[A Case of Dedifferentiated Liposarcoma of the Spermatic Cord].

A 52-year-old man was referred to our hospital for evaluation of painless right scrotal swelling persisting for 3 months. Palpation detected swelling and induration centered on the head of the upper epididymis, and ultrasonography revealed a blood-filled nodular mass at the same site continuing to the spermatic cord. No abnormalities were observed in the bilateral testes. Blood tests were negative for tumor markers such as α fetoprotein and human chorionic gonadotropin-ß. Right radical inguinal orchiectomy was performed, and the pathological diagnosis was dedifferentiated liposarcoma of the spermatic cord. Although the spermatic cord stump was negative, the peri-spermatic cord stump, which had an exfoliated surface, was positive. No residual tumor was found on magnetic resonance imaging, but the tumor was suspected to remain. Thus, after approximately 1month, the tissue around the spermatic cord was resected. Eight months after the initial operation, no recurrence was observed. Here, we report a case of dedifferentiated liposarcoma of the spermatic cord, which is relatively rare, and review the related literature.

[Clear Cell Variant of Invasive Urothelial Carcinoma of the Renal Pelvis: A Case Report].

A 74-year-old woman with gross hematuria for 3 months was referred to our hospital. Contrast-enhanced computed tomographic scan showed a mass on the upper-right renal calyx, and retrograde pyelography showed stenoses from the renal pelvis to the renal calyx infundibulum. We performed an endoscopic biopsy, which led to a diagnosis of urothelial cancer. Therefore, she underwent total right nephroureterectomy, and pathological examination revealed a clear cell variant of invasive urothelial carcinoma. Irradiation was performed mainly on the renal arteriovenous stump 2 months postoperatively; subsequently, three courses of combination chemotherapy comprising gemcitabine plus cisplatin (GC) were administered. Port-site recurrence and pelvic recurrence were observed 22 months after the operation, and GC therapy and pembrolizumab were administered. However she died 36 months after the operation. The clear cell variant of invasive urothelial carcinoma of the upper urethra is rarely reported. Moreover, since this was a very rare case, we have included a literature review in our report.

[A Case of Pneumatosis Cystoides Intestinalis during Castration-Resistant Prostate Cancer Treatment].

A 65-year-old man received docetaxel for prostate cancer. Eight months later, we observed abdominal free air and pneumatosis cystoides intestinalis by computed tomography. Pneumatosis cystoides intestinalis can be caused by various etiologies. However, in the present case, multiple factors could have contributed and we could not specify the exact cause. We reduced the dose of steroid hormone, stopped docetaxel, and followed the patient conservatively with oral antibiotics. The pneumatosis cystoides intestinalis and free air resolved promptly.

Off-Pump Minimally Invasive Coronary Artery Bypass Grafting With a Heart Positioner: Direct Retraction for a Better Exposure.

OBJECTIVE: Lateral and inferior territories are difficult to expose during off-pump minimally invasive coronary artery bypass grafting (MICS CABG). The use of cardiopulmonary bypass is required at times. We initiated a direct retraction method by using a cardiac positioner for a better exposure, in order to complete off-pump, multivessel MICS CABG safely. METHODS: We recently initiated multivessel MICS CABG, performed via a 6- to 9-cm left thoracotomy. For distal anastomoses, the lateral pericardial edge was pulled to the chest wall to optimize exposure of the lateral and inferior area. Next, a single- or multisuction cardiac positioner was put on the sides of the target vessel through the small thoracotomy and pulled directly toward the incision. Finally, a distal anastomosis was made with an epicardial stabilizer via the thoracotomy, as in standard off-pump CABG. RESULTS: There was no mortality or conversion to sternotomy. A total of 10 cases were targeted for off-pump multivessel MICS CABG with this approach. Nine were completed, while 1 still required pump assist. The average number of distal anastomoses was 2.8 ± 0.8. Two were successful off-pump quadruple bypass grafting with sequential anastomoses. All patients were discharged and remain well to this day. CONCLUSIONS: Most multivessel MICS CABG was feasible without pump assist even at the initiation period. This approach is easy and helpful in providing good exposure of target vessels without requirement of additional incisions.

[Successful postoperative percutaneous cardiopulmonary support( PCPS) for the right-heart failure in a patient with recurrent mitral valve stenosis and a calcified left atrium; report of a case].

A 79-year-old female underwent open mitral commissurotomy and thrombectomy for mitral valve stenosis and thrombus in the left atrium 21 years ago. She was admitted for congestive heart failure because of recurrent mitral valve stenosis. Cardiac echocardiography showed severe mitral valve stenosis and the calcification of the left atrium wall. We performed mitral valve replacement and removal of thrombus calcification in the left atrium. Cardiopulmonary bypass was weaned successfully. In the intensive care unit, her blood pressure (BP) dropped, central venous pressure (CVP) increased, and urine volume decreased. Cardiac echocardiography revealed functional deterioration and dilatation of the right ventricle. As medical therapy was not effective, percutaneous cardiopulmonary support(PCPS)was established through the femoral artery and vein. Then her BP increased, CVP decreased, and the right ventricular function and the dilatation improved. PCPS was removed after 3 days, and the respirator on the 13th postoperative day. She moved out of the intensive care unit on the 24th postoperative day.

