bypass

Roux-en-Y gastric bypass is a commonly performed bariatric procedure worldwide. Gastric remnant dilatation is an uncommon early complication of this procedure that can be fatal if treatment is delayed, as it can cause peritonitis and death. Herein we report a gastric bypass patient who presented with profound shock 3 months after the surgery. After resuscitation and evaluation, she was diagnosed as having a massive dilatation of gastric remnant, which we managed with percutaneous drainage.

Symptomatic "H" type duplex gallbladder

A case of ductular type duplex gallbladder is presented that was diagnosed by magnetic resonance cholangiopancreatography and managed by laparoscopy.

Gallbladder duplication with an incidence at autopsy of about 1 in 4000 is important in clinical practice, because it may cause some clinical, surgical, and diagnostic problems. Preoperative identification of this rare anomaly avoids biliary injuries and the other consequences of missed diagnosis. In this report, we present a case of ductular type duplex gallbladder diagnosed preoperatively by magnetic resonance cholangiopancreatography (MRCP) and ultrasound and managed successfully by laparoscopy.

Laparoscopic cholecystectomy for left-sided gallbladder (sinistroposition)

Transposition of the gallbladder to the left side without situs inversus viscerum is rare. These gallbladders are situated under the left lobe of the liver between Segment III and IV or on Segment III to the left of the falciform ligament. Because routine preoperative studies may not detect the anomaly, it may provide the surgeons with an unusual surprise during laparoscopy. Awareness of the unpredictable confluence of the cystic duct into the common bile duct and selective use of intraoperative cholangiography aid in the safe laparoscopic management of this unusual problem.

Laparoscopic derotation and cholecystectomy for torsion gallbladder

Torsion of the gallbladder is an unusual cause of gangrenous cholecystitis. Even with the advent of recent radiological imaging modalities, the preoperative diagnosis of this entity remains elusive. Herein, we present a case of gallbladder torsion in a 76-year-old lady who successfully underwent laparoscopic derotation and cholecystectomy.

Interferon-gamma upregulates MUC1 expression in haematopoietic and epithelial cancer cell lines, an effect associated with MUC1 mRNA induction

Epithelial mucin-1 (MUC1) is an important target antigen that it is overexpressed in both epithelial and haematological cancers including multiple myeloma (MM) and some lymphomas and leukaemias. MUC1 has adhesive and immunosuppressive properties, which may promote cancer progression. These studies evaluated the effect of IFNs on MUC1 expression, since these agents are widely used in clinical cancer therapy. MUC1 and interferon (IFN) receptor expression were measured by radioligand binding. Changes in MUC1 mRNA levels in response to IFN-gamma were assessed by semi-quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). IFN-gamma was found to be a more potent inducer of MUC1 expression than IFN-alpha. 125I-IFN binding studies indicated that both IFN receptors were expressed in most of the cell lines. With IFN-gamma treatment, there was upregulation of MUC1 mRNA. IFN-gamma has a more consistent and more potent effect upon MUC1 induction than IFN-alpha. The ability to upregulate MUC1 across a broad range of cancer types by a clinically available cytokine, IFN-gamma, has important implications for enhancing immunotherapeutic approaches targeting MUC1.

Laparoscopic removal of an artery forceps

Numerous foreign bodies, such as surgical gauze, pads and instruments, and other items, have been left behind in the abdominal cavity during open surgeries. These have been traditionally removed at redo open surgeries. Here we describe a case of an artery forceps left behind at a previous surgery (open cholecystectomy and appendicectomy) performed 5 years earlier that was removed by laparoscopy.

Ratio of cathepsin B to stefin A identifies heterogeneity within Gleason histologic scores for human prostate cancer

BACKGROUND

Cathepsin B (CB), a lysosomal cysteine protease, is involved in degradation of extracellular matrix proteins and progression of tumor cells from one biological compartment to another in many solid organ cancers, including prostate cancer. Our objective was to identify patterns of distribution of CB and its endogenous cellular inhibitor stefin A in cryostat sections of frozen BPH and prostate cancer tissue samples and to define these patterns in relation to Gleason histologic scores, clinical stages, and serum total PSA levels.

