Detection of a novel silent deletion, a missense mutation and a nonsense mutation in TCOF1.

BACKGROUND: Treacher Collins syndrome (TCS) is a disorder of craniofacial development, that is caused by mutations in the TCOF1 gene. TCS is inherited as an autosomal dominant trait, and haploinsufficiency of the TCOF1 gene product treacle is proposed to be etiologically involved. METHODS: Mutational analysis of the TCOF1 gene was done in 10 patients diagnosed with TCS using single-strand conformation polymorphism and direct sequencing. RESULTS: Among these 10 patients, a novel 9 bp deletion was found, together with a previously reported 2 bp deletion, a novel missense mutation and a novel nonsense mutation in three different families. Familial studies allowed judgment of whether these abnormal findings were responsible for the TCS phenotype, or not. The 9 bp deletion of three amino acids Lys-Glu-Lys (1378-1380), which was located in the nuclear localization domain of treacle, seemed not essential for the treacle function. In contrast, the novel mutation of Ala26Val is considered to affect the LisH domain, an important domain of treacle. All of the mutations thus far detected in exon 5 have resulted in frameshift, but a nonsense mutation was detected (Lys159Stop). CONCLUSION: The information obtained in the present study provides additional insights into the functional domains of treacle.

Melanoma of thumb: retrospective study for amputation levels, surgical margin and reconstruction.

For the treatment of melanoma of thumb, the evidence about amputation level (IP joint or MP joint) and cutaneous excision margin has not been fully presented. And reconstructions for lost thumbs need to be balanced against functional and aesthetic requirements of individual patients and overall prognosis. We report 15 patients, who underwent primary excision and reconstruction for thumb melanoma between 1986 and 2004 at Department of Plastic and Reconstructive Surgery, University of Hokkaido at Sapporo, Graduate School of Medicine. The patients were reviewed to evaluate the prognostic significance of variables including age and sex of the patient, tumour thickness, staging, level of amputation, and cutaneous excision margin. Our 15 cases were divided into two groups according to amputation level (MP or IP) and cutaneous excision margin (<40 mm or >or =40 mm) and prognosis was analysed statistically. The stage and thickness were identified as prognostic factors for disease-free survival; however, IP amputation and 10-30 mm margin did not compromise disease-free survival. Amputated thumb was reconstructed by pollicization, free toe to thumb transfer, reverse forearm flap, local flap, and skin graft. No major complication of reconstructed thumb occurred. Seven of eight cases of MP amputation were reconstructed by pollicization. On the other hand, five cases of IP amputation were reconstructed by volar skin flap in two cases, reverse forearm flap in two cases, and trimmed first toe transfer in one case. Although a small number of cases, our study is the first attempt focussing on melanoma of thumb, and evaluating amputation level and cutaneous margin separately. The reconstructive algorithm for the amputated thumb is proposed and has various tools including free toe to thumb transfer.

Reconstructive considerations after resection of malignant melanoma in the head and neck.

Little has been written about reconstructive methods after resection of melanomas in the head and neck region. We investigated reconstructive methods retrospectively related to the site and size of the melanomas resected by examining the medical records of 28 patients who had malignant melanomas of the head and neck resected at our hospital from 1984 to 2001. The tumour distribution was 12 in the cheek, 6 in the conjunctiva, 2 in the upper lip, 2 in the lower lip, one each in the lower eyelid, eyebrow, scalp, nose, and auricle. Reconstructive methods were 18 skin grafts, seven local flaps, and three free flaps. Three patients who had skin grafts required secondary reconstruction using free flaps. No local recurrences were observed. Reconstructions with local flaps give better aesthetical and functional results than free flaps and skin grafts. Immediate reconstruction with a flap is safe and it does not affect observation of local recurrences.

Treatment strategy for cutaneous malignant melanoma.

