Diagnostic accuracy of adrenal venous sampling in comparison with other parameters in primary aldosteronism

This retrospective study was aimed 1) to compare the difference of the findings between adrenal CT scan and adrenal venous sampling (AVS) in 35 cases with definite primary aldosteronism (PA) for assessment of the diagnostic efficacy of PA subgroup (unilateral and bilateral adrenal hypersecretion: UAH and BAH), and 2) to determine the clinical and biochemical parameters as potential predictors for PA subgroup. There were significant discordant results based on AVS and CT scan in subgrouping PA; 9 of 17 BAH patients (53%) had unilateral lesion on CT scan, while 4 of 18 UAH patients (22%) had no apparent or bilateral lesions on CT scan. Among three diagnostic criteria, absolute values of plasma aldosterone concentration (PAC) in both adrenal veins, lateralized and contralateral ratios of aldosterone/cortisol after ACTH stimulation during AVS to determine the laterality, none of them showed 100% diagnostic accuracy if applied alone. Among several clinical and biochemical parameters, hypokalemia (<3.4 mEq/l), younger age (<52 y) and poor response of PAC (<1.45) after furosemide-upright posture, proved to be significant predictors for UAH, with higher specificities (100%, 88%, 94%, respectively). Therefore, despite AVS as a gold standard method to determine the laterality of aldosterone hypersecretion in PA, our study shows that no single criterion could provide definite diagnostic value for its laterality by AVS. It is also suggested that most PA patients, if not all, with a distinct unilateral adrenal lesion on CT accompanied by hypokalemia, younger age and poor aldosterone response to renin stimulation, could undergo adrenalectomy without prior AVS.

Aldosterone induces superoxide generation via Rac1 activation in endothelial cells

Currently, aldosterone is believed to be involved in the development of cardiovascular injury as a potential cardiovascular risk hormone. However, its exact cellular mechanisms remain obscure. This study was undertaken to examine the effect of aldosterone on superoxide production in cultured rat aortic endothelial cells with possible involvement of the small GTP-binding (G) protein Rac1. The aldosterone levels showed a time-dependent (6-24 h) and dose-dependent (10(-8) to 10(-6) m) increase in superoxide generation, whose effect was abolished by mineralocorticoid receptor antagonist (eplerenone), Src inhibitor (PP2), and reduced nicotinamide adenine dinucleotide phosphate [NAD(P)H] oxidase inhibitor (apocynin). Aldosterone activated NADP(H) oxidase and Rac1, whose effects were abolished by eplerenone. The aldosterone-induced superoxide generation was abolished either by nonselective small G protein inhibitor (Clostridium difficile toxin A) or dominant-negative Rac1. Dominant-negative Rac1 also inhibited aldosterone-induced ACE gene expression. Thus, the present study is the first to demonstrate that aldosterone induces superoxide generation via mineralocorticoid receptor-mediated activation of NAD(P)H-oxidase and Rac1 in endothelial cells, thereby contributing to the development of aldosterone-induced vascular injury.

Angiotensin II receptor type 1-mediated vascular oxidative stress and proinflammatory gene expression in aldosterone-induced hypertension: the possible role of local renin-angiotensin system

Recently, aldosterone has been shown to activate local renin-angiotensin system in vitro. To elucidate the potential role of local renin-angiotensin system in aldosterone-induced cardiovascular injury, we investigated the effects of selective mineralocorticoid receptor (MR) antagonist eplerenone (EPL), angiotensin (Ang) II type 1 receptor antagonist candesartan (ARB), and superoxide dismutase mimetic tempol (TEM) on the development of hypertension, vascular injury, oxidative stress, and inflammatory-related gene expression in aldosterone-treated hypertensive rats. The increased systolic blood pressure and vascular inflammatory changes were attenuated by cotreatment either with EPL, ARB, or TEM. Aldosterone increased angiotensin-converting enzyme expression in the aortic tissue; its effects were blocked by EPL but not by ARB or TEM. Aldosterone also increased Ang II contents in the aortic tissue in the presence of low circulating Ang II concentrations. Aldosterone induced expression of various inflammatory-related genes, whose effects were abolished by EPL, whereas the inhibitory effects of ARB and TEM varied depending on the gene. Aldosterone caused greater accumulation of the oxidant stress marker 4-hydroxy-2-neonenal in the endothelium; its effect was abolished by EPL, ARB, or TEM. Aldosterone increased mRNA levels of reduced nicotinamide adenine dinucleotide phosphate oxidase components; their effect was abolished by EPL, whereas ARB and TEM decreased only the p47phox mRNA level but not that of p22phox or gp91phox. The present findings suggest that the Ang II-dependent pathway resulting from vascular angiotensin-converting enzyme up-regulation and Ang II-independent pathway are both involved in the underlying mechanisms resulting in the development of hypertension, vascular inflammation, and oxidative stress induced by aldosterone.

Angiotensin II induces monocyte chemoattractant protein-1 expression via a nuclear factor-kappaB-dependent pathway in rat preadipocytes

