Independent Factors Contributing to Daytime and Nighttime Asthmatic Cough Refractory to Inhaled Corticosteroids

BACKGROUND

Cough is a common feature of asthma, which is often resistant to inhaled corticosteroids (ICSs). The pathophysiology of this refractoriness may differ between daytime and nighttime asthmatic cough. We sought to identify factors contributing to ICS-refractory daytime and nighttime asthmatic cough.

METHODS

Sixty-seven patients with asthma presenting solely or predominantly with chronic cough were prospectively enrolled from April 2012 to December 2014. At baseline and 12 weeks after ICS treatment, the capsaicin cough threshold (C2, C5) and methacholine airway sensitivity and reactivity were examined. A visual analog scale (VAS) and numeric scores were used to evaluate daytime and nighttime cough symptoms separately. The Japanese version of the Leicester Cough Questionnaire was also completed. When either the VAS or numeric scores showed an improvement of ≥50% or ≥2 points, patients were considered responders to ICS treatment.

RESULTS

Fifty-five patients were eligible for evaluation. Subjective cough indices improved significantly at 12 weeks after ICS treatment (P<.001). Multivariate analysis revealed that lower C2 significantly contributed to residual daytime cough (P=.04). Meanwhile, methacholine hyperreactivity and lower IgE levels were predictors of the nighttime residual cough (P=.002 and P=.03, respectively).

CONCLUSIONS

Heightened cough reflex sensitivity is an independent factor of daytime asthmatic cough that is refractory to ICSs. In contrast, airway hyperreactivity and less atopic status contribute to ICS-refractory nighttime cough.

IL4Rα and ADAM33 as genetic markers in asthma exacerbations and type-2 inflammatory endotype

BACKGROUND

Genetic markers of susceptibility to asthma exacerbations in adults remain unclear.

OBJECTIVE

To identify genetic markers of asthma exacerbations, particularly in patients with type-2 inflammatory endotype.

METHODS

In this observational study of patients enrolled in the Kinki Hokuriku Airway disease Conference multicenter study, frequency of exacerbations requiring systemic corticosteroids during 2 years after enrolment and associated risk factors was determined. For genetic marker analysis, interleukin-4 receptor α (IL4RA) rs8832 and a disintegrin and metalloprotease 33 (ADAM33) S_2 (rs528557), T_1 (rs2280091), T_2 (rs2280090), and V_4 (rs2787094) variants were included. Elevated serum periostin levels at enrolment (≥95 ng/mL, defined as type-2 inflammatory endotype) were considered in the analysis.

RESULTS

Among 217 patients who were successfully followed up for 2 years after enrolment, 60 patients showed at least one asthma exacerbation during the 2 years. Airflow limitation (%FEV₁ <80%) and recent exacerbations but not genetic variants were identified as risk markers of exacerbations. A total of 27 patients showed type-2 inflammatory endotype (serum periostin ≥95 ng/mL at enrolment) and subsequent exacerbations; risk factors in these patients were airflow limitation (odds ratio, 6.51; 95% confidence interval (CI): 2.37-18.6; P=.0003), GG genotype of IL4RA rs8832 (odds ratio, 4.01; 95% CI: 1.47-11.0; P=.007), and A allele of ADAM33 T_2 (odds ratio, 2.81; 95% CI: 1.05-7.67; P=.04) by multivariate analysis. In addition, GG genotype of IL4RA rs8832 was associated with type-2 endotype, whereas A allele of ADAM33 T_2 was associated with mixed type of eosinophilic/type-2 and neutrophilic inflammations.

CONCLUSIONS AND CLINICAL RELEVANCE

IL4RA and ADAM33 variants may be risk markers of asthma exacerbations in type-2 inflammatory endotype. Precise endotyping may facilitate the identification of genetic risk markers of asthma exacerbations.

Utility of serum periostin and free IgE levels in evaluating responsiveness to omalizumab in patients with severe asthma

BACKGROUND

Omalizumab, a humanized anti-IgE monoclonal antibody, has demonstrated efficacy in patients with severe allergic asthma. However, treatment responses vary widely among individuals. Despite a lack of data, free serum IgE levels following omalizumab treatment have been proposed as a marker of treatment responsiveness.

METHODS

In this prospective, observational study, we assessed the utility of biomarkers of type 2 inflammation in predicting omalizumab treatment responses, as determined by the absence of asthma exacerbation during the first year of treatment. Free serum IgE levels were monitored for 2 years to examine their association with baseline biomarker levels and the number of exacerbations.

RESULTS

We enrolled thirty patients who had been treated with omalizumab for at least 1 year, of whom 27 were treated for 2 years. Baseline serum periostin levels and blood eosinophil counts were significantly higher in patients without exacerbations during the first year of treatment than in patients with exacerbations. Baseline serum periostin levels, but not eosinophil counts, were negatively associated with free serum IgE levels after 16 or 32 weeks of treatment. Reduced free serum IgE levels during treatment from those at baseline were associated with reduced exacerbation numbers at 2 years. In 14 patients who continued to have exacerbations during the first year of treatment, exacerbation numbers gradually and significantly decreased over the 2-year study period, with concurrent significant reductions in free serum IgE levels.

CONCLUSION

Baseline serum periostin levels and serum free IgE levels during treatment follow-up may be useful in evaluating responses to omalizumab treatment.

GLCCI1 variant accelerates pulmonary function decline in patients with asthma receiving inhaled corticosteroids

BACKGROUND

In steroid-naive patients with asthma, several gene variants are associated with a short-term response to inhaled corticosteroid (ICS) treatment; this has mostly been observed in Caucasians. However, not many studies have been conducted for other ethnicities. Here, we aimed to determine the relationship between the annual decline in forced expiratory flow volume in one second (FEV1 ) and the variant of the glucocorticoid-induced transcript 1 gene (GLCCI1) in Japanese patients with asthma receiving long-term ICS treatment, taking into account the effect of high serum periostin levels, a known association factor of pulmonary function decline and a marker of refractory eosinophilic/Th2 inflammation.

METHODS

In this study, 224 patients with asthma receiving ICS treatment for at least 4 years were enrolled. The effects of single-nucleotide polymorphisms (SNPs) in GLCCI1, stress-induced phosphoprotein 1 (STIP1), and T gene on the decline in FEV1 of 30 ml/year or greater were determined.

RESULTS

Besides the known contributing factors, that is, the most intensive treatment step, ex-smoking, and high serum periostin levels (≥95 ng/ml), the GG genotype of GLCCI1 rs37973, and not other SNPs, was independently associated with a decline in FEV1 of 30 ml/year or greater. When patients were stratified according to their serum periostin levels, the GG genotype of rs37973 was significantly associated with blood eosinophilia (≥250/μl) in the high serum periostin group.

CONCLUSIONS

A GLCCI1 variant is a risk factor of pulmonary function decline in Japanese patients with asthma receiving long-term ICS treatment. Thus, GLCCI1 may be associated with response to ICS across ethnicities.

