A vertical stomach reconstruction after pylorus-preserving pancreaticoduodenectomy.

BACKGROUND: Pancreatic fistula (PF) and delayed gastric emptying (DGE) is a leading cause of morbidity after pylorus-preserving pancreaticoduodenectomy (PPPD), occurring in 20% to 40% of patients. METHODS: Between August 1994 and March 2000, 30 consecutive patients underwent our modified PPPD and were evaluated on their incidence of PF and DGE. The major modification of our technique was an antecolic reconstruction and setting the transverse colon between pancreaticogastrostomy and duodenojejunostomy RESULTS: Operative time and blood loss were, respectively, 5.2+/-0.93 hours and 730+/-330 mL. Hospital mortality was 0%. Postoperative morbidity was 23%. Delayed gastric emptying and pancreatic fistula were observed in 3 (10%) and 0 (0%) of 30 patients. Nasogastric suction was required for 7+/-2 days, and a solid diet could be tolerated on postoperative day 11+/-4. CONCLUSIONS: The results show that our reconstruction can minimize DGE.

[Analysis of 200 university hospital hearing aid clinic patients].

We statistically studied patients who visited our hearing aid clinic to determine what segment of the population may benefit from hearing aids. Subjects were 200 patients from 5 to 89 years of age who had visited the Hearing Aid Clinic of Otorhinolaryngology, Nagoya University Hospital, between January 1998 and March 2000. This clinic lent out hearing aids. Subjects were divided into 2 groups those having their own hearing aids either new or earlier (HA group) and those giving up hearing aids after a trial (non-HA group). Mean better hearing levels in pure tone average were 50.6 dB in the HA group and 44.5 dB in the non-HA group. Mean better maximum speech recognition scores were 81.5% in the HA group and 85.3% in the non-HA group. The distribution of better hearing has shown that patients with mild hearing loss (better pure tone average < 40 dB) account for more than a quarter of all hearing aid clinic patients. Among patients with mild hearing loss, 60% had their own hearing aids. The need for rehabilitation in the mild hearing loss population thus appears large. Their intent to wear hearing aids influenced whether patients agreed or declined hearing aids after a trial. The period from use until patients made a decision was 2 weeks in 65% of those declining use and 35% of those agreeing to use. Over 15% of those agreeing called for a trial period longer than 8 weeks. Hearing aid trials provide useful information for both patients and surgeons before choosing surgery for a difficult ear condition. In this research, 18 patients needed counseling about both amplification and surgery. Bridging between ear surgery and hearing aid wearing is a vital role of hearing aid clinics at university hospitals.

Rapidly enlarging dermoid cyst over the anterior fontanel: a case report and review of the literature.

A case report of a rapidly enlarging dermoid cyst over the anterior fontanel is presented. Our presentation demonstrates the course of rapid enlargement of the tumor with radiological images, which were examined at birth and during the process of the tumor enlargement. The literature is reviewed with respect to the nature of this tumor, especially to the relationship of tumor enlargement.

Circadian rhythm-modulated chemotherapy with high dose 5-fluorouracil against gastrointestinal cancers: evaluation and case report.

Circadian variations in chemotherapy toxicity and antitumor effects were investigated in experimental and clinical studies. In the experimental study, Balb/c mice bearing murine colon carcinoma Colon 26 were treated with 4 injections of 5-fluorouracil (5-FU) (80 mg/kg) at 0000 Hours After Light On (HALO), 0600 HALO, 1200 HALO and 1800 HALO. The antitumor effect of treatment at 0000 HALO (early resting phase) group was significantly better with lower toxicity than the 1200 HALO (early activity phase) group, resulting in significantly longer survival (p < 0.05). In the clinical study, the effect of circadian rhythm-modulated 5-FU plus leucovorin therapy was evaluated in an end-stage patient with recurrent gastric carcinoma. After continuous weekly infusion of 5-FU (1000 mg/m2/day x 2) was stopped because of its gastrointestinal toxicity, circadian rhythm-modulated chemotherapy (CRMC) was performed changing the dose of 5-FU to 666 mg/m2/day during the daytime (0500 to 1700) and to 1333 mg/m2/day from evening to night (1700 to 0500). The patient persevered with the 23 CRMC course without any signs of severe side effects and survived for nearly a year, suggesting the potential effect of CRMC in minimizing toxicity and prolonging survival.

