Diagnosis of superficial esophageal squamous cell carcinoma invasion depth before endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is a widely accepted procedure for superficial esophageal squamous cell carcinoma (SESCC) limited to the epithelium or lamina propria mucosae (EP/LPM). We aimed to compare the efficacy of endoscopic ultrasonography (EUS) and magnifying endoscopy with narrow band imaging (ME-NBI) for predicting the tumor invasion depth in patients with SESCC. Specifically, we evaluated the ability of these examinations to distinguish EP/LPM from SESCC invading the muscularis mucosae or superficial submucosa (MM/SM1) and more deeply invasive lesions before ESD.We retrospectively analyzed a database of all patients with SESCC who had undergone both EUS and ME-NBI for pretreatment staging and ESD resection at Hiroshima University Hospital between September 2007 and June 2015. The clinicopathologic characteristics of SESCCs were classified according to the Japanese Classification of Esophageal Cancer.A total of 174 lesions in 174 patients were included: 124 (71%) EP/LPMs, 35 (20%) MM/SM1s, and 15 (9%) SESCCs invading the mid submucosae (SM2). The sensitivity of EUS and of ME-NBI in distinguishing EP/LPM from MM/SM1 and more invasive lesions was 72% and 83%, respectively. The accuracy of EUS and ME-NBI in distinguishing EP/LPM from MM/SM1 and more invasive lesions was 70% and 82%, respectively. Sensitivity and accuracy of ME-NBI in distinguishing EP/LPM from MM/SM1 and more deeply invasive SESCCs is significantly higher than those of EUS (P = 0.048 and P = 0.017, respectively).ME-NBI may be more useful than EUS for the determination of SESCC invasion depth before ESD.

Curative Criteria After Endoscopic Resection for Superficial Esophageal Squamous Cell Carcinomas

BACKGROUND

According to the Japanese Esophageal Society (JES) guidelines, risk factors for lymph node (LN) metastasis in the muscularis mucosa (MM)/submucosa to a depth of up to 200 μm (SM1) in cases of esophageal squamous cell carcinomas (ESCCs) include the presence of lymphatic invasion (ly), venous invasion (v), infiltration pattern (INF)c, and SM1. The long-term prognoses of these patients are unclear, and there are very few reports on the validation of the curative criteria for MM/SM1 ESCCs.

AIMS

To examine the long-term prognoses of these patients and the risk factors for LN metastasis of MM/SM1 ESCCs after endoscopic resection (ER).

METHODS

This study included patients with MM/SM1 ESCCs who underwent ER at Hiroshima University Hospital from December 1990 to November 2016. We evaluated the clinicopathological characteristics of 98 patients and overall survival, disease-specific survival, recurrence-free survival, and recurrence rates in the e-curative and non-e-curative groups.

RESULTS

The mean observation period was 75 months. There was no significant difference in disease-specific survival rate between the e-curative and non-e-curative groups (100 vs. 98%). There was no significant difference in disease-specific survival rates between the groups (100 vs. 98%). In contrast, the LN recurrence-free survival rate in patients with INFa, ly(-), and v(-) was significantly higher than that in patients with INFb/c, ly(+), or v(+) (100 and 87%, P < 0.05).

CONCLUSION

Contrary to the JES guidelines, our findings suggest that new criteria (MM/SM1, INFa, negative vertical margin (VM0), ly[-], and v[-]) may be associated with curative ER without additional treatment.

Development of the micro pixel chamber based on MEMS technology

Micro pixel chambers (μ-PIC) are gaseous two-dimensional imaging detectors originally manufactured using printed circuit board (PCB) technology. They are used in MeV gamma-ray astronomy, medicalimaging, neutron imaging, the search for dark matter, and dose monitoring. The position resolution of the present μ-PIC is approximately 120 μm (RMS), however some applications require a fine position resolution of less than 100 μm. To this end, we have started to develop a μ-PIC based on micro electro mechanical system (MEMS) technology, which provides better manufacturing accuracy than PCB technology. Our simulation predicted the gains of MEMS μ-PICs to be twice those of PCB μ-PICs at the same anode voltage. We manufactured two MEMS μ-PICs and tested them to study their behavior. In these experiments, we successfully operated the fabricatedMEMS μ-PICs and we achieved a maximum gain of approximately 7×103 and collected their energy spectra under irradiation of X-rays from 55Fe. However, the measured gains of the MEMS μ-PICs were less than half of the values predicted in the simulations. We postulated that the gains of the MEMS μ-PICs are diminished by the effect of the silicon used as a semiconducting substrate.