Smoking attenuates the age-related decrease in IgE levels and maintains eosinophilic inflammation

BACKGROUND

Epidemiological studies have shown that smoking increases the propensity for atopy and asthma. However, the effects of smoking on atopy and eosinophilic inflammation in asthmatics, including the elderly, remain unknown.

OBJECTIVE

To determine the effects of smoking on serum immunoglobulin E (IgE) levels and eosinophilic inflammation in asthmatics of all ages.

METHODS

The associations of serum IgE levels, blood eosinophil counts and fractional exhaled nitric oxide (FeNO) levels with smoking and age in steroid-naive asthmatics were cross-sectionally assessed (n = 307). Levels of sputum eosinophil and thymic stromal lymphopoietin (TSLP) that promotes Th2 inflammation were also analysed. Current smokers were excluded when analysing contributing factors of FeNO.

RESULTS

Levels of serum IgE, blood eosinophil and FeNO decreased with increasing age in never-smokers, whereas decrease in serum IgE levels with increasing age was not observed in current smokers. In addition, current smoking was associated with higher blood eosinophil counts. In atopic asthmatics, age-related declines in serum IgE levels were less steep in ex-smokers than in never-smokers, and atopic ex-smokers with asthma showed higher blood eosinophil counts and higher FeNO irrespective of age. Lastly, sputum TSLP levels were associated with sputum eosinophil proportions and pack-years. Current and ex-smokers had higher TSLP levels than never-smokers.

CONCLUSIONS AND CLINICAL RELEVANCE

In steroid-naive asthmatics, smoking may attenuate the age-related decrease in IgE levels and maintain eosinophilic inflammation, in which TSLP may be involved.

An innovative technique for endoscopic submucosal dissection of early gastric cancer using a new spring device

BACKGROUND AND STUDY AIMS

In recent years, endoscopic submucosal dissection (ESD) has been applied for the treatment of gastric tumors, and the en-bloc resection rate of early gastric cancer has greatly improved. Herein, we introduce spring-assisted ESD, for quicker submucosal dissection.

PATIENTS AND METHODS

ESD was carried out in 32 patients (20 men, 12 women; mean age 72.6 years, range 53 - 88 years) for early gastric cancer, with tumors over 10 mm in diameter. The patients were divided retrospectively into two groups (spring-assisted ESD, n = 20; conventional ESD, n = 12). To comparatively evaluate the performance speed of ESD, the circumferential length and the area of the resected specimen were calculated by the approximation formula for ellipse. Then, the circumferential cutting speed, the submucosal dissection speed, and the total ESD speed were calculated as index scores. The scores for spring-assisted ESD and conventional ESD were compared.

RESULTS

The mean (+/-SD) circumferential cutting speeds in spring-assisted ESD and conventional ESD were 0.53 +/- 0.27 and 0.60 +/- 0.30 cm/minute, respectively ( P = 0.51). The mean submucosal dissection speeds in spring-assisted ESD and conventional ESD were 0.67 +/- 0.41 and 0.32 +/- 0.24 cm (2)/minute, respectively ( P = 0.005). The mean total ESD speeds in spring-assisted ESD and conventional ESD were 0.25 +/- 0.10 and 0.17 +/- 0.07 cm (2)/minute, respectively ( P = 0.015). The mean total ESD times were 57 and 75 minutes in the spring and conventional group, respectively ( P = 0.30).

CONCLUSION

Using the aforementioned indices, we evaluated the performance speed of ESD. Spring-assisted ESD may allow faster submucosal dissection.

The Role of Simulator Promis2 in Learning Laparoscopic Skill

Introduction: Laparoscopic surgery is unique and complex in nature, so the training is necessarybefore proceeding to operation room. Many computer aided simulators have been developed forthe purpose. Our objective is to assess the improvement of basic laparoscopic skills after training insimulator.Methods: The fi fth year medical students underwent training of three laparoscopic skills usingPromis2 simulator twice weekly for 4-6 weeks. The skills are laparoscopic orientation, target pointingand objects transferring. Time, path length of instruments and economy of movements were recorded.The comparisons were made for these parameters between session fi rst and the last using a Mann-Whitney U test.Results: Ten volunteers completed the exercises in less time (186.3±55.4 seconds) than the fi rstexercise (215.7±57.4 seconds) (P=0.0027). Both the right and left hand instrument path lengths werealso improved from 4425.8±1284.3 mm in the fi rst exercise to 3925.3±1313.6 mm in the last exercisein the left side (P=0.0219) and likewise from 4273.8±1859.4 mm to 3831.3±1717.4 mm in the right side(P=0.0027). Economy of the movement in the left handed instrument improved from 1114.4±453.5mm in the fi rst exercise to 966.8±411.1 mm in the last (P=0.0443) and in the right handed instrumentfrom 845±398.8 mm to 771.4±370.5 mm according to the software of Promis2 simulator (P >0.005).Conclusions: Training in Promis2 simulator improves the basic laparoscopic skills. The candidatesbecome consistently faster with shorter path lengths and had smoother instruments movements.They also became signifi cantly more consistent in their performance.Key Words: laparoscopy, promis2, simulator, training

The role of simulator Promis2 in learning laparoscopic skill

INTRODUCTION

Laparoscopic surgery is unique and complex in nature, so the training is necessary before proceeding to operation room. Many computer aided simulators have been developed for the purpose. Our objective is to assess the improvement of basic laparoscopic skills after training in simulator.

METHODS

The fifth year medical students underwent training of three laparoscopic skills using Promis2 simulator twice weekly for 4-6 weeks. The skills are laparoscopic orientation, target pointing and objects transferring. Time, path length of instruments and economy of movements were recorded. The comparisons were made for these parameters between session first and the last using a Mann-Whitney U test.

RESULTS

Ten volunteers completed the exercises in less time (186.3 +/- 55.4 seconds) than the first exercise (215.7 +/- 57.4 seconds) (P=0.0027). Both the right and left hand instrument path lengths were also improved from 4425.8 +/- 1284.3 mm in the first exercise to 3925.3 +/- 1313.6 mm in the last exercise in the left side (P=0.0219) and likewise from 4273.8 +/- 1859.4 mm to 3831.3 +/- 1717.4 mm in the right side (P=0.0027). Economy of the movement in the left handed instrument improved from 1114.4 +/- 453.5 mm in the first exercise to 966.8 +/- 411.1 mm in the last (P=0.0443) and in the right handed instrument from 845 +/- 398.8 mm to 771.4 +/- 370.5 mm according to the software of Promis2 simulator (P >0.005).

CONCLUSIONS

Training in Promis2 simulator improves the basic laparoscopic skills. The candidates become consistently faster with shorter path lengths and had smoother instruments movements. They also became significantly more consistent in their performance.

