First successful case of non-invasive in-utero treatment of twin reversed arterial perfusion sequence by high-intensity focused ultrasound.

High-intensity focused ultrasound (HIFU) has excellent potential as a non-invasive therapeutic tool in various fields of medicine. We present a case of twin reversed arterial perfusion sequence, in which non-invasive blood flow occlusion in the acardiac fetus was successfully achieved by means of HIFU exposure from outside the maternal abdomen. HIFU was applied to blood vessels of the acardiac fetus at the point at which the umbilical cord entered the body in a series of four procedures at 3-day intervals starting at 13 weeks' gestation, and in a final procedure with higher power at 17 weeks. The HIFU intensity was set at approximately 2300 W/cm(2) for the initial series of procedures and at 4600 W/cm(2) for the final procedure, with exposure periods of 10 s. As color Doppler examination revealed absence of blood flow to the acardiac fetus after the second round of HIFU exposure, we concluded that complete occlusion of target vessels had been achieved. Delivery was by Cesarean section at 37 weeks' gestation. A male neonate (the pump fetus) was born weighing 1903 g with Apgar scores of 8 and 9 at 1 and 5 min, respectively. At the time of writing, the baby was healthy and growing normally, with the exception of congenital pseudarthrosis.

[Clinical effect of the cauterization for emphysematous bulla].

The purpose of performing pleural cauterization is developing heat denaturation, and we can induce pleural thickening and also reduce the bullae by shrinking the pleura It originates in a method of the cauterization whether there will be tissue damage. So a safe and reliable method of cauterization is required. Here, we investigated the indications for and effectiveness of cauterization techniques performed at our facility. We perform cauterization while dropping saline solution, so when using a Salient Monopolar Sealer, we can avoid excessive thermo-coagulation and more easily control cauterization. Furthermore, on the basis that only emphysematous pleura will turn white on cauterization, bullae can be distinguished, which is particularly effective in the case of lesions with unclear borders. In the case of a large emphysematous bulla, shrinkage of the bulla by cauterization can provide a sufficient surgical field, and a smaller lesion can then be stapled.

The effect of an oral administration of Lactobacillus casei strain shirota on azoxymethane-induced colonic aberrant crypt foci and colon cancer in the rat.

The preventive effect of oral administration of viable Lactobacillus casei strain Shirota (LcS) on azoxymethane (AOM)-induced colonic aberrant crypt foci (ACF) and colon cancers in the rat was investigated. The study consisted of two experiments; in a short-term experiment (Exp-I), the inhibitory effect of 8- and 12-week treatments with LcS. Forty rats each received weekly a subcutaneous injection of AOM at a dose of 15 mg/kg of body weight for 5 weeks. Eight and twelve weeks after the start of the carcinogen treatment, each subgroup of rats were sacrificed, and the colon and the mesenteric lymph nodes (MLN) were removed. The number of ACFs and the surface marker of lymphocytes derived from the MLN were investigated. The large ACF (those comprising four or more aberrant crypts per focus) had significantly decreased in the rats which had consumed the LcS diet. And oral administration of viable LcS significantly recovered CD8 positive lymphocytes to the levels in the control group. In a long-term experiment (Exp-II), 30 rats each received weekly a subcutaneous injection of AOM at a dose of 7. 4 mg/kg of body weight for 10 weeks. Twenty-five weeks after the start of the carcinogen treatment, each subgroup of rats were sacrificed, and the colon were removed. The number and incidence of colon cancers were investigated. The number of rats with colon cancers and the number of colon cancers per rat, were significantly decreased in the rats which had consumed the LcS diet. LcS inhibited chemically-induced colon carcinogenesis in the rat. CD8 positive T lymphocytes may play a key role in the preventive effect against colon carcinogenesis.

Congenital ureteral diverticulum coexistent with hydronephrosis caused by vascular compression involving the uterine artery and umbilical ligament: report of a case.