METHODS

We localized CB and stefin A in the same sections using polyclonal and monoclonal antibody immunoglobulin G (IgGs) against CB and stefin A using immunofluorescence and confocal microscopic techniques. Only cryostat sections of frozen prostates were used in localizations of CB and stefin A.

RESULTS

Benign prostatic hyperplasia (BPH) showed similar localization patterns for CB and stefin A and a ratio of 1 was indicated by CB = stefin A. Confocal studies indicated that most CB and stefin A sites in BPH glandular cells overlapped as shown by the yellow fluorescence of their co-localization. We found considerable variability in individual localization of CB and stefin A within and between Gleason histologic scores for prostate cancers. This variability was also found in Gleason score 6 tumors that are otherwise considered similar histologically and morphologically. Negative control sections did not show localization of CB by FITC, stefin A by Cy3 or yellow fluorescence for co-localization. Our analysis of the ratio of CB to stefin A showed three patterns, namely CB = stefin A, CB > stefin A, and CB < stefin A, within each Gleason score evaluated by us. Confocal microscopy showed more sites of yellow fluorescence when the ratio was CB = stefin A than those found in CB > stefin A or CB < stefin A. Statistical analyses showed prostate cancer cases with ratios of CB > stefin A (P < 0.05) and CB < stefin A (P < 0.05) significantly different from normal prostate and BPH which had ratios of CB = stefin A. Regression analysis did not show any specific relationship between the ratio of CB to stefin A and Gleason scores, clinical stages, and serum total prostate specific antigen (PSA) levels in prostate cancers. Analysis of our data indicates that the homeostatic balance between the enzyme and inhibitor was altered even in Gleason histologic score 6 tumors that are usually considered histologically similar by glandular differentiation.

CONCLUSIONS

We have shown that prostate cancer is a heterogeneous tumor within each Gleason histological score regardless of the progression indicated by lower to higher Gleason score tumors. The ratio of CB > stefin A would indicate a preponderance of enzyme that would favor degradation of extracellular matrix proteins and progression of tumor cells in biological compartments. These tumors are expected to be aggressive prostate cancers. In contrast, prostate tumors showing ratios of CB < stefin A and CB = stefin A are expected to be less aggressive prostate cancers. This is the first report to define heterogeneity within any Gleason score for prostate cancers by the ratios of CB to stefin A.

Ontogeny of alpha-amylase gene expression in sea bass larvae (Lates calcarifer)

The enzymatic activities of alpha-amylase and its corresponding messenger RNA levels in developing sea bass (Lates calcarifer) larvae were studied from hatching until 27 days post hatching (dph). An increasing activity of amylase enzyme was measured until 5 dph, and the activity gradually decreased thereafter and reached a constant level by 12 dph. To achieve a better understanding of the molecular mechanisms underlying amylase expression, we have cloned and sequenced a 318-bp fragment of alpha-amylase complementary DNA. Based on this sequence, a real-time reverse transcriptase polymerase chain reaction technique to monitor the changes in the mRNA levels in the larvae was developed. A correlation between enzymatic activity and mRNA level of alpha-amylase could be demonstrated during the early development of sea bass larvae. This suggests that the changes in alpha-amylase are controlled at least at the transcriptional level during early larval development of sea bass.

Eosinophilic granuloma of spine in adults: a case report and review of literature

A rare case of eosinophilic granuloma in an adult is reported. Eosinophilic granuloma (EG) is a lesion observed more frequently in adults. CT and MRI showed a lytic lesion of the T11 vertebral body. A transpedicular excisional biopsy of the lesion revealed EG. Spinal EG in adults is rare and differs from the childhood disease by the spinal level involvement. Vertebra plana, a condition of spondylitis in which the body of the vertebra is reduced to a sclerotic disc, is not a roentgenographic feature in the 14 cases reported in literature. It should be included in the differential diagnosis of the solitary lytic lesion of vertebrae in adults.