Both monocyte chemoattractant protein-1 (MCP-1), a member of chemokine family, and angiotensinogen, a precursor of angiotensin (ANG) II, are produced by adipose tissue and increased in obese state. MCP-1 has been shown to decrease insulin-stimulated glucose uptake and several adipogenic genes expression in adipocytes in vitro, suggesting its pathophysiological significance in obesity. However, the pathophysiological interaction between MCP-1 and ANG II in adipose tissue remains unknown. The present study was undertaken to investigate the potential mechanisms by which ANG II affects MCP-1 gene expression in rat primary cultured preadipocytes and adipose tissue in vivo. ANG II significantly increased steady-state MCP-1 mRNA levels in a time- and dose-dependent manner. The ANG II-induced MCP-1 mRNA and protein expression was completely abolished by ANG II type 1 (AT1)-receptor antagonist (valsartan). An antioxidant/NF-kappaB inhibitor (pyrrolidine dithiocarbamate) and an inhibitor of 1kappaB-alpha phosphorylation (Bay 11-7085) also blocked ANG II-induced MCP-1 mRNA expression. ANG II induced translocation of NF-kappaB p65 subunit from cytoplasm to nucleus by immunocytochemical study. Luciferase assay using reporter constructs containing MCP-1 promoter region revealed that two NF-kappaB binding sites in its enhancer region were essential for the ANG II-induced promoter activities. Furthermore, basal mRNA and protein of MCP-1 during preadipocyte differentiation were significantly greater in preadipocytes than in differentiated adipocytes, whose effect was more pronounced in the presence of ANG II. Exogenous administration of ANG II to rats led to increased MCP-1 expression in epididymal, subcutaneous, and mesenteric adipose tissue. In conclusion, our present study demonstrates that ANG II increases MCP-1 gene expression via ANG II type 1 receptor-mediated and NF-kappaB-dependent pathway in rat preadipocytes as well as adipose MCP-1 expression in vivo. Thus the augmented MCP-1 expression by ANG II in preadipocytes may provide a new link between obesity and cardiovascular disease.

A case of estrogen-secreting adrenocortical carcinoma with subclinical Cushing's syndrome

A 25-year-old man was found to have a large right adrenal mass detected by abdominal echography and computed tomography, and presented with a mild gynecomastia. Endocrine study showed increased serum concentrations and urinary excretion of estrogens and dehydroepiandorosterone sulfate (DHEA-S). The patient had no Cushingoid features but autonomous cortisol secretion, compatible with the diagnosis of subclinical Cushing's syndrome. Surgical removal of the adrenal tumor led to normalization of serum and urinary excretion of estrogens and DHEA-S. Histopathological examination revealed a high-grade adrenocortical carcinoma (ACC). The disorganized expression of all the steroidogenic enzymes in individual tumor cells was demonstrated by immunohistochemical analysis, and the abundant expression of both aromatase mRNA and insulin-like growth factor (IGF)-II mRNA was shown by RT-PCR. These data suggest the excessive secretion of estrogen as well as the ineffective steroidogenesis by the adrenal tumor. This is a very rare case of estrogen-secreting ACC associated with subclinical Cushing's syndrome.

Olfactory neuroblastoma causing ectopic ACTH syndrome

A 39-year-old woman who presented with typical Cushingoid appearance (moon facies, central obesity, purpura) was admitted to our hospital because of pulmonary infection. She was found to have hypertension, severe hypokalemia, and metabolic alkalosis. Endocrine data revealed elevated plasma levels of ACTH and cortisol with lack of circadian rhythm, non-suppressibility to high-dose dexamethasone, and hyperresponsiveness to CRH stimulation. Although no pituitary mass was detected by MRI of the brain, inferior petrosal sinus sampling showed a step-up of central to peripheral ACTH levels; these data are consistent with the diagnosis of Cushing's disease. She was successfully treated with metyrapone to control hypercortisolemia. Ten months later, a mass was detected in the ethmoid sinus, which was surgically removed. After resection of the ethmoid sinus tumor, her Cushingoid features and hypercortisolemia disappeared, but recurred after enlargement of a second mass in the maxillary sinus. After resection of the maxillary sinus tumor, her hypercortisolemia subsided. Histologically, the tumor tissues from both the ethmoid and maxillary sinus were identical and consistent with the diagnosis of olfactory neuroblastoma. Immunohistochemically, the immunoreactivities of ACTH and POMC were positive in the cytoplasm of tumor cells, and immunoreactive ACTH was demonstrated in both tumor tissues. Thus, this is the second rare case with ectopic ACTH syndrome caused by olfactory neuroblastoma thus far reported.

Aldosterone increases osteopontin gene expression in rat endothelial cells

Aldosterone is currently recognized as one of the important risk hormones for cardiovascular disease. However, the cellular mechanism by which aldosterone affects the process of cardiovascular injury has not been well understood. In the present study, we investigated whether aldosterone induces pro-inflammatory genes expression in rat aortic endothelial cells. Aldosterone significantly increased steady-state osteopontin mRNA and protein levels, but not those of adhesion molecules or chemokine. The stimulatory effect of aldosterone on osteopontin expression was time-dependent (3-24h) and dose-dependent (10(-10)-10(-6)M), and abolished by a mineralocorticoid receptor (MR) antagonist spironolactone, but not by a glucocorticoid receptor antagonist RU486. The aldosterone-induced osteopontin mRNA expression was completely blocked by a transcription inhibitor, actinomycin D, and a protein synthesis inhibitor, cycloheximide. Thus, the present study demonstrated for the first time that aldosterone directly acts on endothelial cells to induce osteopontin gene expression via MR-mediated genomic action, which may be responsible for the initiation of inflammation and fibrosis in cardiovascular tissue induced by aldosterone.

Aldosterone induces angiotensin converting enzyme gene expression via a JAK2-dependent pathway in rat endothelial cells

