St. Jude Medical valve replacement: clinical experience with 1,039 patients

St. Jude Medical valve replacement was performed in 1,039 patients; 320 had aortic (AVR), 543 mitral (MVR), and 176 had double valve replacement (DVR). There were 44(4.2%) early deaths. Follow-up extended in 995 patients from 10 to 130 months, with a cumulative period of 2,730 patients-years. The overall survival rates of AVR, MVR, and DVR patients at 10 years were 60.5%, 89.6%, 90.3% respectively. The linearized incidences of valve thrombosis, thromboembolism, anticoagulation-related hemorrhage, prosthetic valve endocarditis, and significant hemolysis were as follows: 0.11%/pt-yr, 1.33%/pt-yr, 0.04%/pt-yr, 0.18%/pt-yr, and 0.11%/pt-yr, respectively. There were no structural failure after 10 years follow-up. Reoperation (explant and re-replacement or suture repair) was required in 10 patients. Seven of them had periprosthetic leakage, 2 had valve thrombosis, and one underwent reoperation because of a technical error. Actuarially over 98% of patients were free of valve-related mortality at 10 years. St. Jude Medical valve is an excellent alternative for use in the surgical treatment of valvular heart disease.     

Clinical study of penile carcinoma in 38 cases

We retrospectively reviewed 38 patients with primary penile squamous cell carcinoma (stage 1 in 22, stage 2 in 7 and stage 3 in 9) who were treated in our institution from 1963 through 1987. The incidence of regional nodal metastasis was correlated with tumor category, local infiltration and tumor grade. The incidence rate of nodal metastasis of G2 and G3 tumors was statistically higher than that of G1 tumors. Of 27 patients initially treated by radiotherapy and/or chemotherapy, 11 patients achieved complete response. G1 tumors and T1 to 2 tumors had such high response rates as 58 and 50 per cent, respectively, but 5 patients (45 per cent) had local recurrence at an average of 74 months after initial treatment. The 5-year survival rates of over-all, stage 1, 2 and 3 were 73, 90, 75 and 25 per cent, respectively. Patients with stage 3 disease had a statistical lower survival rate than those with stage 1 or 2 disease. Among 13 patients with regional nodal metastasis, none with G2 tumor survived three years, although 3 patients (60 per cent) of those with G1 tumor survived five years. These results suggest that tumor grade is the most prognostic factor for the regional nodal metastasis, the response of conservative treatment and the survival of metastasized patients.     

Analysis of DNA copy number aberrations in hepatitis C virus-associated hepatocellular carcinomas by conventional CGH and array CGH.

To clarify the genetic aberrations involved in the development and progression of hepatitis C virus-associated hepatocellular carcinoma (HCV-HCC), we investigated DNA copy number aberrations (DCNAs) in 19 surgically resected HCCs by conventional CGH and array CGH. Conventional CGH revealed that increases of DNA copy number were frequent at 1q (79% of the cases), 8q (37%), 6p (32%), and 10p (32%) and that decreases were frequent at 17p (79%), 16q (58%), 4q (53%), 13q (42%), 10q (37%), 1p (32%), and 8p (32%). In general, genes that showed DCNAs by array CGH were usually located in chromosomal regions with DCNAs detected by conventional CGH analysis. Increases in copy numbers of the LAMC2, TGFB2, and AKT3 genes (located on 1q) and decreases in copy numbers of FGR/SRC2 and CYLD (located on 1p and 16q, respectively) were observed in more than 30% of tumors, including small, well-differentiated carcinomas. These findings suggest that these genes are associated with the development of HCV-HCC. Increases of MOS, MYC, EXT1, and PTK2 (located on 8q) were detected exclusively in moderately and poorly differentiated tumors, suggesting that these alterations contribute to tumor progression. In conclusion, chromosomal and array CGH technologies allow identification of genes involved in the development and progression of HCV-HCC.     

