Preoperative estimation of remnant hepatic function using fusion images obtained by (99m)Tc-labelled galactosyl-human serum albumin liver scintigraphy and computed tomography.

BACKGROUND: Assessment of hepatic functional reserve is important in hepatic resection. The aim of this study was to evaluate the role of hepatic asialoglycoprotein receptor (ASGP-R) analysis in the preoperative estimation of remnant liver function in liver surgery. METHODS: One hundred and one patients undergoing hepatic resection for liver tumours were studied. Seventeen patients had preoperative percutaneous transhepatic portal vein embolization (PTPE). Function of the hepatic remnant was estimated before surgery using radioactivity in fusion images of both liver single-photon emission computed tomography and computed tomography scans using (99m)Tc-labelled diethylene triamine penta-acetate-galactosyl-human serum albumin. RESULTS: All three patients with an ASGP-R concentration below 400 nmol/l and preoperative total amount of receptor in the future remnant liver (R0-remnant) of less than 53.0 nmol per liver died. Two patients with chronic hepatitis and R0-remnant values between 53.0 and 65.0 nmol per liver and a receptor concentration lower than 600 nmol/l developed liver dysfunction. The incidence of liver failure decreased inversely with increasing R0-remnant value. CONCLUSION: A combination of receptor concentration and the amount of hepatic receptor in the future liver remnant as detected on fusion images is useful in evaluating the risk of postoperative liver failure.

Helicobacter pylori eradication reduced the incidence of gastric cancer, especially of the intestinal type.

BACKGROUND: Although Helicobacter pylori infection is closely associated with gastric cancer development, follow-up studies after H. pylori eradication are still scarce. AIM: To clarify the cancer preventive effect of H. pylori eradication, with special attention to differences in effect according to histology. METHODS: Patients who underwent H. pylori eradication therapy and were followed-up endoscopically for at least 1 year were analysed. The incidence of gastric cancer and factors associated with cancer development were investigated. RESULTS: A total of 1807 patients were enrolled. Six of 1519 H. pylori eradicated and five of 288 persistent subjects developed gastric cancer. Four of the eradicated subjects developed the intestinal type and two the diffuse type, while four of the persistent subjects developed the intestinal type and one the diffuse type. Kaplan-Meier analysis indicated a significantly lower incidence in eradicated patients than in persistent patients. The incidence of intestinal type was significantly lower than in eradicated patients, while the diffuse type could not be evaluated because of the low incidence. CONCLUSIONS: Helicobacter pylori-eradicated patients had a reduced incidence of gastric cancer compared with H. pylori-persistent patients, particularly the intestinal type, suggesting that H. pylori is strongly associated with intestinal-type gastric cancer.

Differential diagnosis of small round cervical lymph nodes: comparison of power Doppler US with contrast-enhanced CT and pathologic results.

PURPOSE: The purpose of this study was to differentiate reactive small round lymph nodes (SRLNs) from metastases by power Doppler ultrasonography (PD-US) and contrast-enhanced CT (CE-CT). MATERIALS AND METHODS: Both PD-US and CE-CT were performed in 99 cervical lymph nodes (LNs) with a maximum diameter of 1.5 cm or smaller and maximum longitudinal/transverse ratio of 1.5 or smaller in 76 patients with head and neck cancer. At pathologic examinations, 45 were reactive and 54 were metastatic LNs. The vascular patterns on PD-US were classified as hilar, avascular, peripheral, and miscellaneous vascular patterns. The enhancement patterns on CE-CT were classified as homogeneous, heterogeneous, and ring enhancement. RESULTS: On PD-US, the hilar pattern was more frequently associated with benignancy (91%) and the peripheral, miscellaneous vascular pattern with malignancy (91%). The avascular pattern included both benign (58%) and malignant (42%) LNs. On PD-US, accuracy was 85%. On CE-CT, ring enhancement showed metastasis (100%), and these LNs showed avascular or peripheral patterns on PD-US. On CE-CT, accuracy was 77%. When information on CE-CT results was added to PD-US results, the accuracy rate increased significantly, to 94% (p=0.01). CONCLUSION: Vascular patterns evaluated with PD-US and enhancement patterns on CE-CT can characterize SRLNs. For an avascular pattern on PD-US, information on CE-CT results can significantly increase the accuracy of characterization.

Gastric scirrhous carcinoma as a rare cause of aggressive fibromatosis in the neck.