The localization of cyclic nucleotides in the human epidermis: an immunohistochemical study

Immunohistochemical localizations of 3',5'-cyclic AMP (cAMP) and 3',5'-cyclic GMP (cGMP) were performed in the involved and non-involved epidermis of psoriasis and in the normal controls. The following results were obtained: 1. In the normal epidermis, cAMP was located in the cytoplasm throughout the epidermis but it was more pronounced in its upper portions, especially in the granular layers. Occasionally it was also observed in the nuclear membrane. However, cGMP was located mainly in the cytoplasm of the lower layers of epidermis, though the fluorescence was less pronounced as compared with that of cAmP. 2. In the noninvolved psoriatic epidermis, the localization pattern of cAMP was basically similar to that in the normal control, but its fluorescence seemed more pronounced. The fluorescence of cGMP was essentially the same as that in the normal control. 3. In the involved psoriatic epidermis, the distribution pattern of cAMP was essentially the same as that in the normal control, but its fluorescence seemed more pronounced. Marked increase in the fluorescence of cGMP was observed in the involved psoriatic epidermis, though it was much more pronounced in its lower portions.

Ce:YIG/Silicon-on-Insulator waveguide optical isolator realized by adhesive bonding

A waveguide optical isolator realized by adhesive bonding of a garnet die, containing a Ce:YIG magneto-optic layer, on a silicon-on-insulator waveguide circuit is demonstrated. The die was bonded on top of an asymmetric Mach-Zehnder interferometer using a 100nm thick DVS-BCB adhesive bonding layer. A static magnetic field applied perpendicular to the light propagation direction results in a non-reciprocal phase shift for the fundamental quasi-TM mode in the hybrid waveguide geometry. A maximum optical isolation of 25 dB is obtained.

[Coronary artery bypass grafting in patients with dialysis-dependent renal failure]

From January 1995 to May 2003, 36 patients with dialysis-dependent renal failure underwent coronary artery bypass grafting. We performed the operation with cardiopulmonary bypass (group On) in 17 cases and without cardiopulmonary bypass (group Off) in 19 patients [off-pump coronary artery bypass grafting (OPCAB) 15, minimally invasive direct coronary artery bypass (MIDCAB) 4]. There were no statistical differences regarding mean age, sex, duration of dialysis, preoperative hypertension, diabetes and peripheral and cerebral vascular diseases. Mean operation time and the number of bypass grafts were 315 +/- 53 minutes, 2.8 +/- 0.8 grafts in group On and 284 +/- 78 minutes, 2.4 +/- 1.1 grafts in group Off, respectively (not significant). Seventeen patients (100%) of group On and 12 patients (63%) needed blood transfusion. Hospital stay after operation was significantly longer in group On (40 days) of group Off than that in group Off (26 days). After the operation, continuous hemodiafiltration (CHDF) was used in 10 cases (59%) in group On and 3 cases (16%) in group Off. In coronary artery bypass grafting (CABG) on dialysis patient, it is very effective to have various operation techniques, such as off-pump bypass and on-pump beating bypass. Also control of water-electrolyte balance using early postoperative CHDF is useful. However, off-pump cases could be controlled by conventional hemodialysis.

Clinical benefit of liver hanging maneuver for right-side major hepatectomy

15171

Background: Liver hanging maneuver is a new technique in anterior approach of major hepatectomy. However, the impact of the maneuver has never been fully investigated in patients with liver tumors. To evaluate the surgical benefits of liver hanging maneuver, we set up a comparative study in right-side major hepatectomy. Methods: From 2000 to 2006, 326 hepatectomy were performed in our institution. Fifty-eight patients with liver tumor (hepatocellularcarcinoma in 36, metastatic liver tumor in 13, and the others in 9) considered for right-side major hepatectomy were prospectively analyzed. Right-side hepatectomy included 26 right hepatectomy, 24 extended right hepatectomy, and 8 tri-segmentectomy. The patients were devided into a group with conventional approach (n = 21), a group with anterior approach without hanging maneuver (n = 19), and a group with approach with liver hanging maneuver (n = 18). In the three groups, age, body mass index, child-pugh classification, type of liver tumor, staging in hepatocellularcarcinoma, tumor size, resected liver weights, intraoperative blood loss, frequency of transfusion and surgical time were analyzed. Results: In conventional approach, anterior approach without hanging maneuver, and approach with liver hanging maneuver, mean age was 55, 59, and 65 years, and mean tumor size was 65, 75, and 108mm, respectively. Patients with liver hanging maneuver were significantly elder (p<0.05) and have larger tumor size (p<0.01). There were no significant differences in body mass index, child-pugh classification, type of liver tumor, staging in hepatocellularcarcinoma, and resected liver weights. Mean intraoperative blood loss was 1771, 805, and 704g, and mean surgical time was 562, 483, and 435minutes, and the frequency of red blood cell transfusion was 33, 21, and 17%, respectively. Patients with liver hanging maneuver had significantly less intraoperative blood loss (P=0.0001) and surgical time (P=0.002). The frequency of red blood cell transfusion in the liver hanging maneuver group was significantly lower than that of the conventional group (p<0.05). Postoperative morbidity rate were 33.3, 15.8, and 16.7%, respectively. Conclusions: Liver hanging maneuver is less invasive and a quite useful method for right-side major hepatectomy.