Hyposensitization to allergic reaction in rDer f 2-sensitized mice by the intranasal administration of a mutant of rDer f 2, C8/119S.

C8/119S is a mutant of recombinant Der f 2 (rDer f 2), and lacks a disulphide bond possessed by wild-type rDer f 2. In humans and mice, C8/119S has a very weak IgE-binding capacity compared with the wild-type, but possesses a T cell reactivity comparable to that of the wild-type. C8/119S may thus be a safe immunotherapeutic agent for house dust mite allergy. The aim of the present study was to evaluate whether the intranasal administration of C8/119S could suppress an immediate allergic reaction in mice sensitized with wild-type rDer f 2, possessing an allergic activity comparable to native counterparts purified from mite extract. Seven-week-old male A/J mice were immunized with wild-type rDer f 2 four times, and then intranasally administered 0.2-2 microg of wild-type, 0.2-20 microg of C8/119S, or PBS alone, three times a week for 4 weeks. Seven days after the last administration, the mice were examined for an immediate allergic reaction. The animals administered 2 microg of C8/119S (C2.0 group) showed significantly reduced immediate bronchoconstriction provoked by the i.v. injection of 1 and 10 microg of wild-type rDer f 2, compared with the PBS-treated mice. Similar results were obtained when we examined mice 10 weeks after the last administration. The reactions in the other groups given wild-type or C8/119S also tended to decrease in severity in comparison with the animals of the PBS group. The allergic phenotypes of the T cells, B cells, and basophils in the C2.0 group were shifted to that of naive mice without immunization. We conclude that C8/119S has hyposensitizing activities in mice sensitized with wild-type rDer f 2. C8/119S may be useful for immunotherapy of house dust mite allergy.

[Surgery and multidisciplinary treatment for colorectal cancer].

Evaluation of surgery and multidisciplinary treatment for colorectal cancer was performed based on the review of the results of clinical trials. Although most improvement in prognosis for colorectal cancer patients was obtained by the development of surgical techniques until the mid-70's, further extended surgery could not have demonstrated the obvious improvement in survival after the 80's. In this regard, various multidisciplinary treatments were evaluated by a meta-analysis of clinical trials. Among those modalities, preoperative irradiation for rectal cancer, postoperative adjuvant chemotherapy for resected colorectal cancer and biochemical modulation of 5-fluorouracil by methotrexate or leucovorin for advanced colorectal cancers proved to be significantly effective for improvement of prognosis. Clinical trials of immunochemotherapy using either levamisole or PSK for resected colorectal cancers, a trial of hepatic artery infusion for liver metastasis, and a trial of an adjuvant monoclonal antibody treatment, were also reported to demonstrate significant effects. For further progress in multidisciplinary treatment for colorectal cancers, standardization of the appropriate surgical technique for each stage of the disease is much anticipated.

Thromboxane A2, released by the anti-tumour drug irinotecan, is a novel stimulator of Cl- secretion in isolated rat colon.

1. A camptothecin derivative, irinotecan (Cpt-11), is a topoisomerase I inhibitor and has a strong activity against a broad range of human cancer. One of the side-effects of this drug is diarrhoea. Here, we tried to determine the mediator of the irinotecan-induced Cl- secretion which may underlie this diarrhoea, using isolated mucosae of rat distal colon. 2. Irinotecan increased Cl- secretory current in a concentration-dependent manner across the mucosa, set between Ussing chambers. Thromboxane A2 (TXA2) has not been reported to date as a physiological stimulant of Cl- secretion in the distal colon. However, the major part of the present irinotecan-induced current was inhibited by selective thromboxane A2 receptor antagonists (KW-3635 and ONO-3708), and a selective thromboxane synthase inhibitor (Y-20811). In fact, we found that irinotecan stimulated the release of TXA2 in a concentration-dependent manner from the isolated mucosa into the bathing solutions. 3. Furthermore, 9,11-epithio-11,12-methano-thromboxane A2 (STA2), a stable analogue of TXA2, induced Cl- secretion, which was almost completely inhibited by the TXA2 receptor antagonists. 4. In single cells of isolated crypts, STA2 depolarized the cell and increased the membrane conductance, indicating that STA2 opened the apical Cl- channel of the crypt cells. 5. We conclude, therefore, that the irinotecan-induced endogenous TXA2 is a novel stimulant of the Cl- secretion from the crypt cells of distal colon.