Aldosterone is currently recognized as a risk hormone for cardiovascular disease. However, the cellular mechanism by which aldosterone acts on vasculature has not been well understood. In the present study, we investigated whether aldosterone affects angiotensin-converting enzyme (ACE) gene expression in rat endothelial cells. Cultured rat aortic endothelial cells (RAECs) from Sprague-Dawley rats were used in the study. ACE mRNA levels and its enzyme activities in RAECs were examined by real-time RT-PCR and enzyme assay using hippuryl-His-Leu as substrates, respectively. Aldosterone significantly increased steady-state ACE mRNA levels and its enzymatic activities. This effect was dose dependent and time dependent and abolished by mineralocorticoid receptor antagonist spironolactone or transcription inhibitor actinomycin D. Dexamethasone also increased steady-state ACE mRNA levels, whose effect was completely blocked by glucocorticoid receptor antagonist RU486, but not by spironolactone. By contrast, the aldosterone-induced ACE mRNA expression was only partially blocked by RU486. The stimulatory effect of aldosterone on ACE mRNA expression was completely blocked by a protein tyrosine kinase inhibitor (genistein) and JAK2 inhibitor (AG490), partially by Src kinase inhibitor (PP2) and epidermal growth factor receptor kinase inhibitor (AG1478), but not by platelet-derived growth factor receptor kinase inhibitor (AG1296). Transfection of dominant-negative JAK2 construct, but not wild-type construct, significantly blocked the aldosterone-induced ACE mRNA up-regulation. Furthermore, aldosterone induced phosphorylation of JAK2, whose effect was blocked by spironolactone and actinomycin D. In conclusion, the present study demonstrates for the first time that aldosterone induces ACE gene expression and its enzyme activity mainly via a mineralocorticoid receptor-mediated and JAK2-dependent pathway in rat endothelial cells. This may constitute a positive feedback loop for a local renin-angiotensin system, possibly involved in the development of aldosterone-induced endothelial dysfunction and vascular injury.

A case with primary aldosteronism due to unilateral multiple adrenocortical micronodules

A 46-year-old male with long-term treatment-resistant hypertension and past history of cerebral hemorrhage was found to have suppressed plasma renin activity (PRA) and normal plasma aldosterone concentration (PAC) with aldosterone/renin ratio of 25.3. Furosemide plus upright test did not stimulate PRA, but computed tomography scan of the abdomen revealed no abnormal lesions in either adrenal gland. Selective adrenal venous sampling (SAVS) showed that PAC in the left and the right adrenal vein were 1000 ng/dl and 230 ng/dl, respectively, which increased to 1500 ng/dl and 620 ng/dl, respectively, after ACTH stimulation. Diagnosis of primary aldosteronism due to hypersecretion of aldosterone from the left adrenal gland was made, and laparoscopic left adrenalectomy was performed. Pathological examination of the 'apparently normal' adrenal tissue resected revealed the presence of poorly encapsulated multiple adrenocortical micronodules which showed positive immunoreactivity for 3beta-hydroxysteroid dehydrogenase by immunohistochemical study, but negative immunoreactivity in the hyperplastic zona glomerulosa consistent with paradoxical hyperplasia associated with primary aldosteronism. Postoperatively, PRA was normalized and his high blood pressure was well controlled with lower doses of antihypertensive drugs than those used before surgery. The clinicopathological features of our case are consistent with the diagnosis of unilateral multiple adrenocortical micronodules (UMN), a new subset of primary aldosteronism, in which SAVS proved to be a useful diagnostic tool for its localization.

The peroxin Pex14p. cDNA cloning by functional complementation on a Chinese hamster ovary cell mutant, characterization, and functional analysis

Rat cDNA encoding a 376-amino acid peroxin was isolated by functional complementation of a peroxisome-deficient Chinese hamster ovary cell mutant, ZP110, of complementation group 14 (CG14). The primary sequence showed 28 and 24% amino acid identity with the yeast Pex14p from Hansenula polymorpha and Saccharomyces cerevisiae, respectively; therefore, we termed this cDNA rat PEX14 (RnPEX14). Human and Chinese hamster Pex14p showed 96 and 94% identity to rat Pex14p, except that both Pex14p comprised 377 amino acids. Pex14p was characterized as an integral membrane protein of peroxisomes, exposing its N- and C-terminal parts to the cytosol. Pex14p interacts with both Pex5p and Pex7p, the receptors for peroxisome targeting signal type 1 (PTS1) and PTS2, respectively, together with the receptors' cargoes, PTS1 and PTS2 proteins. Mutation in PEX14 from ZP161, the same CG as ZP110, was determined by reverse transcription-PCR as follows. A 133-base pair deletion at nucleotide residues 37-169 in one allele created a termination codon at 40-42; in addition to this mutation, 103 base pairs were deleted at positions 385-487, resulting in the second termination immediately downstream the second deletion site in the other allele. Neither of these two mutant forms of Pex14p restored peroxisome biogenesis in ZP110 and ZP161, thereby demonstrating PEX14 to be responsible for peroxisome deficiency in CG14.

Anomalous union of the pancreaticobiliary ductal system without dilation of the common bile duct or tumor: case reports and literature review

Among 698 patients subjected to endoscopic retrograde cholangiopancreatography, an anomalous union of the pancreaticobiliary ductal system (AUPBD) was found in 6 patients (0.9%). One of these 6 patients had an associated congenital choledochal cyst, and 4 did not. Two of these 4 patients, however, had advanced gallbladder cancer. The remaining 2 patients had no associated carcinoma of the biliary tract. A clinicopathological study was performed on these 2 patients and 26 such cases have been reported in the literature. The diagnosis of AUPBD was made by direct cholangiography. Regarding the type of union, the Pancreatic-Biliary type was present in 15 of 18 (83.3%) of these patients. Fifteen of 28 patients (53.6%) had right upper abdominal pain. Thickness of the gallbladder wall was visualized in 26 of the 28 (92.9%) patients. Gallstones were present in 4 (14.3%). AUPBD should always be kept in mind when a patient with abdominal pain is diagnosed as having gallbladder wall thickness without gallstones. ERCP should be performed in these patients in order to detect AUPBD without dilation of the bile duct. This may allow early detection of carcinoma of the biliary tract.