Coexistence of congenital ureteral diverticulum and hydronephrosis caused by vascular compression is a rare entity. The authors experienced a case of congenital ureteral diverticulum coexistent with hydronephrosis caused by aberrant vascular compression by uterine and umbilical arteries in a 14-year-old girl. The authors could not diagnose accurately this abnormality preoperatively by 3-dimensional computed tomography. After partial ureterectomy, including resection of the saccular lesion and ureteroneocystostomy, the frequency of urinary tract infection decreased.

Secretory carcinoma of the breast. Correlation of aspiration cytology and histology.

We analyzed the fine needle aspiration findings in five cases of secretory carcinoma of the breast in adults to clarify their cytomorphologic features and correlate them with their histology. The cytologic smears revealed grapelike clusters of mucous globular structures (MGSs); single MGSs; clusters and sheets of cells with pale green and slightly granular cytoplasm with or without intracytoplasmic vacuolization; some ordinary duct carcinoma-like arrangements; scattered, single, vacuolated cells; some extracellular mucus; and a clean background. The MGSs were globular structures consisting of distinctive vacuolated cells containing large globules of a secretory product. The cytologic findings showed a similar wide variation in the range of histologic appearances; however, the grapelike clusters of MGSs, which corresponded to a microcystic or microfollicular pattern histologically, were present in most cases and should suggest a diagnosis of secretory carcinoma.

Staged resection of large hypervascular vestibular schwannomas in young adults.

Two young adults underwent resection of large hypervascular vestibular schwannomas (acoustic neuromas) via two-stage surgery. The first patient, a 27-year-old woman with hydrocephalus, had a large hypervascular vestibular tumor in the left cerebellopontine angle (CPA) supplied by the left anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA). The second patient, a 34-year-old woman, had a large AICA-supplied hypervascular vestibular tumor in the left CPA that displaced the brain stem significantly. At the initial stage, only the lateral aspect of the tumor was debulked due to excessive bleeding from the tumor bed. Angiography 1 or 2 months after the initial operation showed that the tumor was hypovascular. At the second stage, the remnant medial aspect of the tumor was relatively avascular and nonadherent to the brain stem. Without blood transfusion during the second stage, the tumor was removed totally in the first patient and subtotally in the second patient. Pathological examination revealed that dilatated blood vessels were prominently increased at the first surgery; however, at the second surgery, the number of blood vessels had decreased, showing necrosis and degeneration. Although there are no absolute indications for the staged resection of vestibular schwannomas, this procedure may represent one of the safest options for these difficult lesions in young adults.

Fatal severe vasospasm due to rewarming following hypothermia--case report.

A 37-year-old female died of cerebral vasospasm as a complication of rewarming following hypothermia therapy for severe head injury. She presented with severe consciousness disturbance and anisocoria after falling down a flight of stairs. Computed tomography (CT) revealed a right acute subdural hematoma and temporal contusion. Following surgery, mild hypothermia was started and rewarming was completed by the 11th day. Neurological examination showed no abnormalities, but intracranial pressure (ICP) suddenly increased and she manifested anisocoria on the 13th day. Repeat CT revealed a low density area in the right middle cerebral artery region and cerebral angiography showed diffuse narrowing of the main arterial trunks. A cerebrospinal fluid (CSF) sample was collected using an intraventricular ICP monitoring catheter. The CSF level of 8-hydroxy-2'-deoxyguanosine was elevated during the rewarming period, indicating substantial deoxyribonucleic acid (DNA) oxidation. She died on the 15th day due to uncontrollable ICP. Histological examination at autopsy of the narrowed artery found the waving phenomenon in the internal elastic lamina and invasion of inflammatory cells into the adventitia. These findings constitute the possible evidence that free-radical-mediated oxidative DNA damage may be important in the genesis of severe vasospasm due to rewarming following hypothermia.

[Reconstruction of the sellar floor during transnasal pituitary surgery using ceramics composed of a combination of hydroxyapatite and tricalciumphosphate].

