Utility of autologous fecal microbiota transplantation and elucidation of microbiota in diversion colitis

Objectives

Diversion colitis (DC) is an inflammatory disorder caused by interruption of the fecal stream and subsequent nutrient deficiency from luminal bacteria. The utility of fecal microbiota transplantation (FMT) for DC was recently investigated; however, the precise pathogenesis of this condition remains unclear. This study aimed to evaluate the utility of autologous FMT in DC and to determine the related changes in the intestinal microbiota.

Methods

Autologous FMT was performed to reestablish the intestinal microbiota in five patients (average age, 64.6 ± 8.3 years) with DC. They underwent double‐ended colostomy. We assessed the diverted colon by endoscopy and evaluated the microbiota before and after FMT using the 16S rRNA gene sequencing method.

Results

All five patients had mild inflammation (ulcerative colitis endoscopic index of severity [UCEIS] 2–3) in the diverted colon based on the colonoscopic findings. Three patients presented with symptoms, such as tenesmus, mucoid stool, and bloody stool. With FMT treatment, all patients achieved endoscopic remission (UCEIS score of 0 or 1) and symptomatic improvement. We observed a significantly decreased α‐diversity in DC patients compared to healthy controls. The frequency of aerobic bacteria, such as Enterobacteriaceae, in the diverted colon decreased after autologous FMT.

Conclusions

This study was the first to show that the microbiota in the diverted colon was significantly affected by autologous FMT. Since interruption of the fecal stream is central to the development of DC, FMT can be considered a promising treatment.

Rapid progression of colonic mucinous adenocarcinoma with immunosuppressive condition: A case report and review of literature

BACKGROUND

Colorectal mucinous adenocarcinoma is a rare subtype of colorectal cancer and is characterized by an abundance of mucin in the tumor. In addition, the colorectal mucinous adenocarcinoma often demonstrates poor differentiation in the histology of tumor cells and poor prognosis compared with those with adenocarcinoma. Here, we present the case of a young woman with colonic mucinous adenocarcinoma showing significantly rapid progression within four months of immunosuppressant therapy for Henoch–Schönlein purpura.

CASE SUMMARY

Here we report a rare case of ascending colon mucinous adenocarcinoma with lymph node and liver metastases which developed and progressed rapidly within four months during the treatment of Henoch–Schönlein purpura using corticosteroids. The systemic screening examinations showed no tumors before the immunosuppressant therapy. Fortunately, the patient was successfully treated with chemotherapy.

CONCLUSION

While no direct evidence that the immunosuppressants accelerated the tumor development, the case presenta tion and review of the literature demonstrated that surveillance for malignancies before and during treatment with immunosuppressive agents is essential.

Effect of Lenvatinib on a Hepatocellular Carcinoma with Fibroblast Growth Factor Receptor 4 Expression: A Case Report and Review of the Literature

Basic and clinical research have shown that the expression of molecules involved in the hepatocellular carcinoma (HCC) cell signaling pathway is related to the sensitivity to molecular-targeted agents. We herein report a case of HCC that was effectively treated with lenvatinib after a poor response to sorafenib. The tumor showed a high expression of fibroblast growth factor receptor 4, which is reportedly related to the sensitivity to lenvatinib in vitro. The information obtained from this case and from our literature review highlights the importance of assessing the expression of the molecules involved in tumors for effective precision medicine.

A case of Helicobacter pylori -negative early gastric adenocarcinoma with gastrointestinal phenotype

A 40-year-old man with slightly depressed (0-IIc) type gastric cancer of the pyloric anterior gastric area underwent pre-operative screening for tetralogy of Fallot and endoscopic submucosal dissection (ESD) and was tested for Helicobacter pylori antigens and antibodies. Both tests were negative. He did not have a history of eradication. Pathological diagnosis of ESD showed a well-differentiated adenocarcinoma. The tumor was CD10-positive, MUC5AC-negative, and MUC6-confocal positive; it showed differentiation with gastrointestinal phenotype. Moreover, the tumor cells were lysozyme-positive, resembling Paneth cells. Mucosal glands exhibited intestinal metaplasia on the anal side of the tumor lesion. On the oral side of the tumor, metaplasia was non-existent, with normal pyloric glands present in the mucosal layer. The patient was not infected with H. pylori ; however, intestinal metaplasia existed around the early gastric cancer. This suggested that the intestinal metaplasia occurred due to bile reflux, and the gastric neoplasia arose with the metaplasia without an H. pylori infection. This case may potentially help explain gastric cancer development in the absence of H. pylori infection.

Comparison of Oral and Esophageal Microbiota in Patients with Achalasia Before and After Peroral Endoscopic Myotomy

BACKGROUND/AIMS

Patients with achalasia have a high incidence of esophageal squamous cell carcinoma (ESCC), which may be associated with alterations in oral and esophageal microbiota caused by food stasis. This study compared the oral and esophageal microbiota of patients with achalasia before and after peroral endoscopic myotomy (POEM). It also compared patients with achalasia to those with ESCC.

MATERIALS AND METHODS

The study prospectively examined 6 patients with achalasia and 14 with superficial ESCC. Oral samples obtained from the buccal mucosa using a swab and esophageal samples obtained from the mid-esophagus using a brush via endoscopy were analyzed by 16S rRNA metagenome sequencing. Additionally, endoscopic and histological findings of patients with achalasia before and after POEM were prospectively compared.

RESULTS

In patients with achalasia, Streptococcus was most abundant in both the oral and the esophageal microbiota, and these microbiota were significantly different. Although the overall structure of the oral and esophageal microbiota did not change after POEM, the relative abundance rate of Haemophilus and Neisseria increased in the esophagus, and endoscopic findings of inflammation improved after POEM (P = .04). The relative abundance of microbiota was not different among patients with achalasia from those with ESCC.

CONCLUSIONS

The oral and esophageal microbiota were significantly different in patients with achalasia, and some of the composition of the esophageal microbiota changed after POEM. However, these findings and disease-specific microbiota should be further evaluated in large-scale studies.