Effect of 17beta-estradiol on the expression of somatostatin genes in rainbow trout (Oncorhynchus mykiss)

In the present study, the effects of 17beta-estradiol (E(2)) treatment on the expression of preprosomatostatin (PPSS) I, PPSS II', and PPSS II" mRNA in the hypothalamus and endocrine pancreas (Brockmann body), as well as the effects of E(2) treatment on plasma somatostatin (SS)-14 and -25 concentrations in sexually immature rainbow trout (Oncorhynchus mykiss), were investigated. E(2) treatment significantly (P < 0.001) depressed both plasma SS-14 and SS-25. In the hypothalamus, E(2) treatment significantly (P < 0.001) decreased the levels of PPSS I and PPSS II" mRNA. However, there was no effect of E(2) treatment on PPSS II' mRNA levels. In the pancreas, E(2) treatment had no significant effect on the levels of either PPSS II' mRNA or PPSS II" mRNA. However, E(2) treatment significantly (P < 0.005) decreased levels of PPSS I mRNA. These data suggest that E(2) acts, in part, to increase plasma growth hormone levels in rainbow trout by decreasing the endogenous inhibitory somatostatinergic tone by inhibiting plasma levels of both SS-14 and SS-25 and hypothalamic levels of mRNA encoding these proteins.

Synovial chondromatosis of the temporomandibular joint with intracranial extension

We present a rare case of synovial chondromatosis of the left temporomandibular joint with intracranial extension and review the relevant literature. This is the sixth published report of such a skull base tumour. We discuss imaging characteristics and the differential diagnosis with regards to a curative surgical resection.

Dipeptidylpeptidase IV activities are elevated in prostate cancers and adjacent benign hyperplastic glands

Dipeptidylpeptidase IV (DPP IV) is a serine exopeptidase that has been implicated in cell-extracellular matrix interactions and bioactive peptide/cytokine/growth factor metabolism. The objective of this study was to determine if DPP IV activities were changed with development of cancer in the prostate. DPP IV activity was measured in human prostate cancer and benign prostatic hyperplasia (BPH) tissues by biochemical assays with glycylprolyl-p-nitroanalide as substrate in tissue extracts (BPH, n = 8: cancer, n = 7; 2 with Gleason score 5 and 5 with Gleason score 7) and quantitative morphometry of histochemical activities with glycylproline-4-methoxy-beta-naphthylamide as substrate (BPH, n = 9: cancer, n = 13, 1 with Gleason score 4, 10 with Gleason score 6, 2 with Gleason score 8) in frozen-tissue sections. Data were analyzed by analysis of variance. The peptidase activity was detected in epithelial but not stromal cells of BPH and cancer tissues, and it was present as a single band of activity of approximately 160 kDa in electrophoretically separated activity blots of the extracts. DPP IV activity was increased approximately twofold in cancer versus BPH tissues as determined by biochemical and quantitative histochemical methods. In addition, DPP IV activity was increased to a similar extent in BPH glands associated with the cancers. These data indicate that DPP IV activity is increased not only in primary prostatic cancers but also in associated BPH glands, suggesting that there may be some local factors produced by cancer cells that influence adjacent BPH epithelial cells to positively affect the immediate growth environment of the cancer.

The relationship of cathepsin B and stefin A mRNA localization identifies a potentially aggressive variant of human prostate cancer within a Gleason histologic score