MAGE-A protein and MAGE-A10 gene expressions in liver metastasis in patients with stomach cancer

Tumour samples from 71 patients with stomach cancer, 41 patients with liver metastasis (group A) and 15 patients each in stages II–IV (group B) and stage I (group C) without liver metastasis were analysed. MAGE-A protein expression was evaluated by immunohistochemistry using a 6C1 monoclonal antibody and MAGE-A10 mRNA expression was detected by highly sensitive in situ hybridisation using a cRNA probe. Expressions of MAGE-A protein and MAGE-A10 mRNA in group A were detected in 65.9 and 80.5%, respectively. Both protein and gene showed significantly higher expression in group A than those in groups B (6.7, 26.7%) and C (0, 0%) (P=0.0003, P=<0.0001, respectively). MAGE-A10 mRNA expression in liver metastasis was found in eight (88.9%) out of nine patients. The concordant rate between MAGE-A family protein expression and MAGE-A10 mRNA expression in the primary sites was 81.7% (P<0.0001). MAGE-A10 gene expression was associated with reduced survival duration. The results of this study suggest that MAGE-A10 is a possible target in active immunotherapy for advanced stomach cancer.

A case of an inflammatory myofibroblastic tumor in the lung which expressed TPM3-ALK gene fusion

We herein describe a 4-year-old boy who after being treated for pneumonia showed an abnormal shadow at the hilus of the right lung on chest X-rays with continued inflammatory findings in his laboratory data. CT and MR investigations suggested the existence of a neoplasm at that site. An open biopsy was thus performed for a definite diagnosis. The histological findings and the expression of TPM3-ALK fusion gene confirmed a diagnosis of an inflammatory myofibroblastic tumor. A right upper and middle lobectomy including the tumor was thus performed for a complete resection. In addition to the histological diagnosis, the detection of the tumor specific fusion gene provided objective evidence in making a diagnosis.

A non-acromegalic case of multiple endocrine neoplasia type 1 accompanied by a growth hormone-releasing hormone-producing pancreatic tumor

Cases of acromegaly due to GHRHproducing pancreatic endocrine tumors have been reported. Here we present a case of a 31-yr-old nonacromegalic man with hyperparathyroidism and elevated serum IGF-I with normal serum GH levels. Serum GH was not suppressed below 1 ng/ml by the glucose tolerance test and increased in response to TR H and GHRH administration. Magnetic resonance imaging (MRI) revealed pituitary hyperplasia and an abdominal computed tomography (CT ) scan showed a tumor in the pancreatic tail. Plasma concentration of GHRH was elevated. Based on these clinical data, multiple endocrine neoplasia (MEN) type 1 was suspected. Three enlarged parathyroid glands were removed and a distal pancreatectomy was performed. Pathological examination of the parathyroid glands and pancreatic tumor showed nodular hyperplasia and a well-differentiated endocrine tumor, respectively, both compatible with MEN features. Immunohistochemistry revealed positive immunoreactivity for GHRH, SS , insulin, glucagon, chromogranin A, and pancreatic polypeptide in the pancreatic tumor. After pancreatic surgery, elevated levels of GHRH and IGF-I were normalized and pituitary hyperplasia definitely decreased in size. In cases of pituitary hyperplasia with elevated IGF-I, ectopic GHRH syndrome must be considered even if physical features of acromegaly are absent. It is also important to measure plasma GHRH concentrations in order to give a diagnosis.

Haemodynamic changes in the liver under balloon occlusion of a portal vein branch: evaluation with single-level dynamic computed tomography during hepatic arteriography

AIM

To assess haemodynamic changes in the liver under temporary occlusion of an intrahepatic portal vein.

MATERIALS AND METHODS

Between February 2000 and October 2004, 16 patients with hepatobiliary disease underwent single-level dynamic computed tomography during hepatic arteriography (SLD-CTHA) under temporary balloon occlusion of an intrahepatic portal vein. All patients needed percutaneous transhepatic portography for therapy of their disease. SLD-CTHA was undertaken to clarify the time-attenuation curve influenced by portal vein occlusion, and it was performed continuously over a period of 30s. The difference in absolute attenuation of the liver parenchyma in segments with occluded and non-occluded portal vein branches was determined by means of the CT number, and the difference in absolute attenuation of the occluded and non-occluded portal veins themselves was also evaluated.

RESULTS

SLD-CTHA demonstrated a demarcated hyperattenuation area in the corresponding distribution of the occluded portal vein branch. The attenuation of the liver parenchyma supplied by the occluded portal vein was significantly higher than that in the non-occluded area (p<0.01). The balloon-occluded portal branch enhancement in 15 of 16 cases (94%) appears due to arterio-portal communications. Failure to evaluate a remaining case for portal branch enhancement was due to absence of a visualized portal branch in the section.

CONCLUSION

Under temporary occlusion of an intrahepatic portal vein, hepatic angiography produced enhancement of the occluded portal branches and their corresponding parenchymal distribution; this finding is considered consistent with the presence of arterio-portal communications.

Serum p53 antibody as a predictor of early recurrence in patients with postoperative esophageal squamous cell carcinoma

It is reported that surveillance of serum p53 antibody (Ab) is a useful marker in detecting esophageal squamous cell carcinoma (ESCC). But there is little reported about prognostic significance of serum p53-Ab in postoperative patients with ESCC. The aim of this study is to evaluate the significance of preoperative serum p53-Ab as a marker of early recurrence after curative resection for ESCC. Enzyme-linked immunosorvent assay (ELISA) was used to analyze serum p53-Ab before treatment in 44 patients with ESCC. Carcinoembryonic antigen (CEA) and squamous cell carcinoma antigen (SCC-Ag) were examined by immunoradiometric assay. The patients who were strongly positive and positive in serum p53-Ab were more likely to have early recurrence after curative resection than seronegative patients. There were no significant correlations between CEA, SCC-Ag positivity and early recurrence. We found that serum p53-Ab was useful to predict a risk of early recurrence after curative surgical resection for ESCC.

Insights into infant neuroblastomas based on an analysis of neuroblastomas detected by mass screening at 6 months of age in Japan

BACKGROUND/PURPOSE

Mass screening (MS) for neuroblastoma (NB) at 6 months of age in Japan was discontinued in 2004. We have previously reported that the majority of NB detected by MS showed a good prognosis, with only a few cases demonstrating an unfavorable outcome (J Pediatr Surg 2002, Cancer 2001). This study aims to provide insights into infant NB by assessing the details of the clinical courses in patients treated with a standard regimen and the biological features of such cases using highly sensitive methods at one institution in Japan.

METHODS

In 76 NB detected through MS treated at Kyushu University Hospital, the clinical features and MYCN amplification, 1p deletion, 17q gain, the expression level of TRKA using FISH and the quantitative PCR were analyzed.