Evaluation of intestinal microbiota, short-chain fatty acids, and immunoglobulin a in diversion colitis

It is reported that an increase in aerobic bacteria, a lack of short-chain fatty acids (SCFAs), and immune disorders in the diverted colon are major causes of diversion colitis. However, the precise pathogenesis of this condition remains unclear. The aim of the present study was to examine the microbiota, intestinal SCFAs, and immunoglobulin A (IgA) in the diverted colon. Eight patients underwent operative procedures for colostomies. We assessed the diverted colon using endoscopy and obtained intestinal samples from the diverted colon and oral colon in these patients. We analyzed the microbiota and SCFAs of the intestinal samples. The bacterial communities were investigated using a 16S rRNA gene sequencing method. The microbiota demonstrated a change in the proportion of some species, especially Lactobacillus, which significantly decreased in the diverted colon at the genus level. We also showed that intestinal SCFA values were significantly decreased in the diverted colon. Furthermore, intestinal IgA levels were significantly increased in the diverted colon. This study was the first to show that intestinal SCFAs were significantly decreased and intestinal IgA was significantly increased in the diverted colon. Our data suggest that SCFAs affect the microbiota and may play an immunological role in diversion colitis.

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Anaerobic bacteria like Lactobacillus significantly decreased in the diverted colon.

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Fecal short-chain fatty acids significantly decreased in the diverted colon.

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Acetic acid also decreased significantly in the diverted colon.

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Fecal immunoglobulin A levels were significantly increased in the diverted colon.

Usefulness of ultrasonography to assess the response to steroidal therapy for the rare case of type 2b immunoglobulin G4-related sclerosing cholangitis without pancreatitis: A case report

BACKGROUND

A type 2b immunoglobulin G4 (IgG4)-related sclerosing cholangitis (SC) without autoimmune pancreatitis is a rare condition with IgG4-SC. While the variety of the imaging modalities have tested its usefulness in diagnosing the IgG4-SC, however, the usage of ultrasonography for the assessment of the response to steroidal therapy on the changes of bile duct wall thickness have not been reported in the condition. Therefore, the information of our recent case and reported cases have been summarized.

CASE SUMMARY

We report the case of an 82-year-old Japanese man diagnosed with isolated IgG4-related SC based on the increase of serum IgG4, narrowing of the bile duct, its wall thickness, no complication of autoimmune pancreatitis, and IgG4 positive inflammatory cell infiltration to the wall with the fibrotic changes. The cholangiogram revealed type 2b according to the classification. Corticosteroid treatment showed a favorable effect, with the smooth decrease in serum IgG4 and the improvement of the bile duct wall thickness.

CONCLUSION

As isolated type 2b, IgG4-SC is rare, the images, histological findings, and clinical course of our case will be helpful for physicians to diagnose and treat the new cases appropriately.

Esophageal Ulcers Associated with Ulcerative Colitis: A Case Series and Literature Review

Ulcerative colitis, a chronic and recurrent inflammatory disease, is localized to the colonic mucosa but can affect other organs and lead to various complications. Gastroduodenitis associated with ulcerative colitis has been reported. However, little is known about esophageal ulcers. We herein report two rare cases of esophageal ulcers associated with ulcerative colitis. Furthermore, the clinical and histological characteristics of 18 previously reported cases are summarized. This case series and literature review will encourage the accurate diagnosis and treatment of esophageal ulcers associated with ulcerative colitis.

Cytapheresis for pyoderma gangrenosum associated with inflammatory bowel disease: A review of current status

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis clinically characterized by the presence of painful skin ulcerations with erythematous. As it is frequently associated with inflammatory bowel diseases, including ulcerative colitis, gastroenterologists should be familiar with the disease including therapeutic options. Therefore, we have conducted a review focusing on the cytapheresis for PG in cases of inflammatory bowel diseases. A literature search was conducted to extract studies published in the last 20 years, with information on demographics, clinical symptoms, treatment, and the clinical course from a total of 22 cases reported and our recent case. In most patients, cytapheresis was associated with improvement or resolution of PG after failure of conventional therapeutic options such as corticosteroids, antibiotics, immunosuppressive agents and immunoglobulin. Based on the information summarized, cytapheresis is helpful in the majority of patients with PG refractory to medical treatment associated with inflammatory bowel diseases and could be further studied in a multicenter, randomized trial.

Change in body composition in patients with achalasia before and after peroral endoscopic myotomy

BACKGROUND AND AIM

Patients with achalasia experience weight loss because of dysphagia caused by impaired relaxation of the lower esophageal sphincter. This study aimed to use dual bioelectrical impedance analysis (BIA) to determine the change in bodyweight and body composition in patients with achalasia before and after peroral endoscopic myotomy (POEM).

METHODS

Patients with achalasia who underwent POEM from 2013 to 2018 (n = 72) were retrospectively analyzed for change in bodyweight before and after 3 months. Additionally, change in body composition was prospectively investigated in the final 10 of 72 patients using non-radiation dual BIA.

RESULTS

Twenty patients (27.8%) were underweight (body mass index < 18.5) before undergoing POEM. No clinical parameters were identified to be associated with the underweight condition before POEM and be predictive of an increase in bodyweight after POEM. Low visceral fat volume observed on dual BIA correlated closely with the result obtained using computed tomography (Pearson correlation coefficient: r = 0.850, P < 0.01). Patients with achalasia had a statistically significant increase in visceral (P < 0.01) and subcutaneous fat volumes (P < 0.01) after POEM. Skeletal muscle mass index slightly increased (P = 0.02), although the value after POEM was still low. No blood biomarkers were indicators for low bodyweight or low visceral fat volume.

CONCLUSIONS

Dual BIA is an effective non-invasive tool to evaluate the change in body composition of underweight patients with achalasia. Skeletal muscle volume was not enough after POEM, although a rapid increase in the intra-abdominal fat volume was observed. Additional studies are warranted to understand the pathological implications.

Variation in small bowel transit time on capsule endoscopy

Background

Small bowel motility remains inadequately understood because of the complex and various functions as well as its anatomical position. The aimed of the study was to investigate the small bowel transit time (SBTT) of capsule endoscopy (CE) and to analyze the clinical factors affecting SBTT.

Methods

SBTT was analyzed in patients who underwent small bowel CE. Factors contributing to SBTT and CE retention were investigated.

Results

Among 397 patients enrolled in this study, 336 (84.6%) completed CE. The mean SBTT (± standard deviation) was 282.1±132.2 min. According to the univariate and multivariate analyses, aging and small bowel stenosis extended SBTT. In 38 patients who underwent multiple CE studies, considerable variation in SBTT were observed [mean of standard deviations (SDs) =97.97 min, SD of the SDs =81.99 min]. CE retention was observed in 61 patients (13.3%), and it was statistically associated to small bowel lesion.

