Impact of flow cytometry crossmatch B-cell positivity on living renal transplantation.

BACKGROUND: Various studies have reported poorer graft survival among individuals displaying T-cell-positive flow cytometry crossmatches (FCXM). Good outcomes have been observed in immunologically high-risk patients with the use of rituximab, plasmapheresis, and γ-globulin. Because the relevance of FCXM B-cell-positivity (BCXM (+)) alone remains controversial, we examined its impact on living donor renal transplantations. PATIENTS AND METHODS: We retrospectively studied 146 adult renal transplantation recipients from April 2007 to June 2012, dividing the patients into BCXM (+) (n = 31) versus BCXM (-) recipients (n = 115). We examined patient and graft survivals as well as rejection rates at 0 to 3, 3 to 12, and 12 to 24 months. We also determined the incidence of infectious diseases. We performed stepwise multivariate regression to identify risk factors contributing rejection episodes. RESULTS: One-year patient and graft survivals were 100% in both groups. The BCXM (-) group have a 16.8% rejection probability whereas the BCXM (+) group, 33.2% (P = .201). There were no significantly differences in the incidence of infectious diseases. Only the rate of a sensitizing history was an independent risk factor for a rejection episode. CONCLUSION: BCXM (+) showed only a tendency but not a significant impact on rejection episodes compared with BCXM (-); short-term graft survivals were similar.

Bisphenol A induces a rapid activation of Erk1/2 through GPR30 in human breast cancer cells.

Bisphenol A (BPA) has been considered as an endocrine disruptor due to its ability to interact with estrogen receptors (ERs). While G protein-coupled receptor 30 (GPR30) is a novel estrogen receptor, its role in BPA-induced activation of Erk1/2 remains unknown. Human breast cancer cell lines, MCF-7, MDA-MB-231 and SKBR3, were used as experimental models to discriminate between ERs-dependent, putative ERs-independent and/or GPR30-associated effects. BPA induced a rapid activation of Erk1/2 in both ERα/ß-positive and negative breast cancer cells, and this effect was not blocked with an ER antagonist, ICI 182,780. A small interfering RNA assay revealed that the expression of GPR30 was necessary for BPA-induced activation of Erk1/2 and transcriptional regulation of c-fos. In addition, BPA regulates the expression of c-fos likely through an AP1-mediated pathway. As a conclusion, GPR30 plays an important role in the BPA-induced activation of Erk1/2 in a manner distinguishable from that in ERα-mediated signaling.

Primary Ewing's sarcoma: peripheral primitive neuroectodermal tumour of the jugular foramen.

We describe an extremely rare example of Ewing's sarcoma (ES)/peripheral primitive neuroectodermal tumour (pPNET) originating from the jugular foramen. The patient was a 10-year-old boy who presented with progressive symptoms due to right lower cranial nerve palsies. Computed tomographic (CT) scan and magnetic resonance imaging (MRI) revealed a tumour at the right jugular foramen which showed extra-cranial extension. Open biopsy of the extra-cranial lesion was performed, and diagnosis of ES/pPNET was made by histopathological, immunohistochemical and genetic investigations. The patient received a combination of multi-drug chemotherapy and irradiation. By 12 months after the diagnosis, MRI showed complete remission of the lesion, and the patient has been well apart from slight dysphagia. Previously, there was only one report of a jugular foramen ES/pPNET and in which treatment had failed. To our best knowledge, this is the first patient treated successfully with chemoradiotherapy.

Surgical approaches for the treatment of aneurysms on the P2 segment of the posterior cerebral artery.