The incidence of cutaneous malignant melanoma has been rising in Japan. With education, recent advances in accurate diagnosis and establishment of the concept, more lesions are being diagnosed as early melanomas, for which there is a high cure rate. However, many patients will still present with thicker lesions or nodal involvement, which carries a significantly worse prognosis. Recently there have been advances in the management and treatment of cutaneous melanoma. This article reviews the clinical evidence behind the current treatment recommendations for primary and recurrent cutaneous melanoma in Japan.

Management of superficial leiomyosarcoma: a retrospective study of 10 cases.

BACKGROUND: Superficial leiomyosarcoma is a rare soft-tissue tumor. Management of this tumor, including pathological evaluations and therapies, is not clearly defined in the existing literature. METHODS: Ten patients with superficial leiomyosarcoma treated in our institutes were recalled and scheduled for examination. Assessments were carried out according to clinical characteristics, therapies used, histological grade (based on the grading system of the Fédération Nationale des Centres de Lutte Contre Le Cancer), tumor-node-metastasis stage (using the American Joint Committee on Cancer staging system), recurrences rates, state of metastases, and the current condition of each patient. RESULTS: No local recurrences or distant metastases were seen in eight patients with low-grade and early-stage disease, whereas two patients with high-grade and advanced-stage disease had recurrence and one of these two patients died of the disease. CONCLUSIONS: This study indicates that evaluations using the Fédération Nationale des Centres de Lutte Contre Le Cancer grading system and the American Joint Committee on Cancer tumor staging system were useful. The authors advocate that surgical treatment of low-grade cutaneous leiomyosarcoma by complete excision with a narrow margin is adequate. For low-grade and early-state subcutaneous or soft-tissue leiomyosarcoma, wide excision with a minimum 2-cm lateral margin and one-tissue barrier deep margin is recommended. Management of high-grade leiomyosarcomas is still difficult; adequate wide excision may be the only option.

Arterial blood flow changes after free tissue transfer in head and neck reconstruction.

BACKGROUND: The authors measured pedicle arterial flow volume output using color Doppler ultrasonography in 23 patients after free tissue transfer in head and neck reconstruction. METHODS: Transferred flaps included six free jejunums, eight free radial forearm flaps, and four anterolateral thigh flaps. Flow volume output could be measured on all patients and was selectively measured in 17 patients with color Doppler ultrasonography on days 1, 4, 7, 14, 21, and 28 after surgery. The authors compared output change in different periods. In addition, they compared flow volume output on the first postoperative day in the different flaps and in the different recipient arteries and veins, and the effectiveness of irradiation in the different patients. RESULTS: Three of the 17 patients developed venous thrombosis. Flow volume output on the skin flaps increased gradually from day 1 to 7 after surgery and decreased gradually until day 28 in 14 patients without venous thrombosis. The free jejunum had more pedicle arterial blood flow than the skin flaps and it showed minimal flow volume output change. There were no significant differences among different recipient vessels or different skin flaps, or in the effectiveness of irradiation in the different patients. Three patients who developed venous thrombosis were salvaged by reanastomoses of the thrombosed vein. CONCLUSIONS: Before reanastomosis, abnormal arterial waveform, decreasing flow volume output, and a lack of venous blood flow were observed in the patients who developed venous thrombosis. After reanastomoses, the output was significantly improved and the flaps survived completely in all three cases. The authors conclude that color Doppler ultrasonography is useful for detecting venous thromboses too.

Mutational analysis of the TCOF1 gene in 11 Japanese patients with Treacher Collins Syndrome and mechanism of mutagenesis.

Treacher Collins Syndrome (TCS) (OMIM 154500) is a congenital, craniofacial disorder inherited as an autosomal dominant trait. The responsible gene for TCS, TCOF1, was mapped to 5q32-33.1 and identified in 1996. Since then, TCOF1 mutations in patients with TCS have been reported from Europe, North and South America, however, no TCS cases from an Asian country have been molecularly characterized. Here we report mutational analysis for 11 Japanese patients with TCS for the first time, and have identified TCOF1 mutations in 9 of them. The mutations detected were various, but most likely all the mutations are predicted to result in a truncated gene product, known as treacle. One mutation frequently reported was included in our cases, but no missense mutations were detected. These findings are similar to those for the previous studies for TCS in other races. We have speculated about the molecular mechanisms of the mutations in most cases. Collectively, we have defined some of the characteristic molecular features commonly observed in TCS patients, irrespective of racial difference.