Engineering of the major house dust mite allergen Der f 2 for allergen-specific immunotherapy.

A major problem with allergen-specific immunotherapy involving repeated injection of allergens is the risk of an anaphylactic reaction. We engineered the major house dust mite allergen, Der f 2, to reduce its capacity to induce skin test reactivity and histamine release from peripheral blood basophils in allergic patients. The engineered allergen, in which the disulfide bond that linked the N- and C-terminal sequences of Der f 2 was disrupted, retained T-cell epitopes essential for immunotherapy and ability to stimulate T-cell proliferation. Such engineered allergens are potentially useful for safer and more effective immunotherapy for allergies.

Immunohistochemical analysis of the poorly differentiated stomach adenocarcinoma with medullary growth pattern.

Poorly differentiated gastric adenocarcinoma with medullary features (poor medullary) is distinguished by a propensity for hepatic metastasis. To classify it antigenically, we compared it to poorly differentiated adenocarcinoma with scirrhous growth pattern (poor scirrhous), well and moderately differentiated adenocarcinoma (differentiated adenocarcinoma), and normal gastric mucosa (foveolar and deep epithelium) using immunohistochemistry with antibodies against CEA, AFP, NSE, and Lewis-type antigens. Lewis(a) antigen was significantly associated with differentiated adenocarcinoma and foveolar epithelium, although Lewis(x) antigen was significantly expressed in poor medullary, poor scirrhous, and deep gland epithelium. From the viewpoint of expression of Lewis(a), there was no significant differentiation between poor medullary and differentiated adenocarcinoma, but it was definite between poor scirrhous and differentiated adenocarcinoma. Therefore, we conclude that in antigenic expression, poor medullary carcinoma is allied with differentiated adenocarcinoma rather than poorly differentiated scirrhous carcinoma.

MIB-1 immunostaining and DNA flow cytometry in meningiomas.

The correlation between S- and G2/M-phase fractions and MIB-1 index in meningiomas was investigated. Flow cytometric analyses were performed on cell suspensions from 81 samples of paraffin-embedded tissue from 29 patients with a total of 28 meningiomas and 1 hemangiopericytoma using the modified Hedley's method. Sections from the paraffin-embedded tissues were stained with anti-MIB-1 monoclonal antibody after microwave oven processing. Five hundreds cells were scored. Correlations between data were estimated using linear regression. DNA aneuploidy was present in 4/29 tumors. Mean S- and G2/M-phase fractions in the 25 nonrecurrent tumors were 1.77 and 4.76%, and in the recurrent tumors were 2.41 and 5.81%, respectively. The proliferative index (PI = S + G2/M fraction) was 6.52% in the nonrecurrent tumors and 8.29% in the recurrent tumors. The mean MIB-1 score in the nonrecurrent tumors was 1.25% and in the recurrent tumors was 2.69%. There was a linear correlation between percentage of S-phase fraction or PI and the MIB-1 score. Both methods are useful to assess the proliferative activity in meningioma.

The effectiveness of medroxyprogesterone in the treatment of multiple metastasizing leiomyosarcomas: report of a case.

A 51-year-old woman was admitted to our hospital for further investigation of chest X-ray films which showed multiple shadows that had been growing slowly over 2 years. Her only symptom was hemosputa. The lesions were suspected of being metastasizing leiomyoma due to her past history of uterine leiomyoma. Just 1 week before undergoing scheduled open lung biopsy, the lung lesions increased remarkably in size and number. A thoracotomy was performed and six of the numerous nodules were removed. The resected specimens were pathologically diagnosed as metastasizing leimyosarcoma which was positive for the progesterone and estrogen receptors. Thus, 1 month postoperatively, a course of medroxyprogesterone (MPA), 600 mg daily, was commenced. The residual lesions in her chest started to diminish, shortly afterward. She has remained well on this MPA regimen for 45 months. The prognosis of patients with metastasizing leiomyosarcoma is poor because of its low sensitivity to chemotherapy; however, some types of leiomyosarcoma are hormone-sensitive. It is therefore important to examine the hormone receptors of excised tumors from patients suspected of having metastasizing leiomyoma or leimyosarcoma.