Our clinical experience with reconstruction of the sellar floor during transnasal-transsphenoidal surgery for pituitary tumors using ceramics composed of a combination of hydroxyapatite and tricalciumphosphate (pituitary plate) is described. A pituitary plate was used to reconstruct the sellar floor in 15 patients with pituitary tumors that included 13 pituitary adenomas and 2 Rathke's cleft cysts. This method is indicated for cases of reoperation and cases in which there is of much cerebrospinal fluid leakage during surgery. This material is provided as a pituitary plate 12 x 12 mm round and 2 mm thick. There are four holes in the center by which the plate can be held with regular bipolar forceps. At the time of closing the sellar floor window, a pituitary plate was carved with scissors into a suitable shape and slipped inside the bony defect. The postoperative position of the pituitary plate could be clearly identified on skull roentgenogram and magnetic resonance imaging. No displacement or migration of the implanted pituitary plate was observed in any patient during follow-up radiological examinations. Infections such as a pituitary abscess or meningitis were not observed clinically or radiologically in any patient. In three patients who underwent repeated transnasal surgery for regrowth of the tumor, the pituitary plate that had been placed at the initial procedure was covered with a thin fibrous capsule and the plate was well preserved. These results indicate that a pituitary plate can be useful for reconstruction of the sellar floor in transnasal-transsphenoidal surgery.

[Importance of lateral inspection of the scrotum and value of intraoperative spermatic phlebography in varicocele].

Varicocele appearing on the posterior surface of the scrotum is apt to be overlooked in a routine physical examination. Lateral inspection of the scrotum is important to detect a varicocele of this type. Intraoperative spermatic phlebography on high ligation for varicocele was valuable in confirming the ligation of a single vein or in visualizing the vessel(s) left unligated.

[Tunica albuginea cyst associated with hydrocele testis: report of a case].

The patient is a 54-year-old male presenting with a chief complaint of a right intrascrotal mass. Ultrasonographic image of the right testis demonstrated a marginally located cyst, 5 mm in diameter, with hydrocele fluid. Partial orchiectomy and hydrocelectomy with Bergmann's method were performed without any morbidity. Histopathological diagnosis was tunica albuginea cyst. To date, this case is the sixth reported case in Japan.

[Diagnosis of the upper urothelial tumor using a rigid ureteroscope].

We preoperatively diagnosed four cases suspected as malignant urothelial tumor of upper urinary tract using a rigid ureteroscope. In three cases of ureter tumor, biopsy was successful and showed low grade malignancy. Nephroureterectomy was performed in two cases with upper ureteral tumor. The tumor was fulgurated ureteroscopically in a case of lower ureteral tumor. In one case of renal pelvic tumor, biopsy was unsuccessful though the tumor was observed as a papillary configuration. Successively, biopsy using a flexible ureteroscope was performed and the tumor was treated by fulguration. Ureteroscopy is very useful for preoperative diagnosis of ureteral tumor and selection of treatment.

A case large protruding cystitis glandularis: clinical, histological and mucin-histochemical study.

A case of large protruding cystitis glandularis is reported. A 36-year-old man was admitted to our hospital due to acute cholecystitis, and large protruding masses were incidentally found in the urinary bladder by abdominal ultrasonography. The histological study revealed that they consisted of a large number of Brunn's nests with or without cysts which were often accompanied with columnar epithelial metaplasia, and of glandular structures closely resembling the colonic crypts. The mucin-histochemical study demonstrated glandular lesions in the bladder secreted colonic type mucin, and endocrine cells positive with Grimelius' staining. A review of literature disclosed 19 clinical cases of cystitis glandularis, since 1970, in Japan, but such a large protruding lesion as this case is rare. We first performed detailed histological and mucin-histochemical studies for this clinical case.

[Retroperitoneal myxoid leiomyoma: report of a case].

We report a case of retroperitoneal myxoid leiomyoma in a 36-year-old woman complaining of urinary retention. An ultrasonogram revealed a mass in the pelvic space, while CT and MRI demonstrated a retroperitoneal tumor. Open resection of the tumor was performed. The resected tumor weighed 600 g and measured 16 x 11 x 9 cm. Histological examination disclosed a tumor mainly composed of smooth muscle with myxomatous change and only rare mitoses. The pathologic diagnosis was retroperitoneal myxoid leiomyoma. Twenty-seven cases of this type of lesion previously reported in the Japanese literature were reviewed.