RESULTS

Of these 76 persons with NB treated at one institution, 97 % are still alive, while 2 cases died from other diseases. Three patients experienced a recurrence after complete remission (CR), and 2 patients demonstrated refractory disease since the initial diagnosis. Two of the 3 NB patients with recurrence have demonstrated a 2nd CR, while one case still has multiple active diseases. Regarding the findings of highly sensitive biological analyses, 5/74 (7 %) showed MYCN amplification, 2/24 (8 %) cases had a 1p deletion, 3/33 (9 %) cases had a 17q gain, 5/50 (10 %) cases had diploidy, 1/25 (4 %) cases had a low expression of TRKA, and 2/76 (3 %) cases had an unfavorable histology. Of the 76 NB, 13 tumors (17 %) had one or more unfavorable factors (UF). Of the 5 refractory NB, 1 case had 3 UF, 1 case had 2 UF, 1 case had 1 UF, and 2 cases had no UF. As a result, 60 % of the refractory NB had one or more UF.

CONCLUSIONS

Of the NB detected by MS at one institution in Japan, 17 % had one or more unfavorable factors (UF) and might have a higher risk of recurrence than the patients with no UF, although the unfavorable biology of several refractory cases is still unclear even after highly sensitive analyses. At least one-fifth of the NB cases detected by MS are anticipated cases. In infantile neuroblastomas, it may therefore be most important to analyze biologically prognostic factors using highly sensitive methods followed by immediate surgical intervention. Since the MS program has been discontinued in Japan, it will be necessary in future to assess the mortality and characteristics of NB detected clinically.

Routine laparoscopic ultrasound can significantly reduce the need for selective intraoperative cholangiography during cholecystectomy

BACKGROUND

The use of intraoperative cholangiography (IOC), routinely rather than selectively, during laparoscopic cholecystectomy (LC) is controversial. Recent findings have shown laparoscopic ultrasound (LUS) to be safe, quick, and effective not only for screening of the bile duct for stones, but also for evaluating the biliary anatomy. This study aimed to evaluate, on the basis of the LC outcome and the cost of LUS and IOC, whether and how much the routine use of LUS would be able to reduce the need for IOC.

METHODS

During LC, LUS was used routinely to screen the bile duct for stones and to evaluate the biliary anatomy, whereas IOC was used selectively only when LUS was unsatisfactory or unsuccessful.

RESULTS

For 193 (96.5%) of 200 patients, LUS was completed successfully, whereas IOC was needed for 7 patients (3.5%). Bile duct stones were identified in 20 patients (10%). For the detection of bile duct stones, LUS yielded 19 true-positive, 175 true-negative, 0 false-positive, and 1 false-negative results. It had a sensitivity of 95%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 99.4%. The postoperative complications included bile leaks from the liver bed in two patients and a retained bile duct stone in one patient. If IOC had been used selectively in a traditional manner on the basis of preoperative risk factors, IOC would have been needed for 77 patients (38.5%). The total cost of LUS plus IOC for the current 200 patients was 26,256 dollars. The total estimated cost of selective IOC, if it had been performed for the 77 patients, would have been 31,416 dollars.

CONCLUSIONS

Routine LUS accurately diagnosed bile duct stones and significantly reduced the need for selective IOC from a potential 38.5% to an actual 3.5% without adversely affecting the outcome of the LC or increasing the overall cost. The routine use of LUS during LC is accurate and cost effective.

Association between the HER2 expression and histological differentiation in Wilms tumor

Human epidermal growth factor receptors (HER) play a critical role in the branching morphogenesis of renal tubules. In the current study, we analyzed the expression of HER2 in Wilms tumor and assessed the role of this gene in the tumorgenesis of Wilms tumor. During the period from 1960 to 2005, 40 patients with Wilms tumor were treated in our department. Twenty-four of those patients (except those with clear cell sarcoma of the kidney and malignant rhabdoid tumor of the kidney) were collected and assessed. The histological component of each Wilms tumor was divided into three categories (epithelial, blastemal, and mesenchymal) and the extent of HER2 protein expression was analyzed immunohistochemically. The normal kidney tissue accompanied with 12 cases of Wilms tumor was also examined. In the normal kidney, HER2 showed a strong immunoreactivity in the cell membranes of the collecting tubules and in the endothelial cells. Of 24 cases, 15 cases showed an epithelial component, while 24 cases had a blastemal component and 21 cases had a mesenchymal component, respectively. Among the 15 specimens with epithelial cell differentiation, eight (53.3%) showed HER2 immunoreactive epithelial cells. HER2 immunoreactive blastemal cells were present in 11 (45.8%) of 24 specimens with blastemal cells. On the other hand, only 3 (14.3%) of 21 specimens containing mesenchymal cells showed HER2 immunoreactivity. These results suggest that the extent of HER2 expression is associated with epithelial differentiation in Wilms tumor. These histological findings may therefore help to explain the development of Wilms tumor from the standpoint of histological differentiation.

MYCN gene amplification is a powerful prognostic factor even in infantile neuroblastoma detected by mass screening

MYCN is the most powerful prognostic factor in cases of older children. However, how MYCN is related to the prognosis of infantile cases is not clear. A mass screening program was carried out by measuring urinary catecholamine metabolites (VMA and HVA) from 6-month-old infants. Of 2084 cases detected by the screening program, MYCN amplification (MNA) was examined by Southern blot analyses in 1533 cases from 1987 to 2000. Of the 1533 cases examined, 1500 (97.8%) showed no MNA, 20 cases (1.3%) showed MNA from three to nine copies, and 13 (0.8%) cases showed more than 10 copies. The 4-year overall survival rates of these three groups (99, 89 and 53%, respectively) were significantly different (P<0.001), indicating that MYCN copy number correlates with the prognosis. Cases with MNA more than 10 copies were more advanced than those without amplification (stage III, IV vs I, II, IVs; P<0.001). Patients with MNA more than 10 copies had significantly higher serum levels of neuron-specific-enolase (NSE) and ferritin than non-amplified patients (P=0.049, P=0.025, respectively). MYCN amplification was strongly correlated with a poor prognosis in infantile neuroblastoma cases. Therefore, for the selection of appropriate treatment, an accurate determination of MNA is indispensable.

Splenic artery embolization before laparoscopic splenectomy in children

BACKGROUND

This study assessed the safety and utility of preoperative splenic artery embolization before laparoscopic splenectomy in children.

METHODS

Five young girls with a mean age of 13.2 years underwent laparoscopic splenectomies at the authors' institution from August 1998 to April 2003. Three of the patients had idiopathic thrombocytopenic purpura, and two had hereditary spherocytosis. Preoperative splenic artery embolization was performed the day before the surgery in all cases. The laparoscopic splenectomy was performed using traditional laparoscopic procedures and standard laparoscopic instruments with the patient in the right semilateral position.

RESULTS

The mean spleen weight was 252.6 g, and the mean length was 11.6 cm. All the patients reported postembolic pain, but not to a level unmanageable by intravascular narcotics. There were no severe complications in the splenic artery embolization. The laparoscopic splenectomies were completed in a mean of 211 min, with a mean estimated blood loss of 9 ml. None of the operations required conversion to traditional open laparotomy, and none of the patients died or experienced operative complications.