Amplification of the c-met, c-erbB-2 and epidermal growth factor receptor gene in human gastric cancers: correlation to clinical features

We examined amplification of the c-met, c-erbB-2, and epidermal growth factor receptor (EGFR) gene in the patients with primary gastric cancer, and compared the data with clinical features in order to clarify the relationship between oncogenic abnormality and clinical features. Oncogene amplifications were examined by slot blot hybridization using DNAs extracted from formalin-fixed and paraffin-embedded tissues of primary gastric cancers. Seven of the seventy cancers (10.0%) had c-met gene amplification, nine (12.9%) had c-erbB-2 gene amplification, and six (8.6%) had EGFR gene amplification, respectively. Eighteen cases (25.7%) exhibited one or multiple oncogene amplification, and two cases (2.9%) exhibited simultaneous amplification of the three genes. The cases with c-met gene amplification tend to show invasive character and were related to peritoneal dissemination. The cases with c-erbB-2 gene amplification were related to lymph node metastasis. The cases with EGFR gene amplification had large tumors and were in highly advanced stage. The survival rate in patients with oncogene amplification was significantly lower than that in patients without amplification. Our data indicated that these genes were related to growth and metastasis of gastric cancer. Furthermore, this study about the three genes suggested that the type of activated gene might decide on the type of metastasis and clinical features.

The relation between the growth patterns of gastric carcinoma and the expression of hepatocyte growth factor receptor (c-met), autocrine motility factor receptor, and urokinase-type plasminogen activator receptor

BACKGROUND

Hepatocyte growth factor receptor (c-met), autocrine motility factor receptor (AMFR), and urokinase-type plasminogen activator receptor (uPAR) are known to play important roles in tumor cell migration, invasion, and metastasis. The authors studied the relation between the expression patterns of these genes and the growth patterns of human gastric carcinoma.

METHODS

The relation between the expression of c-met, AMFR, and uPAR and clinicopathologic parameters was studied using immunohistochemical preparations from 102 paraffin embedded primary gastric carcinomas.

RESULTS

Of 102 cases, 43 (42%) had overexpression of c-met, and AMFR and uPAR immunoreactivity was observed in 41 cases (40%) and 38 cases (37%), respectively. Macroscopic examination revealed that all three genes were expressed in 1 (3%) of 32 early stage gastric carcinomas, 0 (0%) of 29 localized carcinomas (Borrmann types 1 and 2), and 16 (39%) of 41 infiltrating carcinomas (Borrmann types 3 and 4). In particular, the incidence (68%, 13 of 19 cases) of simultaneous expression of the three genes was significantly higher in Borrmann type 4 gastric carcinoma than in the other macroscopic types (P < 0.01). The overexpression of these genes was also closely associated with lymph node metastasis and peritoneal dissemination. In addition, the simultaneous overexpression of the three genes was associated with positive lymphatic vessel invasion and infiltrating type. Patients with tumors that simultaneously expressed all three genes had significantly poorer prognoses than those with tumors expressing only one or two of the genes. Furthermore, the number of genes expressed was closely related to the prognosis, and the Cox proportional hazards model identified this as one of the independent prognostic factors.

CONCLUSIONS

These results suggest that the expression patterns of c-met, AMFR, and uPAR may be closely associated with the progression and invasion of gastric carcinoma as well as the prognoses of the patients. Borrmann type 4 gastric carcinoma is characterized by the diverse and simultaneous expression of these three genes.

Double cystic duct found by intraoperative cholangiography in laparoscopic cholecystectomy

We report a rare case of double cystic duct in a 74-year-old woman. The patient complained of mild epigastric discomfort, and several stones were discovered by ultrasonography and computed tomography. Any anomalies of the biliary tract were undetectable in the preoperative examinations without direct cholangiography. Laparoscopic cholecystectomy was performed. After clipping the cystic duct close to the gallbladder, as usual, serial intraoperative cholangiography was performed and unexpectedly showed the inflow of contrast medium into the gallbladder via another cystic duct arising from the right hepatic duct, thus revealing one gallbladder and two cystic ducts, one of which joined the common hepatic duct and the other the right hepatic duct. There was only one cystic artery that arose from the right hepatic artery and accompanied the primary cystic duct to be distributed to the gallbladder. The existence of contrast medium in the resected specimen was confirmed by radiography. No complications occurred during or after laparoscopic cholecystectomy. This is the first report of double cystic duct found in laparoscopic cholecystectomy. We recommend routine preoperative or intraoperative cholangiography.

Expression of autocrine motility factor receptor correlates with disease progression in human gastric cancer

Up-regulation of autocrine motility factor receptor (AMF-R) expression has been shown to be associated with invasion and metastasis of experimental tumour systems and human neoplasms. Monoclonal antibodies against AMF-R (gp78) were used to stain 221 primary gastric cancer specimens, and level of expression was examined in relation to pathological stage and prognostic values. In 125 out of 221 (56.6%) patients, gp78 was detected. Expression of gp78 was associated with macroscopic type, lymphatic and venous invasions, and lymph node and peritoneal metastasis. The level of gp78 expression in the cancer specimens was associated with histopathological stage and grade of tumour penetration. Positive gp78 expression was significantly associated with poor prognosis (P < 0.001). This significant relationship remained among patients in stage II and III. The results suggest that gp78 expression could be used as a prognostic marker in gastric cancer patients.

[Chemohyperthermic peritoneal perfusion and high-dose chemotherapy followed by peripheral blood stem cell transplantation in advanced colon cancer--a case report]

A 49-year-old woman who suffered from caecal cancer in 1988 underwent chemohyperthermic peritoneal perfusion for peritoneal and ovarian metastases in 1990, and high dose chemotherapy (HDC) with peripheral blood stem cell transplantation (PBSCT) for lung metastases in 1995. Heated saline containing anticancer drugs such as cisplatin, mitomycin C, etoposide (ETP), and pirarubicin, was intraperitoneally perfused at 43 degrees C for 60 minutes. The CD34 positive cells were mobilized by intravenous 500 micrograms G-CSF administration on five consecutive days. These cells were transplanted three days after the last day in the course of HDC, which included intravenous administration of 475 mg carboplatin, 2,020 mg cyclophosphamide, and 540 mg etoposide. The patient has survived with no sign of the disease.