OBJECTIVE: The P2 segment of the posterior cerebral artery has remained a challenging region to expose surgically. We establish a surgical strategy for P2-segment aneurysms. METHODS: Each segment of the posterior cerebral artery was classified according to Zeal and Rhoton's classification. Fourteen of 18 P2-segment aneurysms were surgically treated. The patient's outcome, the aneurysm location, and the surgical procedures were evaluated. A cadaveric study was performed to clarify the surgical view obtained via three different surgical approaches. RESULTS: Nine aneurysms were clipped, two were trapped, one was coated, and one was excised with parent artery reconstruction. Cerebral revascularization techniques were used for three patients. The pterional approach exposed the anterior half of the P2a segment. The subtemporal approach revealed the P2a segment, but its exposure was restricted by its localization in the ambient cistern. Via the occipital interhemispheric transtentorial approach, the P2p segment was visible and could be manipulated. When the posterior half of P2a segment was high on a coronal view of magnetic resonance imaging, it was extremely hard to access via any approach. CONCLUSION: A surgical strategy for the P2 aneurysm can be planned with accurate prediction of the aneurysm location. When the localization of an aneurysm on the posterior half of P2a segment is high, a resection of brain tissue may be required.

Topography of the vestibulocochlear nerve.

OBJECTIVE: The terms superior vestibular nerve and inferior vestibular nerve have been used in the field of neurosurgery to indicate anatomically the two respective vestibular components of the vestibulocochlear nerve. To reappraise the aptness of this terminology, fascicular patterns and the anatomic relationship of the vestibular and cochlear components were examined. METHODS: Twenty vestibulocochlear nerve specimens were obtained from cadavers. The nerves were excised, with care taken to sustain their spatial relationships, then embedded in paraffin blocks and cross sectioned in 10-microm-thick slices. Serial cross sections were stained and examined with a light microscope. RESULTS: The vestibular component was separated into two parts only at the lateral fundus of the internal auditory canal, lateral to the vestibular ganglion. In the internal auditory canal of all specimens, the vestibular component was represented by numerous fascicles. Around the porus acusticus, the fascicular pattern among the specimens was diverse: 13 of the 20 specimens were still polyfascicular, 4 specimens consisted of two large, distinct fascicles, and, in the remaining 3 specimens, a portion of the vestibular fascicles had fused with the cochlear component. Near the root entry zone, all vestibular fascicles fused and merged with the cochlear nerve to form a single trunk. CONCLUSION: There was no evidence to support the anatomic correctness of specifying the superior and inferior vestibular nerves, except in the lateral fundus of the internal auditory canal.

[Production and clinical application of fibrin sealant with high concentrated fibrin (fibrin patch)].

OBJECT: The sealing properties of fibrin sealant with high concentrated fibrin (fibrin patch) were examined. MATERIAL AND METHODS: A commercial fibrin sealant (Bolheal) produced from pooled human plasma was utilized for this study. The fibrin sealant made of fibrinogen and thrombin solutions mixed in a volume ratio 5:1 was applied as the fibrin sealant with high concentrated fibrin (fibrin patch). The burst pressure of the fibrin clots of either 1:1 or 5:1 mixing ratio, which sealed the small holes, was measured by a water-leak preventing model. The tensile strength of the fibrin patch was measured by the breaking pressure of the fibrin clot. The burst pressure of the fibrin patch, which sealed the dural defect with a diameter of 15 mm, was compared with that of expanded polytetrafluoroethylene (ePTFE). RESULTS: The burst pressure was elevated from 287 +/- 23.1 to 445 +/- 30.5 mmHg by changing the mixing ratio from 1:1 to 5:1. The breaking pressure of the fibrin patch showed 131 +/- 25.4 mmHg and that of the patch mixed at the ratio of 1:1 showed 46.6 +/- 9.9 mmHg. The result of dural repair with the fibrin patch revealed higher sealing effectiveness than that of ePTFE. The burst pressure averaged 70.5 +/- 21.4 mmHg in the fibrin patch samples and 51.4 +/- 13 mmHg in the ePTFE samples. CONCLUSION: The fibrin patch revealed higher performance as a sealant and has the potential to be a candidate for acceptance as the new dural repair material.

Development of a handpiece and probes for a microsurgical ultrasonic aspirator: instrumentation and application.