Altered expressions of HOX genes in human cutaneous malignant melanoma.

HOX genes act as master genes to control morphogenesis. In human, HOX genes form 4 clusters composing 9 to 11 HOX genes (39 genes in total) on different chromosomes. We hypothesized that aberrant expression of HOX genes was associated with development and subsequent progression of melanoma and that the 39 HOX gene expression pattern determined the sites where melanoma grew. The expression levels of 39 HOX genes in 15 human cutaneous melanoma specimens and 7 nevus pigmentosus specimens were quantified by a comprehensive analysis system based on the real-time RT-PCR method. We found that the expression levels of HOXA11, A13, B9, D12 and D13 in melanoma were higher than those in nevus pigmentosus and that the expression levels of HOXA11, B2 and C13 were significantly different between pT4 melanoma and pT1 to pT3 melanoma. It was most notable that the expression levels of HOXA1, A2, C4 and B13 in melanoma with distant metastasis were higher than those in melanoma without it. On the other hand, we found no relationship between HOX genes expression patterns and the growing sites of melanoma. These results indicated that the misexpressions of some specific HOX genes were implicated in melanoma genesis and metastasis but had no linkage with melanoma sites.

Treatment of ischial pressure sores by means of sclerotherapy using absolute ethanol.

The ischial region is a common site of pressure sore. The ischial pressure sore with a large subcutaneous bursa is resistant to conservative treatment and tends to require radical surgical treatment. In this article the authors describe their experience with a simple surgical treatment on 8 ischial pressure sores in 7 patients with subcutaneous bursa by means of sclerotherapy using absolute ethanol. This method involves causing the bursa to become scarred and closing it up by sterilizing, fixing, and denaturing by the pharmacologic effect of absolute ethanol instead of surgical excision of the bursa. This alternative method has a possibility of treating pressure sores as well as other fistulous diseases in various areas.

Epigenetic silencing of E- and P-cadherin gene expression in human melanoma cell lines.

The degree of E- and P-cadherin expressions inversely correlate with the progression stage of human melanoma. In the present study, we analyzed mechanisms of down-regulation of E- and P-cadherin gene expressions in 8 human melanoma cell lines. In 5 of the 8 melanoma cell lines, E-cadherin expression was lost or markedly decreased compared to that in normal melanocytes, and 4 of the 5 melanoma cell lines lost P-cadherin expression. All of the melanoma cell lines expressed snail, which is known to encode a transcription repressor for E-cadherin, at a higher level than melanocytes whereas expression levels of the snail varied among cell lines. Transduction of snail gene into MMAc cells which expressed a high level of E-cadherin and an extremely low level of snail decreased expression of E-cadherin but not P-cadherin. In contrast, transduction of antisense-snail gene into A375M cells which expressed no E-cadherin and a high level of snail restored expression of E-cadherin but not P-cadherin. Methylation-specific PCR analysis revealed CpG methylation in the promoter region of E-cadherin of MeWo and AKI cells. Further, the treatment with a demethylating agent, 5-azacytidine led AKI and A375M cells to re-express both E- and P-cadherin. The results show E-cadherin gene is silenced by at least two distinct mechanisms (methylation and transrepression by Snail) in human melanoma cell lines whereas P-cadherin gene seems to be silenced by methylation but not by snail.

Change of weight-bearing pattern before and after plantar reconstruction with free anterolateral thigh flap.

