[A case of heparin-induced thrombocytopenia after transurethral resection of prostate during anticoagulant therapy].

A 66-year-old man had been receiving anticoagulant therapy for myocardial infarction with warfarin potassium (abbreviated as warfarin) 2 mg/day. Though he had been treated with tamsulosin hydrochloride 0.2 mg/day as diagnosis of benign prostatic hyperplasia, he experienced severe dysuria and wanted to undergo transurethral resection of the prostate. We decided to continue anticoagulant therapy because cardiologist judged that intermission of anticoagulant therapy could cause myocardial infarction. Warfarin 2 mg/day p.o. was replaced with heparin sodium (abbreviated as heparin) 5000 u x 2/day s.c. 6 days prior to surgery, and anticoagulant therapy was stopped on the day of surgery, but resumed on the following day. Purpura appeared around the extremities 18 days after the surgery. Although coagulation testing was normal, platelet counts had markedly been reduced (2,000/mm3). Platelet counts recovered to a level of 228,000/mm3 13 days after cessation of heparin. No other adverse effects were observed. Heparin-induced thrombocytopenia (abbreviated as HIT) was diagnosed clinically. We consider monitoring of platelets to be necessary because an increasing number of patients are on anticoagulant therapy in Japan, and accordingly, the use of heparin is likely to be increased.

[Treatment and prognosis of T 4 renal cell carcinoma].

BACKGROUND: We studied the cases with T 4 renal cell carcinoma (RCC) to characterize the factors associated with prolonged survival and to clarify the indication of extended nephrectomy. MATERIALS AND METHODS: The study population consisted of 53 patients (44 male and 9 female) with pT 4 RCC treated at the Yokohama City University Hospital and its affiliated hospitals from 1965 to 1994. Survival rates were analyzed with respect to clinicopathological factors (patient age, sex, symptom, tumor growing type, tumor size, histological grade, cell type, structural type, lymph node metastasis, vein invasion, distant metastasis and extended nephrectomy). RESULTS: One-year, 2-years, and 3-years survival rates of the cases with T 4 RCC were 30.4%, 16.4%, and 9.4% respectively. In univariate analysis, improved survival were correlated with no extra-urinary symptom (Logrank: p = 0.0048, Wilcoxon: p = 0.0423), no lymphnode metastasis (Logrank: p = 0.1045, Wilcoxon: p = 0.0199), no distant metastases (Logrank: p = 0.0007, Wilcoxon: p = 0.0006), and enforcement of extended nephrectomy (Logrank: p = 0.0018, Wilcoxon: p = 0.0008). In 28 cases with extended nephrectomy, improved survival was correlated with no extra-urinary symptom, no abdominal wall invasion and no distant metastases. In 5 cases with more than 3 year survival after extended nephrectomy, 4 cases were found to have no distant metastases at the time of operation. Non-operative therapy including interferon for 20 cases without extended nephrectomy were almost ineffective. CONCLUSIONS: These results indicate that if curative excision for T 4 RCC cases without distant metastases could be done, some patients might be appropriate candidates for extended nephrectomy.

[Tubeless cutaneous ureterostomy through a single stoma with new extraperitoneal ureteral route up to stoma].

Tubeless cutaneous ureterostomy through a single stoma has been said to be difficult to establish in patients with normal ureters or normal ureters combined with thick fatty abdominal wall, because of the poor blood supply at the end of the ureters. The technical improvements observed were as follows: 1) The peritoneal fold and the upward traction of the gonadal vessels decrease the ureteral tension and keep the blood supply to the ureters in the extraperitoneal approach. 2) The gonadal vessels and its surrounding tissue, covering the subcutaneous fatty tissue, help the ureteral adhesion at the anastomotic site. 3) Full diminution of the skin defect caused by flap formation, decreases the horizontal tension of the side-to-side anastomized ureters. Sixteen patients with normal ureters underwent this procedure. In a short-term (4-37 months) observation, 4 of the patients, including one with thick abdominal fat, showed unilateral hydronephrosis and 2 patients unilateral non-function kidney. The remaining 10 patients had no complications. Moreover, all the patients have kept their ureterostomies tubeless and their serum blood urea nitrogen and creatinine levels were within normal limits except for one patient. It is reasonably concluded that the new method will result in success clinically even in patients with normal ureters and thick abdominal fatty tissue.

Preparation of 2'-deoxyribonucleosides with an identically 2H/13C-labeled sugar residue.

Thymidine with the stereoselectively 2H/13C-Labeled sugar moiety, (2'R)(5'S)-[1',2',3',4',5'-(13)C5;2',5'-(2)H2]-thymidine, was synthesized from uniformly 13C-labeled glucose, via the selectively deuterated ribose derivative prepared by the stereo-controlled deuteride transfer reactions. The labeled sugar moiety of the thymidine was then transferred to 2'-deoxyadenosine, 2'-deoxyguanosine, and 2'-deoxyuridine, by the enzymatic transglycosylation reactions by purine and pyrimidine nucleoside phosphorylases, in good yields. Labeled 2'-deoxyuridine was chemically converted to 2'-deoxycytidine. Consequently, all of the 2'-deoxynucleosides prepared by this method has the identically labeled sugar moiety. By using DNA oligomers containing the identically labeled sugar residue for NMR studies, any possible complexity in NMR data analyses expected to be observed for DNA oligomers containing variously labeled nucleosides can be minimized.