[Pure red cell aplasia with thymoma, myasthenia gravis and normal pressure hydrocephalus].

Cases of pure red cell aplasia with thymoma and myasthenia gravis are rare. We described a patient who had concomitant pure red cell aplasia, thymoma, myasthenia gravis and a normal pressure hydrocephalus. A 63-year-old man with disturbances of gait, left blepharoptosis and anemia was presented to our hospital. Laboratory examination on admission revealed severe anemia. Bone marrow aspirates showed erythroid hypoplasia of marked degree. Chest x-ray and chest CT revealed a tumor to the right of cardiac wall. The tensilon chloride test and antiacetylcholine receptor antibody were positive. A hydrocephalus was demonstrated with brain CT. Cerebrospinal fluid pressure was in the normal range. He was diagnosed as having pure red cell aplasia with thymoma, myasthenia gravis and a normal pressure hydrocephalus. This appears to be a fairly rare case. It seems important to consider that a normal pressure hydrocephalus may have immunological disorders.

[Tumor heterogeneity in DNA ploidy of renal cell carcinomas as revealed by static cytofluorometry and flow cytometry].

DNA ploidy of 49 renal cell carcinomas of 46 patients were examined with static cytofluorometry (SCM) and flow cytometry (FCM). We used several paraffin blocks for each tumor (mean, 2.4), separated each block into several samples based on histological findings, and measured the DNA content of each sample. More samples could be analyzed with SCM than with FCM. With FCM, it was sometimes difficult to detect polyploid cells, or to determine whether diploid cells were tumor cells or stromal cells. DNA heterogeneity might thus be more accurately detected with SCM than with FCM. DNA aneuploidy was demonstrated for 59% of the tumors, and was significantly less common in grade 1 tumors than in higher-grade tumors. The incidence of polyploid cells in diploid tumors tended to increase with grade of tumor. Fifty-five percent of the tumors displayed DNA heterogeneity, the incidence of which tended to increase with grade of tumor. Ninety-four percent of the tumors were found to yield a diploid cell line. The findings of this study indicate that DNA content is associated with the histological grading. Diploid tumors with polyploid cells should be dealt with clinically in a separate fashion from diploid tumors without them. These findings suggest that diploid renal cell carcinomas with polyploid cells may be an intermediate stage between diploidy and aneuploidy.

[Multicentric Castleman's disease with lymphoid interstitial pneumonia died of aggressive course with adult respiratory distress syndrome].

A 49-year-old man was admitted to our hospital with anemia and hypergammaglobulinemia. Physical examination revealed superficial lymph node swelling and no hepatosplenomegaly. Laboratory findings showed WBC 5,300/microliters with normal hemogram, microcytic and hypochromic anemia. Total protein was 11.5 g/dl and immunoglobulinemia (IgG 10,100 mg/dl, IgA 295 mg/dl, IgM 160 mg/dl) was observed without M-component in serum and urine. The CD4/CD8 ratio of lymphocyte subsets was 0.58 and the tuberuculin skin test was negative. Urinary protein was positive and renal biopsy disclosed plasma cell infiltration. Lymph node biopsy revealed multiple lymphoid follicles and infiltration of plasma cells in the interfollicular areas. A diagnosis of multicentric Castleman's disease (MCD) was made baredon clinical findings and lymph node biopsy. After therapy with plasmapheresis and the CHOP regimen, he was given etoposide. Although discharged with clinical improvement and a decrease of serum IgG, he was readmitted because of pyrexia after 4 days and died of pneumonia with adult respiratory distress syndrome. The autopsy revealed lymphoid interstitial pneumonia. It seems important to notice that some of MCD have poor prognoses because of accompanying immunodeficiency.

