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Background Extended-release tacrolimus (TacER), administered once daily, offers improved adherence with reduced side effects while still maintaining an immunosuppressive potency equivalent to that of conventional tacrolimus preparations. Methods The study included 83 patients who received consecutive living-donor kidney transplants at our facility from June 2013 to December 2016. Comparisons were made between 48 cases of induction with TacER and 35 cases of induction with cyclosporine (CyA). The observation period was 3 months after transplantation. Transplanted kidney function, rejection, infectious disease, lipid abnormalities, and glucose tolerance were compared. Results The 2 groups showed no significant difference in donor background or transplanted kidney function. Within the 3-month observation period, an acute rejection response was observed in 2 cases in the TacER group and in 8 cases in the CyA group. After transplantation, hyperlipidemia requiring medication was observed more frequently in the CyA group. The 2 groups did not show a marked difference in systemic infection or renal calcineurin inhibitor toxicity in histopathologic examination of the transplanted kidneys 3 months after surgery. Discussion Proactive use of TacER leads to improved adherence while yielding immunosuppressive potency equivalent to that of conventional tacrolimus preparations; however, tacrolimus has a potent blood sugar-elevating effect; thus, direct comparison with the CyA group is important for assessing the side effects. Conclusion TacER has the potential to also reduce side effects in the early stages after surgery, suggesting its potential as a drug of first choice. more...

Introduction The number of young women who wish to become pregnant opting for kidney transplants is increasing, as becoming pregnant under hemodialysis or peritoneal dialysis is associated with many risks. However, there have been reports indicating that these patients are subject to a higher risk of miscarriage compared to women with normal renal function. We examine and report cases of patients that experienced pregnancy after undergoing kidney transplantation at our hospital. Subjects and method Of the kidney transplantation cases that were performed at our hospital between 1985 and 2016, there were 7 cases of pregnancy. The serum creatinine levels, urine protein findings, etc, of these 7 cases were examined during the pre-pregnancy, pregnancy, childbirth, and postpartum periods. Results All 7 cases were able to give birth. There were two cases of transient postpartum hypertension. There were no cases of obvious pregnancy toxemia or fetal growth retardation. Two of the cases resulted in the failure of the transplanted kidneys. Discussion According to previous studies on pregnancy and childbirth after kidney transplantation, the presence of high blood pressure and proteinuria as well as the renal function at the time of pregnancy is closely associated with postpartum renal function. Urine protein was detected prior to pregnancy in both cases and resulted in the failure of the transplanted kidneys. The influence of immunosuppressants on the mother and fetus is also an important consideration. Conclusion We believe it is extremely important to ensure a thorough informed consent process prior to pregnancy and systematic use of immunosuppressants for young female transplant recipients. more...

Introduction Elderly kidney donors have recently become more common in living related kidney transplantation in Japan. Therefore, it is important to evaluate whether kidney function in elderly donors after nephrectomy is preserved over long periods of time. Doppler ultrasonography measurement is practical for donors after nephrectomy because it involves simple and noninvasive examinations. Doppler ultrasonography can detect compensatory hypertrophy and blood flow parameters, namely resistive index (RI) and pulsatility index (PI), of the preserved kidney in living donors. Patients and Methods Our study included 58 donors, divided into 2 groups according to age; the elderly donor group was comprised of those 65 years old or older. We measured length, width, and short diameter of the preserved kidney using Doppler ultrasonography, and calculated kidney volume. Results The elderly group was comprised of 13 patients. In this group, the median preserved kidney volume was 145.0 cm 3 (101.8–193.5) before nephrectomy, and 127.6 cm 3 (99.0–183.4) and 145.5 cm 3 (141.3–148.6) at 1 and 12 months after nephrectomy, respectively. We did not observe significant compensatory hypertrophy in the preserved kidneys of elderly donors postoperatively. Both the mean PI and RI values of elderly donors increased progressively after nephrectomy. No compensatory hypertrophy occurred in the preserved kidneys of elderly donors, although the PI and RI did increase in these donors. Conclusion Our results indicate that nephrectomy caused nephrosclerosis in the preserved kidneys of elderly donors and that prevention of hypertension may be important after nephrectomy in elderly donors. more...

Background To increase the number of cadaveric kidney transplants in Japan, it is necessary to proactively perform transplantation from marginal donors. We had the opportunity to frequently perform kidney transplantation from expanded-criteria donors (ECDs), and it is anticipated that there will be increases in the number of ECD kidney transplants. Methods In our institution, 18 patients underwent cadaveric kidney transplantation from January 2001 to December 2011. Sixteen of those patients were classified into 2 groups according to donation after brain death (BD) or after cardiac death (CD). We also classified donors as ECDs or standard-criteria donors (SCDs). Results Kidney graft survival and engraftment were observed in all of the patients. Renal function at 1 year after transplantation was significantly better in the BD group than in the CD group. However, there was no significant difference between the groups in renal function at 3 and 5 years. Renal function at 1 and 3 years after transplantation was significantly better in the SCD group than in the ECD group, but there was no difference in renal function between the SDC and ECD groups at 5 years. Conclusions The results were good for all of the patients. There are many reports that graft survival rate at 3–5 years after transplantation from ECDs is poorer than from SCDs. However, no statistically significant difference was found in kidney function at ≥5 years between the ECD and SCD groups in our patients. more...