CONCLUSION

The authors concluded that splenic artery embolization is safe and useful as an adjuvant procedure performed before elective laparoscopic splenectomy in children.

Differential expression of TCEAL1 in esophageal cancers by custom cDNA microarray analysis

To find new genes involved in esophageal squamous cell carcinogenesis, we constructed custom cDNA arrays and used the arrays to compare gene expression profiles of 12 matched normal and malignant esophageal samples including seven superficial cancer tissues. The arrays represented nearly 4000 genes, including 1728 that were specifically selected based on pilot studies to find genes that were differentially expressed in esophageal cancers. Expression values for all genes were normalized for each sample and were compared in normal versus tumor tissues. There was a marked decrease in the levels of the transcriptional elongation factor A gene in all 12 of the squamous cell cancer samples compared to matched normal samples. Because the transcription elongation factor A gene has not been previously reported to be involved in cancer development, our results suggest that further investigation of its role in esophageal carcinogenesis is warranted.

Diagnostic value of culture, histology and PCR for Helicobacter pylori in the remnant stomach after surgery

BACKGROUND

Diagnosis of Helicobacter pylori infection in the remnant stomach has not been established.

AIMS

To investigate the diagnostic value of culture, histology, PCR and serum IgG against H. pylori (ELISA) with and without eradication therapy in the remnant stomach, compared with the unoperated stomach.

METHODS

Biopsy samples for bacterial culture and histological diagnosis of H. pylori were taken from the stoma and upper corpus of the remnant stomach and gastric juice was used for PCR assay.

RESULTS

Bacterial culture-based diagnosis in the remnant stomach, sensitivity and specificity of culture were 95.1%, 100%; histology 89%, 92.3%; PCR 66%, 89.7%; and ELISA 100%, 50%, respectively, in cases without H. pylori eradication therapy. In assessment of the results of therapy for the remnant stomach, sensitivity and specificity of culture were 100%, 100%; histology 80%, 96.8%; PCR 80%, 91.7%; and ELISA 100%, 0%, respectively.

CONCLUSION

Bacterial culture had the highest diagnostic value in the remnant stomach as well as unoperated stomach. Sensitivity by histology and PCR was lower in the remnant stomach than the unoperated stomach, but specificity values were equal. Serum ELISA assay was not suitable for the remnant stomach.

Sex differences in mucosal response to Helicobacter pylori infection in the stomach and variations in interleukin-8, COX-2 and trefoil factor family 1 gene expression

BACKGROUND

Gastric cancer incidence in men is almost double that in women. We investigated mucosal responses in the stomach against Helicobacter pylori (H. pylori) infections to elucidate the interindividual or sex-related differences, which may in turn be associated with gastric cancer incidence, mucosal changes of stomach as measured by the Sydney System, and interleukin-8, cyclooxygenase-2 and trefoil factor family 1 (TFF1) gene expression.

METHODS

An age-, sex-, H. pylori status- and disease-matched case-control study was performed in 574 H. pylori-positive and 225 H. pylori-negative patients selected from 4125 patients with a diagnosis of benign disease of the stomach. Levels of acute and chronic inflammations, atrophy and intestinal metaplasia scored according to the Sydney System were compared by stomach site and by sex. Two biopsy specimens (antral and corpus gastric mucosa) from patients with benign gastric diseases (142 patients; 72 men, 70 women) were analysed for interleukin-8, cyclooxygenase-2 and TFF1 mRNA expression as measured by real-time PCR.

RESULTS

Inflammation and activity scores in antrum with H. pylori infection were higher in men, but scores declined according to age. Atrophy and intestinal metaplasia scores in corpus with H. pylori infection appeared more severe in men than in women, especially in older patients. In women, atrophy score increased with increasing age, particularly in postmenopausal H. pylori-negative patients. Interleukin-8 mRNA induction was detected in both antrum and corpus mucosa in H. pylori infection, but sex differences were not found. Response of cyclooxygenase-2 mRNA expression against H. pylori infection in the mucosa was higher in men than women. In H. pylori-negative patients, TFF1 mRNA levels in women were significantly higher than in men, and TFF1 mRNA was significantly lower in positive than negative women.

CONCLUSIONS

Sex differences in mucosal responses to H. pylori infection in the stomach may be correlated with sex differences in the incidence of stomach cancer.

Hand-assisted laparoscopic hepatectomy after partial splenic embolization

The case of a patient with hepatocellular carcinoma and thrombocytopenia secondary to liver cirrhosis who underwent successful hand-assisted laparoscopic hepatectomy after partial splenic embolization is described. A 67-year-old man with severe liver cirrhosis was admitted for treatment of hepatocellular carcinoma. His early phase of hepatic angiography showed two hypervascular tumors in segment 6. The patients liver function was poor, with the indocyanine green retention at 15 min of 49.5%, a total serum bilirubin concentration of 2.0 mg/dl, an albumin concentration of 2.8 g/dl, and an hyaluronic acid concentration of 649 ng/ml. The platelet count was 3.0 x 10(4)/microl secondary to hypersplenism. Partial splenic embolization decreased the splenic volume by 50% preoperatively. At 2 months later, the platelet count was 6.0 x 10(4)/microl, and hand-assisted laparoscopic partial hepatectomy was performed uneventfully. The patients postoperative course was unremarkable, and he was discharged on postoperative day 12.

Improved survival outcome for hepatoblastoma based on an optimal chemotherapeutic regimen--a report from the study group for pediatric solid malignant tumors in the Kyushu area

BACKGROUND/PURPOSE

The survival outcome for patients with hepatoblastoma normally depends on the resectability of the tumor. In Japan, the pre and/or postoperative chemotherapy protocol using a combination of cisplatin (CDDP) and tetrahydropyranyl-Adriamycin (THP-ADR) has been the standard treatment since 1991. This study aims to assess exactly what influence the establishment of this chemotherapy protocol has had on both the tumor resectability and the outcome of patients with hepatoblastoma.

METHODS

From 1982 to 1997, 60 patients with hepatoblatoma were treated in the Kyushu area, Japan. Based on the pretreatment extent of disease (PRETEXT), the outcome and tumor resectability were compared between group A (1982 to 1990, n = 27, PRETEXT I:5, II:8, III:6, IV:8) and group B (1991 to 1997, n = 33, PRETEXT I:9, II:9, III:5, IV:10).

RESULTS

The 5-year survival rates (group A and group B) were 33% and 73% for all cases (P <.01), 100% and 89% for PRETEXT I, 38% and 89% for II (P <.05), 17% and 80% for III (P <.01), and 0% and 40% for IV (P <.01), respectively. The 5-year survival rates for patients with metastases were 0% for group A (n = 5) and 57% for group B (n = 7; P <.01). The rates of a complete resection of primary tumor were 48% for group A and 67% for group B. In particular, a significant difference was found regarding the complete resection rate between groups A and B in the patients with PRETEXT III (17% for group A and 80% for group B; P <.01). In the patients with an incomplete tumor resection (14 for group A, 11 for group B), the 5-year survival rates were 0% for group A and 45% for group B (P <.01).