Decreased expression of p16 gene in gastric cancer

We analyzed gastric cancers for p16 gene alterations. Homozygous deletion of the p16 gene was found in 1 of 8 gastric cancer cell lines and none of 20 primary gastric cancers. Mutations of the p16 gene were not detected in exon 1-3. Reverse transcription-polymerase chain reaction (RT-PCR) analysis showed decreased or no expression of the p16 gene in 1 of 8 cell lines (12.5%) and in 8 of 20 tumors (40%), although no homozygous deletions or mutations within exon 1-3 were detected. These results suggest that the p16 gene may correlate to tumorigenesis due to decrease or loss of gene products in gastric cancers.

Cytoreductive surgery and sandwich therapy with chemohyperthermic peritoneal perfusion and intra-aortic chemotherapy for peritoneal dissemination in gastric cancer

Cytoreductive resection (RST), chemohyperthermic peritoneal perfusion (CHPP) and/or intra-aortic chemotherapy (IA-chemo) were performed for peritoneal dissemination in gastric cancer. Ninety-six patients with peritoneal dissemination were grouped into tubercular (TB), 40; nodular (ND), 31; diffuse (DF) type, 19; and others, 6, respectively, by the gross findings. Sixty-three patients underwent RST. Fifty-nine patients received CHPP by 10-liter heated saline. Thirty patients underwent intra-aortic catheterization for the IA-chemo. The 1-year and 2-year survival rate (1-ysr and 2-ysr) of the RST(+) group were 47% and 10% significantly greater than the 9% and 0% of the RST(-) group (p<0.001). The 1-ysr and 2-ysr of the CHPP(+) group were 37% and 11% significantly greater than the 27% and 0% of the CHPP(-) group (p=0.04). In the TB type the 1-ysr and 2-ysr of the former was 43% and 8% significantly greater than the 15% and 0% of the latter (p=0.04). But there was no significant difference in survival time between the CHPP(+) and the CHPP(-) group in the ND type (p=0.22) or in the DF type (p=0.42). The 1-ysr and 2-ysr of the IA-chemo(+) group were 49% and 19% significantly greater than the 27% and 2% of the IA-chemo(-) group (p<0.01). In the DF type the 1-ysr and 2-ysr of the former was 50% and 33% significantly greater than the 8% and 0% of the latter (p=0.02). However, there was no significant difference in survival time between the IA-chemo(+) and the IA-chemo(-) group in the TB type (p=0.06) or in the ND type (p=0.50). Moreover, the effect of the combination therapy of CHPP and IA-chemo (the sandwich therapy, SDW) were examined. The 1-ysr and 2-ysr of the SDW(+) group were 49% and 22% significantly greater than the 24% and 0% of the SDW(-) group (p=0.002). The sandwich therapy should be performed in addition to cytoreductive surgery for improvement of prognosis in the patient with intractable peritoneal dissemination.

Correlation between overexpression of c-met gene and the progression of gastric cancer

The c-met oncogene encodes a receptor of hepatocyte growth factor (HGF), which has both mitogenic and motogenic activities. We have studied the c-met gene expression in gastric cancer by immunohistochemical method using an antibody specific to the c-met beta-chain. c-met immunoreactivity was preferentially localize on the cell membrane, and 55 (43%) of 127 primary gastric cancers showed c-met immunoreactivity. Strong correlation was found between c-met expression in large tumors, lymph node involvement, serosal invasion, as well as peritoneal dissemination. Furthermore, c-met positive tumors had a tendency to metastasize to more distant lymph node sites. Regarding the macroscopic type, Borrmann type 4 gastric cancer showed the highest incidence (12/16, 76%) of positive c-met expression. Patients with c-met positive tumor ran a significantly poorer prognosis than those with c-met negative one. These results indicate that the c-met protein participates in the progression and invasion of stomach cancer, and that c-met tissue status is a useful biological marker in gastric cancer.

[Chemohyperthermic peritoneal perfusion and subtotal peritonectomy for peritonitis carcinomatosa in gastroenteric cancer]

A new operative procedure, called subtotal peritonectomy (SP), in combination with chemohyperthermic peritoneal perfusion, was developed for the treatment of peritonitis carcinomatosa in gastrointestinal cancer. SP includes resection of primary lesion, colon, small bowel, spleen, and gall bladder and parietal peritonectomy. Six patients with gastric cancer and two patients with colon cancer underwent these procedures. A great deal of discharge from the peritoneal cavity, an increase in systemic vascular resistance index, and a decrease in central venous pressure represented much decrease in circulatory volume on days 1 to 2 postoperatively. This state improved at 3 to 4 days after operation. Histopathological study revealed multiple peritoneal seedings with negative surgical margins in all patients. There were no related deaths though bleeding, perforation, and abscess occurred in two patients each. One patient died of peritoneal recurrence after one year, but the other have survived.

Amplification of epidermal growth factor receptor gene and its relationship to survival in human gastric cancer

The correlation between the clinical features in 103 patients with primary gastric carcinoma and amplification of epidermal growth factor receptor (EGFR) gene was analyzed retrospectively. EGFR gene amplification was examined by slot-blot hybridization using DNA extracted from formalin-fixed, paraffin-embedded tissues. EGFR expression was also examined immunohistochemically using the same tissues with a monoclonal antibody that is monospecific for EGFR. In 5 of 103 cases (4.9%), a 2- to 11-fold amplification of EGFR gene was detected. Four of these 5 cases were poorly differentiated adenocarcinomas. All of them had overexpressions of EGFR. The cumulative survival rate of patients with EGFR gene amplification was significantly lower than that of the patients without amplification (p < 0.05) and all of them died within 3 years. Except for tumor size (p < 0.03), there were no significant clinicopathologic differences between the two groups. On the other hand, 41 of 103 cases (39.8%) exhibited expression of EGFR. However, there was no significant correlation between EGFR expression and clinicopathologic factors or prognosis. These results indicate that EGFR gene amplification may occur in advanced stages during the progression and be an important indicator of poor short-term prognosis in gastric carcinoma.