Aggressive fibromatosis is characterized by locally aggressive proliferation of fibroblasts and occasionally occurs in the head and neck. Although the etiology of this disease is still controversial, recent studies have shown that high levels of growth factors are found in these lesions. This article reports a case of 51-year-old woman with aggressive fibromatosis in the neck and inguinal region bilaterally. Gastric fiberscopic examination revealed a complication of advanced gastric scirrhous carcinoma. There were remarkably high levels of basic fibroblast growth factor (bFGF) and platelet-derived growth factor (PDGF) in the serum. Postmortem autopsy examination was performed and scattered gastric carcinoma cells were observed in the fibromatosis lesions. Immunohistological staining showed positive expression of bFGF in the fibromatoses and stomach. We concluded that this was a rare case in which bFGF and PDGF released from gastric carcinoma cells caused aggressive fibromatosis by promoting unregulated proliferation of fibroblasts and collagen production locally.

[Vascular anastomoses in free jejunal reconstruction to the neck vessels: an experience of consecutive 20 cases without using surgical microscope].

Twenty consecutive cases of pharyngoesophageal cancer who underwent free jejunal reconstruction were reported. The common carotid or external carotid artery was used for a feeder of the free graft. The internal jugular vein were served as a drainage vein. All anastomoses were performed in an end-to-side fashion without using surgical microscopes. Mean carotid artery clamping time was 16 minutes and no neurological complications were noticed postoperatively. Graft failure was occurred in 1 patient. The presenting technique, showing 95% success rate, is recommended as a simple option for vascular anastomosis in free jejunal reconstructive surgery.

Initial steroid hormone dose in the treatment of idiopathic sudden deafness.

OBJECTIVE: The purpose of this study was to clarify whether higher doses of steroids improve the prognosis of idiopathic sensorineural hearing loss (ISHL) and the suitable dose of steroid hormone. STUDY DESIGN: The study was a retrospective statistical analysis. SETTING: This study was performed at the Department of Otolaryngology, Head Neck Surgery, Kumamoto University School of Medicine. PATIENTS: Two hundred fifty patients with ISHL were analyzed in this study. They were divided into two groups: those receiving less than a specified daily dose of steroid and those receiving a daily dose greater than or equal to the specified dose. INTERVENTIONS: The patients received systemic steroid therapy combined with adenosine triphosphate, vitamins, diuretics, vasodilators, hyperbaric oxygen therapy, stellate ganglion block, or volume expander. MAIN OUTCOME MEASURES: The correlation between the initial dose of steroid hormone and the improvement rate was analyzed. RESULT: Spearman's correlation coefficients and partial correlation coefficients between the initial dose and the prognosis were all significantly negative. On the other hand, the correlations between the initial dose and the prognosis were positive in the group receiving <30 mg/day, whereas they were negative in the group receiving > or =30 mg/day, although these correlations were not significant. CONCLUSION: The general use of steroid hormone to treat ISHL is not recommended. Furthermore, if steroid hormone is used for treatment, the use of <30 mg/day of prednisolone is preferable.

Analysis of individual specific cytotoxic T lymphocytes for two MAGE-3-derived epitopes presented by HLA-A24.

BACKGROUND: The human MAGE-3 gene encodes tumor-specific antigens that are recognized by cytotoxic T lymphocytes (CTLs) and expressed in a high percentage of various malignant tumors. Of the five MAGE-3-derived CTL epitopes identified to date, two nonapeptides (TFPDLESEF and IMPKAGLLI, designated MAGE-3.A24a and MAGE-3.A24b, respectively) can be expressed on the tumor surface by binding to the HLA-A24 molecule, which is the most frequent HLA class I molecule in Asian populations. To compare the immunogenecities of the two peptides, individual specific CTL lines were generated for each peptide (MAGE-3.A24a and MAGE-3.A24b). METHODS: Peripheral blood mononuclear cells (PBMCs) from four HLA-A24+ healthy donors were stimulated in vitro with autologous dendritic cells pulsed with MAGE-3.A24a, MAGE-3.A24b or both and were subsequently cultivated with a cytokine combination including interleukin-2. RESULTS: We succeeded in generating peptide-specific CTL lines in two of the four donors. The two CTL lines showed similar cytolytic levels against three MAGE-3+/HLA-A24+ cancer cell lines and also target cells pulsed with the corresponding peptide. Cytolytic activities were blocked by either anti-CD8 or anti-HLA-A24 monoclonal antibodies. CONCLUSIONS: The results suggest that MAGE-3.A24a and MAGE-3.A24b peptides have equal potential in inducing MAGE-3-specific and HLA-A24-restricted CTLs.