BACKGROUND Everolimus (EVL) plus tacrolimus (TAC) therapy is effective and safe in renal transplantation. However, the pharmacokinetic and pharmacodynamic information for EVL combined with TAC is limited. We investigated the pharmacodynamic drug-drug interaction between EVL and TAC at their therapeutic concentration range. MATERIAL AND METHODS Isolated peripheral blood mononuclear cells (PBMCs) from 22 healthy participants aged 22 to 24 years were cultured with concanavalin A (Con A) in the presence of EVL and/or TAC for 4 days, and the proliferation rate of the PBMCs was calculated. RESULTS TAC promoted the inhibitory efficacy of EVL against the mitogen-activated proliferation of PBMCs at the EVL therapeutic concentration range. When 0.175 ng/mL or more of TAC was combined with 30 ng/mL or more of EVL, the antagonistic effect of TAC on the inhibitory efficacy of EVL against the mitogen-activated proliferation of PBMCs was observed. Conversely, when 0.4 ng/mL TAC and 10 ng/mL or more of EVL were combined, the antagonistic effect of EVL on the inhibitory efficacy of TAC against the mitogen-activated proliferation of PBMCs was observed. CONCLUSIONS The pharmacodynamic synergistic efficacy of EVL and TAC in combination on mitogen-activated PBMCs was evident at the therapeutic concentration range, which is used in renal transplantation. However, these drugs antagonize each other to suppress the proliferation of activated PBMCs at concentrations higher than those clinically used. more...

In elderly kidney transplant (KT) recipients, the incidence of acute rejection is decreased, while that of fatal infections is increased. There are currently no guidelines for an upper age limit for KT, which is very difficult to determine. Here we examined several cases of elderly KT recipients.We evaluated 127 KT patients treated at our department between 2003 and 2012 and followed them for 3 years post-transplant. The subjects were divided into two groups by age: ≥60 years (elderly group; n = 24); and 59 years (non-elderly group; n = 103). The presence or absence of acute rejection and infection, dose of immunosuppressive drugs, trough calcineurin inhibitor level, renal function, and graft and patient survival rates were retrospectively examined.Our basic immunosuppressive regimen was a combination of calcineurin inhibitor, methylprednisolone, mycophenolate mofetil, and basiliximab. At 1 year post-transplantation, the average tacrolimus and cyclosporine dose and trough levels were not significantly different. The mean dose of mycophenolate mofetil in the elderly group at 1 year post-transplantation was significantly lower than that of the non-elderly group. The incidences of cytomegalovirus infection and acute rejection during follow-up did not differ significantly between groups. There were no significant differences in creatinine level between the two groups. In the elderly group, the graft survival rates at 1 and 5 years were 100% and 95.4%, respectively, while those in the non-elderly group were 98.1% and 92.5%, respectively.Using our current immunosuppressive protocol, the outcomes of patients in the elderly group were considered acceptable. more...

Background To increase the number of cadaveric kidney transplants in Japan, it is necessary to proactively use organs from all donors. Since the revision of the Organ Transplant Law, the number of organ donors after cardiac death (DCD) has decreased but the number of organ donors after brain death (DBD) has increased; however, the number of donor organs and awareness of cadaveric transplantation have increased. Methods At our institution, 28 patients underwent cadaveric kidney transplantation from January 2001 to December 2016. These patients were classified into 2 groups according to DBD or DCD. Furthermore, 10 patients received transplants from expanded criteria donors (ECD) and 18 received them from standard criteria donors (SCD). Results Kidney graft survival and engraftment were observed for all patients. There were no significant differences in renal function at 6 months for DBD and DCD transplant recipients. Renal function at 1, 3, and 5 years and serum creatinine levels were better for the ECD group. Renal function at 5 years after transplantation was significantly better for the SCD group than for the ECD group; however, there was no difference in delayed graft function between the SCD and ECD groups. Comparisons of the 3 groups showed good renal function for transplants from DBDs, but there was no significant difference in survival rates. Conclusions Results were good for all patients. There were no significant differences in outcomes of our patients who received transplants from ECD or SCD. more...

Background In this retrospective study, we analyzed histologic changes identified through protocol biopsy (PB) at 1 year after kidney transplantation (KT). We focused on the pathologic changes observed in patients with a history of treatment for graft rejection within 1 year of transplantation. Methods Between January 2008 and December 2011, 56 patients underwent KT at our center. We assessed the histologic findings observed at 1 year after renal transplantation using the Banff 2007 classification. At our center, PBs are performed immediately after or at 1 hour after transplantation, and at 1 year after KT. PBs were performed in 39 patients; PBs could not be performed in 17 patients because of various causes. Of the 39 patients, 29 stabilized without clinical rejection and without treatment (the NTx group); 10 patients showed pathologic changes or clinical rejection after steroid pulse therapy within 1 year (the Tx group). We compared these 2 groups with respect to baseline data, renal function, and pathologic scores. Results The interstitial fibrosis (“ci”) score, according to the Banff classification, was significantly greater in the NTx group (0.89) than in the Tx group (0.50) at 1 year after transplantation. Conclusions The currently applied early steroid withdrawal regimen may be not be ideal for preventing pathologic changes occurring after KT. In addition to the PB performed 1 year after KT, PB should be performed within 1 year of renal transplantation to identify early signs of rejection and to provide access to appropriate treatment regimes. more...