Conclusions

Aging and small bowel stenosis were associated with longer SBTT. Furthermore, SBTT analyzed by CE should be interpreted carefully considering the intra-individual differences in SBTT.

Methotrexate-related lymphoproliferative disorders in the liver: Case presentation and mini-review

BACKGROUND

Immunosuppression is effective in treating a number of diseases, but adverse effects such as bone marrow suppression, infection, and oncogenesis are of concern. Methotrexate is a key immunosuppressant used to treat rheumatoid arthritis. Although it is effective for many patients, various side effects have been reported, one of the most serious being methotrexate-related lymphoproliferative disorder. While this may occur in various organs, liver involvement is rare. Information on these liver lesions, including clinical characteristics, course, and imaging studies, has not been summarized to date.

CASE SUMMARY

We present a case of 70-year-old woman presented with a 2-wk history of fever and abdominal pain. She had had rheumatoid arthritis for 5 years and was being treated with medication including methotrexate. Contrast-enhanced computed tomography revealed multiple low density tumors in the liver and the histological analyses showed significant proliferation of lymphocytes in masses that were positive on immunohistochemical staining for CD3, CD4, CD8, and CD79a but negative for CD20 and CD56. Staining for Epstein-Barr virus-encoded RNA was negative. And based on these findings, the liver tumors were diagnosed as Methotrexate-related lymphoproliferative disorders. A time-dependent disappearance of the liver tumors after stopping methotrexate supported the diagnoses.

CONCLUSION

The information obtained from our case and a review of 9 additional cases reported thus far assist physicians who may face the challenge of diagnosing and managing this disorder.

Overlap in disease concept of functional esophageal disorders and minor esophageal motility disorders

BACKGROUND AND AIM

Functional gastrointestinal disorders are the most common disorders in gastroenterology and are currently considered as gut-brain interaction disorders with multiple related factors including motility disturbance. However, high-resolution manometry (HRM) had revealed a new disease concept known as minor esophageal motility disorders. This study aimed to investigate the correlation between functional esophageal disorders (FEDs) and minor esophageal motility disorders.

METHODS

Functional esophageal disorders were diagnosed using upper endoscopy, pH monitoring, and HRM, to exclude achalasia, esophago-gastric junction outflow obstruction, and other major esophageal motility disorders. FEDs with or without minor esophageal motility disorders were compared using the Chicago classification.

RESULTS

Twelve healthy volunteers also subjected to HRM showed no minor esophageal motility disorders. Of the 40 patients with FEDs, 15 (37.5%) were diagnosed with minor esophageal motility disorders. Characteristics were not different between patients with and without minor esophageal motility disorders (sex: P = 0.609, age: P = 0.054, body mass index: P = 0.137, and presence of psychiatric disorders: P = 0.404). The type and location of symptoms were not related to the comorbidity rate of minor esophageal motility disorders (P = 0.744 and 0.094). No patients with FEDs developed major esophageal motility disorders.

CONCLUSIONS

Minor esophageal motility disorders were frequently observed in FEDs, but the causal relationship between esophageal symptoms remains unclear. The disease concepts of FEDs and minor esophageal motility disorders are considered to overlap and are both independent of major esophageal motility disorders.

Epidemiological analysis of achalasia in Japan using a large-scale claims database

BACKGROUND

Achalasia is a well-known esophageal motility disorder, but epidemiological studies in Japan are lacking. We investigated the incidence and period prevalence of achalasia in Japan, including the rate of coexistence of esophageal carcinoma, and evaluated treatment trends.

METHODS

To estimate the nationwide number of patients with achalasia, a large-scale insurance claims database from 2005 to 2017 were used for our analyses. Patients with achalasia and coexistence of esophageal carcinoma were identified based on the diagnosis code registered. Interventional treatment was also evaluated.

RESULTS

Of the total 5,493,650 populations, 385 were diagnosed with primary achalasia. The incidence was calculated as 0.81-1.37 per 100,000 person-years (male-to-female ratio was almost 1; mean age at diagnosis was 43.3 ± 14.4 years). The period prevalence was 7.0 per 100,000 persons. There were statistically significant trends of increase in the incidence and period prevalence over age groups (all p values < 0.0001). Four men with achalasia developed esophageal carcinoma, and the incidence of esophageal carcinoma with achalasia was estimated as 0.25 per 100 person-years. With regard to intervention, esophageal dilation was performed as a first treatment in 64.7% of patients, with repeat intervention required in 56.9% of these. The proportion of patients treated using peroral endoscopic myotomy (POEM) increased annually to 41.1% in 2017.

CONCLUSIONS

In Japan, the incidence and period prevalence of achalasia is comparable to that in other countries. The absolute risk of esophageal carcinoma is rather low. Esophageal dilation has been the mainstay of achalasia treatment, and the role of POEM has increased annually.

Treatment of bilateral renal cell cancer and multiple lung metastasis: nephron-sparing surgery and resection of lung tumors after interleukin-2 therapy

We report a case of bilateral renal cell cancer and multiple lung metastasis who was first treated with left radical nephrectomy and nephron-sparing surgery of the right kidney. Consecutive interleukin-2 administration achieved partial response in lung disease and residual tumors were surgically removed. The disease-free state has continued for 33 months.

Interaction between inflammatory cells and heparin-surface-modified intraocular lens

PURPOSE

To investigate the interaction and adherence of inflammatory cells to a heparin-surface-modified intraocular lens (HSM IOL).

SETTING

Department of Ophthalmology, Tokyo Medical University Hospital, Tokyo, Japan.

METHODS

Splenic mononuclear leukocytes from rats with experimental autoimmune uveitis were cultured with the optic of an HSM IOL for 96 hours. The number of adherent cells on the HSM IOL surface was measured with and without the addition of interphotoreceptor retinoid-binding protein and concanavalin A (ConA) to the culture medium. The adherent cells were observed under a light microscope or a scanning electron microscope.

RESULTS

Interphotoreceptor retinoid-binding protein and ConA increased the number of adherent cells on the HSM IOL relative to the control. Adherent cells on the HSM IOL were small and round, considered to be mainly lymphocytes.

CONCLUSION

Activated lymphocytes tended to adhere to the surface of the HSM IOL.