Cathepsin B (CB) is involved in degradation of extracellular matrix proteins during tumor progression in human solid organ tumors (such as colorectal, bladder, and breast cancers), including human prostate cancer. Its activities are regulated by endogenous inhibitors (such as stefins or cystatins). Increased expression of cathepsin B message, protein, and membrane association have been linked to malignancy, but there are very few studies of their mRNA expression in prostate cancer using in situ hybridization techniques. Our objective was to determine the relationship of CB and stefin A (cystatin A) mRNA localization to the Gleason grading system for histologic scores in the hope of distinguishing aggressive and less aggressive variants of prostate cancer. We used a 25-base biotinylated oligonucleotide CB cDNA antisense probe to localize CB message and a 27-base biotinylated oligonucleotide stefin A cDNA antisense probe to localize stefin A message. Prostate samples from 41 prostatectomy patients were collected along with their pre-surgery serum PSA levels and clinical stage of the disease. Sections prepared from frozen prostate tissue samples were hybridized with the CB and stefin A and control pBR 322 probes using techniques reported by Sinha et al. [1] and their distribution quantitated by an image analysis system. Prostate sections treated with RNAse before hybridization or incubated with the pBR 322 control probe showed little or no reaction products, confirming that localization of CB and stefin A probes was specific. In prostate cancer, the reaction products were found in neoplastic and invasive cells and occasionally in stromal cells. The ratios of CB to stefin A were similar in normal prostate and benign prostatic hyperplasia (BPH) whereas they varied consistently within and between Gleason histologic scores for prostate cancer. These variations showed three localization patterns; namely, prostate cancers with higher levels of CB than stefin A, lower levels of CB than stefin A, and similar levels of CB and stefin A. All three patterns and ratios for CB and stefin A were found in prostate samples (22/41) represented by the Gleason histologic score 6 tumors. In these tumors, serum PSA levels ranged from 1 to 78 ng/ml and prostate cancers showed B, C, and D clinical stages. There was no correlation of CB/stefin A ratio and serum PSA values or clinical stage in a limited number of prostate cancer cases. Our data showed that there were prostate cancer cases within Gleason histologic scores which expressed high, similar, and low levels of CB when compared to stefin A. We postulate that prostate cancer cases showing higher levels of CB compared to stefin A probably represent an aggressive variant of this cancer within any one Gleason histologic score. If this is the case, aggressive variants of prostate cancer would occur within Gleason scores 3 to 10 even though higher scores are usually considered more aggressive forms of prostate cancers. Since our study is based upon a very limited number of frozen prostate samples, we emphasize that a larger series of archival prostate cancer samples along with their survival data should be analyzed to establish any relationship of CB/stefin A ratio and aggressive variants of this cancer. Therefore, our conclusion is tentative. Our study provides a partial explanation for differences in the clinical course of prostate cancer in patients. This is the first study to show that determination of CB and stefin A mRNA ratios may lead to identification of aggressive and less aggressive variants of prostate cancer within a Gleason histologic score.

Intravenous injection of an immunoconjugate (anti-PSA-IgG conjugated to 5-fluoro-2'-deoxyuridine) selectively inhibits cell proliferation and induces cell death in human prostate cancer cell tumors grown in nude mice

Current chemotherapeutic and/or endocrine treatments for adenocarcinoma of the prostate are not delivered selectively to prostate cancer cells, therefore, they are used in very high doses that induce many unpleasant side effects in patients. New approaches are, therefore, needed to deliver drugs directly to prostate cancer cells to improve treatment effects. We hypothesized that antibody immunoglobulin G (IgG) against human prostate specific antigen (PSA) (anti-PSA-IgG) could function as a carrier protein for conjugated chemotherapeutic drugs (such as 5-fluoro-2'-deoxyuridine, doxorubicin, etc.) and that the immunoconjugate could be delivered selectively to PSA-producing neoplastic prostate. Immunoconjugate would then preferentially inhibit cell proliferation and induce cell death in PSA-producing tumor cells, but not in non-PSA-producing prostate cancer cells or other solid organs of the host. The short-term treatment effect could be assessed by measuring cell death and cell proliferation in tumor-bearing animals. We tested our hypothesis by intravenously injecting an immunoconjugate (anti-PSA-IgG-5-fu-2'-d) into nude mice with subcutaneous PSA-producing LNCaP or non-PSA-producing Du-145 prostate tumors. During 5 days of treatment, we observed that immunoconjugate was retained preferentially in PSA-producing LNCaP tumors where it produced cytotoxic effects in neoplastic prostate cells as revealed by decreased cell proliferation and increased cell death, but similar effects were not observed in non-PSA-producing Du-145 tumor cells or mouse organs. Analysis of untreated control mouse with LNCaP tumor, anti-PSA-IgG alone, anti-irrelevant-IgG-drug complex, and drug alone treatments indicated that there was little or no cytotoxic effects of these treatments on LNCaP and Du-145 tumors, and host organs. Our analysis of control and experimental data showed that the immunoconjugate was highly specific in imparting cytotoxic effects on LNCaP prostate tumors, but not on Du-145 tumors and mouse organs. Thus, we have shown that the immunoconjugate selectively delivered a chemotherapeutic drug to PSA-producing prostate tumor cells where it produced measurable cytotoxic effects on cell proliferation and cell death. This is the first report to show a successful delivery of a chemotherapeutic drug in the immunoconjugate to PSA-producing LNCaP prostate tumors in nude mice and without inducing cytotoxic effects on mouse organs.