Investigation of etiologies for acute renal failure due to rhabdomyolysis in 5 patients

We experienced 5 cases of acute renal failure due to rhabdomyolysis during the last two years and investigated those etiologies. Diagnosis of rhabdomyolysis was established by the detection of elevated serum creatine phosphokinase, myoglobin, aldolase, myoglobinuria as well as by the clinical course. The respective underlying illness of the 5 cases were grand mal seizures, infection (high fever), heat stroke, diabetes mellitus with hyperosmolar nonketotic coma and cerebral infarction treated by barbiturate. In this investigation, however, any single cause was not enough as the etiologies of rhabdomyolysis. There were multiple factors responsible to rhabdomyolysis in each case, such as hypokalemia, hypophosphatemia, shock, arteriosclerosis, etc. Some cases could not be classified as traumatic or non-traumatic rhabdomyolysis. Thus, in one case, acute renal failure due to rhabdomyolysis induced by the combination of grand mal seizures and serum potassium/phosphate depletion. 2 cases recovered without hemodialysis. 3 cases died in multiple organ failure, included a case treated by hemodialysis. We conclude that acute renal failure due to rhabdomyolysis induced easily by numerous diseases and early diagnosis is recommended.     

Ultrasonic duplex system to facilitate assessment of portal blood flow velocity

The usefulness of an ultrasonic duplex system to assess portal blood flow was investigated. In a model involving a steady flow through a vinyl tube in agar, there was a significant linear correlation between the maximum blood flow velocity measured by this system (V-max) and the mean blood flow velocity calculated from the actually measured blood flow volume (V-mean), that is, V-mean = 0.53 X V-max was obtained (r = 0.994; n = 47). This equation was used to calculate the mean portal blood flow velocity by this system (V-dopp) in 10 patients with liver disease, and the findings were compared with data simultaneously obtained by cineangiographic mapping of Lipiodol droplets released into the portal vein through a catheter placed in situ at the time of surgery (V-cine). A linear correlation between V-dopp and V-cine was statistically significant (r = 0.970; n = 13), and the regression line was V-cine = 1.29 X V-dopp -2.11. The ultrasonic duplex system proved reliable for a quantitative assessment of portal hemodynamics.     

Recurrence of varices after oesophageal transection: intra-operative and postoperative assessment by endoscopy

Intra-operative and postoperative endoscopy were used in 16 patients with portal hypertension to investigate whether intra-operative elimination of oesophageal varices by oesophageal transection with devascularization leads to prevention of variceal recurrence and rebleeding. Intra-operative elimination of the varices was achieved in 12 patients. In ten patients the varices recurred and in two cases rebled, during the follow-up period of 6-43 months (average 25 months). Of the ten patients with recurrent varices, eight (including the two who bled acutely in the postoperative period) successfully underwent endoscopic injection sclerotherapy. Postoperative endoscopy was performed at 5-monthly intervals. It is concluded that intra-operative elimination of the varices will not prevent recurrence and that a closer follow-up using endoscopy more than three times a year is a significant aid in the management of these patients.     

Clinical usefulness of the WHO histological classification of thymoma.

PURPOSE: Rosai et al. published the World Health Organization (WHO) classification of thymic epithelial tumors in 1999, and its clinical usefulness seems to be established. It is our purpose to find the clinically relevant diagnostic points in the WHO Histological Classification of Thymoma. METHODS: Thymomas surgically removed from 100 consecutive patients at Juntendo University Hospital between October 1983 and February 2002 were classified according to the WHO histological classification. We assessed overall survival and recurrence-free rate calculated for each tumor type in the WHO classification compared with those of tumors classified by the Masaoka system. RESULTS: The thymic epithelial tumors in this series comprised 10 type A, 15 type AB, 18 type B1, 21 type B2, 33 type B3, and 3 type C tumors according to the WHO classification. Based on the Masaoka system, the disease was stage I in 53 patients, stage II in 30, stage III in 15, and stage IV in 2. The 15-year recurrence-free rate was 100% for type A, AB and B1, while the rates for types B2 and B3 were 66.7% and 54.5%, respectively. The 10-year recurrence-free rate was 66.7% for type C. The 15-year recurrence-free rate of the 64 patients with type A, AB, B1, and B2 thymomas was significantly higher from that of the 33 patients with type B3 thymoma (p=0.0026). CONCLUSION: When using the WHO classification, it is critical to distinguish type B3 thymoma from other tumor types.