Pharmacological and molecular biological evidence for ETA endothelin receptor subtype mediating mechanical responses in the detrusor smooth muscle of the human urinary bladder

The aim of this study was to characterize endothelin receptor subtypes of the detrusor muscle of the human urinary bladder. The receptor subtypes mediating endothelin (ET)-1-induced activity in the human detrusor smooth muscles have been characterized using isometric contraction and reverse transcription-polymerase chain reaction (RT-PCR). ET-1 (a non-selective ET receptor agonist; 10(-10) M to 10(-6) M) exhibited concentration-dependent contractions in human urinary bladder with a plateau at concentrations above 3x10(-7) M. Neither IRL1620 nor sarafotoxin S6c (both ETB-selective agonists; 10(-10) M to 10(-6) M) elicited contractile activity in the human urinary bladder detrusor smooth muscle. FR139317 (an ETA-selective antagonist; 10(-7) M to 10(-5) M) produced a marked shift to the right of the ET-1 concentration-response curve in human urinary bladder detrusor smooth muscle (from the Schild plot TpA2=7.96; slope=0.95). In contrast, RES701-1 (an ETB-selective antagonist; 10(-7) M to 10(-5) M) had no effect on the ET-1 concentration-response curve. RT-PCR revealed positive amplification of ETA receptor mRNA fragment, but not ETB. These results indicate that the ET-1-induced contractile effects of urinary bladder detrusor smooth muscle seem to be mediated mainly by the ETA receptor, not by the ETB receptor.

Evidence for beta3-adrenoceptor subtypes in relaxation of the human urinary bladder detrusor: analysis by molecular biological and pharmacological methods

The purpose of the present study was to confirm the presence of beta3-adrenoceptor subtype in the relaxation of human urinary bladder detrusor tissue by reverse transcription-polymerase chain reaction (PCR); direct sequencing of the PCR product, in situ hybridization; and isometric contraction. Using reverse transcription-PCR, the mRNAs of three receptor subtypes (beta1, beta2, and beta3) were expressed in the human urinary bladder detrusor tissue. Direct sequencing of the PCR product of the above beta3-adrenoceptor revealed no mutation in the amplified regions. In situ hybridization with digoxygenin-labeled oligonucleotide probe revealed the presence of the mRNA of beta3-adrenoceptor subtype in the smooth muscle of the urinary bladder. The relaxant effects of isoproterenol (a nonselective beta-adrenoceptor agonist); ZD7114, BRL37344, and CGP12177A (putative selective beta3-adrenoceptor agonists); and SR59230A (a putative selective beta3-adrenoceptor antagonist) were tested using an isometric contraction technique. Isoproterenol in either the presence or absence of both atenolol (a beta1-adrenoceptor-selective antagonist) and butoxamine (a beta2-adrenoceptor-selective antagonist) revealed a relaxant effect on the carbachol-induced contraction of the human urinary bladder detrusor. Both BRL37344 and CGP12177A also revealed relaxant effects on the human urinary bladder detrusor, but ZD7114 did not elicit any relaxation. These results suggest that beta3-adrenoceptor may have some role in urine storage in the human urinary bladder.

Angiography of experimental autoimmune uveoretinitis with ultrastructural correlation

BACKGROUND

Indocyanine green (ICG) angiography has been used to evaluate posterior uveitis in the clinical setting, despite the shortage of data on possible pathological correlates of observed findings.

METHODS

We used both ICG angiography and fluorescein angiography to examine rats that developed a mild form of experimental autoimmune uveoretinitis (EAU) induced by immunization with interphotoreceptor retinoid-binding protein (IRBP). Angiography was performed on days 9, 10, 11 and 23 after IRBP immunization, and freshly enucleated eyes obtained on the same days were examined histopathologically by light microscopy and transmission electron microscopy.

RESULTS

Diffuse dilatation and tortuosity of the retinal vessels was observed by both ICG and fluorescein angiography, with leakage from these vessels in focal areas in the periphery. In addition, deep hyperfluorescent spots in the central posterior pole, not associated with retinal vessels, were observed by ICG angiography only. These corresponded to Dalen-Fuchs-like nodules on funduscopy. On histopathological examination, eyes showed inflammatory cell infiltration around retinal vessels, disorganization of outer retinal layers, focal subretinal accumulations of cells (resembling Dalen-Fuchs nodules), and diffuse inflammatory cell infiltration in the choroid. Ultrastructural examination of a Dalen-Fuchs-like nodule revealed a mound of monocytes, appearing to contain phagosomes of lipofuscin and phospholipids, sandwiched between transformed retinal pigment epithelium (RPE) cells with disrupted apical processes and loss of basal interdigitation.

CONCLUSION

These results suggest that ICG angiography may be useful in delineating certain abnormalities at the level of the RPE, in association with posterior ocular inflammation, that cannot be observed by fluorescein angiography alone.

Videofunduscopy and videoangiography using the scanning laser ophthalmoscope in Vogt-Koyanagi-Harada syndrome

AIM

To observe pathophysiological changes in patients with Vogt-Koyanagi-Harada (VKH) syndrome using the scanning laser ophthalmoscope (SLO) to perform videofunduscopy, and indocyanine green (ICG) and fluorescein videoangiography.

METHODS

18 patients diagnosed with VKH syndrome were studied. 15 patients were examined in both acute and convalescent phases, and three patients were examined in the convalescent phase only. Retrospective review of charts was performed to obtain data on visual acuities, clinical findings, and results of cerebrospinal fluid cytology and histocompatibility leucocyte antigen D locus testing.

RESULTS

Videofunduscopy revealed abnormalities in the central macula at the level of the retinal pigment epithelium or choroid in 40% of patients in the acute phase and 83% of patients in the convalescent phase. ICG videoangiography showed irregular hypofluorescence (80%), slow or patchy filling (67%), indistinct or fewer choroidal vessels (73%), filling defects (73%), and focal leakage (33%) in patients in the acute phase. These changes improved with systemic corticosteroid treatment, although at least one ICG videoangiographic abnormality persisted into the convalescent phase in 83% of patients in the absence of clinical inflammation. In contrast, fluorescein videoangiography revealed fewer and decreased severity of abnormalities, with greater resolution in the convalescent phase when compared with ICG videoangiography.

CONCLUSIONS

SLO videofunduscopy and videoangiography revealed numerous abnormalities in patients with VKH syndrome, many of which persisted well after clinical recovery, suggesting the development of permanent morphological changes in the fundus. ICG videoangiography was more sensitive than fluorescein videoangiography in delineating abnormalities in layers deep to the sensory retina.

