Early gastric cancer manifested as brain metastasis: Report of a case

A case of early gastric cancer, limited to submucosal layer, which was manifested as cerebral metastasis is presented herein. A 47-year-old man was admitted to Nagaoka Chuo General Hospital with convulsions and a disturbance in consciousness, where a computed tomography (CT) scan revealed a cerebral tumor in the left temporal lobe. The resected tumor was identified as a metastatic adenocarcinoma. Further investigation revealed gastric cancer involving the posterior wall of the cardia. At laparotomy, multiple and small metastases of the liver and a jejunal metastasis were found, and a palliative total gastrectomy was performed. The surgical specimen revealed a protruding, poorly differentiated medullary adenocarcinoma, with invasion of the submucosal layer. The patient died 4 months after undergoing the laparotomy. This case report is presented to make clinicians aware of the possibility that early gastric cancers may present as brain metastasis.     

Generation of functional and mature dendritic cells from cord blood and bone marrow CD34+ cells by two-step culture combined with calcium ionophore treatment

The object of this study is to explore a culture method to generate a large number of functional and mature dendritic cells (DC) from human CD34+ hematopoietic progenitor cells. In the present study, we used a two-step method combined with calcium ionophore to induce DC from cord blood (CB) or normal human bone marrow (BM) CD34+ progenitor cells. The two-step method consists of 10 days of first step culture for the expansion and proliferation of CD34+ hematopoietic progenitor cells in the presence of SCF, IL-3, IL-6, G-CSF, and 7--11 days of second step culture for the induction of DC in the presence of GM-CSF, IL-4 and TNF-alpha. By the two-step culture, total nucleated cells were increased 208+/-66 (+/-SD, n=13), or 94+/-29 (n=5)-fold in the culture of CB or BM cells, respectively, compared with the number of CD34+ cells at the time of starting culture. Out of the total nucleated cells, 23 +/-10.4% of cells in CB cell culture and 25 +/-5% of cells in the BM cell culture acquired DC characteristic phenotypes, which were marked expressions of CD1a, HLA-DR, co-stimulatory molecules such as CD80, CD40, and adhesion molecule such as CD58. In allogeneic mixed leukocyte reaction (MLR), two-step cultured cells showed potent allo-stimulatory capacity. With this two-step culture, the absolute number of CD1a+ cells that co-expressed HLA-DR, CD80, CD40 and CD58 was enhanced approximately 3 times in CB cell culture and 1.9 times in BM cell culture, compared with the commonly used one-step culture method for the generation of DC from CD34+ cells using SCF, GM-CSF and TNF-alpha. However, on these DC generated in the two-step culture, the expressions of co-stimulatory molecule CD86 and mature DC marker CD83 were not sufficient. By the treatment of two-step cultured cells with calcium ionophore agent (A23187), the expression of co-stimulatory molecules such as CD86 and CD80 (especially CD86) was up-regulated. Besides, the expression of mature DC marker CD83 was remarkably induced by treatment with A23187 for a short duration (24 h). Consistent with the up-regulation of surface molecules CD86, CD80 and CD83, the two-step cultured cells treated with A23187 also showed a stronger allo-stimulatory capacity compared with the cells without A23187 treatment. In conclusion, the present study demonstrated that the two-step culture method effectively improved the yield of CD1a+ DC generated from CD34+ cells, and the phenotypes and functions of these CD1a+ DC could be enhanced efficiently by treatment with a calcium ionophore agent.     

Totally laparoscopic resection of right-sided colon cancer using transvaginal specimen extraction with a 10-mm-long abdominal incision

Techniques in Coloproctology - Natural orifice specimen extraction (NOSE) has been developed as a means of decreasing the incidence of surgical wound complications. We refined the procedure for...     

EB virus-associated peripheral T cell lymphoma presenting with hemophagocytic syndrome and hepatic cell necrosis