Technique of removal of an impacted sharp object in a penetrating head injury using the lever principle

Penetrating head injuries can be difficult to manage as the extensive surgery which may be required can result in severe morbidity and mortality in some patients. A conservative surgical approach with a "pull and see" policy was adopted successfully in a described case. Extraction can be achieved by using the mechanical advantage of the lever principle. By this method while removing the object any movements of sharp edges which will cause secondary damage can be reduced to a minimum.

Codistribution of procathepsin B and mature cathepsin B forms in human prostate tumors detected by confocal and immunofluorescence microscopy

Cathepsin B (CB) is involved in invasion and metastasis of a variety of solid organ tumors, including human prostate cancer. The tertiary structures of the proenzyme and mature forms of CB are related closely, as revealed by crystallographic studies. However, the cellular distributions of the CB forms have not been defined in human prostate and its tumors. Our objective was to investigate the distribution and codistribution of CB and procathepsin B (proCB) in human prostate tumors. Human prostate tissue samples that were obtained from 21 prostatectomy and/or cystectomy patients were collected immediately after surgery and processed for this study. We used a rabbit antihuman liver CB immunoglobulin G (IgG) that recognizes both mature CB and proCB and a mouse antipropeptide monoclonal antibody IgG that recognizes only proCB. Fluorescein isothiocyanate (FITC)-conjugated donkey antirabbit IgG and indocarbocyanine (Cy3; rhodamine)-conjugated donkey antimouse IgG were used to differentiate localization of the enzyme forms. Immunofluorescence of FITC and Cy3 was examined in prostate sections by using epifluorescence and confocal laser-scanning microscopy. Because fluorescence is dependent on section thickness, time needed for study and photography, and the antigenic sites of proCB and mature CB localized by antibodies and by fluorescent markers (Cy3 vs. FITC), the cellular distributions and the relative intensity of fluorescence on cryostat sections were assessed qualitatively. Immunofluorescence of Cy3 for localizing proCB and of FITC for localizing mature CB were observed in prostatic epithelial cells and their tumors and in stromal connective tissue cells. By using confocal microscopy, colocalization of the enzyme forms in the same cells was indicated by yellow fluorescence. In stromal cells (such as smooth muscles, fibroblast, and macrophages), the distribution of proCB and relative fluorescence intensity was moderate to predominant in human prostate and its tumors. In neoplastic prostate, the cellular distributions of CB ranged from low to predominant levels. In some neoplastic glands, Cy3 fluorescence for proCB was absent, whereas the mature form of CB localized in cancer cells and in the subjacent extracellular matrix. Confocal microscopy showed a close association of CB with extracellular matrix surrounding neoplastic acini and invasive cells, indicating that the enzyme form was probably involved in degradation of the matrix proteins. The negative control study showed no specific immunofluorescence for proCB or CB in prostate cancer cases. We have shown a differential distribution of proenzyme and mature forms of CB in normal prostate, benign prostatic hyperplasia, and neoplastic prostate. The enzyme forms were assessed by determining the cellular distributions of CB and proCB. Our study indicates that the differential distribution of proCB and CB might provide clues into aggressiveness of prostate cancers within Gleason grades. However, we emphasize that our observation should be evaluated in a larger series of prostate samples before a definitive conclusion can be reached. This is the first report to show codistribution of proenzyme and mature forms of CB by using confocal microscopy.

