Cytologic differential diagnosis among reactive mesothelial cells, malignant mesothelioma, and adenocarcinoma: utility of combined E-cadherin and calretinin immunostaining.

BACKGROUND: The differential diagnosis between reactive mesothelial cells (RMs), malignant mesotheliomas (MMs), and adenocarcinomas (ACs) is often difficult in cytologic specimens, and the utility of various immunohistochemical markers have been explored. Because recent immunohistologic studies have suggested that E-cadherin (E-cad) and calretinin (Cal) may be useful markers for epithelial and mesothelial differentiations, respectively, the authors investigated their utility in cytologic diagnosis. METHODS: In this retrospective study, immunostaining was performed on smears retrieved from Papanicolaou-stained slides of effusions using the labeled streptavidin-biotin method. Sixteen cases of RM, 9 cases of MM, and 52 cases of AC from various sites, including 13 pulmonary primaries, were examined with primary antibodies against E-cad and Cal. RESULTS: The positive rates for E-cad and Cal, respectively, were as follows: RM, 0/16 (0%) and 16/16 (100%); MM, 9/9 (100%) and 8/8 (100%); and AC, 45/52 (86.5%) and 0/51 (0%). The E-cad expression by neoplastic cells was strongest in the intercellular junctions, and poorly differentiated neoplastic cells in the single cell form showed the weakest expression. CONCLUSIONS: In contrast to the results of previous immunohistochemical studies, the current study indicates that MMs constantly express E-cad, whereas RMs lack its expression in cytologic specimens, which would be useful in the differential diagnosis between the two. On the other hand, E-cad expression is not reliable for distinguishing AC from MM. The Cal expression can be a very useful marker for the distinction between AC and the mesothelial lineage. The combined immunostaining for E-cad and Cal has utility in differential diagnosis among RM, MM, and AC.

[The molecular epidemiological analysis of Shigella sonnei isolates from outbreak cases in Yokohama].

We conducted a molecular epidemiological analysis to evaluate the epidemiologic patterns of Shigella sonnei isolates from outbreak cases in Yokohama to clarify the epidemiologic linkages by contact tracing and sources of infection. In the first case (case A), all of the 6 isolates were the colicin 0 type and resistant to both streptomycin (SM) and trimethoprim/sulfamethoxazole (ST). The 5 isolates have plasmid of 230 kb. By RAPD analysis with 2 kinds of primers specific for Shigella, every 6 isolates showed the same pattern. But the DNA fingerprint analysis by PFGE that was performed according to 2 standardized restriction endonucleases revealed a discriminative pattern. However, the resemblance of all isolates, which was calculated by the UPGMA methods, was 0.90 or higher. In the second case (case B), all of the 14 isolates were the colicin 6 type and sensitive to 16 drugs. The serotype of 13 isolates was phase I. The 11 isolates have plasmids of 230 kb and 3 kb. The resemblance of all isolates, which was calculated by the UPGMA methods, was 0.89 or higher. The analysis with a combination of the plasmid, RAPD analysis and PFGE profiles may be effective in investigating detailed epidemiological features of isolates.

Long-term angiographic prognosis of lesions dilated by coronary angioplasty.

BACKGROUND: To examine the long-term outcome of coronary angioplasty, lesions that remained patent after 3 to 12 months were monitored angiographically at 3-year intervals. There were 252 lesions successfully dilated (from 83% +/- 13% preprocedural stenosis to 19% +/- 14% residual stenosis) between 1983 and 1986 that remained patent on follow-up angiography (23% +/- 15% stenosis) and were monitored further at our outpatient department. METHODS AND RESULTS: Repeat angiography was done for 186 lesions at 2 to 4 years and showed that 179 were patent (0% to 50% stenosis), one had mild stenosis (55% to 70% stenosis), and six had severe stenosis (75% to 100% stenosis). Angiography was repeated for 138 lesions at 5 to 7 years, showing that 127 were patent, four had mild stenosis, and seven had severe stenosis. Finally, angiography was performed for 78 lesions at 8 to 10 years, showing that 63 were patent, four had mild stenosis, and 11 had severe stenosis. CONCLUSIONS: Although numerous lesions were lost to follow-up, most appeared to remain patent for 4 years, after which a significant number developed restenosis.

Hypertrophic cardiomyopathy complicated with acute myocardial infarction due to coronary embolism.

We report a case of acute myocardial infarction due to coronary embolism in a patient with echocardiographically documented hypertrophic cardiomyopathy. Emergency coronary arteriography revealed embolic occlusion of the proximal left circumflex coronary artery and the first diagonal branch. Intracoronary thrombolysis with urokinase and subsequent balloon angioplasty was successful. Transesophageal echocardiography revealed thrombus in the left atrial appendage. Coronary arteriography performed on the 46th hospital day revealed a patent left circumflex coronary artery and diagonal branch. The patient was discharged uneventfully.

