[Gamma-knife radiosurgery for metastatic brain tumors from primary lung cancer].

Forty patients with metastatic brain tumors from primary lung cancer underwent radiosurgery (gamma-knife). We retrospectively compared their prior treatment history number of metastatic foci, and performance status, to evaluate the effects of, and indications for, gamma-knife therapy. After both the primary and the metastatic tumors were controlled, performance status could be used as an index in the choice of gamma-knife therapy. Our results demonstrate that repeated gamma-knife radiosurgeries prolonged survival time. Gamma-knife radiosurgery improves quality of life and prognosis of patients with metastatic brain tumors.

[An urodynamic study on neobladder function].

OBJECTIVE: To analyze the urodynamic characteristics of neobladders, we conducted a pressure-flow study in patients with orthotopic urinary reservoirs. PATIENTS AND METHODS: From 1986 to 1996, 90 patients underwent bladder replacement following cystectomy, using a right colonic, ileocolic, ileal, or sigmoid colonic segment. The subjects were 38 patients (31 men and 7 women) with stable urination and no evidence of cancer recurrence, urethral stricture, urinary tract infection or vesicoureteral reflux. Their mean age was 60.5 years, with a range of 38 to 77 years. Information on neobladder function, such as desire to void, force of micturition, urinary incontinence and other complaints, was obtained by questionnaire. A pressure-flow study was performed in all patients 3 months to 103 months postoperatively to evaluate total reservoir pressure, abdominal pressure and subtracted reservoir pressure during filling and voiding phases. RESULTS: Ten of 38 patients (26.3%) were dissatisfied with their neobladder function, due to weakness of urinary sensation, loss of urinary force and enuresis. In 6 of the 7 patients with enuresis, the urinary reservoir had been created by Heineke-Mikulicz's procedure of detubularization; 4 of these patients had a high degree (over 40 cmH2O) of phasic contraction during the filling phase. In only 2 of the 38 patients, a pressure-flow study showed an almost same pattern as that obtained with a normal urinary bladder. Twelve patients had increased electromyogram of the external urethral sphincter during the voiding phase, while half of the 38 patients showed a flat electromyogram during both the filling and voiding phases. Thus, 31 of 38 patients revealed a sphincter dyssynergia pattern. Mean total reservoir pressure at maximum cystometric capacity was 65.5 +/- 42.1, 48.4 +/- 19.0, 66.0 +/- 61.0 and 107.0 +/- 43.3 cmH2O in ileal, ileocecal, right colonic and sigmoid neobladders, respectively. The value for sigmoid neobladder was statistically different from that for ileocecal neobladder (p < 0.05). Mean total reservoir pressure at maximal flow was 73.1 +/- 42.4, 56.4 +/- 22.6, 88.9 +/- 69.4 and 94.0 +/- 31.8 cmH2O in ileal, ileocecal, right colonic and sigmoid neobladders, respectively. There were no statistically significant differences among these values. The ratio of subtracted reservoir pressure to total reservoir pressure was lower at maximal flow than at onset. Subtracted reservoir pressure may contribute to total reservoir pressure to a greater extent in sigmoid neobladders than in other types of neobladder. CONCLUSIONS: 1. Enuresis may have various causes such as external sphincter dysfunction and involuntary contraction of the reservoir. 2. Urine is evacuated not only by abdominal pressure but also by subtracted reservoir pressure in neobladders. 3. Sphincter dyssynergia due to absence of the detrusor muscle may be one cause of dysuria.

Clinicopathological study on pineocytoma.

Six cases of pineocytoma, which had developed in the parenchyma of the adult pineal body, were examined immunohistochemically and under an electron microscope, after the malignancy of each case had been determined using our classification. One case was rated as grade 1 showing a lobular structure and resembling the normal pineal body. Two cases were rated as grade 2 without a lobular structure but with pineocytomatous rosettes (P-rosettes). Two cases were rated as grade 3 without P-rosettes but with few mitotic figures. One case was rated as grade 4 with marked cellular pleomorphism, numerous mitotic figures and necrotic foci. When examined immunohistochemically, neuron-specific enolase was positive but glial fibrillary acidic protein was negative in all cases. Under an electron microscope, all cases showed abortive synapses, and clear or dense core vesicles. These findings allow us to make two conclusions. First, pineocytoma is always a tumor of neuronal lineage, regardless of their grade of malignancy. Second, the grade 4 pineocytoma should be distinguished from the type of tumor classically called "pineoblastoma." That is, the former seems to be a biologically dedifferentiated tumor, while the latter seems to be biologically undifferentiated tumor.