CONCLUSIONS

The optimal chemotherapeutic regimen of CDDP and THP-ADR was thus found to greatly contribute to the improved survival rate of hepatoblastoma patients. Preoperative chemotherapy resulted in an increased resectability of the tumor, whereas postoperative chemotherapy played an important role in the increased cure rate of cases with either an incomplete tumor resection or metastasis. However, refractory cases with PRETEXT IV or metastasis may still require the development of an even more effective treatment modality, including the use of blood stem cell transplantation.

Response to preoperative chemotherapy affects prognosis in esophageal cancer

The effect of preoperative chemotherapy on prognosis is still controversial. We have investigated the relationship between responses to preoperative chemotherapy and prognosis after curative operations in patients with esophageal squamous cell carcinoma. Thirty-nine patients received preoperative chemotherapy with continuous infusion of 500 mg/m2 of 5-fluorouracil (5-FU) and intravenous injection of 20 mg/m2 of leucovorin every 12 hours for 5 days. On the 5th day alone, 70 mg/m2 of cisplatin was also infused. The effect was evaluated approximately 14 days after the end of one course of chemotherapy. The rates of responders and non-responders were 64.1% and 35.9%, respectively. After an interval of 21-28 days, transthoracic esophagectomy was performed. Significant histological effect by chemotherapy was found in responders compared to non-responders (P < 0.05). Responders had a significantly better prognosis than non-responders by Log-rank test (P < 0.01). This suggests that preoperative chemotherapy may contribute to better prognosis when the tumor is sensitive to chemotherapy.

Percutaneous and laparoscopic approaches of radiofrequency ablation treatment for liver cancer

BACKGROUND/PURPOSE

Radiofrequency ablation (RFA) and microwave coagulation therapy (MCT) have been gaining acceptance as a standard method in the management strategy of liver cancer, for reasons of minimally invasive techniques and effective results. We present our experience of RFA and MCT in patients with liver cancer, and analyze retrospectively the advantages and disadvantages of both of the percutaneous and laparoscopic approaches.

METHODS

Thirty-two consecutive patients (23 men and 9 women) with 19 hepatocellular carcinomas (HCC), 12 metastatic liver cancers, and recurrent cholangiocellular carcinoma (CCC), were enrolled in this study. Out of these 32 patients, as a prior laparotomy, 19 underwent hepatectomy, colectomy, gastrectomy or cholecystectomy, and 15 were treated with the laparoscopic approach, 17 treated with the percutaneous approach, and 2 treated with the combined approach of those two. All of these procedures were carried out under general anesthesia with ultrasound guidance. Seven and 30 days after these procedures, an assessment helical computed tomography was done.

RESULTS

No sign of the residual tissues was noted in all patients except only one case.

CONCLUSIONS

The percutaneous approach was thought to be a more practical and less invasive method regardless previous laparotomy. For the laparoscopic approach, tumors located at the hepatic surface or margin were preferable candidates.

Genetic polymorphisms of aldehyde dehydrogenase 2, cytochrome p450 2E1 for liver cancer risk in HCV antibody-positive japanese patients and the variations of CYP2E1 mRNA expression levels in the liver due to its polymorphism

BACKGROUND

Hepatocellular carcinoma (HCC) in persons with liver cirrhosis (LC) arises following hepatitis virus infection. Alcohol may accelerate the risk of development of LC and HCC. Cytochrome p450 2E1 (CYP2E1) oxidizes ethanol to form acetaldehyde and aldehyde dehydrogenase 2 (ALDH2) detoxifies acetaldehyde, which is carcinogenic in humans, and both alcohol-metabolizing enzymes show the genetic polymorphisms in a Japanese population.

METHODS

Using polymorphism analysis, we studied the frequency of ALDH2 functional deletion due to the G to A single-bp mutation in exon 12 and CYP2E1 polymorphism in the transcriptional region, both associated with higher levels of acetaldehyde, in 135 patients with LC and/or HCC, including 99 with HCC, and 135 non-cancer controls. The mRNA expression levels of CYP2E1 in the liver were also examined in 55 surgical specimens.

RESULTS

The allelic frequency of the homozygous ALDH2 2-2 genotype, coding for the enzyme deletion, was significantly higher compared to that of the homozygous or heterozygous ALDH2 1-1 genotypes in cases with HCC (OR = 5.4, 95% CI 2.1-14.0). There were no differences in the frequencies of specific genotypes of CYP2E1 in cases of HCC, but combined analysis of ALDH2 and CYP2E1 revealed that the odds ratio of occurrence of the C1/C1 homozygosity of CYP2E1 and the ALDH2 2-2 homozygosity was as high as 23.0 (2.9-182). The mRNA levels of CYP2E1 were higher in the liver of patients with the C1/C1 homozygosity of CYP2E1 than in those with other genotypes (P < 0.05).

CONCLUSIONS

ALDH2 and CYP2E1 polymorphisms may modify the risk of development of HCC against the background of LC in the Japanese. Polymorphism analysis of alcohol-metabolizing enzymes using molecular techniques may be useful in the risk assessment of liver cancer in patients with hepatitis C virus infection.

Endoscopic mucosal resection scissors for the treatment of early gastric cancer

Endoscopic mucosal resection (EMR) is currently a common treatment for superficial gastrointestinal tumors. We have developed new EMR scissors for superficial lesions in the esophagus and stomach. These scissors have stainless steel blades with an electrocoagulation device for hemostasis. We report a case in which superficial gastric cancer was treated by means of the EMR scissors. The lesion was removed using the scissors and no major complication was encountered. EMR scissors can be used for endoscopic resection of superficial lesions of the esophagus and stomach.

Effectiveness of preoperative chemotherapy using carboplatin (CBDCA) and surgery against an esophageal small cell carcinoma

A 63-year-old man presented to our hospital with persistent dysphagia. Radiologic and endoscopic examination disclosed a 2.0-cm exophytic tumor in the middle third of the esophagus. An endscopically obtained biopsy specimen was found to represent undifferentiated small cell carcinoma. Computed tomography of the chest, abdomen, and cervical region was performed, as were gallium and bone scintigraphy. Metastasis to an adjacent lymph node was detected, without metastasis to distant organs. After neoadjuvant chemotherapy with carboplatin (CBDCA) (400 mg/m2) and etoposide (VP-16) (100 mg/m2), endoscopy and barium-swallow esophagography showed regression. Thoracic esophagectomy then was performed with mediastinal, abdominal and cervical lymph node dissection. The resected tumor was polypoid, measuring 0.5 x 0.5 cm. The lesion consisted mainly of small anaplastic cells, but included a small focus of squamous cell carcinoma. The patient has survived for more than 7 months with no further treatment and no evidence of recurrent disease.