Assessment of stapes mobility by use of a newly developed piezoelectric ceramic device. A preliminary experiment in dogs.

A piezoelectric device was developed for assessment of stapes mobility during middle ear surgery. The device comprises a pair of ceramic bimorph elements: one for activation of the stapes and the other to pick up the vibration as an electric output, which varies in accordance with the stapes mobility, ie, the inverse of the cochlear input impedance (Zsc). The device is compact and easily manipulated even in the narrow surgical field of the ear. However, the measuring range is restricted to between 1 and 10 kHz. Measurement of Zsc was conducted with this device in 5 ears of 5 dogs. The mean magnitude of Zsc increased with frequency in the range from 1 to 10 kHz: 0.95 megohm at 1 kHz and 8.8 megohms at 10 kHz. After fixation of the stapes with dental cement, the magnitude increased to more than 10 megohms, except at 1 kHz. The results suggest that the device is useful in detecting decreases in stapes mobility in patients with chronic otitis media.

Clinical significance of p53 functional loss in squamous cell carcinoma of the oropharynx.

We examined the frequency of p53 mutations in 38 oropharyngeal squamous cell carcinomas (SCC), using both a yeast functional assay and a conventional immunohistochemical staining method (IHC) to detect p53 mutations. We also explored the clinical importance of p53 mutations in oropharyngeal SCC. An accumulation of p53 protein was detected in 17 of the 38 (45%) tumors by IHC, whereas the yeast-based assay detected 6 additional p53 mutations, for a total of 23 tumors (61%) with p53 mutations. The cDNA sequencing analysis revealed that the 6 mutations undetected by IHC consisted of 3 frameshift, 1 nonsense and 2 missense mutations. Thus, the yeast functional assay was more sensitive than conventional IHC for detecting p53 mutations. Subsequently, the relationship between p53 mutations and the clinico-pathological parameters in oropharyngeal SCC was evaluated using the results of the functional assay. Mutation of p53 was not associated with the patient age, sex, tumor stage or degree of tumor cell differentiation. Interestingly, heavy drinking had a significant positive correlation with the p53 mutation, but heavy smoking did not, suggesting that prolonged exposure to alcohol is more related to p53 mutation in oropharyngeal SCC than to tobacco consumption. Radiation sensitivity was examined by comparing tumor size on magnetic resonance images before and after completion of therapy with 45 Gy radiation, in the 18 cases of T2 oropharyngeal SCC that were initially treated by radiotherapy. The results showed that tumors with wild-type p53 decreased in size significantly compared to those with mutant p53. In 33 patients treated with curative intent, the overall survival after the completion of therapy was better in patients with a wild-type p53 tumor than in patients with a mutant p53 tumor. We conclude that p53 mutation is associated with radiation resistance and a decreased probability of survival in oropharyngeal SCC.

Three-dimensional endoscopic images of vocal fold paralysis by computed tomography.

OBJECTIVE: To describe characteristics of 3-dimensional (3-D) computed tomographic (CT) endoscopic images of the larynx in unilateral vocal fold paralysis and the changes of the paralyzed vocal fold after phonosurgery as indicated by 3-D CT endoscopy. SETTING: A university medical center. PATIENTS: Twelve consecutive patients with unilateral vocal fold paralysis who underwent helical CT examination. Five of them underwent the CT examination before and after phonosurgical treatment. INTERVENTIONS: Three patients underwent arytenoid adduction, and 2 underwent type 1 thyroplasty. MAIN OUTCOME MEASURES: "Sagging," defined as caudal displacement of the vocal fold; and "thinning," defined as a decrease in the vertical thickness of the vocal fold and expansion of the ventricle on the affected side, were evaluated. RESULTS: Excessive motion artifacts in one patient prevented detailed description of his 3-D images. Sagging and thinning of the vocal fold and expansion of the ventricle on the affected side were noted on 6, 11, and 8 occasions, respectively. Adduction or augmentation of the paralyzed vocal fold after phonosurgery was observed in 3-D CT endoscopic images when displayed with bony densities. CONCLUSIONS: The use of 3-D CT endoscopy enables description of 3-D characteristics of unilateral vocal fold paralysis and supplements stroboscopic findings. Furthermore, CT endoscopic images, when simultaneously displayed with bony densities, may help in evaluating the effects of phonosurgical treatment of the paralyzed vocal fold.