Prophylaxis with intraoperative chemohyperthermia against peritoneal recurrence of serosal invasion-positive gastric cancer

Continuous hyperthermic peritoneal perfusion (CHPP) with a solution which contains 30 mg mitomycin C and 300 mg cisplatin has been introduced as a prophylactic treatment for peritoneal recurrence after curative resection of 79 advanced gastric cancers. The control group consisted of 81 patients with advanced gastric cancer who underwent curative surgery during the same period. CHPP was performed for 60 minutes by perfusing MMC- and CDDP-containing saline solutions warmed at 43.5 degrees C by a special CHPP device. In patients with pathologically confirmed serosal invasion-positive tumors, the survival rate of the CHPP group was significantly higher than that of the control group. A survival advantage for stage IV patients was also obtained by CHPP. However, there was no survival advantage between the CHPP group and the control group with serosal invasion-negative tumors. Adverse effects were observed in four patients who underwent CHPP: One developed severe bone marrow suppression, and transient hyperazotemia was observed in the other three. There was no difference in the incidence of mortality and morbidity between the two groups. These results indicate that CHPP is a safe, readily available prophylactic therapy for peritoneal recurrence after gastric cancer surgery.

Continuous hyperthermic peritoneal perfusion for the prevention of peritoneal recurrence of gastric cancer: randomized controlled study

We performed continuous hyperthermic peritoneal perfusion (CHPP) or continuous normothermic peritoneal perfusion (CNPP) combined with cisplatin (CDDP) 300 mg/kg and mitomycin C (MMC) 30 mg/kg in an attempt to prevent peritoneal recurrence after surgery for gastric cancer. Twenty-two patients were treated with perfusion using about 10 liters of saline heated to 41 degrees to 42 degrees C (CNPP group); 18 patients were treated with saline heated to 37 degrees to 38 degrees C (CNPP group); and 18 patients underwent only gastric surgery without perfusion (control group) in a randomized control study. There were two deaths (9%) due to peritoneal recurrence in the CHPP group, four (22%) in the CNPP group, and four (22%) in the control group. The 1-, 2-, and 3-year survival rates were 95%, 89%, and 68%, in the CHPP group; 81%, 75%, and 51%, in the CNPP group; and 43%, 23%, and 23%, in the control group, respectively. There was a significant difference between the three survival curves by the log-rank test (p < 0.01). This difference showed that CNPP and CHPP are both effective procedures for preventing peritoneal recurrence. The maximum concentrations in the perfusate of total and free CDDP with 300 mg administration were 12.2 and 10.1 micrograms/ml, respectively, at the end of the perfusion, and the maximum concentrations of total and free CDDP in plasma were 2.1 and 1.0 micrograms/ml, respectively. The maximum concentrations of MMC in perfusate and plasma with 30 mg administration were 1.00 and 0.05 micrograms/ml, respectively, which are intraperitoneally cytotoxic but systemically safe concentrations.

Correlation between altered expression of retinoblastoma protein and clinical outcome in patients with gastric-cancer

We studied the expression of RB protein in 136 endoscopically obtained biopsied materials from primary gastric cancers by means of immunohistochemistry. The expression of RB protein was variably observed in the nuclei of tumor cells. Tumors could be divided into two groups. Group 1 (RB-positive) comprised 74 tumors (54%) that expressed RB protein in 20% or more of tumor cells, and Group 2 (altered RB) included 62 tumors (46%) that showed RB immunoreactivity in less than 20% of tumor cells. RB-positive tumors (Group 1) were more frequently observed in the early cancers (74%, 28/38) than in advanced ones (48%, 46/98). The incidence of distant metastases was higher and involvement of serosa or lymph nodes was more frequently observed in Group 2 than in Group 1. In addition, patients of Group 1 survived significantly longer than those of Group 2 (p<0.05). However, no correlation could be found between RB tissue status and proliferative activity. These results indicate that tumors with decreased RB-protein expression may have more aggressive biological behavior than tumors showing high expression of this protein.

Prediction of the prognosis of patients with gastric-cancer by erbb-2 tissue status and expression of proliferating cell nuclear antigen

Correlation between erbB-2 tissue status and expression of proliferating cell nuclear antigen (PCNA) was studied in 164 gastric carcinomas, and these results were compared with the risk of metastasis and prognosis. Thirty-one (19%) tumors showe evidence of erbB-2 protein expression, and the PCNA index ranged from 8.2% to 77.2% (mean; 40%). erbB-2 protein positive tumors were most often encountered in the following clinicopathological groups: tumors with serosal invasion, lymph node metastasis, and venous invasion. There was a significant correlation between PCNA index and lymph node metastasis. In addition, erbB-2 positive tumors showed significantly higher PCNA index than erbB-2 negative tumors. Cox prortional hazard model identified lymph node metastasis. In invasion, liver metastasis, and erbB-2 tissue status as independent prognostic factors, but PCNA index was not an independent prognostic factor. However, by combining erbB-2 tissue status and PCNA index, PCNA index. was a good prognostic factor particularly in patients with erbB-2 negative tumors. These results indicate that the determination of erbB-2 tissue status, when combined with PCNA index, may be useful in the prediction of the prognosis and in deciding the therapeutic schedule of patients with gastric cancer.