Genetic differences in interleukin-1 betapolymorphisms among four Asian populations: an analysis of the Asian paradox between H. pylori infection and gastric cancer incidence

The prevalence of Helicobacter pylori infection is high among Asian populations, but the incidences of gastric cancer differ greatly among northern and southern Asian populations. Here, we studied histopathological findings in stomach tissue using an updated Sydney System and the frequencies of interleukin (IL)-1betapolymorphisms, thought to be associated with an increased risk of gastric cancer, in four Asian populations. Endoscopic-guided biopsies from three regions of the stomach and the -511 T-to-C polymorphism in the IL-1betagene were examined in 228 Japanese, 116 Chinese, 159 Thai and 83 Vietnamese patients with gastric diseases. H. pylori colonization, inflammation and activity were more severe in the Japanese and Thai populations than in the Chinese and Vietnamese populations and these scores were more antrum-predominant in the Thai and Vietnamese populations than in the Japanese and Chinese populations, with the most severe degree of atrophy and intestinal metaplasia occurring in the angulus region of the Japanese population. The IL-1betapolymorphisms did not differ among the four populations overall, but in cases with severe mucosal atrophy (pepsinogen I/II ratio <3.0), the CC polymorphism was dominant in the Japanese population and the TT+TC polymorphism was dominant in the Chinese population; no difference in C and T allele frequencies was found in the Thai and Vietnamese populations. In conclusion, the incidence of gastric cancer is extremely low, but the prevalence of H. pylori infection is high in the Thai population (Asian paradox). In the Thai population, the scores for corpus gastritis and intestinal metaplasia, which are associated with a high risk of gastric cancer, were low in comparison with the Japanese population. IL-1betapolymorphisms were correlated with mucosal atrophy in the Japanese and Chinese populations, but not in the Thai and Vietnamese populations.

Malignant germ cell tumors: clinical characteristics, treatment, and outcome. A report from the study group for Pediatric Solid Malignant Tumors in the Kyushu Area, Japan

PURPOSE

This study aims to assess the prognostic factors and optimal treatments for malignant germ cell tumors (MGCT) in childhood.

METHODS

Among 117 MGCT, the clinical features were analyzed. Regarding the histology, there were 89 embryonal carcinomas, 13 dysgerminomas, 4 choriocarcinomas, and 11 others. The prognostic factors and treatments were assessed based on the 5-year survival rate.

RESULTS

(1) Stage: 100% for stage I (n = 54), 75.0% for stage II (n = 4), 67.3% for stage III (n = 14), and 54.8% for stage IV (n = 33); Unknown: n = 12. (2) Primary site: 93.4% for the testis (n = 52), 86.7% for the ovary (n = 31), 56.9% for the sacrococcygeal (n = 21), and 60.6% for others (n = 12); unknown: n = 1. (3) Surgical intervention for primary tumor: 100% for stage I with a complete resection (n = 53), 78.4% for stage III, IV with a complete resection (n = 26), and 33.3% for stage III, IV with an incomplete resection (n = 21). (4) Type of chemotherapy for the stage III and IV: 83.9% for the PVB (cisplatin, vinblastin, bleomycin; n = 13), 66.7% for the VAC (vincristine, actinomycin D, cyclophosphamide; n = 6), and 47.1% for other regimens (n = 25).

CONCLUSIONS

An early stage, a diagnosis under 1 year of age and a primary site in the gonads were favorable prognosis factors, whereas histologic findings of choriocarcinoma and liver or lung metastasis were unfavorable. Radical complete resection alone is a sufficient treatment for localized MGCT. The PVB regimen is optimal chemotherapy for advanced MGCT; however, high-risk cases still may require more aggressive treatment.

Combined endoscopic and radiologic intervention to treat esophageal varices

BACKGROUND/AIMS

In patients with esophageal varices, we investigated the impact on long-term outcome of combining interventional radiologic procedures with endoscopic therapy.

METHODOLOGY

Of 133 patients with esophageal varices, 86 were treated with endoscopic therapy alone and 47 underwent endoscopic therapy in addition to interventional radiologic procedures. End-points considered during 5-years of follow-up included recurrent bleeding and retreatment.

RESULTS

Bleeding rates were 24.4% in the endoscopy group and 25.4% in the combined therapy group. Retreatment rates at 1, 3, and 5 years for the endoscopy group versus the combined therapy group were 40.7% versus 30.3%, 72.0% versus 67.5%, and 88.2% versus 80.5%, respectively, representing no significant difference between two groups. However, cumulative retreatment rates in Child's class C cases were significantly lower in the combined therapy group than in the endoscopy group (P = 0.025). Patients who had combined therapy which included all embolizing techniques showed significantly lower retreatment rates than patients treated with endoscopy alone (P = 0.05).

CONCLUSIONS

In combination, interventional radiologic and endoscopic therapies are highly effective and can improve long-term outcome in patients with esophageal varices, especially those with poor liver function and those who undergo embolization by all techniques.

Liver cell adenoma in a 26-year-old man

This is a report of a case of liver cell adenoma (LCA) in a 26-year-old man with no prior history of liver disease or glycogen storage disease and no record of hormonal therapy. He was found to have an asymptomatic hepatic mass during a routine medical examination. The physical findings were unremarkable, and the results of routine laboratory studies were all within normal limits. Selective hepatic arteriography showed a hypervascular mass within the right lobe of the liver. Despite the radiological examination, the nature of the mass was unknown, and preoperative biopsy was unadvisable because of the risk of bleeding. Because of the difficulty of determining the malignancy of the hepatic tumor preoperatively, elective laparotomy for diagnosis and hepatectomy as treatment appeared to be the best available approach. Pathological examination of the surgical specimen resulted in a diagnosis of LCA. A review of the literature revealed that LCA unassociated with the use of oral contraceptives is rare.

An 8-cM interstitial deletion on 4q21-q22 in DNA from an infant with hepatoblastoma overlaps with a commonly deleted region in adult liver cancers

We performed molecular analysis of a germline interstitial deletion of chromosome 4 [del(4)(q21.22q23)], which had been observed in a male infant manifesting early-onset hepatoblastoma (HBL). The chromosomal anomaly in this child was associated with a unique congenital syndrome including HBL, atrial septal defect, ventricular septal defect, patent ductus arteriosus, mental retardation, and seizures. However, the patient did not exhibit a megalencephaly typical of 4q21-22 deletions. His HBL was associated with an increasing serum alpha-fetoprotein level and rapid growth. To define the chromosomal deletion at the molecular level in this child, we analyzed his lymphoblasts with fluorescence in situ hybridization, using as probes a panel of BAC/PAC genomic clones containing STS markers covering the 4q12-27 region. The analysis revealed that the affected chromosome had an 8-cM deletion within 4q21-q22, flanked by markers D4S2964 and D4S2966. This microdeletion overlaps with the commonly deleted region at 4q21-q22 that was recently defined in adult hepatocellular carcinomas.