Immunocytochemical localization of an immunoconjugate (antibody IgG against prostatic acid phosphatase conjugated to 5-fluoro-2'-deoxyuridine) in human prostate tumors

Current chemotherapeutic and/or endocrine treatments for adenocarcinoma of the prostate (CaP) do not selectively target neoplastic prostate cells. Therefore, new approaches are needed to improve treatment for prostate tumors. We hypothesized that because of the specific binding of antibody immunoglobulin G (IgG) against human prostatic acid phosphatase (PAcP), PAcP-IgG could function as a carrier protein for the conjugated chemotherapeutic drugs and that the immunoconjugate would then selectively localize (bind) to epithelial cells of human prostate tumors, but not to epithelial cells of other solid organs. Our objective was to test this hypothesis using human prostate, colon, and kidney tissue samples and human prostate pieces incubated in short-term organ culture. We used derivatives of 5-fluorouracil labeled with fluorescein isothiocyanate (FITC) and rabbit anti-PAcP-IgG tagged with CY3/rhodamine alone or as an immunoconjugate. Localization of PAcP-IgG alone and the immunoconjugate in prostate produced similar and specific immunostaining in prostate epithelial cells and their tumors, but not in epithelia of colon and kidney tissue sections or in prostate sections-treated with normal rabbit serum. Confocal microscopy showed co-localization of CY3 and FITC of the immunoconjugate in the same group of prostate epithelial cells and their tumors. Organ culture studies showed that human prostate tissue samples incubated with normal rabbit serum did not show any fluorescence whereas those cultured with PAcP-IgG immunoconjugate showed fluorescence in glandular epithelial cells. The later study also showed that in organ culture the immunoconjugate had penetrated and labeled prostate glands internal to the cut surfaces. Drug labeled with FITC did not localize specifically in the prostatic epithelium. Analysis of our data has shown that PAcP-IgG was needed for specific localization of the immunoconjugate in prostate glands. We conclude that PAcP-IgG was essential for delivery and binding of the drug in human prostate. This is the first report to show that PAcP-IgG-5-Fu-2'-d-based immunoconjugate was selective and specific to epithelial cells of human prostate and its tumors, as revealed by organ culture, immunocytochemical, and confocal microscopic techniques.

Bladder stone causing renal failure

We describe a 62-year-old man with a large bladder calculus causing bilateral ureteral obstruction. Diagnosis was delayed despite the patient's history of recurrent urinary infections. This case report illustrates the importance of radiological evaluation of patients presenting with recurrent urinary infections. To our knowledge, only three previous reports of bladder stone causing renal failure have been published.

Recurrent hemorrhage for ileal conduit: an uncommon complication of portal hypertension

Massive hemorrhage from an ileal conduit is rare. We report who presented with massive recurrent hemorrhage from previously undiagnosed ileal conduit varices secondary to portal hypertension. Current methods for diagnosis and treatment of this rare but life threatening entity are discussed.

Spinal extradural angiolipomas : report of three cases

Three cases of extrdural spinal agiolipomas of dorsal region presenting as compressive myelopathy are reported. All of them recovered fully following surgery. The role of modern imaging techniques in detecting such lesions along with review of literature is presented. Histopathology in case 2 showed areas suggestive of haemingioma and predominant areas of angiolipoma supporting the hypothesis of common origin of al these from the same pluripotential stem cells.

Cyclophosphamide associated bladder cancer--a highly aggressive disease: analysis of 12 cases

PURPOSE

We gained knowledge of the etiology, treatment and prevention of cyclophosphamide associated urothelial cancer.

MATERIALS AND METHODS

The medical records of 6 men and 6 women (mean age 55 years) with cyclophosphamide associated bladder cancer were reviewed.

RESULTS

All tumors were grade 3 or 4 transitional cell carcinoma. Of the 5 patients initially treated with endoscopic resection alone only 1 is alive without disease. Of the 6 patients who underwent early cystectomy 4 were alive at 24 to 111 months. The remaining patient with extensive cancer underwent partial cystectomy for palliation and died 3 months later.

CONCLUSIONS

Cyclophosphamide associated bladder tumor is an aggressive disease. However, long-term survival is possible when radical cystectomy is performed for bladder tumors with any sign of invasion and for recurrent high grade disease, even when noninvasive.

Effects of cortisol on growth and development in tilapia larvae,Oreochromis mossambicus

Treatment of one-day-old yolksac larvae of tilapia (Oreochromis mossambicus), by immersion in cortisol solution for two weeks, significantly enhanced growth. The standard length, tail length, head width and wet weight showed dose-dependent increases at concentrations of cortisol (hydrocortisone) from 0.05 ppm to 0.5 ppm, with no further increase at 1.0 ppm. However, cortisol at 5.0 ppm retarded the growth of the larvae without causing any morphological abnormality. Yolk absorption and the onset of free-swimming activity in the larvae were also accelerated by cortisol treatment.