Plasma endothelin-1 level in patients with renovascular hypertension - does the kidney with stenosis of the renal artery upregulate production of endthelin-1?

PROBLEM

To examine the value of plasma endothelin-1 (ET-1), we measured the level of plasma ET-1 activity of peripheral venous blood and selective renal venous blood in renovascular hypertension patients, and compared that activity with corresponding renin activity and split renal function.

METHODS

ET-1 level, renin activity in selective renal venous blood and peripheral venous blood, and 99mTc-dimercaptosuccinic acid renal uptake as a split renal function test were measured in 11 patients (mean 42.1 years old) with renovascular hypertension (RVH) and 6 patients with both renal cell cancer (RCC) and essential hypertension.

RESULTS

1. In patients with RVH, resting peripheral venous plasma ET-1 ranged from 0.6 to 8.1 (mean 4.07) pg/ml and was higher than the normal level (p <0.01). However, the renal vein ET-1 ratio was nor correlated with the renal vein renin ratio. 2. In patients with RCC, resting peripheral venous plasma ET-1 was not different from the normal level. There was no step-up of plasma ET-1, or renin among renal veins, or the proximal and distal parts of the interior vena cava. 3. Both renal vein renin ratio and renal vein ET-1 ratios were inversely correlated with t99mTC-dimercaptosuccinic acid renal uptake as a split renal function examination in patients with RVH. 4. The peripheral plasma ET-1 level was correlated with the degree of stenosis of the renal artery in patients with RVH of a unilateral lesion, but not bilateral lesions.

CONCLUSION

These results suggest that ET-1 may take part in the hypertensive mechanisms of RVH in addition to the renin-angiotensin system, but its significance in RVH still remains to be examined.

Alpha-1 adrenoceptor subtypes (high, low) in human benign prostatic hypertrophy tissue according to the affinities for prazosin

BACKGROUND

A novel classification of alpha-1 adrenoceptor subtypes (High, Low) was applied to human benign prostatic hypertrophy (BPH) tissue.

METHODS

Human BPH specimens were examined by a radioligand binding assay method using 3H-prazosin, and those data were compared with preoperative therapies.

RESULTS

(1) Scatchard analysis showed a high-affinity site (Kd:27.18 +/- 6.41 pM; Bmax:9.29 +/- 0.98 fM/mg protein; mean +/- SE) as alpha 1H, and a low-affinity site (Kd: 4088.0 +/- 744.34 pM, Bmax: 140.81 +/- 19.98 fM/mg protein) as alpha 1L subtype, for prazosin. (2) The Kd and Bmax were not different in the nontreated group (n = 5), alpha 1 blocker group (n = 5), and antiandrogen group (n = 5), in either alpha 1-high affinity or alpha 1-low affinity subtype. (3) Phenoxybenzamine had different pKi values for the above two adrenoceptor subtypes. Scatchard analysis showed that alpha 1-high affinity binding site disappeared in the presence of 1 microM of phenoxybenzamine, and the Kd and Bmax values in the presence of 1 microM of phenoxybenzamine were almost identical to the alpha 1-low affinity site of the two subtypes.

CONCLUSIONS

Human BPH tissue possesses both alpha 1H- and alpha 1L-adrenoceptor subtypes according to the affinities for prazosin, and only the alpha 1H subtype can be completely inhibited by some concentration of phenoxybenzamine. Treatment by alpha 1 blocker may not change the conditions of alpha 1-adrenoceptors in prostatic tissue.

[Laparoscopic management for nonpalpable testis]

In this series, we investigated the efficacy and advantage of laparoscopy for management of nonpalpable testis. Laparoscopic examination was performed in 10 boys, involving one with bilateral nonpalpable testis and 9 with a unilateral nonpalpable testis and a contralateral normal one, between August 1991 and September 1993 in our institution. Three testis were diagnosed as intraabdominal and 8 testis were diagnosed as probably intracanalicular with laparoscopy. Two boys with 3 intracanalicular testis underwent laparoscopic clipping of testicular vessels, and about 6 months later, they underwent the second stage of 2-stage Fowler-Stephens orchiopexy. Eight boys, diagnosed as probably intracanalicular type by laparoscopy, underwent surgical exploration with inguinal incision. Of 8 patients, only 1 boy underwent 1-stage orchiopexy, and the other 7 boys underwent orchiectomy because their gonads were extremely hypoplastic. About 1 year after orchiopexy, 3 testes were normal in both size and location. Laparoscopy seems to be useful for both evaluation and treatment of the nonpalpable testis.

Changes in urinary excretion of endothelin-1-like immunoreactivity in patients with testicular cancer receiving high-dose cisplatin therapy

To assess the value of endothelin-1 (ET-1) in estimating renal injury in patients receiving high doses of cisplatin, urinary excretion of ET-1-like immunoreactivity (U-ET-1), beta 2-microglobulin (U-beta 2-MG), and N-acetyl-beta-d-glucosaminidase (NAG) were measured before, 1 week after, and 2 weeks after the administration of cisplatin in eight patients with testicular cancer (mean age, 33.3 years). Levels of U-ET-1/creatinine (Cr) during and 1 week after cisplatin treatment were significantly higher than before cisplatin treatment. There were no differences in U-ET-1/Cr levels during, 1 week after, and 2 weeks after cisplatin treatment. The level of U-beta 2-MG/Cr during cisplatin treatment was significantly higher than levels before, 1 week after, and 2 weeks after treatment. However, there were no differences in U-beta 2-MG/Cr levels before, 1 week after, and 2 weeks after cisplatin treatment. The level of U-NAG/Cr during cisplatin treatment was higher than levels before, 1 week after, and 2 weeks after treatment; U-NAG/Cr during cisplatin treatment was higher than levels before, 1 week after, and 2 weeks after treatment; U-NAG/Cr gradually decreased after cisplatin treatment. Among the three parameters, only U-ET-1/Cr maintained a higher level after cisplatin treatment. The U-beta 2-MG/Cr level returned most rapidly to normal after cisplatin treatment. Although U-ET-1/Cr did not show any significant correlation with U-NAG/Cr (r = 0.282, P = NS), it showed a significant correlation with U-beta 2-MG/Cr (r = 0.454, P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary endothelin-1-like immunoreactivity in young male patients with testicular cancer treated by cis-platinum: comparison with other urinary parameters