OBJECTIVE: To address the several disadvantages of currently available ultrasonic aspirators used in microsurgery, new instruments were designed for neurosurgical use under a microscope. DESCRIPTION OF INSTRUMENTATION: The weight of the handpiece was reduced to 90 g. Two types of angled probes were constructed. Keyhole-type probes have 93- and 112-mm lengths, a 2.2-mm tip diameter, and 9.5- and 11.2-mm sheath diameters at the most proximal site and produce a tip amplitude of 300 microm (supplied by 23.5-kHz ultrasonic power). Needle-type probes have 89- and 171-mm lengths, a 1.9-mm tip diameter, and 3.5- and 3.3-mm sheath diameters at the proximal site and produce a tip amplitude of 70 microm. All of these instruments are compatible with magnetic resonance imaging. METHODS: The newly developed handpiece and probes were used in an experimental model. The 119 mass lesions treated included giant thrombosed aneurysms, various gliomas, vestibular schwannomas, deep-seated meningiomas, clival tumors, and suprasellar tumors. EXPERIENCE AND RESULTS: The handpiece and probes were safely used in regions that are difficult to access, such as the third ventricle and the cerebellopontine angle. It was possible to manipulate the needle-type probe in the suprasellar region through the transsphenoidal route, and the probe was very efficient for thrombectomy in giant aneurysms. The ultrasonic power of keyhole-type probes was sufficient to remove meningiomas. CONCLUSION: This newly developed neurosurgical handpiece with angled probes has great utility for microscopic dissections, because of its small size and light weight.

Complete response of a large brain metastasis of renal cell cancer to interferon-alpha: case report.

BACKGROUND: Interferon-alpha (IFNalpha) is a drug widely used in the treatment of metastatic renal cell cancers, especially lung lesions. Successful treatment using IFNalpha for histologically proven brain metastasis has not been reported. CASE REPORT: A large pineal tumor was found in a 51-year-old man with renal cell cancer in the left kidney. The histological diagnosis of biopsied specimens was a brain metastasis from renal cell cancer. The patient was treated with intramuscular injections of IFNalpha. The brain metastasis gradually decreased in size and disappeared completely 6 months after the initial injection of IFNalpha. The IFNalpha therapy was continued for 9 months. Fifteen months later, no recurrence was evident on brain magnetic resonance imaging. CONCLUSION: This is an extremely rare case in which the long-term use of IFNalpha induced a complete response of a brain metastasis from renal cell cancer.

Evaluation of application techniques of fibrin sealant to prevent cerebrospinal fluid leakage: a new device for the application of aerosolized fibrin glue.

OBJECTIVE: This report evaluates the sealing effects of fibrin sealant applied on the dura mater using different techniques. METHODS: Three application methods were studied: a sequential layer method, a simultaneous method using a cannula, and a spray method using a newly developed spray device. The sealing effects of these methods were compared using in vitro histological analysis and a pressure resistance test. The clinical efficacy of the fibrin sealant to prevent water leakage through the dura mater was retrospectively analyzed in a total of 509 patients. The process of absorption of a clinically applied fibrin clot in vivo was examined using surgical specimens. RESULTS: The fibrin plate made using the spray method withstood a hydrostatic pressure greater than 200 cm H2O. A scanning electron microscopic study of the fibrin clots showed that the sequential and simultaneous methods produced a fibrin fiber network; in contrast, our spray method formed a dense fibrin tissue in which the fibrin molecules fused together forming stratified laminae. Of the 295 supratentorial craniotomies during which spraying was used, postsurgical cerebrospinal fluid leakage occurred in 9 cases (3.1%), whereas of the 214 craniotomies during which spraying was not used, cerebrospinal fluid leakage occurred in 19 cases (8.9%). Histological examinations of 10 surgical specimens obtained during second craniotomies revealed that the spray-made fibrin clots had been gradually replaced by mature granulation composed of collagenous connective tissue. CONCLUSION: The optimal technique for applying fibrin sealant is the spray method that aerosolizes fibrin glue and produces a tough fibrin plate.