Early recovery from shock improves prognosis in patients with severe sepsis and septic shock. During this period, cytokine imbalances mediate the development of organ damage and mortality. In Japan, we have access to hemoperfusion using an immobilized polymyxin B fiber column for endotoxin removal (PMX-DHP) and continuous hemodiafiltration (CHDF) as artificial support for patients with septic shock, with the aim of improving hemodynamics and organ dysfunction caused by elevated inflammatory cytokines and mediators. In this Short communication, we discuss recent findings showing anti-inflammatory treatment following these continuous renal replacement therapies in sepsis. more...

ABO-incompatible kidney transplantation has increased the possibility of finding suitable living donors for patients with renal failure. However, there are inevitable immunological risks, including a high risk of early post-transplantation complications. The purpose of this study was to evaluate recipient outcomes following ABO-incompatible kidney transplantation.Seventy-one patients who had undergone living-donor kidney transplantation (LDKT) at our center between January 2008 and December 2013 were divided into ABO-incompatible (ABOi; n = 21) and ABO-compatible (ABOc; n = 50) groups. Baseline data, graft function, immunosuppressant use, and the results of biopsy 1 year after LDKT were compared between the groups.Recipient preemptive LDKT rates were significantly different between groups (P = .017). Graft function, incidence of infection, and rates of T-cell-mediated rejection and borderline changes requiring medication were not significantly different. There was no acute antibody-mediated rejection. Selectivity of the immunosuppressant, tacrolimus, was significantly different between groups (P .01); however, steroid withdrawal rates, mycophenolate mofetil doses, and calcineurin inhibitor trough levels were not different. Regarding biopsy data, interstitial fibrosis scores were significantly different between groups (P = .011), as were interstitial fibrosis and tubular atrophy scores (P = .045) and arteriolar hyalinosis score (P = .022).ABOi LDKT was relatively safe, with no significant difference in the incidence of rejection compared to ABOc LDKT. Managing chronic pathological changes and arteriolar hyalinosis prophylaxis after ABOi LDKT may result in more successful outcomes. more...

Background: In Japan ABO-incompatible liver transplantation has been done on >100 occasions up to 2003. However

Clinical practice guidelines for pancreatic cancer based on evidence-based medicine (2006) were published by the Japan Pancreas Society (Committee for revision of clinical guidelines for pancreatic cancer) in March 2009 in Japanese, revised to Clinical Practice Guidelines for Pancreatic Cancer based on evidence-based medicine (2009) in July 2009 in Japanese and further revised to Clinical Practice Guidelines for Pancreatic Cancer (2013) in October 2013 in Japanese. These guidelines were established according to evidence-based medicine. A total of 629 papers were collected from among 4612 reports concerning pancreatic cancer listed in PubMed and Igakuchuo Zasshi between May 2007 and January 2011. This new set of guidelines was written by members of the Committee for the Revision of Clinical Practice Guidelines for Pancreatic Cancer in the Japan Pancreas Society. The guidelines provide an algorithm for the diagnosis (Fig. 1) and treatment (Fig. 2) of pancreatic cancer and address six subjects (Diagnosis, Surgery, Adjuvant therapy, Radiation therapy, Chemotherapy and stent therapy), with 35 clinical questions and 57 recommendations. more...

Objective The incidence of biliary complications after adult living donor liver transplantation (ALDLT) are still high even though various devices have been reported to overcome them. Method From October 2000 to April 2007, we performed 52 ALDLTs which included 15 ABO-incompatible grafts. Median follow-up was 565 days. In 49 procedures, we used duct-to-duct anastmosis with a stent inserted in the recipient duct and out through the common bile duct wall as an external stent, and in 3 procedures, we used duct-to-jejunostomy anastomosis. We investigated postoperative biliary complications and their management. Results Forty-four patients received right lobe grafts and 8 received left lobe grafts. Among patients in whom duct-to-duct anastomosis was used, nine (20.5%) developed biliary complications including bile leakage in five and biliary strictures in four. All bile leakage was treated with reoperation. Three biliary strictures were treated with stent placement, and one biliary stricture was treated with magnetic compression anastomosis. Among the three patients in whom duct-to-jejunostomy was used, two (66.7%) had bile leakage and stricture, respectively. Two of four ABO-incompatible patients (50%) had hepatic artery thrombosis with biliary complications, a high incidence. Conclusion In our series of ABO-incompatible patients undergoing ALDLT, those who developed hepatic artery thrombosis exhibited a high incidence of biliary complications. more...