[Dural AVF of the posterior fossa associated with sinus occlusion presenting as intracerebral hemorrhage: case report].

A 69-year-old man was admitted because of sudden onset of consciousness disturbance. Neurological examination on admission revealed slightly disturbed consciousness, sensory aphasia and right hemiparesis. CT scan disclosed a hematoma in the left posterior temporal lobe. Left carotid angiograms showed dural AVF of the transverse/sigmoid sinus fed mainly by the left occipital and posterior auricular arteries. On the angiograms the left sigmoid sinus was completely occluded. This was associated with retrograde venous flow into the cortical veins, the superior petrosal sinus and the contralateral traverse sinus. After stabilizing the condition, we totally resected the dural AVF including the left transverse sinus. The postoperative course was uneventful. Histopathological examination of the surgically resected specimen revealed that the dural A-V fistula per se existed in the sinus wall.

Effects of intravenous nitroglycerin combined with dopamine on intracranial pressure and cerebral arteriovenous oxygen difference in patients with acute subarachnoid haemorrhage.

The effects of intravenous nitroglycerin (NTG) combined with dopamine on intracranial pressure (ICP) and cerebral arteriovenous oxygen difference (AVDO2) were studied in 11 patients with acute subarachnoid haemorrhage (SAH). The study was performed on Days 1 to 3 of SAH after aneurysmal clipping. Treatment consisted of an intravenous drip infusion of NTG in increasing incremental doses of 0.5, 1.0, 1.5, 2.0, and 2.5 micrograms/kg/min at one-hour intervals. Dopamine (5 to 10 micrograms/kg/min) was also given concurrently to maintain systemic blood pressure. ICP values before NTG administration ranged from 7 to 24 mmHg (mean. 11.91 +/- 5.30 mmHg). ICP began to increase immediately after the administration of NTG 0.5 microgram/kg/min and peaked at 14.64 +/- 5.93 mmHg 10 minutes after onset of infusion. Thereafter, ICP gradually returned to pretreatment levels. Increasing the dose of NTG failed to induce further significant rises in ICP. Mean AVDO2 before NTG administration was 4.69 +/- 0.62 ml/dl. This parameter showed no significant change during NTG infusion, although cerebral perfusion pressure decreased to between 75% to 94% of the control value after NTG administration. These results indicate that continuous NTG infusion combined with dopamine does not have adverse effects on ICP (the ICP increase is minimal and transient) and may even have beneficial effects on CBF in patients with acute SAH.

[Extracorporeal shock wave lithotripsy of urolithiasis].

A total of 159 patients underwent 194 treatments with extracorporeal shock-wave lithotripsy for upper urinary tract calculi between August 4 and November 30, 1986. A single treatment was performed in 76% of the patients with renal stones and 90% of the patients with ureteral stones. Treatment was successful in 153 patients (93%). Seventy percent of the patients with renal stones and 95% of those with ureteral stones were stone-free over the one-month follow-up, while about 15% had small and asymptomatic fragments believed to be passable spontaneously. Only one patient required surgical removal of the calculi due to severe ureteral edema. Adjunctive urological management is required in about 9% of the patients preoperatively or postoperatively. The period of hospitalization averaged about 11 days after treatment and patients usually returned to work within a few days after their discharge. Extracorporeal shock-wave lithotripsy is the preferred form of management for symptomatic ureteral and renal calculi.

[Viscus perforation as an unusual complication of Politano-Leadbetter ureteral reimplantation].

