Three-dimensional CT in isolated dissecting aneurysm of the superior mesenteric artery: a case report.

Isolated dissecting aneurysm of the superior mesenteric artery (SMA) without aortic dissection is a rare condition. We report a case of isolated dissecting aneurysm of the SMA incidentally detected by postcontrast abdominal computed tomography (CT). Three-dimensional CT using helical scanning was helpful for the evaluation of dissecting aneurysmal structures such as the intimal flap, true lumen, and false lumen with thrombosis. CT angiography (CTA) was useful for the assessment of characteristic morphology and three-dimensional relationship between the dissecting portion and SMA branches.

Interictal crossed cerebellar hyperperfusion on Tc-99m ECD SPECT.

Crossed cerebellar hyperperfusion (CCH) in epilepsy is a rare condition that is observed on ictal cerebral perfusion SPECT. The mechanism of CCH assumes that hyperperfusion in the epileptic foci of the unilateral supratentorium causes hyperperfusion secondary to the corticopontocerebellar pathway (CPCP)-mediated remote effect in the contralateral cerebellar hemisphere. This phenomenon is similar to that of crossed cerebellar diaschisis (CCD). In this report we demonstrated interictal CCH in a patient with epilepsy in technetium-99m-ethyl cysteinate dimer (Tc-99m ECD) SPECT of the brain. To the best of our knowledge, interictal CCH has not been reported in the literature. This is the first report to describe the phenomenon with interictal Tc-99m ECD SPECT.

Transient seizure activity demonstrated by Tc-99m HMPAO SPECT and diffusion-weighted MR imaging.

Cerebral perfusion single photon emission computed tomography (SPECT) has been used to confirm the localization of the epileptic focus and the evaluation of seizure. Recently, diffusion-weighted MR imaging (DWI) has been recognized for evaluation of seizure activity. We describe a case of transient seizure activity demonstrated by Tc-99m HMPAO SPECT and DWI. This patient was a 61-year-old woman with a 10-month history of right middle cerebral artery (MCA) infarction who had a generalized seizure during MRI. DWI immediately after seizure showed transient hyperintensity in the right frontal gray matter and the white matter, and these apparent diffusion coefficients (ADC) were transiently decreased. This transient hyperintensity on DWI corresponded to transient hyperperfusion identifying the epileptic focus on interictal Tc-99m HMPAO SPECT. Transient sustained seizure activity might cause these changes on DWI and SPECT. It was considered that interictal Tc-99m HMPAO SPECT showed the delayed hyperperfusion caused by excitatory neuronal overaction and DWI showed cytotoxic edema seizure-induced by energy failure of the membrane-bound Na/K-ATPase pump.

[Gastrointestinal bleeding from capillary hemangioma of the ileum detected by 99mTc-HSAD scintigraphy].

It has been well-known that technetium-99m-human serum albumin-diethylenetriaminepenta-acetic acid (99mTc-HSAD) scintigraphy is useful for diagnosis of the localization of the gastrointestinal arterial or venous bleeding. In this report, we describe a case of venous bleeding from capillary hemangioma of the ileum end detected by 99mTc-HSAD scintigraphy. This patient was a 9-year-old girl with severe anemia. Gastrointestinal bleeding was suspected from her clinical course and laboratory tests. Immediately after melena occurred, 99mTc-HSAD scintigraphy showed the extravasation of RI suggesting gastrointestinal bleeding in the ileum end. Abdominal angiography immediately after 99mTc-HSAD scintigraphy, however, could not show the extravasation of contrast agent. Because the condition of the patient became worse, laparotomy was performed on the basis of 99mTc-HSAD scintigraphy findings. At surgery, venous bleeding from capillary hemangioma in the ileum end was observed. It was suggested that 99mTc-HSAD scintigraphy was very useful for identifying the gastrointestinal venous bleeding.

Current management of incidentally discovered adrenal masses, with a review of Japanese literature.

It is becoming increasingly common to discover adrenal masses incidentally on radiologic imaging studies. We herein present our experience with 61 cases of incidentally discovered and surgically removed adrenal incidentalomas, including 11 pheochromocytomas. Only four were adrenocortical carcinomas. A review of the literature, including Japanese journals, for the prevalence of incidentantally discovered adrenal mass, their differential diagnosis and management are discussed.

Urinary steroid profile in adrenocortical tumors.