Posttransplant anemia (PTA) influences kidney graft function and prognosis; however, there is no consensus regarding target hemoglobin (Hb) levels.We examined several cases of PTA to identify any correlation between Hb levels and graft function. We evaluated 84 kidney transplant recipients (50 men and 34 women; mean age, 46.7 years) who were treated at our department between February 2004 and March 2012 and were available for a 2-year post-transplant follow-up.Hb levels and serum creatinine levels before transplantation and at 1, 3, 6, 12, and 24 months after transplantation were compared. We examined the correlation between the degree of anemia and renal function among the patients. Data were analyzed using Spearman's rank correlation coefficient and Friedman tests. The mean pretransplantation Hb level was 10.4 g/dL, whereas Hb levels at 6, 12, and 24 months after transplantation were significantly increased to 11.6, 12.2, and 12.4 g/dL, respectively, suggesting an improvement in anemia after the transplantation. Correlation analysis between anemia and kidney graft dysfunction revealed significant correlations at 1, 3, 12, and 24 months after transplantation. Subjects were stratified for correlation analysis according to Hb level at 24 months after transplantation:10, 10-10.9, 11.0-11.9, 12.0-12.9, and ≥ 13.0 g/dL. A significant improvement in kidney graft function was noted in patients with an Hb level ≥ 11 g/dL at 2 years after transplantation. Anemia improved significantly by 3 months after transplantation.A significant correlation between PTA and kidney graft function was apparent, and the prognosis for kidney graft function was poor in patients with Hb levels ≤ 11 g/dL. more...

The in vitro response of peripheral blood mononuclear cells (PBMCs) to the suppressive effects of calcineurin inhibitors is known to correlate with the clinical efficacy of drugs used in renal transplantations. The present study was conducted to examine the differences of PBMC responses to calcineurin inhibitors between chronic renal failure (CRF) patients awaiting renal transplantation and cirrhosis patients awaiting liver transplantation. The study included 99 CRF patients awaiting renal transplantation and 27 cirrhosis patients awaiting liver transplantation. Twenty milliliters of venous blood was taken 1–7 days before transplantation. The in vitro drug concentrations giving 50% inhibition of PBMC blastogenesis stimulated with concanavalin A (IC50s) were calculated. The suppressive effects of tacrolimus against PBMC blastogenesis were more than 10–100 times stronger than those of cyclosporine. The median IC50value for cyclosporine against the CRF PBMCs was not significantly different from the median IC50value against the cirrhosis PBMCs. In contrast, tacrolimus sensitivity in cirrhosis PBMCs is approximately seven times higher than that in CRF PBMCs. The median IC50value for tacrolimus against cirrhosis PBMCs was significantly lower and therefore the effect was stronger in comparison to the CRF PBMCs ( p < 0.001). These data suggest that the PBMCs of cirrhosis patients, in comparison to those of CRF patients, are highly sensitive to the suppressive effect of tacrolimus. However, PBMC sensitivity to cyclosporine was not significantly different between the CRF and cirrhosis patients. These observations raise the possibility that treatment with tacrolimus, rather than cyclosporine, may therefore be a better choice to reduce the risks of allograft rejection in liver transplantation. more...

Living donor liver transplantation (LDLT) offers timely transplantation for patients with hepatocellular carcinoma (HCC). If ABO-incompatible LDLT is feasible, the need for pretransplantation treatment may be eliminated, which may reduce overall morbidity. In this article, we have described 8 adult HCC patients who successfully underwent LDLT from ABO-incompatible donors. Antirejection therapy included multiple preoperative plasmaphereses, splenectomy, and an immunosuppressive regimen with tacrolimus, methylprednisolone, and mycophenolate mofetil. The maintenance dose of immunosuppression did not differ from that of the ABO-identical cases. In addition, we also performed intrahepatic arterial infusion of prostaglandin E1. In 5 patients, we administered a single dose of rituximab, a chimeric CD20 monoclonal antibody. As a result of this treatment, 6/8 patients are still alive. Our experience has shown that it is possible to control antibody-mediated humoral rejection and other complications in adult ABO-incompatible LDLT. more...

Background. In Japan, living donor renal transplantation has gained momentum due to an increased number of patients with end-stage renal disease. Living donation not only provides better outcomes, but also the recipients usually need less medications, thereby increasing the quality of life and reducing the potential side effects of immunosuppression. Materials and Methods. For the past 25 years, our center had performed 140 open donor nephrectomy (OPNx) renal transplantations. Since July 2003, we changed our procurement operation to living hand-assisted laparoscopic donor nephrectomy (HALNx) in 49 cases. Our operative technique consisted of two 12-mm ports placed in the midaxillary line at the superior and inferior levels of the umbilicus. Next, a 5-cm incision was made in the midline periumbilicus and the hand port system fitted through a midline abdominal incision. Results. In 49 cases, HALNx was completed successfully; no patient required conversion to laparotomy. The estimated blood loss was 33.0 ± 43.4 g and no patient required blood transfusion. In comparison, in OPNx the blood loss was 426.5 ± 247.6 g (P more...

