Percutaneous cryoablation of renal cell carcinoma guided by horizontal open magnetic resonance imaging

BACKGROUND: Cryoablation is a treatment option for some patients with small exophytic lesions of the kidney. The purpose of this study is to determine the feasibility, safety, and intermediate-term treatment outcome of percutaneous cryoablation of renal cell carcinoma guided by horizontal open magnetic resonance imaging (MRI). METHODS: We prospectively used cryoablation to treat 13 patients with radiographically confirmed enhancing small, solid renal tumors (< or =4.8 cm). An argon gas-based cryoablation system was used. One to four cryoprobes with 2 or 3-mm diameters were placed percutaneously into the tumor under local anaesthesia and MRI guidance. Ice ball dimensions were monitored by 2-D MR images. Double freeze-thaw cycles were conducted throughout the procedure. After successful cryoablation, patients were followed on a regular basis to evaluate the treatment's clinical outcome. RESULTS: Median follow up from time of procedure is 35 months (range, 28-42). In all cases the entire procedure was accomplished without significant morbidity or complications. A mild retroperitoneal hematoma, which subsided spontaneously, was noted in one patient. Follow-up dynamic computed tomography (CT) at 3 months after operation confirmed the absence of enhancement in resolved tumor masses for 11 of 13 cases. None of these 11 patients had clinical evidence of recurrent disease at last follow up. The remaining two patients had lesions with some enhanced areas. Subsequent partial nephrectomy histologically confirmed the presence of vital tumor in, respectively, the center and the periphery of the residual masses. One of these patients developed multiple lung and ipsilateral adrenal metastases 13 months after surgical resection. CONCLUSIONS: Percutaneous cryoablation of small renal cell carcinomas under horizontal open MRI guidance appears to be safe and feasible. An intermediate-term follow up continues to demonstrate efficacy in most patients; however, a few patients experience incomplete ablation with risk of treatment failure. The ideal candidates for this procedure still need to be determined in longer follow up with diligent observation.     

Cold activation of complement in sera from patients with persistent hepatitis C virus infection on interferon therapy

The loss of haemolytic activity in sera during storage at low temperature (the cold activation of complement) was observed in 136 of 184 (74%) patients with chronic liver disease associated with hepatitis C virus (HCV) infection. This was more frequent than observed in the three of 40 (8%) patients with chronic hepatitis B (P < 0.001) or none in 43 normal controls (P < 0.001). Of 103 patients with chronic hepatitis C who had completed a full course of recombinant interferon-α2a therapy (total dose: 516×10⁶U), 40 responded completely and 21 responded partially, as judged by the normalization or decrease of alanine aminotransferase levels 6 months after the completion of therapy; 42 patients did not respond at all. The cold activation of complement persisted in five (13%) complete responders, less often than in 33 (79%) non-responders (P < 0.001). At the completion of interferon therapy, the cold activation of complement persisted in 12 of 54 patients despite the normalization of alanine aminotransferase. Spontaneous exacerbation of hepatitis occurred in seven of 12 (58%) patients with cold activation, which was more frequent than in the four of 42 patients (10%) without it (P < 0.01). The cold activation of complement disappeared along with the loss of HCV-RNA in five of six responders during the 6 month period after the completion of interferon therapy, while both cold activation and HCV-RNA persisted in all eight non-responders. These results indicate that the cold activation of complement may be useful as a marker of HCV viraemia for monitoring the response to interferon in patients with HCV infection.     

Comparison of parameters to determine the cause of urinary disturbance in men with prostate volume less than 20 milliliters

BACKGROUND: A pressure-flow study, although a slightly invasive procedure, can evaluate bladder outlet obstruction and detrusor contractility. This study was conducted in men with a non-enlarged prostate to determine the cause of urinary disturbance by less invasive examinations that might eventually replace pressure-flow study. METHODS: Thirty-six men with lower urinary tract symptoms were enrolled. Their prostate volume, estimated by transrectal ultrasonography, was less than 20 mL. All patients were examined using pressure-flow study, free-flowmetry, transrectal ultrasonography, prostate specific antigen and an interview using the International Prostate Symptom Score and Quality of Life Index. With determination of the cause for urinary disturbance, parameters that correlated with outflow obstruction or impaired detrusor contractility were sought. RESULTS: Twenty-one (60%) of the 36 men were judged as having outflow obstruction, and 16 of these 21 men had normal detrusor function. Impaired detrusor contractility was observed in 17 men. Only three of these 17 men had no outflow obstruction. Four patients had an unstable bladder. All these four had normal detrusor contractility, but had outflow obstruction. Among the parameters examined, only the maximum flow rate in a flow metrogram (Qmax) correlated significantly with the degree of outflow obstruction (P = 0.04). The positive predictive value of Qmax for outflow obstruction was 65% at a flow rate of less than 10 mL/s, and 100% at that of less than 5 mL/s. No parameter correlated with detrusor contractility. CONCLUSION: The only parameter that was a clear indicator of outflow obstruction was Qmax. Other indicators of detrusor contractility should be sought.     

Slit‐Like Deformation of the Coronary Sinus Orifice due to Compression of the Inferior Pyramidal Space by the Severely Dilated Left Ventricle

The coronary sinus is located within the inferior pyramidal space, which is the part of the epicardial visceral fibroadipose tissue wedging between the four cardiac chambers from the bottom of the heart. Therefore, this region is susceptible to the morphological changes of the cardiac chambers. We present a case of slit‐like deformation of the coronary sinus orifice due to compression of the inferior pyramidal space by the severely dilated left ventricle, which has not been previously described.     