No significant financial relationships to disclose.

Doubling time of preoperative serum alpha-fetoprotein level can predict recurrence and prognosis after hepatic resection of hepatocellular carcinoma

15118

Background: It is quite important to predict postoperative recurrence or prognosis in the patients with hepatocellular carcinoma (HCC) before surgery. There have been few reports about the value of doubling time of preoperative serum a-fetoprotein (AFP) or protein induced by vitamin K absence (PIVKA-II) levels. Methods: Between January 2000 to December 2005, 160 consecutive HCC patients underwent hepatic resections in our institution. Serum AFP and PIVKA-II level was prospectively measured at least two points before surgery to calculate a doubling time. Clinical factors such as age, gender, BMI, etiology of hepatitis, degree of liver damage, gross tumor type, tumor size, tumor numbers, portal vein tumor thrombosis (PVTT), and AFP-L3 were concurrently investigated. Univariate and multivariate analyses were done to clarify predictive factors of postoperative recurrence and survival. Results: There were no relationship between preoperative levels and doubling time of both tumor markers. In univariate analysis, significant predictors of postoperative recurrence were AFP > 200 ng / ml, PIVKA-II > 200 mAU / ml, AFP-L3 > 10%, non-simple nodular type tumor, tumor size > 3 cm, multiple tumors, PVTT positive, and doubling time of AFP < 40 days. The significant prognostic factors were AFP > 200 ng / ml, HBs antigen positive, non-simple nodular type tumor, multiple tumors, PVTT positive, and doubling time of AFP < 40 days. In multivariate analysis, multiple tumors (odds ratio: 1.48), and doubling time of AFP < 40 days (odds ratio: 2.17) were significant predictors of recurrence. The significant prognostic factors were non-simple nodular type tumor (odds ratio: 6.41), multiple tumors (odds ratio: 7.62), and doubling time of AFP < 40 days (odds ratio: 6.49). Postoperative mean recurrence free survival time of HCC patients with doubling time of AFP < 40 days was only 2.8 months and mean survival time was 34 months. Conclusions: In HCC patients, doubling time of preoperative serum AFP level is useful to predict early recurrence and poor prognosis. Perioperative adjuvant therapy should be considered for such high risk patients.

No significant financial relationships to disclose.

[Ascending aorta to biaxillar and left femoral artery bypass]

A 68-year-old man was admitted to our hospital because of ischemia in the upper and lower extremities with rest pain. Aortography revealed complete bilateral subclavian artery occlusion and left femoral artery occlusion. We planned simultaneous revascularization of upper and lower extremities. Ascending aorta to biaxillar and left femoral artery bypass was performed. The postoperative course was uneventful and he was discharged on the 18th day after operation. This procedure was useful for patient with upper and lower limb ischemia.

[Dor operation for left ventricular aneurysm with sustained ventricular tachycardia]

A 60-year-old woman was admitted to our hospital because of syncope attack due to sustained ventricular tachycardia (VT). She was treated medically after cardiopulmonary resuscitation. Coronary arteriography revealed a 99% stenosis of right coronary artery (posterior descending artery: # 4 PD), a 90% stenosis of left descending artery (# 6) and left akinetic aneurysm was demonstrated. The patient successfully underwent Dor operation with endocardial cryoablation. The postoperative course was uneventful and the recurrence of VT was never recognized clinically.

Dependence of Threshold Switching Power on the Control-Light Wavelength in a Nonlinear Distributed-Feedback GaInAsP Waveguide

We demonstrate all-optical bistable switching by using orthogonally and parallelly polarized control light in a nonlinear distributed feedback GaInAsP waveguide. When the control light that is orthogonally polarized to the signal light is within its stopband, it is possible to extract the signal without using any external devices. Also, we investigate theoretically and experimentally the dependence of threshold switching power on the wavelength and polarization of control light.

[Clinical laboratory data and reference intervals standardized in Fukuoka]

In Fukuoka whose population is approximately five million inhabitants, surveys on the accuracy of laboratory data have been performed by the Fukuoka Prefecture Medical Association for the last 30 years. We have been attempting to evaluate the data for routine use since 1988, and it has become possible to share laboratory data between all institutions in Fukuoka prefectures. As a result, reference intervals for 23 clinical chemistry analytes were established in 1995, to which were added in 1996 five serum protein constituents that have been utilized for clinical examinations. Methods for documentations and monitorings the data obtained in the prefecture were also established, standardization of the above analytes extended to 97% of the institutions in the prefecture. Results for 14 of the 23 clinical chemistry analytes have become highly reliable and clinically useful as differences between institutions in terms of results have narrowed. Standardization of other analytes is now in progress.