[Clinicopathological study on patients with renal cell carcinoma according to whole area histological sections].

BACKGROUND: We tried to establish new classification of histological grade and indication of elective nephron-sparing surgery (ENSS) in renal cell carcinoma (RCC), and studied histological changes according to tumor size. METHODS: We made whole area histological sections on 142 cases with RCC and investigated histological aspects and prognosis. RESULTS: (1) To classify the grade of the cases, the worst grade which occupied more than 10% of the tumor provided most appropriate prognosis. (2) In 144 cases (kidneys), satellite tumor lesions (STL) were observed in 69 cases (47.9%), and the cases with vein invasion were observed in 75 cases (51.4%). Incidence of these two factors increased with tumor size. (3) From the point of view of location of STL and vein invasion, ENSS was possible with taking more than 2 cm surgical margin in the cases with less than 4 cm in size and slow growing type. But indication of ENSS should not be decided with ease. (4) Incidence of the cases with multiple structural and cell types and grades increased with tumor size. (5) Incidence of the cases with solid structure, spindle or pleomorphic cell type and high grade increased with tumor size. (6) It was supposed that tumor heterogeneity and progression could be associated with tumor growth in each cases. CONCLUSION: These results suggest the necessity of treatment of the cases with RCC as small as possible. If the tumor is less than 4 cm, prognosis tends to be good, and ENSS might be possible in some cases.

[Prognosis in the cases with renal cell carcinoma according to clinical parameters].

BACKGROUND: The objects of this study is to evaluate the clinical prognostic factors in renal cell carcinoma. MATERIALS AND METHODS: During a 30-year period from January 1965 to December 1994, 1301 cases with renal cell carcinoma were treated at the Yokohama City University Hospital and its affiliated hospitals. In these cases, cause specific 679 cases from January 1965 to December 1990 were analyzed in a study undertaken to investigate long-term treatment results and clinical prognostic factors. RESULTS: 1. The cause specific 5-, 10-, 15-, and 20-year survival rates were 48.7%, 41.1%, 32.3%, and 26.5% respectively, indicating thus that a great number of cases had an ominous prognosis even 5 years or moreafter surgical treatment. 2. Among patients under 40 years of age (n = 29) none died more than 2 years after receiving operation, the prognosis for this particular group of cases being relatively good. 3. Female, incidentally detected cancer, small tumor size (< or = 4.0 cm), slow growing type and low stage were proven to be favourable prognostic factors in renal cell carcinoma. 4. The cause specific 5-year survival rate for the patients (n = 239) from 1965 to 1981 was 33.8%, while the rate for the patients (n = 440) from 1982 to 1990 was 56.5%. This improvement of survival rate was brought by the increase of the incidentally detected renal cell carcinoma. 5. In the incidentally detected renal cell carcinoma, the incidence of slow growing cases and the cases of less than 4.0 cm tumor size were higher than in the symptomatic renal cell carcinoma. 6. Multivariate analysis using Cox's proportional hazard model showed that stage was the most important prognostic factor. CONCLUSIONS: These results suggested that sex, age, symptom, tumor size, growing type, and stage were important prognostic factors in renal cell carcinoma.

Synthesis of stereoselectively 5'-monodeuterated nucleoside with defined S/R-ratios. An application to the assignment of 5'-methylene signals of DNA oligomers.

A method to prepare 5'-monodeuterated nucleosides with various S/R-ratios is described. 5-Oxopentose derivatives synthesized from glucose were converted into 5-monodeuterated pentose derivatives by LiAID4 in the presence of various ligands. The stereoselectivities of the deuteration reactions were investigated under a variety of conditions, and the S/R-ratios of the 5-monodeuterated pentoses varied from 4 : 1 to 1 : 7.4. By mixing these 5-monodeuterated pentose derivatives, we have successfully synthesized thymidine with a defined S/R-ratio at C5'.

Synthesis of stereoselectively 13C/2H-doubly labeled DNA oligomers by the combined use of chemical and enzymatic reactions.

(2'S,5'S)-(1',2',3',4',5'-13C5;2',5'-2H2-thymidine, prepared via labeled ribosyl thymidine as described in the accompanying paper, has been successfully converted into isotopically labeled dA, dG, and dC using enzymatic transdeoxyribosylation reactions.

[A clinical study on lymph node metastasis of renal pelvic and ureteral cancers].

A clinical study was performed on 38 patients with renal pelvic and ureteral cancers who were treated in our hospital between 1977 and 1992. Nine patients (23.7%) had lymph node metastasis. The risk factors of lymph node metastasis were high grade, high stage and class IV or V or urine cytology. None of the patients with G1 or under pT1 had lymph node metastasis. The 5-year survival rate of the patients without [lymph node metastasis was 76.7% and that of the patients with lymph node metastasis was 11.1%. Although 6 of the 9 patients with G1 or G2 and under pT1 did not have adjuvant therapy, none of them died of the cancer. We concluded that lymph node metastasis in renal pelvic and ureteral cancers was the most important prognostic factor and that regional lymphadenectomy might be useful for the decision of adjuvant therapy.