Effect of hypocalcemia on muscle in disorders of calcium metabolism

We reported on three hypocalcemic patients with various serum creatine kinase (CK) levels and Ca metabolic disorders. Two patients with moderate hypocalcemia had increased CK levels (hyper-CK-emia), which normalized during treatment for the hypocalcemia; a negative correlation between the Ca and CK levels was observed in both patients. The remaining patient with mild hypocalcemia had a normal CK level. We discuss the effect of hypocalcemia on muscle in our patients as well as previously reported patients. Muscle may respond to hypocalcemia in three stages, namely homeostatic, asymptomatic hyper-CK-emic and myopathic stages.     

Reversal of acquired cisplatin resistance by modulation of metallothionein in transplanted murine tumors

BACKGROUND: The platinum-based chemotherapeutic agent cisplatin is involved in a broad spectrum of activities against human systemic malignancies. However, acquired resistance to cisplatin reduces its clinical efficacy. Elucidation of the molecular basis of cisplatin resistance is required to improve the effectiveness of cisplatin. In the present study, the mechanism of acquired resistance to cisplatin was studied in C3H mice inoculated with MBT-2 murine bladder tumor cells. METHODS: C3H mice were subcutaneously inoculated with 1.0 x 10(6) MBT-2 cells/mouse on day 0. The mice were given intraperitoneal injections of 10 micro mol/kg cisplatin and subcutaneous injections of 1000 micro mol/kg propargylglycine, an inhibitor of gamma-cystathionase, once a day for 10 consecutive days from day 11 to day 20. RESULTS: The metallothionein content of the tumors was increased to twice the control level by repeated administration of cisplatin. Co-administration of propargylglycine reduced metallothionein induction in the tumors and markedly enhanced the antitumor activity of cisplatin. In contrast, the glutathione content in the tumors did not change from the control level after cisplatin administration. The platinum accumulation in tumors treated with cisplatin alone was 1.7-fold greater than when propargylglycine was administered concomitantly. The platinum concentrations changed in accordance with the metallothionein contents. CONCLUSIONS: These observations suggest that metallothionein, but not glutathione or reduced platinum accumulation, might play a role in the acquired resistance to cisplatin of C3H mice inoculated with MBT-2. Moreover, reversal of this resistance might be possible by biochemical modulation of metallothionein.     

Retrograde endoscopic laser therapy and ureteroscopic surveillance for transitional cell carcinoma of the upper urinary tract

OBJECTIVE: To investigate the efficacy of endoscopic laser therapy and ureteroscopic surveillance for transitional cell carcinoma (TCC) of the upper urinary tract. Methods: Tumors of the upper urinary tract were detected at ureteroscopy. After TCC was diagnosed by biopsy, retrograde endoscopic laser therapy was performed. Recurrent tumors were treated endoscopically and the patients were followed by ureteroscopic surveillance at 3- to 6-month intervals. RESULTS: Seven patients underwent ureteroscopic treatment. The tumor was grade 1 in five patients and grade 2 in two patients. The average tumor size was 1.3 cm. One patient with large, multifocal tumors died of metastatic disease, and one died of an unrelated cause. One patient requested nephroureterectomy after endoscopic treatment. The remaining four patients were followed up for a mean of 32 months after initial treatment. Each patient received an average of 5.3 ureteroscopic surveillance procedures while 3.3 recurrences on average were detected. Recurrence occurred in all the patients who showed normal radiographic findings. Urine cytology was also of little value in predicting tumor recurrence, except in one patient with carcinoma in situ. The recurrent tumors detected by ureteroscopy were successfully treated by repeated endoscopic procedures. After the follow up, three patients remained alive with no signs indicative of disease, but one patient with an initial grade 2 tumor died of recurrence after 30 months. CONCLUSIONS: Given that ureteroscopic evaluation is essential for surveillance after endoscopic treatment of upper urinary tract TCC because of residual concern about recurrence, patients treated endoscopically should be recommended to undergo long-term endoscopic follow up.     

Endoscopic Mucosal Resection for Esophageal Cancer: EMR‐C Procedure

As a therapeutic modality for superficial esophageal cancer, endoscopic mucosal resection (EMR) is now thoroughly established. We routinely perform EMR using a cap (EMR‐C) procedure as a developer. In EMR‐C procedure, injection of a large volume of saline and a certain prelooping along the inner rim of the cap are vital issues for safe and reliable resection. In multi‐sessions of EMR, submucosal injection of saline prior to every session is essential, in order to avoid perforation. In such a manner, total circumferential EMR can be performed safely and easily by the EMR‐C procedure.     

Association of mutations in the core promoter and precore region of hepatitis virus with fulminant and severe acute hepatitis in Japan

It was recently reported that mutations in the precore and core promoter region of hepatitis B virus (HBV) are associated with fulminant hepatitis. The aim of this study was to investigate the association of mutations in the precore and core promoter region of HBV with fulminant and severe acute hepatitis. We studied Japanese patients with acute HBV infection, including seven patients with fulminant hepatitis, 12 with severe acute hepatitis and 41 with acute self-limited hepatitis. The presence of HBV mutants was examined by using a point mutation assay to detect a G to A transition at position 1896 in the precore region and an A to T transition at position 1762 and a G to A transition at position 1764 in the core promoter region. Significant differences in the proportion of mutations in the precore or core promoter region were present between patients with fulminant hepatitis and self-limited acute hepatitis (7/7 (100%) vs 4/41 (9.8%), P < 0.01) and between severe acute hepatitis and self-limited acute hepatitis (6/12 (50.0%) vs 4/41 (9.8%), P < 0.01). The frequency of mutation increased proportionately with the severity of disease in patients with acute HBV infection. Fulminant hepatitis B in Japan is closely associated with mutations in the core promoter and precore gene of HBV. Point mutation assays for HBV precore and core promoter analysis may be useful to predict the outcome of liver disease in patients with acute HBV infection.