1. Urinary excretion of endothelin-1-like immunoreactivity and urinary excretion of other parameters (beta 2-microglobulin, N-acetyl-beta-D-glucosaminidase and microalbumin) were measured before, within 1 week after and 2 weeks after the administration of cis-platinum in five young male patients with testicular cancer (mean age 33.0 years) and were compared. 2. Urinary endothelin-1-like immunoreactivity/creatinine during, 1 week after, and 2 weeks after cis-platinum treatment was significantly higher than before cis-platinum. There was no difference in urinary endothelin-1-like immunoreactivity/creatinine during, 1 week after and 2 weeks after cis-platinum. 3. Among the four parameters, urinary endothelin-1-like immunoreactivity/creatinine showed the highest level after cis-platinum treatment. Urinary beta 2-microglobulin/creatinine most rapidly returned to normal levels after cis-platinum. 4. Although urinary endothelin-1-like immunoreactivity/creatinine did not show any significant correlations with urinary N-acetyl-beta-D-glucosaminidase (r = 0.291, not significant) or urinary microalbumin/creatinine (r = 0.076, not significant), it showed a significant correlation with urinary beta 2-microglobulin/creatinine (r = 0.475, P < 0.05). 5. These results suggest that endothelin-1 may be a sensitive urinary parameter in detecting cis-platinum-induced renal tubular injury.

Changes in urinary excretion of endothelin-1-like immunoreactivity before and after unilateral nephrectomy in humans. Comparison with other urinary parameters and unilateral adrenalectomy

To assess the value of endothelin-1 (ET-1) as a parameter of renal functional overload and the process of hyperfiltration, urinary excretion of ET-1-like immunoreactivity (U-ET-1) and urinary excretion of other parameters [beta 2-microglobulin (beta 2-MG), N-acetyl-beta-D-glucosaminidase (NAG), albumin (Alb) and 24-hour creatinine clearance (Ccr24)] were measured before, 1, 2 and 7 days after unilateral nephrectomy in 15 patients with unilateral renal lesions (renal cell cancer, renal pelvic cancer, ureteral cancer and renal tuberculosis) and after unilateral adrenalectomy in 5 patients with adrenal lesions. In the nephrectomy group (NX), Ccr24 significantly decreased at 1 and 2 days after the operation, but the other 4 parameters significantly increased after the operation as compared to preoperative values. In the adrenalectomy group (ADX), neither Ccr24 nor ET-1/Cr showed any change after the operation, but the other 3 parameters (beta 2-MG/Cr, NAG/Cr and Alb/Cr) significantly increased. Comparing the NX and ADX groups, both ET-1/Cr and beta 2-MG/Cr in NX were significantly higher than in ADX after the operation. On the other hand, neither NAG/Cr nor Alb/Cr in NX differed from values in ADX. Comparing ET-1/Cr and other parameters, only beta 2-MG showed a positive significant correlation. These results suggest that U-ET-1 may be an indicator of functional overload of the kidney.

Measurement of urinary endothelin-1-like immunoreactivity and comparison with other urinary parameters in patients with primary vesicoureteral reflux. A preliminary report

By using a radioimmunoassay specific for endothelin-1 (ET-1), we measured urinary excretion of ET-1-like immunoreactivity in 63 spot urine samples of 48 patients with primary vesicoureteral reflux (VUR). Urinary excretion of N-acetyl-beta-D-glucosaminidase (NAG), beta 2-microglobulin (beta 2-MG), microalbumin (Alb), and creatinine (Cr) were also measured. There was no significant correlation in any pairs of ET-1 and NAG, ET-1 and beta 2-MG or ET-1 and Alb. In patients with grade 2, grade 3, and grade 4 VUR, urinary ET-1/Cr was significantly higher than normal (p < 0.05). Comparing the grade of reflux according to the International Classification with urinary ET-1/Cr, the ratio of more than normal urinary ET-1/Cr increased in proportion to the grade of reflux, but it conversely decreased in grade 5. In conclusion, urinary ET-1 may be an indicator of distal renal tubular or collecting duct injury in patients with primary VUR.

Dissociation of selective renal venous plasma endothelin-1 activity and corresponding plasma renin activity in a patient with hypertension, severe stenosis of unilateral renal artery and ipsilaterally decreased renal function

Plasma endothelin-1 (ET-1)-like immunoreactivity in selective renal venous blood and peripheral venous blood was measured and compared with plasma renin activity and aldosterone level in a 26-year-old woman with suspected renovascular hypertension due to stenosis of the left renal artery. Although there was no significant step-up in plasma renin activity between the right and the left renal vein, left/right ratio of plasma ET-1 in the renal vein was 2.18. This case suggests that ET-1 may be one of the hypertensive mechanisms of suspected renovascular hypertension in addition to the renin-angiotensin system.

Does gadolinium-diethylene triamine pentaacetic acid enhanced MRI of kidney represent tissue concentration of contrast media in the kidney? In vivo and in vitro study

Although Gadolinium-diethylene triamine pentaacetic acid (Gd-DTPA) has been used as a contrast material in magnetic resonance imaging (MRI), it is known that contrast enhancement effect is not uniform if the concentration of Gd-DTPA increases beyond some levels. In this study, to evaluate the proper pulse sequences for dynamic MRI in the human kidney, the concentration of Gd-DTPA was quantitatively measured by inductively coupled plasma (ICP) emission spectrometry in human biological samples after administration of Gd-DTPA. The signal intensity of MRI in the solutions of several concentrations of Gd-DTPA was measured. The results were that in using a low magnetic field apparatus, signal intensity linearly correlated with the concentration of Gd-DTPA between 0 and 2.0 mumol/g under saturation recovery sequences (flip angle = 60 degrees or 90 degrees). Using a high magnetic field apparatus, signal intensity linearly correlated with the concentration of Gd-DTPA between 0 and 2.0 or 3.0 mumol/g under spin-echo or gradient-echo sequences. Gd-DTPA concentration of the renal cortex ranged from 0.132 to 0.152 mumol/g tissue at 5 min after IV injection of Gd-DTPA 0.05 mmol/kg body weight in six patients with adrenal tumor or renal cell cancer, and one patient with both urinary bladder cancer and prostatic cancer. Six of the patients showed normal renal function and the other had renal insufficiency (GFR = 25 ml/min/1.48 m2).(ABSTRACT TRUNCATED AT 250 WORDS)