We reconstructed a large-sized defect at the weight-bearing plantar region by a free anterolateral thigh flap successfully. This is the first case report of using the anterolateral thigh flap for reconstruction of the plantar foot. Based on the preoperative and postoperative pedogram examinations, the pressure distribution on the weight-bearing area reconstructed by the transferred flap was obviously improved and demonstrated a nearly normal pattern. No previous report has compared the weight-bearing pattern before and after large plantar reconstruction with a free flap. The anterolateral thigh free flap, which provides adequate bulk and contour of the foot, and which withstands weight pressure and shearing force and has the ability to provide recovery of sensation, is considered a good alternative in covering a large weight-bearing plantar defect.

Treacher Collins syndrome with craniosynostosis, choanal atresia, and esophageal regurgitation caused by a novel nonsense mutation in TCOF1.

Treacher Collins syndrome (TCS) is caused by mutations in TCOF1 of the nonsense, small deletion, and small insertion types, which most likely result in haploinsufficiency. We report a novel de novo nonsense mutation 2731C --> T, resulting in Arg911Stop, which truncates the protein. Our patient had the classic findings of TCS, but with documented craniosynostosis, choanal atresia, and esophageal regurgitation.

Surgical management of maxillectomy defects based on the concept of buttress reconstruction.

BACKGROUND: Few published large series have described a surgical approach to maxillary skeletal reconstruction on the basis of the extent of maxillectomy. METHODS: We have reviewed a 10-year experience with 38 consecutive maxillary reconstructions with respect to maxillectomy defects, reconstructive procedures, reconstructed buttresses, and functional and aesthetic outcomes. RESULTS: Maxillectomy defects were classified into three categories on the basis of the buttress concept. Buttress reconstruction was most frequently performed in category III maxillary defects (56%), followed by category I (50%) and category II (20%). The vascularized composite autograft included the rectus abdominis myocutaneous free flap combined with costal cartilage, and the latissimus dorsi myocutaneous free flap combined with the V-shaped scapula is an effective method for reliable reconstruction of both skeletal and soft tissues. CONCLUSIONS: A critical assessment for skeletal defects and associated soft tissue defects is essential for an adequate approach to solve complex problems in maxillary reconstruction. On the basis of retrospective analysis of this series, a reconstructive algorithm for surgical management of maxillectomy defects is proposed.

VACTERL association with a cleft hand.

Regarding radial ray deficiency, several reports suggest that preaxial limb anomalies occur frequently, while postaxial limb anomalies and cleft hand (split-hands) are rarely associated with VACTERL. We describe a rare clinical case of VACTERL with cleft hand and a number of visceral anomalies.

Keratinocytes promote proliferation and inhibit apoptosis of the underlying fibroblasts: an important role in the pathogenesis of keloid.

Interactions between epidermal keratinocytes and dermal fibroblasts play an important role in regulating tissue homeostasis and repair. Nevertheless, little is known about the role of keratinocytes in the pathogenesis of keloid. In this study, we investigated the influence of normal skin- and keloid-derived keratinocytes on normal skin- and keloid-derived fibroblasts utilizing a serum-free indirect coculture system. The keloid-derived fibroblasts showed a greater proliferation and minimal apoptosis when cocultured with normal skin- or keloid-derived keratinocytes, and the results were most significant in the latter. This difference was not observed when the fibroblasts were treated with conditioned medium obtained from normal skin- and keloid-derived keratinocytes. Nevertheless, conditioned medium-treated groups showed more proliferation and less apoptosis compared to the nonconditioned medium-treated control groups. We also analyzed the profile of factors involved in cell growth and apoptosis in fibroblasts cocultured with keratinocytes. Extracellular signal-regulated kinase and c-Jun N-terminal kinase phosphorylations and expression of Bcl-2 and transforming growth factor-beta1 were all significantly upregulated in the fibroblasts cocultured with keloid-derived keratinocytes. Together, these results strongly suggest that the overlying keratinocytes of the keloid lesion play an important role in keloidogenesis by promoting more proliferation and less apoptosis in the underlying fibroblasts through paracrine and double paracrine effects.

Use of the "supercharge" technique in esophageal and pharyngeal reconstruction to augment microvascular blood flow.