Unusual complications of the Politano-Leadbetter ureteral reimplantation technique are reported in four ureters in three children with primary vesicoureteral reflux (VUR). These ureters were found to pass through an adjacent intraperitoneal viscus including the sigmoid colon, ileum or broad ligament. This complication occurred in 0.48% of the Politano-Leadbetter antireflux operations for primary VUR. Viscus perforation occurred only in children with a relatively high grade VUR. The prognoses of the hydroureter after ureteric reimplantation or ureterolysis, were good in all cases. Although there are several advantages in the transvesical procedure of the original Politano-Leadbetter method, we should not hesitate to go extravesically if there are difficulties in mobilizing the ureter or inducing it into the vesical cavity.

[Tissue polypeptide antigen (TPA) in urological malignancies. I. S-TPA in bladder cancer patients].

Serum tissue polypeptide antigen (S-TPA) levels in 22 patients with bladder cancer were determined using a radioimmunoassay kit by the two-antibody technique to evaluate the usefulness of this parameter as an index of the presence of cancer. As S-TPA values (mean +/- SD) in 72 Japanese normal blood donors (37 male and 35 female) were in the range of 32.4-97.2 units per liter, values higher than 97.2 u/l were considered positive. We found a remarkably increased level of S-TPA in 14 out of 18 (77.8%) patients with untreated cancer and a slightly increased level of S-TPA in 3 out of 4 patients whose tumors had been removed. Elevated S-TPA levels in patients who had tumors remaining were suggested to correlate with histological stage and grade of tumors, type of growth and size of tumors, although not to correlate with number of tumors and whether tumor occurrence was initial or recurrent. Simultaneous urinary cytological examination and measurement of plasma CEA in the same patients gave the positive ratio of 7/16 (43.8%) and 0/14 (0%), respectively. It is possible that S-TPA may be one of the most useful tumor markers in the screening of cancer, diagnosis of histological characteristics, monitoring of cancer therapy and detection of recurrence.

[Clinical studies of patients with bladder tumors].

One hundred and seventy eight patients treated in our clinic were analyzed. The five-year survival rates for the patients (69 cases) given transurethral resection (TUR), total cystectomy (65 cases) and palliative treatment (40 cases) were 92.7%, 61.1% and 3.9%, respectively. The four patients who could not be treated lived no longer than one month. The five-year survival rate for the patients treated with TUR of the tumor was the highest. The recurrence rate for the TUR group was 19.5% at one year, 39.5% at three years and 47.1% at five years after surgery; and, it was higher in the patients with histologically high grade tumors. Generally, we obtained good results with TUR, but total cystectomy had to be performed later on three patients due to progression of the tumor. We felt the need for an indicator to express the biological activity of the tumor, and maintain that regular follow-up by endoscopy and cytology is mandatory. The clinical results of the total cystectomy and urinary diversion were considered to be satisfactory compared to other reports; and, patients with high stage tumor had poor prognosis. Five patients died of progression of the disease after total cystectomy. Operative mortality was 10.7%, which should be decreased by avoiding operative morbidity. In our experience, two-stage operations or preoperative irradiation can increase the indication for total cystectomy; and, improved clinical results are expected.

Radioautographic studies on the formation and maturation of bone marrow lymphocytes in mice.

DNA labelling by [3H]thymidine and the sandwich radioimmunolabelling method were used to characterize marrow lymphoid cells and to study the kinetics of production and maturation of small lymphocytes in the bone marrow of adult mice. Marrow lymphoid cells consisted of non-proliferating small lymphocytes, 30-40% of which had detectable surface immunoglobulin (SmIg), and proliferating large lymphoid cells lacking SmIg. Double-labelling experiments employing [3H]thymidine in vivo followed by sandwich radioimmunolabelling in vitro indicated that marrow small lymphocytes lack detectable SmIg when they are formed but develop SmIg within the first few days after production. Marrow lymphocytopoiesis includes; (1) proliferation of large lymphoid cells, which are presumptive small lymphocyte progenitors, which have a cell cycle time of 14-15 hr, and (2) a 3-5 day intramyeloid stage when many newly formed small lymphocytes undergo maturational changes towards the B cell lineage.