Value of dimercaptosuccinic acid single photon emission computed tomography and magnetic resonance imaging in detecting renal injury in pediatric patients with vesicoureteral reflux. Comparison with dimercaptosuccinic acid planar scintigraphy and intravenous pyelography

The value of 99mTc-dimercaptosuccinic acid (DMSA) planar renal scintigraphy, DMSA single photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI) in the assessment of renal injury related to vesicoureteral reflux (VUR) was examined in 60 kidneys of 32 pediatric patients (28 bilateral, 4 unilateral) with primary VUR. The results were: (1) detection of minor renal lesions was best with MRI, then DMSA-planar and DMSA-SPECT, and (2) in comparing the positive rate, DMSA-SPECT (85%) and MRI (83.3%) were superior to intravenous pyelography (55%) and DMSA-planar scintigraphy (65%). These results suggest that DMSA-SPECT or MRI may be more sensitive than DMSA-planar scintigraphy and intravenous pyelography in detecting renal injury related to VUR in pediatric patients.

Laparoscopic adrenalectomy for primary aldosteronism: a new operative method

From January 17, 1992 to January 16, 1993, laparoscopic adrenalectomy was performed in 7 patients (3 men, 4 women) with primary aldosteronism ranging in age from 35 to 65 years (mean 48.7 years). Five of the adrenal lesions were on the left side and two were on the right. Five to six trocar-sheath units were used, and adrenal tumors were successfully removed with adjacent normal adrenal glands in all patients. The operative time ranged from 165 to 572 min (mean 302 min), operative blood loss was between 50 and 450 ml (mean 217.2 ml), and there was no major complication. In conclusion, laparoscopic adrenalectomy is a safe alternative operative method for primary aldosteronism, although application of this technique to other types of adrenal lesions remains to be examined.

Concentration of gadolinium-diethylene triamine pentaacetic acid in human kidney--study on proper time for dynamic magnetic resonance imaging of the human kidney on low and high magnetic fields

Although Gadolinium diethylene triamine pentaacetic acid (Gd-DTPA) has been used as a contrast material in magnetic resonance imaging, it is known that contrast enhancement effect disappears if the concentration of Gd-DPTA increases beyond some levels. In this study, to evaluate the proper pulse sequences for dynamic magnetic resonance imaging (MRI) in the human kidney, the concentration of Gd-DTPA was quantitatively measured by inductively coupled plasma (ICP) emission spectrometry in human biological samples after administration of Gd-DTPA, and the signal intensity of MRI is the solutions of several concentrations of Gd-DTPA was measured. The results were; 1. In using a low magnetic field apparatus, signal intensity linearly correlated with the concentration of Gd-DTPA between 0 and 2.0 mumol/g under saturation recovery sequences (flip angle was 60 degrees or 90 degrees). Using a high magnetic field apparatus, signal intensity linearly correlated with the concentration of Gd-DTPA between 0 and 2.0 or 3.0 mumol/g under spin echo or gradient-echo sequences. 2. Gd-DTPA concentration of the renal cortex ranged from 0.132 to 0.152 mumol/g tissue at 5 min after intravenous injection of Gd-DTPA 0.05 mmol/kg body weight in 7 patients with adrenal tumor or renal cell cancer, and 1 patient with both urinary bladder cancer and prostatic cancer. Seven of them showed normal renal function and the other had renal insufficiency (GFR 25 ml/min/1.48 m2). Gd-DTPA concentrations of renal medulla and renal cell cancer tissue were 0.123 and 0.108 mumol/g tissue, respectively, at 5 min after intravenous injection of Gd-DTPA 0.05 mmol/kg body weight. These results suggest that the signal intensity of renal cortex, renal medulla, and renal cell cancer tissue may linearly correlate with Gd-DTPA concentration of tissues at 5 min after intravenous injection of Gd-DTPA 0.5 mmol/kg body weight.

Differential diagnosis of solid renal tumors by MRI. Comparison of in situ relaxation times measured with a 0.1 T imager and histological findings

The T1 and T2 of kidneys in 5 normal volunteers and 27 patients with renal tumors were evaluated preoperatively using a magnetic resonance imager with a 0.1 T resistive electromagnet, and the T1 and T2 of the renal tumors were compared with the pathological findings: (i) the T1 and T2 of the normal renal medulla were longer than those of the normal renal cortex and psoas muscle; (ii) both T1 and T2 of renal pelvic cancer (RPC) were shorter than those of renal cell cancer (RCC, p < 0.05); (iii) the T2 values of RPC were significantly shorter than those of renal medulla (p < 0.01); (iv) the T1 and T2 of the normal renal cortex of subjects < 50 years old were shorter than those of subjects > or = 50 years old (p < 0.05 and p < 0.01, respectively). These findings suggest that preoperative evaluation of the pathological findings of renal tumors may be possible by calculating the relaxation time using MRI under low magnetic field.

Dynamic Magnetic Resonance Imaging of Hydronephrosis using Low Magnetic Field Apparatus. Comparison with Radionuclide Study

We evaluated the value of dynamic magnetic resonance imaging (MRI) under low magnetic field in estimating functional recovery from hydronephrosis by comparing dynamic MRI using a low-magnetic field machine with radioisotope (Rl) renal scintigraphy. 1) Both in normal kidney and hydronephrosis, patterns of dynamic MRI were different from those of 99mTc-diethylene triamine pentaacetic acid renography in most cases. 2) The ratio of signal intensity of renal medulla (or inner parenchyma) and that of renal cortex (or outer parenchyma) at the 3rd image tended to be correlated with the grade of hydronephrosis on intravenous pyelography. 3) When signal intensity of renal cortex (or outer parenchyma) increased from the 1st to the 2nd image more rapidly than that of renal medulla (or inner parenchyma), improvement of function of the hydronephrotic kidney after release of obstruction could be expected according to the change in 99mTc-dimercaptosuccinic acid renal uptake rate. In conclusion, dynamic MRI using a low magnetic field machine may predict functional recovery from hydronephrosis.