[Correlation of DNA ploidy, c-erbB-2 protein tissue status, level of PCNA expression and clinical outcome in gastric carcinomas]

One-hundred and sixty-four patients with gastric carcinomas, who underwent gastrectomy during 1979-1985, were studied. Sixty-five of these cases were early gastric carcinomas, and the others were advanced gastric carcinomas, and the others were advanced gastric carcinomas. The nuclear DNA contents were measured by cytofluorometry, and immunohistochemical study on the expression of c-erbB-2 protein was performed using a monoclonal antibody against the c-erbB-2 oncogene product. Furthermore, immunohistochemical detection of proliferating cell nuclear antigen (PCNA) was performed using a monoclonal antibody against the PCNA. The rates of positive invasion beyond submucosal layer, lymphatic invasion, and vascular invasion in aneuploid cases were significantly higher than those in diploid ones, and the patients with aneuploid tumor had a significantly worse prognosis than those with diploid tumor. The rates of positive lymph node metastases and invasion beyond submucosal layer in the group with positive staining of the c-erbB-2 protein was significantly higher than in the negative group, and the group with positive staining for c-erbB-2 had a significantly worse prognosis than the negative one. PCNA indices showed a significant correlation with lymph node metastasis, and the group with higher PCNA indices had a worse prognosis. The patients with tumor showing both aneuploid and positive staining for c-erbB-2 protein, had the worst prognosis. There is a relationship between c-erbB-2 tissue status and PCNA indices, but no correlations were found among c-erbB-2 tissue status, PCNA indices and DNA contents. From these results, it can be concluded that DNA ploidy, c-erbB-2 protein, and PCNA may reflect the malignant potential of gastric carcinoma.

Chicken leg muscle alpha-connectin as studied by a monoclonal antibody to the 1200 kDa fragment

Chicken leg gracilis muscle contained only alpha-connectin (ca 3000 kDa) without beta-connectin. When myofibrils were kept standing for 20 hr at 4 degrees C, alpha-connectin was degraded to beta-connectin (ca 2000 kDa) and 1200 kDa peptide. The latter was prepared from myofibrils and purified by gel filtration in the presence of SDS. A monoclonal antibody, alpha 7, to this 1200 kDa fragment was prepared. The antibody reacted with the 1200 kDa fragment and its mother molecule alpha-connectin, but not with beta-connectin. Immunoelectron microscopy using alpha 7, as well as other antibodies to chicken breast muscle beta-connectin, revealed that the 1200 kDa peptide covered the portion of alpha-connectin from the Z line to the N2 line region in the I band of chicken leg gracilis muscle sarcomeres. The results were in good agreement with those observed in rabbit skeletal muscle.

DNA polymerase alpha positive-cell rate in colorectal cancer and its relationship to prognosis

A total of 63 patients with colorectal cancer were studied for proliferative activity by an immunohistochemical technique using a monoclonal antibody against DNA polymerase alpha. The DNA polymerase alpha positive cell rates ranged from 24.0% to 74.6%. There was a correlation between the DNA polymerase alpha positive cell rates of biopsies and resected specimens. There was no significant correlation between DNA polymerase alpha positive cell rates and histological type, tumour size, invasion of bowel wall, lymphatic invasion, venous invasion, lymph node metastasis or peritoneal metastasis. Tumours with a high growth fraction (a DNA polymerase alpha positive cell rate greater than or equal to 42%) were more frequently associated with liver metastasis than those with a low growth fraction (a DNA polymerase alpha positive cell rate less than 42%). Patients with high growth fraction tumours had significantly poorer prognoses than those with low growth fraction tumours. The results of multivariate analysis using the proportional hazard model of Cox indicated that the DNA polymerase alpha positive cell rates, liver metastasis, and peritoneal metastasis were independent prognostic factors. The results indicate that the DNA polymerase alpha positive cell rate may be a useful prognostic marker of colorectal cancers.

Localization of beta-actinin in the Z lines of chicken breast muscle, as detected with a monoclonal antibody specific to the beta I subunit (Cap Z alpha)

Immunofluorescence microscopy showed that a monoclonal antibody, 2F3, specific to the beta I subunit (Cap Z alpha) of beta-actinin (Cap Z) bound to the Z lines of chicken breast muscle. When myofibrils were briefly extracted with 0.6 M KI, the reactivity of the Z lines with 2F3 was very weak, but on subsequent treatment with purified beta-actinin, the antibody binding recovered. beta-Actinin inhibited elongation of the actin filaments of isolated I-Z-I brushes, myosin-extracted sarcomeres, on the addition of G-actin. However, when an increased concentration of G-actin was added, the inhibitory action of beta-actinin became negligible, suggesting that beta-actinin did not cap the pointed end of an actin filament in a myofibril.

Observation of the external aperture of the vestibular aqueduct using three-dimensional surface reconstruction imaging

Observation of the external aperture of the vestibular aqueduct was hitherto possible only in cadavers or dry temporal bones; however, by applying three-dimensional surface reconstruction imaging, it is now possible to observe solid-looking images of this structure in living humans. When the width of the external aperture of the vestibular aqueduct was measured in 58 people, it was found to be significantly narrower in the affected ears of patients with Meniere's disease than in normal ears.

A monoclonal antibody to the phosphorylated form of glial fibrillary acidic protein: application to a non-radioactive method for measuring protein kinase activities

Monoclonal antibody YC10 showed specificity for the phosphorylated form of human, bovine and porcine glial fibrillary acidic proteins (GFAPs) and negligible reactivity towards the dephosphorylated form of the GFAPs. Analysis of species specificity and of the epitope, determined using synthetic phosphopeptides, indicated that this antibody recognized the local phosphorylation-site sequence Thr-phosphoSer-Ala-Ala-Arg-Arg (residues 7-12 of GFAP). Making use of this antibody we developed a non-radioactive method to measure protein kinase activities. After incubation of a protein kinase with non-radioactive ATP in ninety-six wells coated with the synthetic peptide Arg-Arg-Arg-Val-Thr-Ser-Ala-Ala-Arg-Arg-Ser-Cys (residues 3-13 of GFAP), the phosphorylated product was detected by using this mouse antibody and peroxidase-labeled goat anti-mouse IgG. This method proved to be equally as sensitive as the radioactive method for the measurement of protein kinase activities and was less affected by concentrations of ATP present in the reaction mixture.

Middle-ear paraganglioma masquerading as traumatic facial nerve palsy

We report the case of a 52-year-old female with middle-ear paraganglioma masquerading as a traumatic facial palsy, and describe the diagnostic steps and surgical treatment by the tympanomastoid approach.