Determination of the urinary steroid profile has been proposed as a sensitive tool for diagnosing adrenocortical tumors. The urinary steroid profiles were determined for patients with adrenocortical tumors. Urinary steroids were extracted, derivatized to form methyloxime-trimethylsilyl ether and analyzed by gas chromatography/mass spectrometry. Patients with adrenal adenomas from primary hyperaldosteronism had increased metabolites of 18-hydroxycorticosterone and aldosterone, and those with Cushing's syndrome had elevated excretion of 11 -deoxycortisol, cortisol, 18-hydroxycortisol, and cortisone metabolites. In patients with adrenocortical carcinomas, increased levels of metabolites of 11-deoxycortisol or 33-hydroxy-5-ene steroids were observed. The urinary steroid profiles of adrenal adenomas and adrenocortical carcinomas were quite different, suggesting the diagnostic validity for discriminating malignant from benign diseases.

Application of region-specific immunoassay for human chromogranin A: substantial clue for detection and measurement of chromogranin A in human plasma.

Chromogranin A (CgA), a secretory protein, is co-released with catecholamines from storage vesicles. It is known to be elevated in the circulation of patients with neuroendocrine and endocrine tumors. For further investigation of the protein, especially in humans, it is essential to facilitate quantitative analysis of the protein in human biological materials. In order to introduce novel immunological methodology for this purpose, we purposely selected human CgA(344-374) for the synthetic immunogen to produce region-specific CgA antibodies. The anti-synthetic peptide antibody thus obtained made it possible to develop an immunological method for measurement and characterization of CgA in human plasma. The plasma CgA-immunoreactivity (LI) level measured by the method was 0.31+/-0.01 pmol/ml (mean+/-SEM) in normal subjects and 1.55+/-0.29 pmol/ml in pheochromocytoma. On gel chromatography and HPLC analysis of the plasma of patients with pheochromocytoma, the region-specific assay system enabled us to show the presence of N-terminal truncated CgA, besides CgA itself. By following up changes of plasma CgA-LI in a pheochromocytoma patient using samples that were collected consecutively over a two-year period, the present assay system using the region-specific antibody, anti-human CgA (344-374) serum, was confirmed to be extremely valuable for the measurement of CgA-LI in human plasma. The characteristic features and high sensitivity of the present assay system will give us a substantial clue to the detection and measurement of CgA to develop further investigation of the protein in humans.

Retroperitoneoscopic adrenalectomy by a lumbodorsal approach: clinical experience with solo surgery.

Laparoscopic adrenalectomy by transperitoneal approaches necessitates the retraction of intraperitoneal organs and, hence, the creation of extra ports for retractors and assistants. The feasibility of retroperitoneoscopic adrenalectomy by a lumbodorsal approach was assessed in 26 patients with adrenal tumors. In six patients the procedure was carried out as solo surgery using the ABSOP robot camera holder, and the performance was compared with that reported for the most recent series of six cases operated upon with one human assistant. The procedures were successful in 25 patients. One patient had to be converted due to tension pneumothorax caused by diaphragmatic injury. The mean blood loss was 43.5 +/- 67.5 ml, and the procedure time averaged 144 +/- 33 min. We required an average of only 3.1 trocars to accomplish solo surgery in 5 of 6 patients (83%). The number of lens smearings decreased to one-fourth of that observed by a human assistant.

Peripheral corticotropin-releasing factor mediates the elevation of plasma IL-6 by immobilization stress in rats.

We previously reported the elevation of plasma interleukin (IL)-6 activity in response to immobilization stress in rats. To investigate the role of peripheral corticotropin-releasing factor (CRF) in this response, we examined the effects of CRF antagonists on immobilization-induced IL-6 response. Intravenous pretreatment with either [D-Phe12,Nle21,38,CalphaMeLeu37]-anti-human rat (h/r) CRF12-41 (1.5 mg/kg) or cyclo(30-33)[D-Phe12, Nle21,38,Glu30, Lys33]-h/rCRF12-41 (Astressin, 0.5 mg/kg) attenuated the IL-6 response to immobilization, which confirmed our previous finding that systemic administration of an antiserum against CRF blocked this response. In addition, an intraperitoneal injection of h/rCRF (100 micrograms/kg) or rat urocortin (10 and 100 micrograms/kg) increased the plasma IL-6 activity, mimicking the response to immobilization. An intravenous injection of h/rCRF (100 micrograms/kg) also elevated plasma IL-6 in adrenalectomized rats. These findings suggest that peripheral CRF mediates the plasma IL-6 elevation in response to immobilization.

Distribution of urocortin-like immunoreactivity in the central nervous system of the rat.