Background Although living donor liver transplantation (LDLT) was established as a treatment for end-stage liver disease in Japan, the indication for LDLT across an ABO-incompatible barrier remains controversial. The purpose of this study was to elucidate the role of plasmapheresis in incompatible LDLT. Methods Eleven adult patients (seven men and four women) who underwent incompatible LDLT were enrolled in this study. Of these three patients had hepatocellular carcinoma, three chronic hepatitis C, one Wilson’s disease, one autoimmune hepatitis, one chronic hepatitis B, one hemochromatosis, and one fulminant hepatic failure. The immunosuppressive regimen consisted of tacrolimus, prednisolone, mycophenolate mofetil (or cyclophosphamide), and prostaglandin E1 in all patients. Multiple plasmapheresis was performed perioperatively to reduce the recipient’s antibody titers against the donor’s blood type. Results Plasmapheresis was useful for the reduction of the recipient’s antibody titers to ×16 or lower before and after transplantation. There was no difference in transplant outcome between the 11 patients with incompatible blood group and 30 patients with identical or compatible blood groups. Discussion Major postoperative complications such as intrahepatic biliary complications and hepatic necrosis may occur in incompatible transplantation. Several investigators suggested that anti-imunoglobulin (Ig) M and anti-IgG antibody titers sustained these complications. The antibody titers must be decreased sufficiently with plasmapheresis. An elevation of anti-ABO titers after transplantation may be a predictive risk factor for increased mortality and morbidity. In order to perform LDLT in a safer manner, plasmapheresis is an indispensable treatment to improve the outcome of ABO-incompatible cases. more...

To compare observer performance on cathode-ray-tube(CRT) monitors for personal computers with that on conventional radiographs in the detection of small lung nodules.Fifty-eight normal chest radiographs and 58 chest radiographs with a small lung nodule were selected. Ten radiologists examined the original conventional films on a viewbox and digitized (8 bit) uncompressed and compressed images of the same patient on a color CRT monitor with a matrix of 1,600 x 1,200, and rated the presence of lung nodules with a five-level scale of confidence. The methods of compression used in this study were the JPEG and wavelet methods, with compression ratios of 6:1 and 15:1. Results were analyzed by receiver operating characteristic methods.There was no significant difference between film and digitized uncompressed and compressed images obtained by the JPEG and wavelet methods with a compression ratio of 6:1. No statistically significant difference was detected between film and digitized image with wavelet compression at 15:1. However, detection was less accurate on digitized images with JPEG compression at 15:1.Digitized (8 bit) uncompressed and compressed images with a compression ratio of 6:1 are acceptable for the detection of small lung nodules. Digitized compressed images at a compression ratio of 15:1 are also acceptable when the wavelet method is used. more...

We present a patient with renal artery stenoses due to fibromuscular dysplasia involving the point of arterial bifurcation that we could successfully dilate with percutaneous transluminal angioplasty. We used the kissing balloon technique to prevent possible complications of percutaneous transluminal renal angioplasty (PTRA), including occlusion of the other branch while dilating one branch. The kissing balloon technique worked well for PTRA of the arterial bifurcation. more...

Gelatin sponge particles were rendered radiopaque by soaking them in small amounts of iodized oil (LP-GS). They were evaluated for their usefulness in transarterial embolization (TAE). The LP-GS particles were well visualized fluoroscopically during TAE. The duration of the opacity of LP-GS exceeded 24 hours both in vitro and in vivo. LP-GS are useful, and are an easily obtainable, radiopaque, embolic material. more...

We contrived a new supporting implement to increase the hit rate of CT-guided needle biopsy (CTNB) for localized pulmonary lesions. Using this implement, twenty-two CTNB examinations for localized pulmonary lesions were performed. In 21 out of the 22 examinations (95%), the lesions were hit, and specimens appropriate for cytological or histological diagnosis were obtained. The course of needle insertion, which was difficult to define in the past, has become to be easier and more precise with this method. Using this new implement, CTNB is now applicable to smaller and deeper lesions. more...

A 54-year-old woman developed torsade de pointes with secondary QT prolongation due to hypokalemia and hypomagnesemia. Her serum K and Mg levels were 2.5 mEq/l and 1.5 mg/dl, respectively. This electrolyte imbalance was due to intentional overdosing of metolazone. Attacks of torsade de pointes occurred three times in the intensive care unit and were corrected by intravenous lidocaine administration. Her serum K level was corrected using KCl infusion, restoring the normal QT interval. Routine computed tomography found a left retroperitoneal paraganglioma. Urinary and serum catecholamine examination revealed extremely high values of epinephrine and norepinephrine. The diagnosis was pheochromocytoma in the left retroperitoneal paraganglion. The tumor which was removed measured 70 x 65 x 60 mm in size. Microscopic examination revealed the characteristic patterns of pheochromocytoma. more...

Seven pulmonary adenocarcinomas with cloudy zone (CZ), which was defined as a lower density zone in the pulmonary lesion than pulmonary vessels in the surrounding normal lung on high resolution computed tomography (HRCT), were followed up for at least 3 months. There were three tumors with homogeneous CZ, one of which showed no change when rescanned after three months, the others showed enlargement with or without replacement by high density areas on rescanned images obtained after more than one year. Two tumors containing some high density areas on the initial scans showed slight decreases in size on rescanned images obtained after 1 to 3 months. However, on rescanned images obtained after more than 1 year and 9 months, these tumors also showed enlargement of CZ. Pathologically, CZs corresponded to well-differentiated adenocarcinoma of the bronchioloalveolar type with no or mild interstitial change, whereas high density areas mainly corresponded to papillary adenocarcinoma with severe interstitial fibrosis. In conclusion, long-term careful follow-up of CZ is necessary to detect enlargement or the appearance of high density. Unchanged CZ in short-term follow-up should be considered a finding suggestive of malignancy. more...