Emergence of avian influenza viruses with enhanced transcription activity by a single amino acid substitution in the nucleoprotein during replication in chicken brains.

To explore the genetic basis of the pathogenesis and adaptation of avian influenza viruses (AIVs) to chickens, the A/duck/Yokohama/aq10/2003 (H5N1) (DkYK10) virus was passaged five times in the brains of chickens. The brain-passaged DkYK10-B5 caused quick death of chickens through rapid and efficient replication in tissues, accompanied by severe apoptosis. Genome sequence comparison of two viruses identified a single amino acid substitution at position 109 in NP from isoleucine to threonine (NP (I)109(T)). By analyzing viruses constructed by the reverse-genetic method, we established that the NP (I)109(T) substitution also contributed to increased viral replication and polymerase activity in chicken embryo fibroblasts, but not in duck embryo fibroblasts. Real-time RT-PCR analysis demonstrated that the NP (I)109(T) substitution enhances mRNA synthesis quickly and then cRNA and viral RNA (vRNA) synthesis slowly. Next, to determine the mechanism underlying the appearance of the NP (I)109(T) substitution during passages, four H5N1 highly pathogenic AIVs (HPAIVs) were passaged in the lungs and brains of chicken embryos. Single-nucleotide polymorphism analysis, together with a database search, suggests that the NP (I)109(T) mutation would be induced frequently during replication of HPAIVs in brains, but not in lungs. These results demonstrate that the amino acid at position 109 in NP enhances viral RNA synthesis and the pathogenicity of highly pathogenic avian influenza viruses in chickens and that the NP mutation emerges quickly during replication of the viruses in chicken brains.

NP body domain and PB2 contribute to increased virulence of H5N1 highly pathogenic avian influenza viruses in chickens.

The molecular basis of pathogenicity of H5N1 highly pathogenic avian influenza (HPAI) viruses in chickens remains largely unknown. H5N1 A/chicken/Yamaguchi/7/2004 virus (CkYM7) replicates rapidly in macrophages and vascular endothelial cells in chickens, causing sudden death without fever or gross lesions, while H5N1 A/duck/Yokohama/aq10/2003 virus (DkYK10) induces high fever, severe gross lesions, and a prolonged time to death, despite the 98% amino acid identity between the two viruses. To explore the molecular basis of this difference in pathogenicity, a series of eight single-gene reassortant viruses from these HPAI viruses were compared for pathogenicity in chickens. Two reassortants possessing the NP or PB2 gene from DkYK10 in the CkYM7 background reduced pathogenicity compared to other reassortants or CkYM7. Inversely, reassortants possessing the NP or PB2 gene of CkYM7 in the DkYK10 background (rgDkYK-PB2(Ck), rgDkYK-NP(Ck)) replicated quickly and reached higher titers than DkYK10, accompanied by more rapid and frequent apoptosis of macrophages. The rgDkYK-NP(Ck) and rgDkYK-PB2(Ck) reassortants also replicated more rapidly in chicken embryo fibroblasts (CEFs) than did rgDkYK10, but replication of these viruses was similar to that of CkYM7 and DkYK10 in duck embryo fibroblasts. A comparison of pathogenicities of seven rgDkYK10 mutants with a single amino acid substitution in NP(Dk) demonstrated that valine at position 105 in the NP(Ck) was responsible for the increased pathogenicity in chickens. NP(Ck), NP(105V), and PB2(Ck) enhanced the polymerase activity of DkYK10 in CEFs. These results indicate that both NP and PB2 contribute to the high pathogenicity of the H5N1 HPAI viruses in chickens, and valine at position 105 of NP may be one of the determinants for adaptation of avian influenza viruses from ducks to chickens.

Broad detection of diverse H5 and H7 hemagglutinin genes of avian influenza viruses by real-time reverse transcription-PCR using primer and probe sets containing mixed bases.

Real-time reverse transcription-PCR (RT-PCR) was developed for broad detection of diverse H5 and H7 genes in Eurasian and American lineages of avian influenza viruses by using primer and probe sets containing mixed bases. Optimal use of the mixed bases enabled us to minimize sequence mismatches and to broaden the gene detection spectrum without decreasing sensitivity.

Phenotypes influencing the transmissibility of highly pathogenic avian influenza viruses in chickens.