[Experimental reconstruction of the urinary bladder using atelocollagen sponge]

An experimental reconstruction of the urinary bladder using specially designed bovine cross linked atelocollagen sponge was performed after partial cystectomy in 12 male rabbits. Bladder reconstruction with hybrid type biomaterials using both atelocollage sponge and cultured autologous cells were performed in 5 rabbits (the 1st group). The autologous cells were collected from the mucosa and muscular layer of the urinary bladder and were seeded on the atelocollagen sponge before reconstruction. Reconstruction using atelocollagen sponge without autologous cells were performed in the other 7 rabbits (the 2nd group). In 9 of these 12 rabbits, atelocollagen sponge was successfully implanted in the native urinary bladder. Histopathological findings revealed that seeded autologous cells and growth of surrounding host cells could be seen similarly in the atelocollagen sponge but these could not be differentiated by these could not be differentiated by routine histopathological techniques. In conclusion, these results showed a possibility of construction of artificial urinary tract using both atelocollagen sponge and autologous cells.

Effect of Percutaneous Transluminal Renal Angioplasty on Absolute Split Renal Function in Patients with Renovascular Hypertension. Influence of Age and Other Parameters

Tc99m-dimercaptosuccinic acid renal uptake (DMSA uptake) was examined to assess the changes in split renal function following percutaneous transluminal renal angioplasty (PTRA) in 9 patients with a total of 12 renal artery stenoses and renovascular hypertension (RVH). The results were studied with respect to age, degree of renal artery stenosis, and renal vein renin ratio (RVRR) before PTRA. Although the degree of renal artery stenosis, systolic blood pressure, and peripheral blood plasma renin activity were improved 3 months after PTRA, neither the DMSA uptake of the affected kidneys nor that of the contralateral kidneys improved. Although restenosis occurred during the long follow-up period in one patient, DMSA uptake did not change in parallel with the degree of stenosis or RVRR. The degree of improvement in DMSA uptake, blood pressure, and plasma renin activity after PTRA in patients aged under 70 years was significantly higher than that in patients 70 years or older. Good improvement of renal function was attained in a 4-year-old boy, despite the fact that split renal function prior to PTRA was so poor that nephrectomy had been considered instead of PTRA. These results suggest that several factors before PTRA, such as DMSA uptake, degree of renal artery stenosis, and RVRR, are not absolutely predictive of results after PTRA, and that the effect of PTRA on blood pressure and renal function is greater in younger patients.

Value of urinary endothelin-1 in patients with primary vesicoureteral reflux

By using a radioimmunoassay specific for endothelin-1 (ET-1), we measured urinary excretion of ET-1-like immunoreactivity (LI) in 63 spot urine samples of 48 patients with primary vesicoureteral reflux (VUR). And also, urinary excretion of N-acetyl-beta-D-glucosaminidase (NAG), beta 2-microglobulin (beta-2-MG), microalbumin (Alb) and creatinine (Cr) were measured. There was no significant correlation in any of the pairs ET-1 and NAG, ET-1 and beta 2-MG, and ET-1 and Alb. Comparing the grade of reflux according to the International Classification with urinary ET-1, urinary ET-1/Cr levels in patients with grade 2, 3 and 4 VUR were higher than normal, and the ratio of more than normal urinary ET-1/Cr increased in proportion to the grade of reflux, but it conversely decreased in grade 5. In conclusion, urinary ET-1 may be an indicator of renal tubular injury in patients with primary VUR, and its meaning may be different from conventional urinary parameters.

Evaluation of upper urinary tract dynamics by diuresis renography in patients receiving urinary reservoir operation. Comparison of full and empty reservoir

Upper urinary tract dynamics was evaluated using diuresis renography during full and empty reservoir in 14 patients (11 men, 3 women, 13-70 years old) with intestinal urinary reservoir or intestinal bladder augmentation. Types of operation were Mainz pouch urinary diversion 5, Mainz neobladder to urethra, 5, Kock pouch urinary diversion 2, and Mainz bladder augmentation 2. Diuresis renography was performed using 99mTc-DTPA and furosemide during full and empty reservoir, and several parameters (Tmax, T75, T50, GFR) in addition to the patterns of renogram were evaluated. In the normal control, none of the parameters of the diuresis renogram with full bladder differed from those with empty bladder. In 5 of 14 patients, abnormal waves on cystometry (CMG) were found, and in 4 of these 5 patients, the patterns of diuresis renogram of full reservoir were worse than those of empty reservoir. However, the patterns of diuresis renogram of full reservoir were not different from those of empty reservoir in 9 patients without abnormal waves on CMG. In conclusion, renal injury may easily occur in patients with intestinal reservoir and abnormal waves on CMG.

[Gonadotropin of chorioepithelioma -- its heterogeneity -- (author's transl)]

Crude gonadotropins extracted from the urine of patients with chorioepithelioma (choriocarcinoma) by Bradbury method was purified by a combination of Sephadex gel filtration, CM-C and DEAE-C chromatography. Two biologically active fractions (fraction t-hCG-A and fraction t-hCG-C) were obtained. The former cross-reacted with anti-hCG sera and the latter cross-reacted with anti-hCFSH sera in experiments with Ouchterlony immunodiffusion and immunoelectrophoresis. But the hCG or hCFSH from normal pregnancy and t-hCG-C from choriocarcinoma were different in their potency of being adsorbed on ion-exchange cellulose respectively. T-hCG-C was poorer in aspartic acid and glycine, and richer in serine, threonine and tyrosin to which carbohydrates bind than hCFSH from normal pregnancy. These two fractions contained high concentrations of carbohydrates, especially hexose and sialic acid, less concentration of hexosamine, compared to those of hCG and hCFSH obtained from urine of normal pregnant women. Sera of normal pregnant women in the first and third trimester and those of patients with chorionic neoplasias were gel filtrated on a Sephadex G-100 upward flow column in the same conditions. Biological activity of hCG in sera of normal pregnant women was recognized in 2-3 peaks on the gel filtration, and the molecular weights of those were considered to be about 25,000-40,000. In case of sera of chorionic neoplasias, however, it was admitted as multi-peaks (the molecular weights: about 10,000-70,000). It might be one of the features of chorionic neoplasias that the biological activity was found even in fractions of molecular weight 10,000 on the gel filtration, and to pay attention to this phenomenon might be a useful sign for the diagnosis or the management of patients with chorionic neoplasias. As a conclusion, all the above findings suggest that the molecular structure of t-hCG-A and t-hCG-C from choriocarcinoma differes from that of hCG and hCFSH from normal pregnancy respectively.