Genetic diagnosis of micrometastasis based on SCC antigen mRNA in cervical lymph nodes of head and neck cancer.

This study is designed to assess gene expression of squamous cell carcinoma antigen (SCCA) mRNA to detect micrometastases in cervical lymph nodes (LNs) of head and neck cancer. We examined the expression of SCCA mRNA in 12 primary tumors and 212 cervical LNs (101 LNs taken from 8 patients with tongue cancer, 71 from 7 patients with gingival cancer, 19 from 2 patients with laryngeal cancer, 9 from 2 patients with pharyngeal cancer, 7 from 1 patient with cancer of the buccal mucosa, and 5 from 1 patient with cancer of floor of the mouth). Detectability of metastatic LNs by nested and single reverse transcriptase-polymerase chain reaction (RT-PCR) was compared with semiserial sections (hematoxylin-eosin staining and keratin immunostaining). All primary tumors expressed SCCA mRNA. Of 198 histologically metastasis-negative nodes, SCCA mRNA was detected in 37 (18.7%) by nested PCR. Eleven micrometastatic foci in 9 LNs (4.6%) were discovered by semiserial sectioning. This suggests that SCCA mRNA is a promising tumor marker for detecting the micrometastases in cervical LNs of head and neck cancer.

[Analysis of 33 patients with nasopharyngeal carcinoma--surgical management for persistent tumor after radiation therapy].

We report thirty-three patients treated for nasopharyngeal carcinoma (NPC) in our clinic from 1976 to 1997. They consisted of 24 males and 9 females, and their ages ranged from 17 to 76 years with an average of 56 years. Fourteen patients initially presented with ear symptoms due to tubal insufficiency, 11 with cervical lymphadenopathy, 6 with nasal symptoms and 4 with cranial nerve paralysis. The mean interval from the onset of their complaints to the time of difinite diagnosis of NPC was 5.8 months. Seventeen patients (51.5%) had primary sites with T3 or T4. Twenty-four (72.7%) had cervical lymphnode metastases. Thirty (90.9%) were classified as stage III or IV. Radiation therapy is a mainstay of treatment of NPC because of anatomic restrictions and a high degree of radiosensitivity. An average of total radiation dose was 63.9Gy for the primary site except in one patient (28Gy followed by surgery due to poor response to radiation). In two patients, high-dose intracavity radiation by remote afterloading system was performed. They have been free from disease since then for more than 3 years. Radiation therapy was combined with an administrations of 5-fluorouracil and vitamim A (FAR therapy), or a low-dose of cisplatin in 2 and 5 patients, respectively. Local recurrence was detected in none of these patients and this combined therapy seemed to be effective in controlling the primary lesion. The overall 5-year survival rate was 56.9% (Kaplan-Meier method), however, that of patients with stage IV was still poor; 33.2%. This emphasizes the importance of an early diagnosis of NPC. Twelve patients underwent surgical resection of the residual tumor at the primary site after radiotherapy. As a surgical approach to the nasopharynx, the transmandibular transpterygoid approach was employed in five patients. This procedure offers a wider exposure of the nasopharynx than either the transmaxillary or the transpalatal approaches. Although distant metastasis was detected in three of the five patients, none of them developed local recurrence. The 5-year survival rate in 12 patients with surgery was 65.6%, which was better than 49.2% in 21 patients without surgery. Neck dissection was performed on 14 patients after radiotherapy. None had cervical recurrence postoperatively. The surgical treatments are recommended for patients with postradiation residual primary tumor and/or cervical metastasis.

[Radiotherapy combined with daily administration of low-dose cisplatin for squamous cell carcinomas of the head and neck].

The effects of radiotherapy combined with daily administration of low-dose cisplatin (CD DP) and radiotherapy alone for squamous cell carcinomas of the head and neck were compared clinically and histologically. There was no difference in the response rate between two groups with and without CDDP for pre-operative irradiation (30-40 Gy). However, the complete response rate in the radical irradiation group (60-70 Gy) with CDDP was significantly higher than without CDDP. In the histologic effect assessed by the classification of Shimozato in 9 of 19 patients undergoing radical irradiation with CDDP, 3 patients in this group showed a grade III effect, and the other 6 a grade IV effect. Only 5 of 11 patients having irradiation alone showed grade III or IV effect. In conclusion, full-dose radiotherapy combined with CDDP provided a high level of organ preservation and local control because of the high clinical and histological complete response rate at the primary site.