Celiac artery aneurysm: a case evaluated preoperatively with three-dimensional computed tomographic angiography

In a 63-year-old woman computed tomography (CT) incidentally detected a celiac artery aneurysm approximately 3 cm in diameter. While conventional angiography suggested that the splenic artery and common hepatic artery arose from the celiac artery aneurysm, three-dimensional CT angiography indicated that the aneurysm involved only the mid portion of the celiac artery. Considering the risk of eventual aneurysm rupture, surgery was performed. Aneurysmectomy and devascularization of hepatic, splenic, and celiac arteries were carried out following complete cross-clamping of the celiac artery. The distal segment of the celiac artery was directly anastomosed to the proximal segment in an end-to-end fashion. Histologically, the aneurysm wall showed atheromatous changes. Contrast-enhanced abdominal CT confirmed complete removal of the celiac artery aneurysm, and postoperative angiography confirmed good arterial flow. The patient recovered uneventfully after surgery, with normalization of transiently abnormal hepatic function parameters. In this case of celiac artery aneurysm, three-dimensional CT angiography was found to be valuable in determining the relationships of the aneurysms to important arterial branches.

Clinical and biologic characteristics for recurring neuroblastoma at mass screening cases in Japan

BACKGROUND

It is said that most cases detected by neuroblastoma mass screening at 6 months of age tend to have a favorable clinical course after a surgical resection either with or without mild chemotherapy. However, a few cases have an unfavorable outcome. In the current study, the authors analyzed the clinical and biologic characteristics for recurring neuroblastoma in mass screening cases.

METHODS

In 245 cases detected through mass screening in the Kyushu area in Japan, the clinical data and biologic features (N-myc status, DNA ploidy, Shimada histology, neuron-specific enolase (NSE), ferritin) were investigated, whereas, in particular, the data for recurring cases also were analyzed.

RESULTS

Of 245 cases, 28 tumors had one or more biologically unfavorable prognostic factors, and 6 patients experienced recurrence. Three of the six patients with recurring disease underwent a complete resection of the primary tumor, whereas three cases had undergone an incomplete resection of the tumor. Regarding the initial chemotherapy, three cases received mild chemotherapy, two cases received no chemotherapy, and one case had high-dose multidrug chemotherapy. Regarding biologic prognostic factors, four of six cases with recurring disease had one or more unfavorable factors, whereas two cases had no unfavorable factors. Regarding the outcome after recurrence, four cases are CR, one case has a stable residual tumor, and one case died of disease with N-myc amplification.

CONCLUSIONS

Most neuroblastomas detected by mass screening at 6 months of age have biologically favorable factors. However, approximately 10% of the cases had one or more unfavorable factors and thus might have a higher risk of recurrence than the patients with no unfavorable factors. Conversely, some cases with recurring disease had no unfavorable factors; however, the reason for this is still unclear. A long-term follow-up for mass screening cases is important, and it also might be necessary to research the established biologic factors and identify other new prognostic factors.

Hypersplenism induced by hepatectomy

BACKGROUND/AIMS

We encountered a case of posthepatectomy splenic enlargement and hypersplenism followed by disseminated intravascular coagulopathy with airway hemorrhage causing death.

METHODOLOGY

We, therefore, retrospectively investigated postoperative splenic enlargement, hypersplenism and disseminated intravascular coagulopathy by computed tomography and laboratory data in 57 hepatectomized patients with a malignant or benign disease in the postoperative period.

RESULTS

Of 32 patients with hepatocellular carcinoma or biliary tract carcinoma (group A), 12 with metastatic hepatic lesions (group B), and 13 with benign liver disease (group C); remarkable (20%) splenic enlargement was noted in 8 patients in group A, 2 in group B, and 2 in group C. Seven of the 12 patients were associated with liver cirrhosis, 5 with preoperative splenomegaly, and 8 had undergone major hepatectomy. Postoperative hypersplenism developed in 5 patients in group A, and one patient in group C. All of them were associated with liver cirrhosis or chronic hepatitis and preoperative splenomegaly, and five had undergone hepatic lobectomy or more extensive resections. All except for the disseminated intravascular coagulopathy case recovered. Statistically, splenic enlargement was significantly related to the extent of hepatectomy; lobectomy versus segmentectomy = 28.3 +/- 28.5% (n = 14) versus 12.4 +/- 13.8% (n = 20), (unpaired Student's t test, P = 0.037). Platelet counts of the patients with liver cirrhosis or chronic hepatitis is lower than those without the diseases, both pre- and postoperatively (14.0 +/- 6.0 x 10(4)/mm3 vs. 21.5 +/- 6.2 x 10(4)/mm3, P = 0.0001).

CONCLUSIONS

Postoperative hypersplenism was noted only in the patients with liver cirrhosis or chronic hepatitis and preoperative splenomegaly, and developed more frequently after larger hepatectomies than after smaller hepatectomies; 5 (45%) of 11 versus 1 (7%) of 14, chi 2 test, P = 0.026).

Reconstruction of the portal vein using a peritoneal patch-graft

BACKGROUND

Reconstruction of the portal vein with autologous veins requires extra incisions. Prosthetic material is associated with an increased risk of infection. We therefore created an animal model of portal vein reconstruction using the peritoneum.

METHODS

A 2.5 x 2.5 cm piece of the peritoneum was resected from Landrace pigs weighing 30 to 40 kg and was dipped in 100% alcohol for 10 minutes. The anterior wall of the portal vein measuring 1.2 x 0.6 cm was resected. The peritoneal patch-graft fitting the defect of the portal vein was used to repair it.

RESULTS

All 7 pigs survived the surgery, and were killed at 2, 7, 7, 14, 21, 35 and 49 days, respectively, after surgery. There was no evidence of thrombosis or obstruction of the reconstructed portal vein or any other complications. Complete endothelialization of the patches were noted at day 14.

CONCLUSIONS

Our patch-graft technique using the peritoneum is considered to be a good and safe alternative for reconstruction after partial resection of the portal vein in clinical surgery.

Acute cholecystitis caused by a cholesterol polyp

A 39-year-old man hospitalized with upper abdominal pain had been found to have a 3mm polyp in the body of the gallbladder 3 years previously. Laboratory tests on admission showed mild liver dysfunction. Ultrasonography depicted a dilated gallbladder with increased wall thickness; the polyp could no longer be seen. Computed tomography with drip infusion cholangiography again showed a dilated gallbladder, and also stenosis of the distal cystic duct. The resected specimen obtained by laparoscopic cholecystectomy showed disappearance of the polyp from the body of the gallbladder. A cholesterol stone was incarcerated in the cystic duct, representing an impacted detached cholesterol polyp causing acute cholecystitis. Spontaneous detachment of a cholesterol polyp from the gallbladder mucosa, then, can result in acute cholecystitis.