To identify critical phenotypes that affect avian influenza virus transmission in chickens, we compared the transmissibility of three H5N1 highly pathogenic viruses of different pathogenicity in chickens by monitoring the exact time of death using wireless thermo-sensors. This study showed that, despite quick deaths, the most virulent H5N1 A/chicken/Yamaguchi/7/2004 transmitted quickly in chickens via contact and airborne routes. Intermediate virulent H5N1 A/chicken/Miyazaki/K11/2007 spread moderately and less virulent H5N1 A/duck/Yokohama/aq10/2003, causing severe clinical signs and a long period to death, spread slowly among the animals. The transmissibility was correlated with virus titres of oropharyngeal and cloacal swabs, and the time for swab virus titres to reach 50 % chicken infective dose affected the transmission speed. These results demonstrate that peak virus titres excreted and the time required for virus titres to reach a minimal chicken infectious dose may be the critical phenotypes influencing the transmissibility of highly pathogenicity avian influenza viruses in chickens.

[Prognosis of type A acute aortic dissection treated conservatively].

We examined 58 cases of type A acute aortic dissection treated from 2003 to 2005 in our hospital. Thirty-three patients were treated surgically and 25 patients were treated conservatively. Among the 25 patients treated conservatively, 13 patients had open false lumen, and were eligible for surgical therapy. Surgical therapy was abandoned however, for various reasons (stroke, advanced age, malignancy, renal disease, lung disease, or patient's reject). Thirteen patients (52%) treated conservatively died while only 1 patient (3%) treated surgically died. Patients with thrombosed false lumen had good prognosis while those with open false lumen or ischemic complication had poor prognosis. It is concluded that patients with thrombosed false lumen of type A acute aortic dissection could receive conservative therapy with surgical team's back up and close computed tomography (CT) follow up to detect recanalization and enlargement of the aorta.

Association of increased pathogenicity of Asian H5N1 highly pathogenic avian influenza viruses in chickens with highly efficient viral replication accompanied by early destruction of innate immune responses.

The Asian H5N1 highly pathogenic avian influenza (HPAI) viruses have been increasing in pathogenicity in diverse avian species since 1996 and are now widespread in Asian, European, and African countries. To better understand the basis of the increased pathogenicity of recent Asian H5N1 HPAI viruses in chickens, we compared the fevers and mean death times (MDTs) of chickens infected with the Asian H5N1 A/chicken/Yamaguchi/7/04 (CkYM7) strain with those infected with the H5N1 Duck/Yokohama/aq10/03 (DkYK10) strain, using a wireless thermosensor. Asian H5N1 CkYM7 caused peracute death in chickens before fever could be induced, whereas DkYK10 virus induced high fevers and had a long MDT. Real-time PCR analyses of cytokine mRNA expressions showed that CkYM7 quickly induced antiviral and proinflammatory cytokine mRNA expressions at 24 h postinfection (hpi) that suddenly decreased at 32 hpi. In contrast, these cytokine mRNA expressions increased at 24 hpi in the DkYK10 group, but decreased from 48 hpi onward to levels similar to those resulting from infection with the low-pathogenicity H5N2 A/chicken/Ibaraki/1/2004 strain. Sequential titrations of viruses in lungs, spleens, and kidneys demonstrated that CkYM7 replicated rapidly and efficiently in infected chickens and that the viral titers were more than twofold higher than those of DkYK10. CkYM7 preferentially and efficiently replicated in macrophages and vascular endothelial cells, while DkYK10 grew moderately in macrophages. These results indicate that the increased pathogenicity in chickens of the recent Asian H5N1 HPAI viruses may be associated with extremely rapid and high replication of the virus in macrophages and vascular endothelial cells, which resulted in disruption of the thermoregulation system and innate immune responses.

[Clinical study of 38 cases of pheochromocytoma --correlation between the instability of intraoperative blood pressure and 24-hour urinary vanillylmandelic acid].

Pheochromocytoma is a rare tumor of chromaffin tissues most commonly arising from the adrenal medulla. We retrospectively reviewed the records of 38 patients with pheochromocytoma who underwent surgical treatment between 1977 and 2004 at our Yokohama City University Medical Center and Yokohama City University Hospital. Twenty two patients (57.9%) were females and 16 (42.1%) were males. The most frequent symptoms were headache (58%). One patient had bilateral adrenal tumors and pathological examination revealed malignant pheochromocytoma. Six patients had an extra-adrenal tumor and in 2 patients the tumor occurred in the urinary bladder. Twelve patients (31.6%) had sustained hypertension, 21 patients (55.3%) had paroxysmal hypertension and 5 patients (13.1%) remained normotensive. The 24-h urinary total metanephrines and vanillylmandelic acid (VMA) were the most sensitive biochemical tests for the diagnosis of pheochromocytoma. The sensitivity of urinary total metanephrines was 92.0% for all the patients and was 92.3% for the patients without paroxysmal hypertension. Fifteen patients had intraoperative hypertensive reactions in the surgical manipulation or hypotension after tumor resection. This group had more urinary excretion of VMA before surgery, compared with that with stable intraoperative blood pressure (p < 0.005).