Magnum Meier wires with Crag Fx wire catheter for total occlusive coronary arteries.

Magnum Meier wire was used with Crag Fx wire catheter instead of Magnum balloon catheter to facilitate wire crossing through total occlusion by improving flexibility of the system without losing wire pushability. Of 372 coronary angioplasty procedures performed between January 1994 and April 1995, there were 12 subacute occlusions with an interval of 3 wk or less and 30 chronic occlusions with an interval of > 3 wk. Regular over-the-wire-type balloon catheters failed to dilate four subacute occlusions and nine chronic total occlusions. Magnum Meier wire with Crag Fx wire catheter was tried for one subacute occlusion and four chronic occlusions that were undilatable with a regular balloon system and successfully dilated the subacute occlusion and three of the chronic occlusions. The lesions successfully dilated by this new approach were either long or tandem lesions in vessels that were excessively tortuous or showed an acute angle at the orifice. Thus the Magnum Meier wire with Crag Fx wire catheter can be a useful tool for dilating totally occluded lesions in tortuous coronary arteries.

Repeat coronary angioplasty as the treatment of choice for restenosis.

A prospective study was performed to determine whether multiple repeat coronary angioplasty can achieve final lesion patency after restenosis. Between 1983 and 1992, 1455 lesions (excluding acute myocardial infarction or total occlusion) were successfully dilated for the first time. Only 941 (68%) of the 1385 lesions followed up showed improved coronary flow (< or = 70% stenosis) after the first procedure. However, 1248 (93%) of 1345 lesions showed improved coronary flow after angioplasty had been repeated as many as three times, and 1268 (94%) of 1345 did so after as many as six procedures. Only 23 (1.6%) lesions required four or more procedures, and 20 of them showed final patency. These findings indicate that repeat angioplasty can be used as a reasonable treatment strategy for restenosis.

Tricuspid valve endocarditis with large vegetations in a non-drug addict without underlying cardiac disease.

We report a case of gamma-streptococcal tricuspid valve endocarditis in a patient with no history of intravenous drug abuse. Echocardiography revealed large vegetations on the anterior and septal cusps. The patient had persistent fever and recurrent septic pulmonary embolism despite prolonged antibiotic therapy. However tricuspid valve replacement was successful.

Long-term angiographic follow-up of lesions patent 6 months after percutaneous coronary angioplasty.

To determine long-term angiographic prognosis after successful angioplasty (< 50% residual stenosis, > or = 20% reduction of stenosis, and no major complications), coronary angiography was performed 2 to 4 years after angioplasty in patients who were < or = 70 years old at the time of treatment and who showed patency (< or = 50% stenosis) 6 months after the initial procedure. Among 407 lesions that were dilated in 333 patients between 1983 and 1989, 298 (73.2%) lesions were reviewed by long-term angiography after 177 +/- 34 weeks. At long-term follow-up, 4 (1.3%) lesions were totally occluded, 3 (1.0%) had severe stenosis (> or = 75% stenosis), 9 (3.0%) had mild stenosis (> 50% to < 75% stenosis), and 282 (94.6%) were patent (< or = 50% stenosis). The percentage of stenosis of patent lesions decreased from 24% +/- 14% at 6 months to 21% +/- 13% at long-term follow-up (p < 0.0001). No specific clinical or angiographic characteristics were identified in patients with severe stenosis at long-term follow-up. These findings indicate that when patency is obtained 6 months after angioplasty, a 95% long-term patency rate with regression of stenosis can be expected.

Double perfusion system for coronary angioplasty at the origin of the main vessel.

For the treatment of stenosis near the origin of either the left anterior descending artery or the left circumflex artery, one autoperfusion catheter was used to dilate the lesion while another was used to maintain perfusion of the nonstenosed vessel, which would normally suffer from a decrease in blood flow. This technique was applied to nine procedures in six patients. The balloon could be inflated for more than 60 sec in all cases. Satisfactory dilation was achieved without a significant decrease of systemic blood pressure during the procedure.

Percutaneous transluminal coronary angioplasty for acute myocardial infarction.

Between 1986 and 1991, direct coronary angioplasty was attempted in 79 patients. The procedure was successful in 76 patients (96%), unsuccessful without complications in 2 patients, and major complications occurred in 1 patient (ventricular fibrillation and cardiogenic shock). Reperfusion was obtained from 1 to 7.5 hours (mean: 3.3 +/- 1.3 hours) after the onset of chest pain. Among the 76 successfully dilated patients, there was one cardiac death and 68 had predischarge angiography (64 patent, 2 stenosed, and 2 occluded). Although only 33 of the 58 patients (57%) angiographically followed after discharge showed persistence of primary patency, 52 of the 57 (91%) followed further obtained final patency when angioplasty was repeated up to 4 times. These results indicate that direct angioplasty in the community hospital setting can achieve a high primary success rate and a low reocclusion rate.