Demonstration of an Optical Isolator with a Semiconductor Guiding Layer that was Obtained by Use of a Nonreciprocal Phase Shift

We present the experimental study of an optical isolator with a semiconductor guiding layer that was obtained by use of a nonreciprocal phase shift. The isolator is equipped with an optical interferometer composed of tapered couplers, nonreciprocal phase shifters, and a reciprocal phase shifter. The nonreciprocal phase shifter was constructed by wafer direct bonding between the semiconductor guiding layer and the magneto-optic cladding layer. The isolator, designed for the 1.55-mum wavelength, was fabricated to investigate the characteristics of each component. By applying an external magnetic field to the nonreciprocal phase shifter, we achieved an isolation ratio of approximately 4.9 dB in the interferometric isolator.

An analysis of serum interleukin-6 levels to predict benefits of medroxyprogesterone acetate in advanced or recurrent breast cancer

Treatment of advanced or recurrent breast cancer with medroxyprogesterone acetate (MPA) shows high response rates and the accessory effects of appetite stimulation, improvement in performance status (PS) and bone marrow protection. In recent years, interleukin-6 (IL-6) has been reported to cause cachexia. In this study, to clarify the significance of IL-6 in advanced or recurrent breast cancer, the relationship between the IL-6 level and clinical findings or effect of MPA was investigated. Sixty-five patients with recurrent or advanced breast cancer participated in a prospective study. The age of patients ranged from 28 to 79 years with an average age of 51.3 years. IL-6 level was investigated in these patients dosed with 800 mg/day of MPA and in 17 postoperative nonrecurrent patients. Serum MPA level was measured by high-performance liquid chromatography and IL-6 level was measured prior to MPA administration, 4 weeks (in 59 cases) and 12 weeks (in 32 patients) after MPA administration by ELISA. Serum IL-6 level was significantly higher in recurrent cases, especially in those with visceral metastasis. Further, in patients for whom MPA therapy was effective, the IL-6 level prior to the treatment was clearly low. The IL-6 level was significantly increased after 4 weeks. However, response to MPA was significantly higher and PS was improved in those cases demonstrating less increased IL-6 levels after 4 weeks. In addition, the effect of MPA was significantly related to a higher serum concentration of MPA-positive ER, and longer disease-free interval, although there was no significant predictive factor for the clinical effect of MPA therapy in multivariate analysis. In conclusion, MPA therapy was effective in cases demonstrating a low IL-6 level and less increased IL-6 levels after 4 weeks. PS was improved in those cases in which the degree of IL-6 increase was suppressed by MPA, and many such cases showed low IL-6 levels prior to MPA therapy. Furthermore, PS was improved even in nonresponders to MPA. Therefore, it is suggested that MPA therapy might be useful in treating recurrent breast cancer, and its benefits might be mediated by IL-6.

Autoimmune pancreatitis detected as a mass in the tail of the pancreas

A mass in the tail of the pancreas was detected in a 62-year-old male patient who had hypergammaglobulinaemia, and was positive for antinuclear antigen and anti-SS-A antibody. Endoscopic retrograde pancreatography revealed focal irregular narrowing of the main pancreatic duct in the tail of the pancreas. Dynamic computed tomography showed swelling of the pancreatic tail, which was enhanced on delayed phase. Autoimmune pancreatitis was suspected and corticosteroid therapy was commenced. This led to significant resolution of the pancreatic stricture. It is important to recognize this clinical entity as corticosteroid therapy may avoid unnecessary surgery.

Demonstration of an optical isolator by use of a nonreciprocal phase shift

The experimental study of an optical isolator by use of a nonreciprocal phase shift is demonstrated. The isolator has an optical interferometer composed of tapered couplers, nonreciprocal phase shifters, and a reciprocal phase shifter. The isolator, designed for a 1.55-microm wavelength, was fabricated to investigate the characteristics of each component. The branching and coupling characteristics of the tapered coupler were measured. The nonreciprocal and reciprocal phase shifts were also evaluated. By applying an external magnetic field to the interferometer, we confirmed the nonreciprocal phase shift in the interferometric isolator.

Thymidylate synthase levels as a therapeutic and prognostic predictor in breast cancer

5-Fluorouracil (5-FU) is a commonly used adjuvant therapeutic drug in treating breast cancer. 5-FU is metabolically converted to 5-fluorouracil-2'-deoxyuridine-5'-monophosphate-(FdUMP) which is believed to inhibit DNA synthesis in neoplastic cells by forming a tightly bound ternary complex with thymidylate synthase (TS). In the present study, we examined the possible relationship between TS levels and clinico-pathologic and prognostic features in breast disease. Mean TS levels of 2.9 pmol/g, 6.1 pmol/g, and 23.1 pmol/g were obtained in cases of benign breast disease (3 cases), primary breast cancer (115 cases), and recurrent tumors (4 cases), respectively. In breast cancer, mean TS levels significantly correlated with S-phase fraction (SPF), DNA polymerase a and lymphatic invasion. Thus, TS levels in breast cancer significantly reflected cell proliferation and malignancy. Regarding the survival rate, patients with TS values above 10 pmol/g showed an unfavorable prognosis. The effectiveness of adjuvant 5-FU derivatives chemotherapy was reflected in a higher disease-free survival rate in node (+) cases showing TS levels between 5 and 10 pmol/g (p < 0.1), but not in node (-) cases. In conclusion, TS levels in neoplastic tissues of the breast were highest in recurrent tumors, followed by those in primary cancer, benign breast disease and in breast cancer which reflected proliferative activity. Breast cancers with extremely high TS levels were accompanied by an unfavorable prognosis; however, those with moderately high TS levels tended to respond to adjuvant chemotherapy with 5-FU derivatives.