Delayed/salvage radiation therapy in patients with elevated prostate specific antigen levels after radical prostatectomy. A long term follow-up

BACKGROUND

In this article the authors report an analysis and long term results of delayed/salvage radiation therapy administered to asymptomatic patients who had an elevated prostate specific antigen (PSA) level, many months to many years after radical prostatectomy.

METHODS

During 1987 to 1990, 40 asymptomatic patients were found to have an elevated PSA level 9 to 96 months after radical prostatectomy. The patients underwent transrectal needle aspiration biopsy of the urethrovesicle junction anastomosis (uvj); 28 patients had a positive biopsy and 12 patients had a negative biopsy. Delayed/salvage radiation therapy was administered to the pelvis (45 Gray [Gy]) and prostate bed (59.5 Gy), including the uvj.

RESULTS

Twenty-four of 37 patients (65%) were free of clinical disease. In 10 patients (27%), the radiation therapy resulted in a durable decrease in the elevated PSA level below a detectable level for a minimum 5-year follow-up. Five patients were alive with clinical disease. Eight died of disease. Three patients were lost to follow-up.

CONCLUSIONS

This experience shows that delayed/salvage radiation therapy to the pelvis (45 Gy) and prostate bed (59.5 Gy), even many years after radical prostatectomy for pathologic stage pB, pC, and pD1 carcinoma of the prostate, was well tolerated and provided freedom from clinical disease in 24 of 37 patients (65%), and a decrease in elevated PSA level in 10 patients (27%). Delayed/salvage radiation therapy appears to be beneficial for patients who had undergone radical prostatectomy only and then developed rising PSA levels during the follow-up period.

Retrograde ureteral intussusception: a rare complication

A 45-year-old man with a history of cyclophosphamide exposure underwent repeated ureteroscopy for positive urine cytology findings after resection of a Grade 2 papillary transitional-cell carcinoma of the bladder. Despite careful technique, an intussusception developed in the left ureter, which was repaired by resection and construction of a Boari flap. To our knowledge, this is the first report of retrograde ureteral intussusception caused by ureteroscopy.

Report of a multicenter clinical evaluation of the Dura-II penile prosthesis

PURPOSE

Information was collected during the first 2 years of an ongoing, prospective, multi-institutional evaluation of the Dura-II penile prosthesis. Evaluation included data on clinical outcomes and a patient satisfaction survey, and will continue for 5 years after implantation for each patient.

MATERIALS AND METHODS

To date 196 patients have been evaluated. Surgical data, adverse events and information from satisfaction surveys are reported.

RESULTS

At a followup of 13.4 +/- 8.4 months postoperatively, adverse events occurred in 8.2% of the patients, resulting in reoperation in 5.1%. There have been no mechanical failures. Overall satisfaction rates were 85% at 3 months, 83% at 1 year and 91% at 2 years after implantation, and levels of sexual functioning were correspondingly high. A majority of patients assigned high scores to rigidity, concealability, ability to have intercourse and erection size, although satisfaction with erection size ranked lower than the other measures.

CONCLUSIONS

The Dura-II penile prosthesis provides a satisfactory result and has an acceptable level of complications associated with its use. Further followup will assess temporal changes in satisfaction rates and sexual functioning for these patients.

Paradoxical progression of tuberculous lesions during chemotherapy of central nervous system tuberculosis. Report of four cases

The peculiar phenomenon of paradoxical progression during the treatment of central nervous system tuberculosis is discussed. A few cases with this phenomenon were reported in the past, and the authors have treated four such cases. During the treatment for tuberculous meningitis, the four patients developed new lesions, mainly in the form of tuberculomas, which progressed for some time and later regressed. In all these cases the initial drug regimen was not changed, except for the addition of steroids for a short period at the time of deterioration. All four patients underwent ventriculoperitoneal shunt insertion during the course of treatment. The authors discuss the significance of the changes in the lesions and management of such cases, and review the literature.