Pliability of the vocal fold mucosa in relation to the mucosal upheaval during phonation.

OBJECTIVES: To quantitatively evaluate the effect of vocal fold lengthening on pliability of the mucosa measured along the superior-inferior axis and to examine the relation of the location of mucosal upheaval (MU) during phonation to the changes in pliability pattern of the mucosa when the vocal fold was lengthened. DESIGN: Investigation of mechanical characteristics of the vocal fold in relation to the MU during phonation. MATERIALS: Five excised canine larynges. INTERVENTIONS: Vibrations with and without vocal fold lengthening were recorded from the tracheal side via high-speed photography or video recording combined with stroboscopic illumination. Tattooed marks on the lower surface of the vocal fold were used to locate the MU. Pliability was defined as the maximal distance elevated in response to a constant focal negative pressure. RESULTS: Pliability decreased significantly (P=.05) when the vocal fold was lengthened. The point of minimal pliability and MU without vocal fold lengthening were located slightly above the area where the muscular layer approached the epithelial layer. They were located closer to the free edge of the vocal fold when it was lengthened than when it was not. Discrepancy of their locations when the vocal fold was lengthened was suggested. CONCLUSIONS: The MU occurs around the point of minimal pliability when the vocal fold is not lengthened, whereas the MU occurs slightly more laterally than the point of minimal pliability when the vocal fold is lengthened. Although further study is necessary to explain this discrepancy, the presence of the sparse deep layer of the lamina propria seems to be essential in the generation of the mucosal wave.

Histochemical study of the canine inferior pharyngeal constrictor muscle: implications for its function.

The inferior pharyngeal constrictor muscle (IPC), which consists of the thyropharyngeal (TP) and cricopharyngeal (CP) muscles. plays an important role during deglutition. The histochemical properties of the canine IPC muscle were investigated. The motor endplates of the TP muscle clustered at the midlength of the muscle, while those of the CP muscle were scattered diffusely. The glycogen depletion technique suggested that most of the CP muscle fibers terminated into the belly of the muscle and fiber lengths varied. With ATPase stain, type II fibers were shown to be predominant in the TP muscle, while type I fibers were predominant in the CP muscle. The diameter of the TP muscle fibers was significantly larger than that of the CP muscle. Although the histochemical characteristics of these two muscles were markedly different, they gradually changed, resulting in their coordinated physiological movements.

Three-dimensional endoscopic mode for observation of laryngeal structures by helical computed tomography.

We produced high-quality three-dimensional (3D) endoscopic images of the larynx using helical scanning computed tomography. Subjects included two normal volunteers and 10 patients: five with laryngeal cancer, four with unilateral recurrent laryngeal nerve (RLN) palsy, and one with atrophied vocal folds. Two vertically split hemilaryngeal images were displayed together with the oral and tracheal views. Although motion artifacts were seen in four patients, laryngeal structures including the vocal fold, ventricular fold, and ventricle were clearly identified in all subjects. In the patients with cancer, axial images showing the extent of the tumor in each patient provided more information than 3D endoscopic images. In the patients with RLN palsy and atrophied vocal fold, combination of 3D endoscopic and cross-sectional images offered more diagnostic information than axial images alone.

[Thermoradiotherapy combined with daily administration of low dose cisplatin for locally advanced laryngeal carcinoma].

We applied thermoradiotherapy combined with daily administration of low dose cisplatin (CDDP) to five patients with locally advanced laryngeal carcinoma. The total response rate (CR + PR) was 100% after irradiation of 30 or 40 Gy. One case showed CR, and the larynx could be preserved by adding a full dose of irradiation. CDDP administration was discontinued in two cases due to renal dysfunction or thrombopenia, but other cases tolerated the therapy without severe side effects. Total laryngectomy and bilateral neck dissection was carried out in four cases after irradiation of 30 or 40 Gy. Removed larynxes were prepared for light microscopic observations of the serial sections. One of the four specimens revealed a CR histologically. The combination of thermoradiotherapy with low dose CDDP showed a remarkable effect on reduction of tumor size and cytotoxicity of tumor cells. This might contribute to saving the larynx of patients with locally advanced laryngeal carcinoma.