All-optical switching in a distributed-feedback GaInAsP waveguide

The characteristics of all-optical switching in a waveguide device with a distributed-feedback structure were experimentally investigated. The device was composed of a strip-loaded GaInAsP/InP waveguide and a distributed-feedback structure, which was fabricated by a combination of reactive-ion etching and electron-beam exposure. In the experiments, several optical switching operations were demonstrated. In particular, the all-optical set-reset operation and threshold operation were obtained.

[The 5q- syndrome associated with marked erythroid hypoplasia and Coombs test positive hemolysis]

The 5q- syndrome is a myelodysplastic disorder characterized by macrocytic anemia, hypolobulated micromegakaryocytic hyperplasia, and an interstitial deletion of chromosome 5 as a solitary cytogenetic abnormality. The majority of patients with this syndrome are elderly women exhibiting red blood cell transfusion-dependent refractory anemia with a normal-to-increased number of platelets and modest granulocytopenia. The prognosis is relatively favorable with a low incidence of leukemic transformation. We report on a patient with 5q- syndrome associated with autoimmune hemolytic anemia (AHIA) and severe erythroid hypoplasia mimicking pure red cell aplasia (PRCA). A 65-year-old woman was admitted because of severe anemia. Elevated serum levels of LDH and indirect bilirubin, and a positive direct Coombs' test suggested AIHA associated with a huge ovarian dermoid cyst. However, lack of peripheral reticulocytes and bone marrow eryhroblasts, characteristic megakaryocytic morphology, and solitary 5q- anomaly favored a diagnosis of 5q- syndrome complicated by PRCA-like feature. Underlying immunological abnormalities ascribed to aberrant lymphoid clones intrinsic to MDS may be responsible for red cell aplasia and autoantibodies against red blood cells.

[A clinical study on the cases of ischemic colitis: comparison of clinical images based on time from onset of the disease to detection of bloody stool]

A study was performed on 28 cases of ischemic colitis. The patients were divided into three groups: Group A (9 cases with bloody stool detected within 2 hours after the onset of abdominal pain), Group B (7 cases with bloody stool detected in 2 to 6 hours), and Group C (12 cases with bloody stool detected after more than 6 hours). These cases were comparatively studied. Variables used were as follows: (1) age, (2) sex, (3) constipation, (4) vomiting, (5) peak value of WBC count (/microliter) after admission, (6) peak value of log CRP (microgram/dl), (7) presence of ulcerative lesion in endoscopic findings in acute stage. Using Group A B and C as classification variables, canonical discriminant analysis was performed. As a result, clear linearity was recognized in Group A-->B-->C, and the values (5), (6) and (7) were extracted as the corresponding variables. For these variables, significant difference was also noted in multivariate analysis of covariance. These results suggest that it is possible to predict the severity of the disease to some extent as represented by objective markers of inflammation by finding the time from onset of abdominal pain to detection of bloody stool.

Evaluation of third generation anti-HCV test kit (SYNPEP HCV-EIA II) using sera of inhabitants from HCV hyperendemic area

We examined the characteristics and usefulness of a third generation anti-HCV test kit, SYNPEP HCV-EIA II (Kyokuto Pharmaceutical Inc., Tokyo, Japan). The sera of inhabitants from a hepatitis C virus (HCV) hyperendemic area were used. The kit had even or more anti-HCV detection sensitivity and reproducibility than ORTHO HCV III ELISA Test System (Ortho-Clinical Diagnostic K.K., Tokyo, Japan) or HCV PHA 2nd Generation (Dinabot Co., Ltd., Tokyo, Japan). SYNPEP HCV-EIA II needed less total reaction time than other EIA kits, resulting in a simple procedure. Also, HCV RNA was detected in 90% of subjects who had a 7.5 or greater cut-off index (COI) of SYNPEP HCV-EIA II kit. In conclusion, SYNPEP HCV-EIA II require cheap cost and simple procedure and it could be applied to mass screening to find out HCV RNA positive persons who may need clinical care.