Wilms' tumor is an uncommon disease in adults. Wilms' tumor typically presents as a large complex mass with cystic component and varying degrees of vascularity. The previously reported radiologic findings have reflected this complex appearance. We present a case of cystic Wilms' tumor in an adult patient. The tumor presented as a large, rapidly growing, hypovascular, multicystic mass with minimal solid component which showed as septation on ultrasound, contrast enhanced CT, and MR studies. The preoperative findings were suggestive of multilocular cystic nephroma. We suggest that Wilms' tumor should be included in the differential diagnosis of a patient who presents with a large, rapidly growing, multicystic renal mass. more...

Between 1982 and 1990, 55 patients with prostate cancer (clinical stage A2-C) underwent pelvic lymphadenectomy at the Public Toyooka Hospital. The patients were subsequently treated either by radical prostatectomy (36 cases) or external radiation therapy (19 cases). The age of the patients varied from 56 to 85 (Mean 73.1). The outcome of the 46 patients with negative lymph node (prostatectomy 31, radiation 15) were compared. The 10-year disease-specific survival rates were 100% for the patients treated by prostatectomy and 78% for those treated by radiation (P = 0.035). The 5-year progression-free survival rates for the prostatectomy group and radiation group were 97% and 56%, respectively (P = 0.013). Among the radiation groups, patients with well differentiated carcinoma showed a lower progression rate as compared to those with moderately or poorly differentiated carcinoma (5-year progression-free survival, 81 vs 20%, P = 0.094). The outcome of the 9 patients with positive lymph node (prostatectomy 5, radiation 4) was not satisfactory because of the high progression rates in the two groups (5 year progression-free survival, 30% in prostatectomy and 25% in radiation group). more...

We performed a quantitative sudomotor function test on 11 patients with classic amyotrophic lateral sclerosis (ALS) and 11 age-matched control subjects. Thermal warming increased the sweat rate in the forearm of ALS patients and in the forearm and thigh of control subjects. The sweat rate in the thigh of ALS patients was lower than that of controls. Thyrotropin releasing hormone increased the sweat rate in the forearm and thigh and decreased oral temperature in both ALS and controls but the lower extremity response was reduced in ALS. Results of the sudomotor axon reflex test on the thigh indicate that in ALS, there is mild postganglionic sudomotor dysfunction. We conclude that patients with ALS have mild thermoregulatory sweat dysfunction due to postganglionic lesions in the lower extremities. more...

We assessed the outcome of 200 patients with prostatic cancer treated at the Public Toyooka Hospital from 1980 to 1989. The patient's age varied from 53 to 94 years (mean 76.8). Overall actuarial survival rate at 5 and 10 years were 52% and 25%, respectively. The 5-year survival according to clinical stage was 69% for stage A, 66% for stage B, 43% for stage C and 32% for stage D disease. A significant difference was noted between the survival of patients with stage A or B and those with stage C or D. Patients with Gleason score of less than 7 showed significantly better survival as compared to those with Gleason score of 7 or more (5-year survival, 64% vs 33%). No significant difference was observed between the survival of patients under the age of 75 and those 75 or older. more...

We assessed the treatment outcome of 71 patients (45 men and 26 women) with renal cell cancer treated at the Public Toyooka Hospital from 1969 to 1992. The patient's age varied from 15 to 85 (mean 64). The overall actuarial and disease specific survival rates at 5 years were 55% and 67%, respectively. Statistical analysis of various parameters associated with prognosis was performed. The parameters achieving statistical significance were pT, PV, distant metastasis, grade, histological architecture, cell type, tumor size and erythrocyte sedimentation rate. more...

This is a report of a patient with hepatocellular carcinoma whose hepatic arterial catheter, which was introduced via a subclavian arterial branch, migrated into his right gastric artery. The catheter was successfully maneuvered to a suitable position without any further invasive procedure. The importance of preparatory embolization of the right gastric artery is underscored. more...

Calcium ion (Ca2+) plays a central role in regulating E-C coupling in the heart. Intracellular Ca2+ homeostasis is maintained when all of subcellular steps for Ca2+ handling are functioning synchronously. Many investigators have proposed that the pathophysiologic basis for abnormal mechanical characteristics of the failing myocardium may be disturbed intracellular Ca2+ handlings, at one or more of the cellular sites. Recent advances of Ca2+ indicators have enabled to directly study the hypothesis in actively contracting myocardium. In acute contractile failure with ischemia or hypoxia, cellular sites or materials which block the normal E-C coupling have been mostly identified. For the mechanisms of abnormal contractions in the chronic failing myocardium, investigations are going on by using several experimental models and human hearts. more...