Urocortin was recently cloned from the rat midbrain. Urocortin is a member of the corticotropin releasing factor (CRF) peptide family and shows 45% sequence identity to CRF and 63% sequence identity to urotensin. It binds with a high affinity to CRF1 and CRF2 receptors, resulting in the stimulation of their adenylate cyclase activity. We used a polyclonal antibody against rat urocortin to define the distribution of urocortin-like immunoreactivity in the rat central nervous system. Several immunostained cell bodies were found in the supraoptic, paraventricular, and ventromedial hypothalamic nuclei. A large number of neurons with urocortin-like immunoreactivity were seen in the dorsolateral tegmental nucleus, in the linear and dorsal raphe nuclei, and in the substantia nigra. The most abundant immunoreactive (ir) perikarya were found in the Edinger-Westphal nucleus. Some neurons showed immunoreactivity in the interstitial nucleus of Cajal, the nucleus of Darkeschewitsch, and the periaqueductal gray. A dense immunoreactive fiber network was found in the lateral septal area. Some faintly stained axon terminals were observed among urocortin-ir perikarya in the supraoptic and paraventricular nuclei, in the central and periaqueductal gray, and in the Edinger-Westphal nucleus. No fibers with urocortin-ir were seen in the median eminence or the posterior pituitary. The distribution of urocortin-ir overlapped with the expression of the mRNA for the CRF2 receptor in several brain areas. These data support the hypothesis that this peptide is the endogenous ligand for the CRF2 receptor. Urocortin has been implicated in various endocrine responses, such as blood pressure regulation, as well as in higher cognitive functions.

Immunohistochemical demonstration of the intracellular localization of pituitary adenylate cyclase activating polypeptide-like immunoreactivity in the rat testis using the stamp preparation.

Radioimmunoassay has revealed an abundance of PACAP in the rat testis. In the present study, a novel stamp preparation together with light microscopic immunohistochemistry were used to investigate in detail the intracellular localization of PACAP-like immunoreactivity (PACAP-LI) in rat germ cells. Samples were obtained by pressing the freshly cut surfaces of the testes against glass slides. PACAP-LI was clearly identified in developing acrosomes using five antisera which recognize PACAP 38, or both PACAP 27 and PACAP 38. Immunoreactivity with the antisera specific to PACAP38 was strictly localized in the developing acrosomes of the spermatids but vanished in the mature spermatids. Using an antiserum which detects PACAP 27 specifically, little staining was observed. Based on the specificities of antisera used, it was suggested that the PACAP-LI in the acrosomes represents mainly PACAP 38-LI. In addition, the present results supported the usefulness of the stamp preparation for immunohistochemical study of testicular tissues.

[A case of drug-induced immune hemolytic anemia during alpha-interferon therapy for renal cell carcinoma].

A Case of drug-induced immune hemolytic anemia during alpha-interferon (alpha-IFN) therapy for renal cell carcinoma is reported. A 61-year-old woman was admitted to Tochigi cancer center for the treatment of left renal cell carcinoma. She underwent left radical nephrectomy. From 7th post operative day, alpha-IFN (6 x 10(6) IU) was administered every other day. Diclofenac and indomethacin were administered for pain and high fever induced by alpha-IFN. Hemoglobinuria was first noted on 20th post operative day. Immune hemolytic anemia was suspected by blood examinations including Coombs' test, serum haptoglobin, serum LDH and serum GOT. alpha-IFN therapy and administration of diclofenac and indomethacin were discontinued and prednisolone therapy (50 mg daily) was begun. Hemoglobinuria disappeared by 5 days and laboratory data became in normal range by 3 weeks. Drug-induced immune hemolytic anemia was diagnosed by the process of laboratory data, especially of direct Coombs' test. Though drug-induced immune hemolytic anemia is a rare adverse side effect during alpha-INF therapy for renal cell carcinoma, it seemed an important complication.

[A case report of renal leiomyoma and its DNA ploidy pattern].

We experienced a case of renal leiomyoma. A 51-year-old woman was referred to the Department of Urology, Tochigi Cancer Center with a complaint of right renal incidentaloma pointed out on CT scan. The renal mass was removed by enucleation. Histological examination revealed the tumor composed of monotonous proliferation of spindle shaped cells without atypia. Thus, the diagnosis of leiomyoma was confirmed. DNA flow cytometric analysis of this tumor was performed and diploid pattern was shown.

[A case of mucinous adenocarcinoma of the prostate].

We experienced a case of mucin producing prostate carcinoma, which occurred 46-year-old male patient. Serum tumor markers of prostate carcinoma were all in normal levels, and physical findings were similar to those of benign prostate hypertrophy. Histopathological study showed poorly differentiated mucinous adenocarcinoma occupying more than 30% of specimen. In literatures there seemed two types of mucin producing prostate carcinoma, the one is different from usual prostate carcinoma as our case and the other is a subtype of usual one, and so it was suggested that we must respect to this point on diagnosis and therapy of it.