Hemophagocytic syndrome in five patients with Epstein-Barr virus negative B-cell lymphoma

BACKGROUND

The recent recognition of the association of Epstein-Barr virus (EBV) with T-cell/natural killer cell (T/NK-cell) lymphoma has documented that particular types of EBV-containing T/NK-cell lymphoma are frequently complicated by hemophagocytic syndrome (HPS). This observation suggests that both EBV and proliferating T/NK-lymphoma cells play significant roles in the development of HPS. Cytokines released from neoplastic T cells are presumed to account for the activation of macrophages, which is followed by a complex cascade of cytokine production, resulting in full-blown HPS. Five patients with B-cell lymphoma complicated by HPS were studied for elevated serum cytokines, the association of EBV, and CD25 expression of lymphoma cells; the aim of this study was to verify whether the mechanisms of HPS development hypothesized for T/NK-cell lymphoma also operate in B-cell lymphoma.

METHODS

Sera were analyzed for the presence of inflammatory and immunoregulatory cytokines. Flow cytometry, immunohistology (IH), in situ hybridization (ISH), polymerase chain reaction (PCR), and Southern blot analysis were performed using bone marrow aspirates, biopsy specimens, and autopsy specimens.

RESULTS

Immunophenotypic and Southern blot studies verified that the lymphoma cells of all five patients were of B-cell lineage. Bone marrow aspirates demonstrated histiocytosis with extensive hemophagocytic activity. Marked elevation of serum cytokines and expression of CD25 were observed in all five patients. However, the results of PCR, ISH using EBER1 probe, and IH for latent membrane protein indicated that these lymphoma cells were free of EBV infection.

CONCLUSIONS

In patients with B-cell lymphoma, EBV infection is not necessarily required for the initiation of HPS. In this article, the pathogenesis of HPS assumed to be operative in B-cell lymphoma is discussed with reference to T/NK-cell lymphoma complicated by HPS.

Chronic myeloid leukemia with minor-bcr breakpoint developed hybrid type of blast crisis

Although a breakpoint in the minor breakpoint cluster region (m-bcr) of the BCR gene is observed in about two-thirds of patients with Philadelphia chromosome-positive acute lymphoblastic leukemia, this type of genomic rearrangement occurs very rarely in chronic myeloid leukemia (CML). We describe here the eighth case of m-bcr CML, and delineate unique clinical characteristics found in common to the 7 cases reported previously. Monocytosis with a low neutrophil/monocyte ratio resembling chronic myelomonocytic leukemia was the most striking feature of m-bcr CML. Splenomegaly and basophilia were not conspicuous in chronic phase. A high percentage of immature granulocytes and low neutrophil alkaline phosphatase score were the findings in common with classical CML. Lymphoid and myeloid blast changes have been observed at and shortly after presentation so far. We found a hybrid type of blast crisis in the course of m-bcr CML.Thus, m-bcr CML may be a definite subtype of CML, exhibiting distinct clinical characteristics. The presence of fusion product of m-bcr mRNA in an earlier myeloid cell may involve monocytic lineage in addition to myeloproliferative defects.

Erythropoietin in pediatric cardiac surgery: clinical efficacy and effective dose

We assessed the clinical efficacy and determined the effective dose of erythropoietin (EPO) in 48 children scheduled for open heart surgery without blood transfusion. The children were divided into three groups: group 1 (n=21) was treated with 300 U/kg of EPO; group 2 (n=11) was treated with 150 U/kg of EPO; and group 3 (n=16) was not treated with EPO. EPO was administered on the day of hospital admission (6 to 7 days prior to surgery), on the following day, immediately after surgery, and on the following day. Immediately after surgery, the hemoglobin concentration in groups 1 and 2 was significantly higher than that in group 3. The reticulocyte count in groups 1 and 2 was significantly higher than that in group 3. Open heart surgery was completed without transfusion in all 21 patients in group 1 (100%), 10 of 11 in group 2 (90.9%), and 11 of 16 in group 3 (68.8%). EPO caused no adverse reactions. In conclusion, EPO was effective as an adjuvant therapy for open heart surgery without blood transfusion in children. Administration of a relatively high dose of EPO (300 U/kg) seems to be effective for pediatric patients.

[Left thoracotomy for coronary artery bypass grafting without cardiopulmonary bypass in a patient with porcelain aorta]

Extended calcification of the total aorta and arch vessels may make coronary revascularization with cardiopulmonary bypass impossible. We report the left thoracotomy approach for a case of a 70-years diabetic man who was revascularized without cardiopulmonary bypass because of porcelain aorta extended into abdominal aorta, the arch vessels and femoral arteries. He had had prior anterior wall infarction. Cardiac catheterization showed poor ventricular function with an EF of 25% and there was a 60% occlusion of left main trunk, 90% occlusion of circumflex coronary. Through a left thoracotomy, saphenous vein grafting was performed without cardiopulmonary bypass from the noncalcified left subclavian artery to the circumflex coronary artery. During distal anastomosis, distal perfusion of coronary artery was carried out to support the heart up. Intraoperatively, hemodynamic remained stable with no electrocardiographic change. This technique may offer a practical solution to this problem.