Evaluation of the effect of pancreatic resection in advanced pancreatic cancer with special reference using hospital-free survival as a measure of quality of life.

Comparisons of surgical procedures and the identification of prognostic factors in pancreatic cancer were carried out on 158 patients who underwent surgery in Aichi Cancer Center from 1975 to 1991 for advanced pancreatic ductal adenocarcinoma. Survival and 'hospital-free survival (HFS), which we consider the best general means of measuring quality of life (QOL) in such severe and often fatal disease, were identified as primary end points, and the effect of pancreatectomy, compared with palliative surgery (by-pass operation, etc.) for TNM Stages III and IV pancreatic cancer was evaluated. Both survival and HFS were significantly longer in the group of patients who underwent pancreatectomies (R group, n 25) compared to the group without pancreatic resection (NR group, n 35) in Stage III cases. In Stage IV cases, however, no significant difference was observed between the R (n 12) and NR (n 86) groups. From these results, we conclude that an extensive pancreatic resection against Stage III pancreatic cancer may improve prognosis. For Stage IV pancreatic cancers, however, aggressive surgery might not always be beneficial either for survival or for QOL.

Prognostic values of preoperative and postoperative CEA and CA19.9 levels in pancreatic cancer.

Preoperative serum levels of carcinoembryonic antigen (CEA) and/or carbohydrate antigen 19.9 (CA19.9) were measured in 90 patients with advanced pancreatic cancer. CEA antigen was above the cutoff levels of 5.0 ng/ml in 51% of patients and CA19.9 was above the cutoff limit of 37 U/ml in 87% of patients. High preoperative CEA and CA19.9 levels were related to a poor prognosis of the patients. In multivariate analysis, the hazard rate was significantly higher in the high-CEA group (> 2.5 ng/ml) compared to the low-CEA group (< 2.4 ng/ml). An increase in CEA and/or CA19.9 within 1 month after the operation was also significantly related to the hazard rate. This study reconfirms the prognostic importance of preoperative and postoperative CEA and CA19.9.

Germ cell tumors of the basal ganglia and thalamus.

The clinicopathological findings in 6 patients with germ cell tumors originating in the basal ganglia and thalamus are presented. Clinical, biological and diagnostic features were somewhat different from germ cell tumors in the pineal region. Early and comprehensive treatment is recommended because of the possible presence of nongerminomatous germ cell components.

Clinical, biological and histological considerations on primary intracranial germinomas in the prevalent sites.

Twenty-four germinomas from which tumor sites were 11 pineal, 7 suprasellar, and 6 basal ganglial and thalamic (BG-T) were subjected. Humoral tumor markers of HCG, CEA and AFP were measured and compared with immunohistochemistries for these tumor markers along with PLAP, HPL and PKK1. Humoral tumor markers and immunohistochemistries did not always comprehend to each other. Difference of the survival rates among tumor sites was thought to be attributed to the variabilities in their histological, immunochemical and flow cytometric results.

[DNA analysis of meningiomas using paraffin-embedded surgical specimens in connection with clinical recurrence].

Meningioma includes some clinically malignant cases which grow multifocally or recur rapidly. To develop methodology to distinguish clinically malignant cases, we examined the nuclear DNA of meningiomas by flow cytometry using paraffin-embedded specimens. 52 surgical specimens were studied from 52 cases of meningioma. Among these cases, 3 multiple meningiomas that recurred multifocally within 3 years were included. Malignancy was assessed by the proliferative index (%S + %G2/M) and DNA ploidy of the specimens. Six cases were histologically malignant, while aneuploidy was observed in only 2 (33.3%). No significant correlation was observed when analyzing the 23.9% aneuploidy rate among benign cases. Moreover, three cases of clinically malignant meningiomas were all diploid. In contrast, the proliferative index of 19.82 +/- 9.45% among histologically malignant cases was significantly higher as compared to that for benign cases (11.50 +/- 5.49%). The proliferative index was 15% or more (average 22.02 +/- 6.01%) for patients with clinically malignant meningioma. This was considerably higher than the corresponding value for clinically benign meningiomas. Our analysis indicated that the assessment of benignancy or malignancy of meningioma on the basis of DNA ploidy alone is difficult. The proliferative index so obtained relates significantly to prognosis, apparently providing a useful prognostic assessment.