[A case of retroperitoneal dedifferentiated liposarcoma with tumor thrombus in the inferior vena cava].

We experienced a case of retroperitoneal dedifferentiated liposarcoma with tumor thrombus in the inferior vena cava. A 45-year-old man was pointed out a retroperitoneal mass on ultrasound examination. He was referred to the Department of Urology, Tochigi Cancer Center for critical evaluation. Image diagnostic procedures showed a retroperitoneal mass surrounded by loose tissue and large thrombus in the inferior vena cava. The tumor was removed surgically with right lobe of the liver and segment of the inferior vena cava. Histological examination revealed the tumor composed of the peripheral well differentiated liposarcoma and the central dedifferentiated liposarcoma. Characteristic radiological findings of retroperitoneal liposarcoma with dedifferentiation could be pointed out.

[A case of abdominal desmoid causing urinary tract obstruction].

A 62-year-old male patient presented with a complaint of the lower abdominal distention. Ultrasonography demonstrated bilateral hydronephroses and a huge heterogeneous mass in the pelvic cavity. Excretory urogram showed left-non visualized kidney and right-hydronephrosis. CT showed a heterogenous mass, situating 25 cm in diameter, adjacent to the left side of the bladder. Tumor resection was carried out on May 17th of 1994. Histopathological diagnosis of the surgical specimen was abdominal desmoid with HE stain.

[A case of huge renal hamartoma].

We experienced a case of renal hamartoma of mesothelial origin. A 21-year-old was referred to our hospital with a complaint of growing abdominal mass. The diagnosis of right renal tumor was confirmed based on the radiographic examinations. The renal tumor was removed by partial nephrectomy. Histological examination revealed the tumor composed of fibroblasts, smooth muscle and a few tubule-like epithelial tissue. Thus, this case was classified as renal hamartoma of mesothelial origin.

[Experience in seven cases of laparoscopic adrenalectomy].

We have experienced 7 cases of laparoscopic adrenalectomy for adrenal tumors during the past two years since our department opened in July, 1992. In four cases, the tumors were clinically diagnosed preoperatively as primary aldosteronism and in the other three cases as endocrine-inactive tumors. Four tumors were found on the left adrenal and three on the right. Five tumors were successfully resected with laparoscopic surgery, but in the other two cases it was immediately followed by open surgery because of an uncontrollable hemorrhage. Laparoscopically unresected tumors existed, one on the right and the other on the left adrenal. The average operation time for laparoscopic adrenalectomy was twice as much as that of open adrenalectomy previously performed. However, the operation time has been recently shortened to be less than 200 minutes. Hemorrhage during the operation was rather less in laparoscopic surgeries if they were successfully done. Postoperative recovery was found to be much faster and the hospital stay was shortened by more than 10 days in patients operated with a laparoscope. These findings indicate that laparoscopic adrenalectomy is a minimally invasive operation that can increase the QOL's of the patient. Although we consider that this operation may propagate as a method for adrenalectomy in future, it must be performed with a careful backup system in the case of an emergency.

[Clinical study on 26 cases of incidental adrenal tumors: a consideration on surgical indication].

At our medical center we have seen 151 patients who have undergone adrenalectomy from 1971 up until June 1992. There has been a recent increase in the number of cases since 99 patients have been seen in the last eight years from 1985. This increase is related to the increase in the number of incidental tumors. Of those 99, 26 have been incidental tumors. Twenty-four of those have been endocrine inactive tumors, and the remaining 2, both active endocrinologically, were pheochromocytoma. We propose that our tentative indications for surgical treatment of incidental tumors are 1) tumors of diameter 3.5 cm or greater, 2) tumors undeniably malignant by imaging diagnosis, 3) tumors that tend to increase in size with every six-month re-examination, even though the original size is less than 3.5 cm in diameter, and 4) tumors endocrinologically active. The main purpose of this study was to make a differential diagnosis of malignant tumors among incidental tumors. Diagnostic modalities included 1) imaging diagnosis such as echography, CT, MRI, and angiography, 2) analysis of DNA ploidy and BrdU uptake utilizing flow cytometry of excised adrenal tumor tissues, and 3) analysis of urinary steroid fraction. It is generally thought that there are currently no methods by which malignant tumors can be differentiated with certainty, even with modern diagnostic technology, and review of the literature, finds approval or disapproval with regard to the methods we selected to evaluate tumors. What has aroused interest in our results is urinary 17KS fraction.(ABSTRACT TRUNCATED AT 250 WORDS)