Inhaled low-dose nitric oxide for postoperative care in patients with congenital heart defects

Postoperative pulmonary hypertensive crisis is a major problem that may account for a substantial part of the postoperative mortality and morbidity. We, therefore, evaluated the effect of inhalation of low-dose nitric oxide (NO) on postoperative care in pediatric patients with pulmonary hypertension. We studied 10 infants and children ages 1-108 months (median age, 11 months) with congenital heart disease associated with pulmonary hypertension. The NO and N2 gas mixture was then mixed with varied quantities of air and oxygen and delivered into a respirator instead of an inspiratory tube. Patients were treated with inhaled NO for 38.6 +/- 19.6 h (range 1-200 h). All patients were eventually weaned from high level sedation and respirator. The NO concentration ranged from 2 to 5 parts per million. During NO inhalation patients demonstrated a statistically significant reduction in systolic pulmonary arterial pressure by approximately 26%; from 55 +/- 10 to 41 +/- 20 mm Hg. Inhalation of NO resulted in a significant increase of Pao2 from 110 +/- 16 to 149 +/- 29 mm Hg. A-aDo2 significantly decreased from 284 +/- 27 to 247 +/- 31 mm Hg. In conclusion, we have shown that a low-dose NO inhalation acted as pulmonary vasodilator in patients with preexisting pulmonary hypertension.

Clinical experience with the Nikkiso centrifugal pump

The Nikkiso HPM-15 is a minimally sized centrifugal pump. Preliminary results regarding clinical use of this pump for cardiopulmonary bypass (CPB) procedures have been reported previously. Recently, we have managed some additional cases using a newly developed controller. This article reports our clinical experiences with the use of this pump. We have managed 23 cases with a Nikkiso centrifugal pump. Twenty-two patients underwent CPB and 1 patient with fulminant viral myocarditis underwent percutaneous cardiopulmonary support (PCPS). With this pump, the circuit was extremely easy to prepare and deaeration was achieved readily. Hemodynamics during CPB and PCPS were stable in all cases. The increase in serum-free hemoglobin levels during CPB with this pump was as low as that seen in preliminary tests. A decrease in the platelet count was observed after the initiation of CPB with this pump; however, platelet counts returned to preoperative values 7 days after surgery. Moreover, urine output during CPB with this pump was as high as that seen in preliminary tests. No abnormalities in renal or liver function occurred during CPB. It appears that this new centrifugal pump is safe and easy to operate, and we conclude that it is useful for CPB and PCPS.

Weighted distributed feedback structure for all-optical bistable devices

We proposed to use a distributed feedback structure with a weighted coupling coefficient (W-DPB) in an all-optical bistable device in order to improve on-state transmittance and to reduce threshold intensity. Through numerical calculations, characteristics of the W-DPB structure were discussed compared with those of a conventional DPB structure. The W-DPB optical bistable device exhibits high on-state transmittance and low-threshold input intensity. Fabrication of the W-DPB structure with a periodicity of 169.8 nm is demonstrated on a CdS(x)Se(1-x)-doped glass substrate by means of holographic exposure with a double-coated photoresist and reactive ion etching in CHP(3).

Surgery for T4 lung cancer: the prognoses of T4 lung cancer

The prognoses of T4 lung cancer patients treated surgically were investigated in 76 patients. Extended resection was performed in 21 patients, palliative resection in 21 and exploratory thoracotomy in 34. Although the five-year survival of the extended resection group did not differ significantly from that obtained in the exploratory thoracotomy group, the mean survival time of the extended resection group was 3.1 months longer than that of the exploratory thoracotomy group. Two patients who had undergone resection for left atrial involvement, survived for two years or more, and a T4N0 patient with squamous cell carcinoma, in whom resection for aortic involvement was carried out, died from an unrelated disease after 15 months. Two patients with pleural dissemination, who underwent panpleuropneumonectomy, survived for two years. Surgical intervention did not improve the prognosis of patients with N2-squamous cell carcinoma, those with malignant effusion or those with multiple organ involvement.

Treatment of aortic dissections with a percutaneous intravascular endoprosthesis: comparison of covered and bare stents

PURPOSE

The authors developed a percutaneous endoprosthesis for treatment of aortic dissections. The device is a Gianturco stent wrapped with Dacron or nylon mesh. Effectiveness of the covered stent versus a bare stent was compared in the treatment of acute aortic dissection.

MATERIALS AND METHODS

Experimental aortic dissections were created in 10 mongrel dogs. Occlusion of intimal tears was attempted with covered stents in five dogs (group 1) and with bare stents in the remaining five dogs (group 2).

RESULTS

In group 1, entry tears were obliterated within 1 day (n = 3) or 1 week (n = 2) after stent placement and false lumina were thrombosed within 1 week (n = 3) or 1 month (n = 2). In group 2, entry tears and false lumina remained patent. Histologic specimens showed that the covered stents were entirely covered with smooth neointima.