[Ticlopidine may prevent subtotal or total occlusion of dilated lesions after percutaneous coronary angioplasty].

The efficacy of ticlopidine and probucol plus oryzanol for reducing restenosis after dilation was examined in 151 patients with 229 stenotic lesions treated by coronary angioplasty after complete resolution of associated acute myocardial infarction, unstable angina, and variant angina. The stenotic lesions were 90% or less in diameter and less than 10 mm in length, and residual stenosis was 40% or less after treatment. Patients were randomly assigned to receive no medication, ticlopidine (200 mg daily) and/or probucol (1,000 mg daily) plus oryzanol (300 mg daily). One hundred forty-six patients with 220 dilated lesions were examined angiographically to evaluate restenosis. The medications achieved no clear reduction in restenosis, but subtotal or total reocclusion occurred in 6 of 102 patients not receiving ticlopidine, and in none of 118 patients receiving ticlopidine (p < 0.008). Ticlopidine may prevent subtotal or total reocclusion in dilated lesions.

[Clinical efficacy of coronary angioplasty for totally occluded lesions in recent transmural myocardial infarction].

Percutaneous coronary angioplasty was used to treat the occlusive lesions responsible for prior myocardial infarction occurring 1-8 weeks previously. Angioplasty was successful in 31 of 33 patients' lesions. Follow-up angiography showed dilated lesions were patent (0-50% diameter stenosis) in 10 patients, mildly stenosed (51-74%) in 3, severely stenosed (75-90%) in 10, subtotally occluded in 2, totally occluded in 5 and one was lost to follow-up. By repeating angioplasty up to two times, the lesions became patent in 23 patients, mildly stenosed in one, totally occluded in 4, and 3 were lost to follow-up. Measuring the left ventricular function in 22 patients with patent lesions and one with mildly stenosed lesion showed the left ventricular ejection fraction was improved from 60 +/- 13.1 to 69 +/- 11.6% (p < 0.00005), and hypokinetic areas (from 18 +/- 15.1% of left ventricular wall to 11 +/- 9.9%, p < 0.05) and an akinetic area (from 11 +/- 12.5% to 4 +/- 7.3%, p < 0.002) were decreased. The findings indicate that angioplasty for totally occluded lesions within 12 weeks of infarction achieves satisfactory lesion patency and functional recovery of the infarcted myocardium.

Coronary angiography using 4-French preformed catheters--percutaneous brachial approach.

4-French performed catheter systems were developed for coronary angiography. After several new technical features were introduced, these catheters were applied in 384 outpatients between January 1989 and December 1989. Diagnostic coronary angiography was performed in all cases without major complications. In the left coronary artery, 4.0 cm left Judkins catheters were generally used; however, 3.5 cm left Judkins catheters were used if the patient was < or = 164 cm tall and left Amplatz catheters were employed for those > or = 165 cm tall. Although 4.0 cm right Judkins catheters were mainly used for right coronary arteries, there were no predictive factors for subsequent catheter selection. This technique is believed to be suited to meet the increasing demand for coronary angiography.

Overall clinical effect of percutaneous coronary angioplasty: a critical analysis by follow-up and long-term angiography.

In order to determine the clinical efficacy of coronary angioplasty, the outcome was analyzed in 557 patients who underwent initial angioplasty prior to the end of 1987. Primary success (reduction of stenosis greater than or equal to 20% and residual stenosis less than 50%) was achieved in 492 (88.3%) of the patients. Follow-up angiography showed patency (stenosis less than or equal to 50%) in 295 or 60.0% of the 471 patients and ultimate lesion patency was achieved by repeating angioplasty up to 4 times in 425 (91.4%) of 465 patients followed angiographically. At the 3-year angiography performed in 209 patients with patent lesions, only 2 patients exhibited progression of their disease at dilated sites, while 48 had new lesions. Taking into consideration the 55 patients with unsuccessful primary angioplasty, 10 patients with major complications and 9 patients with mild restenosis, 434 out of 530, or 81.9% of the patients appear to have benefited from angioplasty.

[Effect of denopamine on residual left ventricular dysfunction after complete revascularization].

Denopamine (15 mg/day) was administered to 20 patients with residual left ventricular dysfunction after successful percutaneous transluminal coronary angioplasty (75% or more diameter stenosis). Echocardiography was performed before and 6 months after denopamine administration to analyze the left ventricular function. There were significant decreases in both end-diastolic and end-systolic dimensions from 58 +/- 8.3 to 54 +/- 8.4 mm (p = 0.001), and from 44 +/- 10.1 to 40 +/- 10.3 mm (p = 0.005)), respectively, while % fractional shortening remained nearly constant (from 25 +/- 8.3 to 27 +/- 9.6%). Thus, denopamine improved the left ventricular function by decreasing left ventricular size while maintaining wall contractility.