We assessed the treatment outcome of total cystectomy for 93 patients (71 men and 22 women) with bladder cancer treated in the Public Toyooka Hospital from 1970 to 1989. Patient age varied from 36 to 87 (mean 67). The overall actuarial survival rates at 5 and 10 years were 51% and 36%, respectively. The 5-year survival rates were 72% for grade 2 and 44% for grade 3 disease. The 5-year survival rates according to the pathological stage were 66% for pT0-1, 51% for pT2, 35% for pT3, 44% for pT4a disease. A statistical difference was noted between the 5-year survival rate of patients with pT0-2 disease and that with pT3. Patients with pT4aN0 disease showed a relatively high survival rate (67%). The 5-year survival rates were 54% for the patients with negative lymph node and 22% for those with positive lymph node. Although we could not demonstrate the efficacy of preoperative radiotherapy, the combination of radiation and chemotherapy was suggested to improve the survival after cystectomy. Patients who received simultaneous urethrectomy showed a higher 5-year survival rate as compared to those who did not. more...

We assessed the clinical significance of multiple mucosal biopsies in new cases of superficial papillary bladder tumor. Biopsy findings were abnormal (5 dysplasia, 5 transitional carcinoma) in 10 of the 71 cases examined. Abnormalities were observed exclusively at G2 or G3, and more frequently at pT1 than pTa. Cases with multiple tumors showed significantly more abnormalities than cases with a solitary tumor. Recurrence rates were not significantly different between the cases with abnormal biopsy findings and those with normal findings. However, the invasive tumor developed more frequently in the former. Mucosal biopsies seemed to be more useful in cases with multiple tumors than in those with a solitary tumor. more...

We report a case of metallosis due to ceramic fragments in the inner bearing surface of the polyethylene cup of a bipolar hip prosthesis with fracture of the alumina ceramic screws used for grafted bone fixation. After bone-grafting acetabuloplasty with a Bateman bipolar endoprosthesis, gradual migration of the outer head occurred, and fracture of the screws was observed. Seven years after the operation, radiographs showed severe metallosis of the surrounding tissues. At revision, marked wear of the inner head was seen. Detailed examination revealed that many rough-edged ceramic particles originating from the fractured ceramic screws had become embedded in the inner surface of the polyethylene bearing insert. These extremely hard ceramic fragments had entered the prosthetic joint space during joint movement, thereafter causing continuous abrasion of the metal head. After revision, the concentration of the constituents of the prosthesis alloy in the serum decreased toward control levels. To prevent serious complications like those in the present case, screws should be inserted more than 1 cm from the outer head of a bipolar endoprosthesis, and the outer head should be removed as soon as possible if it comes into contact with the screws. more...

A case of renal cell carcinoma with erythrocytosis is presented. A 51-year-old man was referred to us for evaluation of left renal mass. Laboratory data revealed marked erythrocytosis and elevated serum erythropoietin level. These data were normalized after removal of the left kidney. Pathological diagnosis was adenocarcinoma of clear cell type. more...

Computed tomographic (CT)-guided biopsies of the lesions in paraaortic region were performed for three urologic disease conditions: retroperitoneal fibrosis, lymph node metastases of transitional cell carcinoma of renal pelvis and lymph node metastasis of renal cell carcinoma. The biopsies were performed without complications using the Bard Biopty biopsy gun with a Bard Biopty-Cut needle. Every biopsy specimen we obtained by the Biopty rendered an excellent biopsy core from which a definite histopathological diagnosis was made. CT-guided biopsy is considered to be safe and useful for diagnosis of the disease of the paraaortic region, even when ultrasonography guided biopsy is difficult. The use of the Biopty for CT-guided biopsy provides a high quality specimen for histopathological diagnosis. more...

The AMS Hydroflex penile prosthesis was implanted in 34 organic impotence patients between June 20, 1986 and Aug. 6, 1990. Patients ages ranged between 26 and 71 with an average of 50.5. The causes of impotences were; 17 cases of post-radical pelvic surgery, 7 cases of injury, 6 cases of diabetes and 4 of others. First evaluation was made after 12 weeks of implantation in terms of patient satisfaction with sexual intercourse and post operative complication. Sixteen patients (47.1%) were highly satisfied with intercourse, 13 (38.2%) satisfied with intercourse, 2 (5.9%) slightly dissatisfied even with successful intercourse, 1 (2.9%) with no improvement and 2 (5.9%) could not follow. Utility of the prosthesis, e.g. effectiveness and safety was; high utility in 20 (58.8%), good utility in 11 (32.4%), slight utility in 1 (2.9%), no favorable in 1 (2.9%) and no judgement in 1 (2.9%). The overall effectiveness and safety of the Hydroflex was demonstrated based on the above findings. Long term evaluation was made from the initial implantation of the device up to the termination of the trial with average of 19.2 months and was mentioned altogether. more...