[Report of a case--adenoma of the middle ear]

A 44-year-old female with adenoma of the middle ear was reported. Her chief complaint was hearing loss in the right ear. A white mass inside the right external auditory canal was observed. Audiometry revealed a combined deafness with the average hearing of 38.3 dB for the speech frequencies. The study by high resolution X-ray CT revealed a density area as like as a soft mass in the tympanic cavity. A tumor existing mainly in the hypotympanum was surgically removed and modified type III tympanoplasty by interposing the malleus head as an autograft as a columella was done. Postoperative course was good and the average hearing improved slightly to 30 dB. Histopathological study with stains of HE, PAS, mucicarmin, colloid iron, NSE and S-100 protein showed adenoma of the middle ear.

Expression of DNA polymerase alpha and Leu3a molecules in growing and saturated cultures of human leukemic cells: phenotype analysis of proliferative cells by flow cytometry

A flow cytometric method to analyze phenotypes of proliferative cells was developed using human leukemic cell line MOLT 4. A nuclear protein, DNA polymerase alpha (pol alpha), was selected as a marker for proliferative cells, and Leu3a molecule as a cell-surface antigen phenotype marker of the cells. The procedure involved the simultaneous use of fluorescein-conjugated anti-pol alpha antibody, developed by us, and commercially available phycoerythrin-conjugated anti-Leu3a antibody. The optimal fixative for both proteins was phosphate-buffered 2% paraformaldehyde. The pol alpha-positive population in logarythmically growing MOLT 4 cells was estimated, by flow cytometry, to be ca. 95%. A sharp flow cytometry histogram with a strong pol alpha-linked fluorescence was observed. On the other hand, the pol alpha-positive population in the saturated culture was ca. 70%, with weaker pol alpha-linked fluorescence. Thus, the population of pol alpha-positive cells and the amount of pol alpha in cells was dependent on the cell density of the culture. In contrast, ca. 90% Leu3a-positive populations with similar flow cytometry histograms were seen in either growing or saturated states, suggesting that expression of Leu3a was independent of cell density. The flow cytometric method using fluorescein isothiocyanate-conjugated anti-pol alpha antibody is useful for detecting proliferative fractions of free tumor cells, such as leukemic cells. Furthermore, analysis of the phenotype of the proliferative or non-proliferative cells became easier by simultaneous labeling with antibodies against pol alpha and phenotype-specific proteins.

[The clinical application of oxygen saturation pulse oximeter in otolaryngological field]

Recently, we had opportunity to use an oxygen saturation pulse oximeter (minolta pulsox-7) which is a compact, light-weight device and allows continuous, percutaneous easy determination of arterial blood oxygen saturation. We obtained the following results from clinical application of this device in the field of otorhinolaryngology. 1. There was a high coefficient of correlation (0.899) between the values of oxygen saturation determined with a Minolta Pulsox-7 and an arterial blood gas analyzer. 2. This instrument was simple to handle and was clinically applicable, and seems to be highly useful for a) timing of tracheostomy, b) objective evaluation of dyspnea, c) monitor of nasal surgery under local anesthesia.

Reliability of percutaneous test for facial nerve function. Comparison between indirect and direct stimulation method

To evaluate the reliability of conventional tests for facial nerve denervation, comparisons of the thresholds and relationship with prognosis were made between the conventional percutaneous and direct stimulation methods in 11 cases of facial palsy decompressed and followed up for more than 6 months. Although all cases showed complete or severe nerve degeneration in the preoperative percutaneous stimulation test, the threshold for the direct intraoperative stimulation test varied from 4 V (normal) to more than 30 V. The results of the direct intraoperative stimulation test correlated well with prognosis (degree of improvement of palsy score). Our results indicate that the direct stimulation method is better than the percutaneous stimulation method as an electrodiagnostic test for nerve degeneration.

Persistent stapedial artery associated with otosclerosis

A 43-year-old female had bilateral otosclerosis with a persistent stapedial artery in the left ear which measured approximately 0.4 mm in diameter, lying on the floor of the tympanic cavity, running between the crura of the stapes and entering the facial canal. Stapedectomy was performed following section of this vessel and controlling the hemorrhage. Satisfactory hearing gain was obtained in both ears after stapedectomy.

A case of 'spontaneous otoacoustic emission'

A 25-year-old man produced a continuous high-pitched pure tone (6.1 kHz, 37.2-dB sound pressure level) in his right ear. The tone was not audible to the patient. He had sensorineural deafness over 1 kHz with a dip of 45 dB at 6 kHz. The tone was considered to be emitted through the eardrum from the inner ear, ie, a "spontaneous otoacoustic emission".

Magnetic resonance imaging of the eustachian tube. A correlative anatomical study

Magnetic resonance (MR) imaging of the eustachian tube (auditory tube) was performed in normal subjects and in a patient with nasopharyngeal carcinoma. The MR images obtained in an anteriorly tilted transaxial plane parallel to the eustachian tubes were compared with serial slices of a cadaver specimen. The eustachian tube cartilage, mucous lining of the eustachian tube, the lateral pharyngeal recess, the tensor veli palatini muscle, and the levator veli palatini muscle were identified in MR images using anatomical relationships. A patient with nasopharyngeal carcinoma is described to demonstrate an example of topographical morbid changes appearing around the eustachian tube.

Three-dimensional computer graphics of the eustachian tube

Images of the eustachian tube from various directions were obtained using computer graphics. Serial cross sections of a human temporal bone specimen including the eustachian tube were digitized for reconstruction. Wire-frame models of the structures such as the eustachian tube lumen, the tubal cartilage, the tensor veli palatini muscle, and the levator veli palatini muscle were drawn. Through observation of the eustachian tube from various directions with the tubal muscles attached or detached, the physiology of the eustachian tube system could be understood more clearly.