CONCLUSIONS

This endoprosthesis offers an alternative to surgical treatment for dissections of the descending aorta.

New surgical method of chordal replacement for mitral valve incompetence with echocardiographic guidance. An experimental study

Chordal replacement with expanded polytetrafluorethylene suture has become a procedure of choice for repairing anterior leaflet prolapse among certain surgeons. However, most surgeons believe that the chordal replacement is too complicated and not reproducible. This report introduces a new method of chordal replacement using intraoperative epicardial and transesophageal echocardiography. Three dogs underwent the following procedures. One major marginal chorda of an anterior mitral leaflet was resected during cardiopulmonary bypass. A specially designed 3-0 polytetrafluoroethylene suture, having straight needles, was attached to the anterior leaflet by a mattress suture. Then the needles were brought from the root of the anterior papillary muscle to the outside of the left ventricle. After the bypass flow was reduced, both ends of the polytetrafluoroethylene suture were pulled under echocardiographic guidance until valve competence was achieved. At that point, the suture was temporarily tied. When cardiopulmonary bypass was discontinued, competence was again confirmed and the suture was tied permanently. When the procedures were completed, echocardiography showed trivial regurgitation and good pliability of the anterior leaflets in all animals. Left atrial pressures were sufficiently decreased. It appears that this new technique is reproducible for all surgeons because the optimal length of polytetrafluoroethylene chordae is determined with the valve functioning.

Clinical experience with Nikkiso centrifugal pumps for extracorporeal circulation

A comparative study of a newly developed impeller-type centrifugal pump, Nikkiso HMS-15, was made to assess the effects on hemolysis, platelet function, and renal function for extracorporeal circulation (ECC) during open heart surgery. The Bio-pump (cone-type, Medtronic) and the roller pump were used as controls. The increase of serum hemoglobin level in the Nikkiso pump was significantly lower than that in the other pumps. The decrease of platelet counts was recognized after the initiation of ECC in the three pumps whereas the levels of platelet factor 4 and beta-thromboglobulin in the Nikkiso pump group increased by far less than in the other two groups. Moreover, renal function was better maintained in the Nikkiso pump group; in particular, a significantly higher urine output was recorded during ECC and for 1 h after the termination of ECC. The results of our clinical studies suggest that the Nikkiso centrifugal pump is suitable for ECC during open heart surgery.

Treatment of acute aortic dissections with expandable metallic stents: experimental study

PURPOSE

This experimental study was designed to evaluate the effectiveness of metallic stents for the treatment of acute aortic dissection.

MATERIALS AND METHODS

Thoracic aortic dissections were created in 14 mongrel dogs. Aortography performed immediately after creation of dissections showed two types of aortic dissections: rapid flow in the false lumen (group 1) and slow flow in the false lumen (group 2). Each group consisted of seven dogs. For each group, expandable metallic Gianturco stents were placed in five dogs and two dogs were used as controls.

RESULTS

A week later, false lumina were patent in all dogs in group 1 and thrombosed in all dogs in group 2. In group 1, the mean diameter of the true lumina was considerably enlarged from 5.9 mm +/- 1.6 to 9.9 mm +/- 2.8 and that of the false lumina significantly diminished from 9.1 mm +/- 1.3 to 5.2 mm +/- 2.3 (P < .05) after stent placement. In group 2, the true lumina were significantly dilated (5.2 mm +/- 2.3 vs 12.3 mm +/- 3.1, P < .05) and the false lumina disappeared completely (9.2 mm +/- 3.3 vs 0.0 mm, P < .01). Furthermore, the two control dogs in group 2 died of visceral ischemia due to the compression of the true lumen by the thrombosed false lumina, but the dogs with stents showed no symptoms of the visceral ischemia.

CONCLUSION

Expandable metallic stents are not effective in obliterating the false lumen in acute aortic dissection but may be useful in maintaining the blood flow in the true lumen and avoiding visceral ischemia.

[Aggressive transformation of an indolent myeloma with abdominal extramedullary plasmacytoma after 6-year period of observation]

62-year-old female, who had been under observation for an indolent myeloma for six years without therapy, was admitted because of left flank pain. Various imaging modalities disclosed left pleural effusion, and a huge abdominal tumor involving the left crus of the diaphragm, spleen, stomach, pancreatic tail, left adrenal gland, left kidney and left posterior abdominal wall. Morphological and immunological examinations revealed extensive proliferation of more anaplastic myeloma cells within the tumor and in the pleural effusion than those in bone marrow on admission or at the beginning of the period of observation. Chemotherapy reduced serum M-protein, but LDH, the volume of the pleural effusion, and the size of the tumor increased. She died of pancreatitis associated with massive bleeding from the gastric tumor. Renal function was well preserved until her terminal phase. The clinical course showed the progression of indolent myeloma into an aggressive one without chemotherapeutic intervention, implying a rare subtype in terms of the natural history of multiple myeloma.