A 72-year-old woman was admitted with left cervical lymphadenopathy, high fever, pancytopenia and liver dysfunction. Bone marrow aspiration showed infiltration of large atypical lymphoid cells and hemophagocytic histiocytes, thus suggesting a diagnosis of lymphoma associated hemophagocytic syndrome (LAHS). An abdominal CT scan revealed multiple low-density areas in the liver, and the patient's liver function rapidly deteriorated. Histologically, the cervical biopsy showed lymphoma cell infiltration with prominent necrosis and karyorrhectic debris. The lymphoma cells expressed CD3+, CD4-, CD8+, CD20-, CD56+/-, TIA-1+, granzyme B+, and EBER was positive using in situ hybridization. DNA analysis of the TCR beta and gamma chain gene with the Southern blot showed rearranged bands. These findings were compatible with those of EB-virus associated peripheral T-cell lymphoma. After chemotherapy with the THP-COP regimen, the patient's liver dysfunction improved rapidly, but she died from bacterial peritonitis due to perforation of a recurrent duodenal ulcer. Post-mortem examination of the liver showed multiple irregular massive necroses of the hepatocytes, where no lymphoma cell infiltration was present. Hemophagocytic histiocytosis was remarkable in the bone marrow, spleen, lymph nodes, and liver. Marked elevation of serum levels of cytokines such as TNF-alpha or IFN-gamma suggests that these cytokines played an important role in the pathogenesis of the hepatic cell necrosis.     

Successful treatment of acute promyelocytic leukemia complicated with autoimmune hepatitis-induced portal hypertension with all-trans retinoic acid

A 35-year-old man admitted to the hospital for oral hemorrhage was diagnosed with acute promyelocytic leukemia (APL). Remission from APL was achieved by induction therapy with all-trans retinoic acid (ATRA); the PML/RARA fusion gene was not detected on PCR analysis. Despite complete molecular remission, severe persistent pancytopenia, massive ascites, and renal failure were observed. The liver surface appeared rough and irregular on computed tomographic images. On the basis of the liver biopsy results, we diagnosed his condition as portal hypertension due to autoimmune hepatitis. Indocyanine green test showed good residual function of the liver, and therefore, 2 courses of consolidation therapy were administered; chemotherapy was stopped because of severe pancytopenia due to portal hypertension. Instead of continuing the consolidation therapy, maintenance therapy involving 8 rounds of ATRA monotherapy (45 mg/m(2), days1～14) was initiated. Portal hypertension did not progress further with this maintenance therapy and therefore it was continued. The patient has been in remission from APL ever since, and no relapses have occurred since the past 5 years. These results suggest that ATRA can be used for long-term therapy in such cases.     

Evaluation of permanent and primary enamel and dentin mineral density using micro-computed tomography

Oral Radiology - The present study was performed to investigate the mineral density distribution in enamel and dentin for both permanent and primary teeth and to establish the standard density per...     

Clinical guidelines for dental cone-beam computed tomography

Dental cone-beam computed tomography (CBCT) received regulatory approval in Japan in 2000 and has been widely used since being approved for coverage by the National Health Insurance system in 2012. This imaging technique allows dental practitioners to observe and diagnose lesions in the dental hard tissue in three dimensions (3D). When performing routine radiography, the examination must be justified, and optimal protection should be provided according to the ALARA (as low as reasonably achievable) principles laid down by the International Commission on Radiological Protection. Dental CBCT should be performed in such a way that the radiation exposure is minimized and the benefits to the patient are maximized. There is a growing demand for widespread access to cutting-edge health care through Japan’s universal health insurance system. However, at the same time, people want our limited human, material, and financial resources to be used efficiently while providing safe health care at the least possible cost to society. Japan’s aging population is expected to reach a peak in 2025, when most of the baby boomer generation will be aged 75 years or older. Comprehensive health care networks are needed to overcome these challenges. Against this background, we hope that this text will contribute to the nation’s oral health by encouraging efficient use of dental CBCT.     

Studies on systemic hemodynamics and sympathetic nervous activity in portal hypertension

Hemodynamic study was carried out in 53 preoperative cirrhotic patients with portal hypertension and the postoperative prognosis was evaluated. In 16 cases of these patients, cardiovascular responsiveness to cold stress and 60 degrees head up tilt was measured using pneumoplethysmography and Swan-Ganz catheter. In comparison with the controls, cirrhotic patients were in significant hyperdynamic state. Mortality rate from hepatic failure within 2 years after operation was significantly high in the group characterized by higher cardiac index (CI) level exceeding 4.0 l/min/m2 combined with lesser K-ICG level lower than 0.08/min or lesser hepatic extraction rate of ICG (ER) level lower than 50%. Cardiovascular responsiveness to reflex autonomic stimulation was significantly impaired in cirrhotic patients. The reaction index to cold stress was inversely correlated to plasma noradrenaline (NA) concentration. There was a tendency that the higher the corrected wedged hepatic pressure (WHVP) was, the lower the reaction index was. There was also a correlation between NA and corrected WHVP and plasma tyrosine concentration and ER. In summary, impaired liver function and increase of portal pressure, which might induce deranged catecholamine metabolism, may play an important role in decrease in cardiovascular responsiveness to reflex autonomic stimulation in cirrhotic patients with portal hypertension.