Effects of super-extended paraaortic lymphadenectomy (PAL) on biological responses in totally gastrectomized patients with T3 or T4 gastric cancer

Background. In Japan, much attention has recently been paid to super-extended paraaortic lymphadenectomy (PAL) for the treatment of advanced gastric cancer. However, it has been reported that PAL is associated with increased morbidity and mortality, as compared to conventional extended lymphadenectomy (D2 or D3). Therefore, an analysis of the effects of PAL on perioperative changes in the biological responses of patients essential for determining the potential utility of this procedure. Methods. The current non-randomized prospective study included evaluations of perioperative changes in parameters of surgical stress (series I; serum levels of antidiuretic hormone, interleukin-6, trypsin, and phospholipase A ₂ ) and immunocompetence (series II; phytohemagglutinin- and concanavalin A-induced blastogenesis, activity of natural killer cells and the ratio of CD4 cells to CD8 cells) in patients with advanced gastric cancer (T3 or T4), comparing groups treated with D3 plus PAL ( n = 12) and D3 ( n = 13), and a control group with early gastric cancer ( n = 16) treated with D1 lymphadenectomy (perigastric N1 nodes) between April 1995 and April 1997. Results. The duration of surgery and the amount of blood lost were longer and greater in the D3 plus PAL group than in the D3 and D1 groups. D3 plus PAL and D3 were associated with significant postoperative increases in parameters of surgical stress, as well as with significant postoperative immunosuppression, compared to results with D1. However, there were no significant differences in the respective parameters between the D3 plus PAL and D3 groups. Conclusions. Our results indicate that there are no essential differences in patients' biological responses between D3 plus PAL and D3 lymphadenectomy. It appears that PAL-associated morbidity can be minimized by very careful manipulation during the dissection of paraaortic lymph nodes. Received for publication on Feb. 10, 1998; accepted on Jun. 3, 1998     

Significance of a diastolic notch in the uterine artery flow velocity waveform induced by uterine embolisation in the pregnant ewe

Objective To investigate the relation between placental embolisation and the diastolic notch in the uterine artery flow velocity waveform of pregnant ewes under general anaesthesia.
Methods Seven pregnant ewes at a gestation 16 to 17 weeks were anaesthesized and micro beads of gelfoam were injected into the uterine artery; changes in the uterine circulation were assessed by Doppler velocimetry.
Results Gelfoam embolisation reduced uterine blood flow in a dose-dependent manner, from a mean (95% CI) of 568 mL/min (495–641) to 159 mL/min (131–187) after the injection of 30 mg of gelfoam, and increased the uterine vascular resistance from 135 mmHg mine L⁻¹ (103–167) to 498 mmHg mino L⁻¹ (422–574). A diastolic notch in uterine artery flow velocity waveform was observed after 20 mg to 25 mg of gelfoam in two ewes and after injection of 30 mg of gelfoam in all seven animals. Injection of 30 mg of gelfoam increased the pulsatility index to 2–4 (1.9–2.9) from 0.6 (0.5–0.7). The mean uterine vascular resistance at the time of the appearance of a diastolic notch was 414 mmHg mine L⁻¹ (377–451).
Conclusion These findings suggest that an elevated pulsatility index and the presence of a diastolic notch in the uterine artery flow velocity waveform are indicators of increased uterine vascular resistance and impaired uterine circulation.     

Acute promyelocytic leukemia: an unusual cause showing prolonged disseminated intravascular coagulation after placental abruption

Background Disseminated intravascular coagulation (DIC) caused by placental abruption usually improves rapidly after prompt delivery and adequate anti-DIC treatment. Case A 30-year-old nulliparous woman suffered from placental abruption at the 25th week of pregnancy, and emergent cesarean section was done immediately. She exhibited DIC, which continued even after termination of the pregnancy and anti-DIC treatment. She also showed neutropenia. We closely observed her, and at the 58th day postpartum, blast cells appeared in the peripheral blood and she was diagnosed with acute promyelocytic leukemia (APL). Induction chemotherapy was done successfully. The close observation after delivery enabled us to make the prompt diagnosis/treatment, leading to the complete remission. Conclusion APL should be added to the list of differential diagnosis when DIC persists even after prompt delivery and appropriate anti-DIC treatment after placental abruption.     

Femur fracture during abdominal breech delivery

BACKGROUND: While vaginal breech delivery, although rare, can cause femur fracture, abdominal breech delivery is not expected to cause it. CASE: A 2,490-g female infant was delivered at term by elective cesarean section for breech presentation. She sustained a fracture of the femur shaft. A simple splinting led to a complete healing of the fracture without sequelae. CONCLUSION: Although abdominal breech delivery reduces the risk of birth trauma, we must be aware that femur fracture can occur regardless of the mode of delivery.     

Nonfunctional pituitary macroadenoma manifested as muscular symptoms

A 75-year-old man with a large pituitary adenoma presented with general muscular weakness, including difficulty in rising in the morning and forceless defecation and urination, and muscular pain, numbness and atrophy in the shoulder, neck and thigh. Testosterone replacement and subsequent resection of the pituitary tumor resulted in resolution of the symptoms. The value of pituitary imaging tests for men with hypogonadotropic hypogonadism is discussed.     

Prognostic significance of Bcl-xL in human hepatocellular carcinoma

BACKGROUND: Proliferation and apoptosis of liver cancer cells are closely related phenomena. We investigated the correlation between overexpression of Bcl-xL, an anti-apoptosis-related protein of the Bcl-2 family, and the clinical course of hepatocellular carcinoma (HCC). METHODS: Specimens from 7 HCC patients were used for Western blotting and immunoelectron microscopy tests. Samples from 33 HCC patients who had undergone hepatectomies were used for immunohistochemical staining. The degrees of expression of Bcl-xL and Ki-67, as an index of HCC mitosis severity, were each classified into 2 groups. RESULTS: With the use of Western blot analysis, enhanced immunoreactivity of Bcl-xL was found in cancerous specimens. Bcl-xL overexpression was found in cancer specimens in 21 of 33 patients (63.6%). The overall survival (P=.019) and disease-free survival (P=.030) rates of the group overexpressing Bcl-xL were definitely poorer. The Ki-67 higher labeling index LI > 10) group had a poorer survival rate (P=.016). There were significant correlations between Bcl-xL and overall survival and disease-free survival. Multivariate analyses revealed that Bcl-xL, tumor size, histologic portal invasion, and histologic metastatic foci were independent prognostic factors for overall survival and disease-free survival. CONCLUSIONS: These results showed Bcl-xL in HCC specimens, suggesting that Bcl-xL was a significant prognostic factor for disease progression in human HCC.