Left ventricular function during transient coronary occlusion: digital subtraction left ventriculograms during coronary angioplasty.

The impact of transient myocardial ischemia on left ventricular function was examined by digital subtraction left ventricular angiography. Contrast medium was injected into the right pulmonary artery before, at 60 seconds of balloon inflation, and 10 minutes after balloon deflation. A total of 69 patients completed the study. In 52 patients, the left anterior descending artery (LAD) was involved, and in 17, the right coronary artery (RCA) was the focus. Ejection fraction (EF) declined by balloon inflation and returned to baseline value after deflation of the balloon. There was tendency toward a lower EF and wider akinetic area for LAD dilatation. The linear correlation between resting EF and EF during balloon inflation suggested that the effect of momentary coronary occlusion on left ventricular function appears to be additive to pre-existing left ventricular dysfunction, and resting ejection fraction is an important parameter for estimating the degree of diminished left ventricular function during myocardial ischemia.

[Long-term prognosis of coronary angioplasty: angiographic follow-up after three years].

Long-term angiographic follow-up was performed 3 years after percutaneous transluminal coronary angioplasty (PTCA) between 1983 and 1986. Among 294 arteries with initially successful dilatation, in which diameter was reduced by more than 20% and residual stenosis was less than 50%, 192 lesions were angiographically patent (50% or less stenosis) in the 6 month follow-up. Three years later, angiography was again performed for 81 lesions. There was no difference between these 81 cases with angiography and the remaining 111 cases in other clinical manifestations except for a higher frequency of diabetes mellitus observed in the angiography group (33% vs 19%). Progressive deterioration of the disease (more than 50% diameter stenosis) was noted in 5 cases, all of which already had relatively severe stenosis (40% or more) in the 6 month follow-up. It was concluded that dilated coronary artery lesions by PTCA can be expected to have good long-term prognosis once they are proven to be patent in the 6 month follow-up angiography.

Restenosis after percutaneous transluminal coronary angioplasty--a histopathological study using autopsied hearts.

Restenosis was studied histopathologically by serial step sectioning of 22 coronary arteries from 21 patients in whom percutaneous transluminal coronary angioplasty (PTCA) had been performed (9 arteries from patients who had died shortly after PTCA and 13 from those who had died considerably later). Nine of the 13 arteries from the patients who had died long after PTCA were immunohistochemically stained using anti-actin antibody for examination of spindle-shaped cells proliferating in the intima. In the patients who had died shortly after PTCA, all 9 arteries showed fresh thrombus formation. In the patients who had died considerably later after PTCA, however, there was fragmentation of the internal elastic lamina (IEL) in 9 arteries. In each of these 9 arteries, a remarkable proliferation of intimal cells was observed on the intimal side, mainly at the site of the IEL fragmentation. These spindle-shaped cells were identified as smooth muscle cells (SMC) because they stained reddish-brown with Masson's trichrome, and because immunohistochemical staining with anti-actin antibody was also positive. In 2 arteries, proliferation of SMC and elastic fibers was observed on the luminal side of the intima, despite absence of fragmentation in the IEL. Proliferation of SMC in false lumens was identified in 2 patients with medial dissection. From the above findings, the following 4 forms of restenosis after PTCA have been identified: 1. thrombus formation; 2. proliferation of SMC on the intimal side, mainly around fragmentation in the IEL; 3. proliferation of SMC on the luminal side of the intima where there was no fragmentation of the IEL; and 4. proliferation of SMC in dissected false lumen. The proliferation of SMC on the intimal side of the disrupted IEL was thought to have been a result of migration of SMC from the media to the intima, because SMC proliferation was seen around the disrupted region.

[Undesirable outcome of percutaneous transluminal coronary angioplasty including irreversible damage and re-stenosis of dilated lesions].

To clarify the prognostic implications due to the limitations of coronary angioplasty, 564 newly-dilated lesions were analyzed for the prevalence of irreversible damage (sudden deaths, myocardial infarction, re-stenotic lesions and occlusion unsuitable for or unsuccessful following repeated angioplasty) and re-stenosis after re-dilatation. Re-stenosis occurred in 170 of the 564 newly-dilated lesions, and in 36 of the 135 re-dilated lesions. After repeated angioplasty, up to three times, 449 lesions (89.9%) were eventually patent angiographically, while irreversible damage was observed in 21 lesions. Re-stenosis after re-dilatation was observed more often in variant angina and in lesions exceeding 15 mm in length. Irreversible damage occurred more often in elderly patients and in patients with lesions of the right coronary artery.