BACKGROUND: Although gastric tubes are commonly used in thoracic esophageal reconstruction, sometimes circumstances are such that an alternative method must be found. On these occasions, pedicled jejunum transfer and colonic interposition are used. After reconstruction, partial necrosis can occur because of poor blood flow in the oral end of the segment used to restore esophageal continuity. To improve this blood flow, we created a technique-the "supercharge" technique-in which we perform additional microvascular blood flow augmentation. METHODS: The supercharge technique was performed in 82 esophageal reconstructions with microvascular blood flow augmentation. Reconstructive methods included a gastric tube in 5 patients, a gastric tube combined with a free jejunal graft in 2, an elongated gastric tube in 6, a pedicled colonic interposition in 26, and a pedicled jejunum in 43. Recipient vessels were located in the neck or chest regions. RESULTS: After microvascular blood flow augmentation, the color and blood flow of the transferred intestine appeared greatly improved. During the operation, thrombosis was noticed in 3 patients and successfully salvaged by reanastomosis. Partial graft necrosis of the oral end of the segment occurred in only 2 patients; 2 patients had anastomotic leakage. CONCLUSIONS: The risk of leakage and partial necrosis of the transferred gut conduit appear to be reduced by using the supercharge technique to augment microvascular blood flow. This reliable technique contributes to the successful reconstruction of esophageal defects.

[Science in taking medicine].

It is a well-known fact that medicine plays an important role in treatment of several diseases. New development of many drugs led to not only benefits but also unexpected damage to human beings. In Japan, we are plunged into an aging society we have never experienced. We have far more opportunities to take medicine. Under these circumstances, it is very important for each one of us to learn how more reliable to take medicine to prevent unexpected side effects. In this citizen joint symposium, we focused on how to take medicine more logically and effectively from the viewpoint of patients. Participation in this symposium could hopefully help promoting our health care in Hokkaido.

Alternative approach using the combined technique of nerve crossover and cross-nerve grafting for reanimation of facial palsy.

An alternative approach, using a combination of nerve crossover and cross-nerve grafting technique in a single-stage procedure, was developed for the reconstruction of reversible facial palsy. This combined technique provides some benefits such as early facial reanimation resulting from the single-stage procedure, less morbidity and sufficient innervation with an application of the end-to-side anastomosis method, and efficient neural regeneration due to coaptation of the intratemporal facial nerve. Facial nerve rehabilitation, based on double innervation by hypoglossal and contralateral healthy facial nerves, takes advantage of reliable and physiological facial reanimation.

Middle colic artery-gastroepiploic artery bypass for compromised collateral flow in distal pancreatectomy with celiac artery resection.

BACKGROUND/AIMS: Radical distal pancreatectomy with en-bloc resection of the common hepatic, celiac, and left gastric arteries for pancreatic body cancer that involves these arteries does not routinely require arterial reconstruction because the collateral pathways via the pancreatoduodenal arcades from the superior mesenteric artery are recruited immediately. However, accidental injury to the pancreatoduodenal artery compromises collateral blood flow and may lead to fatal complications. This article describes the middle colic artery-gastroepiploic artery bypass as an emergent salvage procedure for restoring collateral flow. METHODOLOGY: The inferior pancreatoduodenal artery was accidentally injured in 2 of 9 patients who underwent the radical procedure between 1997 and 2001. Microvascular anastomosis between the left branch of the middle colic artery and the gastroepiploic artery in an end-to-side fashion was employed. RESULTS: The pulsation of the gastroepiploic artery and the color of the stomach recovered immediately after completion of the middle colic artery-gastroepiploic artery bypass. No ischemia-related complication developed postoperatively. Postoperative angiography showed the middle colic artery-gastroepiploic artery bypass supplying arterial flow to the liver, stomach, duodenum, and pancreas. CONCLUSIONS: The middle colic artery-gastroepiploic artery bypass is an excellent alternative restoring compromised collateral flow via the pancreatoduodenal arcades when microsurgical technique is available.