[Cyclosporin levels in semen of renal transplant patients].

Cyclosporin (CsA) has powerful immunosuppressive properties, and its recent application to organ transplantation has resulted in markedly improved graft survival. However, CsA has certain adverse side effects, the most notable being nephrotoxicity and hepatotoxicity. Among other untoward effects, little is known about the effects of CsA on the reproductive organs. Since good graft survival is now expected with CsA, the long term effect of the drug on the gonads should be monitored carefully, particularly for young recipients. Prior to investigation of the effect of CsA on the testis, the level of CsA in semen of the adult renal transplant patients were measured. Twelve samples of semen from eight recipients, mean age 35 (SD 9), were collected by masturbation in the morning just before taking CsA after more than 5 day abstinence, and it was frozen at -80 degrees C. They had been taking immunosuppressants that were a combination of either CsA and prednisolone, or CsA, azathioprine and prednisolone for 5 to 63 months. The dose of CsA was 3.7 mg/kg to 5.0 mg/kg. The range of the level of serum creatinine was 1.1 mg/dl to 2.9 mg/dl. CsA in whole blood was measured by high performance liquid chromatography (HPLC), and CsA in semen was also measured by HPLC after extracting CsA with diethylether. The level of CsA in semen was 27 ng/ml to 165 ng/ml and that in whole blood was 51 ng/ml to 133 ng/ml. The relation between both levels was linear (r = 0.68, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Metastatic skull tumors from cancers associated with subcutaneous mass lesions].

The incidence of metastatic brain tumors is increasing because of the recent progress in the detection and management of primary cancer. However, metastatic skull tumors from cancers associated with giant subcutaneous mass lesions are rare. We present four patients with metastatic skull tumors: two from hepatic cancer, one from lung cancer, and one from mamma cancer. In these patients, plain skull X-ray and bone CT showed osteolytic lesions. Angiograms revealed a tumor stain fed by abnormal vessels from the external carotid artery. MRI demonstrated masses with marked homogeneous enhancement with the "dural tail sign" in the dura adjacent to the tumors in three skull tumors from hepatic and mamma cancers, and a mass with slightly enhancement without the "dural tail sign" in a skull tumor from lung cancer. At surgery, hemorrhagic well-demarcated tumors were totally removed. The histological diagnosis was skull metastases from cancers in all cases. In cases with the "dural tail sign" on MRI, no tumor cells were seen in the inner layer of the dura and the dura adjacent to the tumors. It is possible that the "dural tail" is due to increased vascular permeability of the dural vessels. The recurrence of these skull tumors was not observed during the follow-up period. Surgical treatment for the metastatic skull tumors from cancers may be indicated to prevent deteriorating neurological symptoms affecting the quality of life.

Application of high-intensity focused ultrasound for umbilical artery occlusion in a rabbit model.

OBJECTIVES: To investigate the application of high-intensity focused ultrasound (HIFU) for fetal umbilical artery blood flow occlusion in a rabbit model. METHODS: A prototype HIFU transducer in combination with an imaging probe with Doppler capability was constructed. Using this transducer, HIFU was applied at 1.4, 2.75 or 5.5 kW/cm(2) through the maternal abdominal skin to the fetal intra-abdominal umbilical arteries of four time-mated Japanese White rabbits (11 fetuses) on gestational day 25. Courses of 5-s HIFU exposure were performed until cessation of umbilical blood flow and cardiac arrest were confirmed by Doppler ultrasonography. Fetal necropsy was performed and exposed lesions were assessed by microscopic histological analysis. RESULTS: The mean diameter of the fetal umbilical artery was 0.6 +/- 0.2 mm and the mean peak systolic velocity of arterial blood flow was 44.7 +/- 18.5 cm/s. When HIFU was applied at 5.5 kW/cm(2), blood flow was completely occluded within 15 courses. HIFU exposure brought about vacuolar degeneration and destruction of elastic fibers in the tunica media of the artery. CONCLUSIONS: HIFU can be used to occlude umbilical artery blood flow in fetal rabbits.