Construction of a continent ileal urinary reservoir (Kock pouch) is associated with a high incidence of late complication because of malfunction of the nipple valve, the efferent limb in particular. We have so far experienced several types of afferent nipple malfunction. We herein report on the unexpected complications of the afferent nipple valve in patients with a post operative observation of 1 year or more. From 1984 through 1989, urinary diversion via a Kock pouch was performed on 47 patients at Kyoto University Hospital and Public Toyooka Hospital. The study group comprises 42 patients with a mean observation of 40 months (range 14 to 60 months). The late complications of the afferent nipple valve were observed in 11 of the 42 (26%) patients. These included erosion of Dacron fabric used as a collar (5 patients), afferent nipple stenosis (3 patients) and afferent nipple obstruction by mucous plug or fungus ball (3 patients). Removal of Dacron collar was performed in 4 of the 5 patients with collar erosion and in 1 of the 3 patients with nipple stenosis. Nipple obstruction was relieved by endoscopic manipulation or diuresis. All of the 11 patients had no problems with their efferent nipples. Our results suggest that the use of nonabsorbable material as a collar and peristaltic direction of the afferent limb are mainly involved in the complications of the afferent nipple. A more reliable and simpler procedure for antireflux anastomosis should be considered. more...

The right caudocranial oblique (RACCO) view which is obtained by tilting the image intensifier 25 degrees caudally and 30 degrees to the right while the patients lie in supine position is proposed for improved depiction of the portal venous system. Transarterial portography with digital subtraction angiography was performed in the RACCO and posteroanterior (PA) views in 32 patients. Comparison of the two views revealed that the RACCO view was superior to the PA view of the left main branch in 25 patients (78%) and of the right posterior lobe branch in 24 (75%) patients. Visibility of more distal portal branches, however, did not always improve by RACCO view. RACCO view will be useful for the evaluation of portal systems of primary and secondary hepatic neoplasms as a special view following portogram in PA projection when more detailed information is necessary on proximal portal branches. more...

Chronic pancreatitis is known to cause vascular disorders including pseudoaneurysm of peripancreatic arteries. Although the incidence of pseudoaneurysms due to pancreatitis detected by angiography has been reported as high as 10% in western literature, they are still considered rare in Japan. We reported two cases of pseudoaneurysm caused by chronic pancreatitis, one in splenic artery and the other in gastroduodenal artery, successfully treated by embolization. The embolizations were performed by occluding proximal splenic artery for splenic arterial aneurysm and gastroduodenal artery distal and proximal to the orifice for the aneurysm of gastroduodenal artery with stainless steel coils. Since the surgical therapy has high mortality rate, we consider transcatheter embolization is the treatment of choice for pseudoaneurysms caused by chronic pancreatitis. more...

We report two cases of primary paraganglioma of the urinary bladder. Case 1. A 61-year-old man was hospitalized with the chief complaints of gross hematuria, dysuria and headache. The patient had a history of hypertension. Cystoscopy disclosed a nonpapillary, sessile tumor in the retrotrigonum of the bladder. An attack of paroxysmal hypertension was induced by bimanual palpation of the tumor, and paraganglioma was suspected. Partial cystectomy with staging pelvic lymphadenectomy was performed. Case 2. A 65-year-old man was hospitalized with the chief complaints of gross hematuria and urinary retention. The patient had no history of hypertension. Cystoscopy disclosed a nonpapillary tumor in the right lateral wall of the bladder. Transurethral resection was performed with no cardiovascular complication. Prostatic needle biopsy showed the histological evidence of prostatic adenocarcinoma. Radical retropubic prostatectomy with limited lymphadenectomy was performed. There was no histological evidence of lymph node involvement of paraganglioma or adenocarcinoma. The histological and biochemical examinations revealed a chromaffin positive, functioning and non-malignant tumor in Case 1, and a chromaffin negative, non-functioning and non-malignant tumor in Case 2. In total, 29 cases of primary paraganglioma of the urinary bladder have been so far reported in Japan. The tumor recurrence, multiple or metastases were recorded in 8 of 29 cases (27.6%), mainly in regional lymph node metastases. We recommend lymphadenectomy at the initial operation, irrespective of pathological finding of the primary paraganglioma of the urinary bladder. more...

To quantify regional wall motion of the left ventricle with two-dimensional echocardiography, the motion of an endocardial surface point in echocardiograms was analyzed throughout systole on frame by frame using video motion analyzer. With a fixed external reference system and in the "69% point (C)" by Ingels et al, the motion vector (M) of a point was expressed in two components; the contracting component (Y) directed toward the point C, and the component vertical to it, the shearing component (X). In the control group, the magnitude of M and its contracting component were widely varied with the location along the endocardial surface (5.6 +/- 1.6, 5.0 +/- 1.5 mm in the apex, 10.9 +/- 2.2, 10.4 +/- 2.0 mm in the inferior base, p less than 0.001 and p less than 0.001, respectively). The shearing component and the angle theta at which M and Y meet, showed narrow normal ranges (1.9 +/- 1.4 mm, 15.1 +/- 1.4 mm, 15.1 +/- 11.2 degrees), and were independent of their locations. In the ischemic group, however, the points of non-ischemic regions showed low values of theta (14.9 +/- 8.9 degrees), which were not significantly different from those of the control group, while the points of ischemic regions showed high values of theta (over 2SD of the control group). The distribution of these points with abnormal theta values was well correlated to that of the segments with asynergic motion evaluated by both real-time two-dimensional echocardiography and left ventriculography (p less than 0.001 and p less than 0.001, respectively). These results suggest that this new approach with quantitative echocardiography is sensitive and specific for the assessment of regional wall motion of the left ventricle and may provide accurate clinical information for the evaluation of ischemic heart disease. more...