Extended transbasal approach: anatomy, technique, and indications.

Appropriate indications for the transbasal approach have not been clearly established. The focus of this study is to determine the feasibility of maximal exposure of the clivus and surrounding regions via this strategy. Further, we sought to determine the key anatomical landmarks and morphometric data necessary for safe, radical exposure. In 20 injected cadaveric specimens, anatomical observations were made grossly and microscopically with 4-40 x magnification. The three basic variations of the transbasal craniotomy were compared with regard to surgical exposure. Maximum exposure of the ventral clivus could be obtained by total ethmoidectomy and sphenoidectomy through the extensive transbasal craniotomy. The lateral limits of exposure were found to be the optic nerves, intracavernous carotid arteries, and hypoglossal canals. Inferiorly, the foramen magnum is the limit of exposure. Morphometric measurements were determined between the key landmarks and were found helpful in subsequent dissections due to the lack of bony structures in relation to neural and vascular structures within the bone. The keys to optimizing the transbasal approach are beyond the simple initial steps of the craniotomy. Maximal exposure from the suprasellar compartment to the foramen magnum is possible via the extended transbasal approach.

A lateral transzygomatic-transtemporal approach to the infratemporal fossa: technical note for mobilization of the second and third branches of the trigeminal nerve.

This report describes an alternative approach to the infratemporal fossa lesions through a lateral zygomato-temporal craniotemy, which modifies the extradural temporopolar technique for cavernous sinus surgery. First, an L-shaped osteotomy of the zygoma from the frontozygomatic suture attaching the zygomatre arch and low positioned temporal cramotomy are made. Through this zygomato-temporal craniotomy and orbitotemporal drilling, leaving the lateral orbital rim and orbital roof intact, skeletonization of the foramens rotundum and ovale are carried out. The key element of this infratemporal exposure is the dissection and mobilization of the trigeminal nerve, trigeminal second branch rostrally, and the third branch caudally, which facilitates a wide exposure of the infratemporal fossa with preserving trigeminal function. The corridor between the mobilized trigeminal branches provides direct access to the lateral and medial pterygoid plate, internal maxillary artery, sphenoid and maxillary sinuses, maxilla and, finally, the parapharyngeal area. Our experiences have demonstrated that this lateral transzygomatic-transtemporal exposure is satisfactory for use with infratemporal fossa tumors. This approach has an advantage for cranial-base exposure with decreased risks of cosmetic deformity and of trigeminal nerve dysfunction.

Extended Transsphenoidal Approach with Sigma-shape Osteotomy of the Maxilla: Technical Note.

The traditional sublabial transsphenoidal approach offers a limited operative field. This report describes a simple surgical technique to widen the sublabial transsphenoidal window to access the midline lesions from the planum sphenoidale to the lower clivus. This technique was developed on the basis of clinical experience and on data obtained by cadaveric dissection study. Following a sublabial incision and separation of the bilateral septal mucosa, a small Sigma-shape osteotomy of the maxilla, including the anterior nasal spine, was performed with a surgical saw. The width of the entrance to the nasal cavity ranged from 32 to 38 mm. Although the plexus of the anterior superior alveolar nerve was partially cut, our clinical experience revealed no significant sensory loss of the incisors after the Sigma-shape osteotomy. The nasal orests of the maxilla and palatine bone were drilled out, and the roof of the nasopharynx was then incised to expose the lower clival bone. Although extradural sellar or clival lesions were the focus of this approach, the intradural anatomical structures examined by cadaveric study were presented. The extended transsphenoidal approach with Sigma-shape osteotomy of the maxilla is a simple technique and provides widened access to the sellar and clival regions.

Prolonged survival in a patient with sinonasal teratocarcinosarcoma with cranial extension. Case report.

Sinonasal teratocarcinosarcoma is a rare malignant neoplasm characterized by the combined histological features of carcinosarcoma and teratoma. The primary symptoms of this tumor are usually nasal obstruction and epistaxis, and a nasal cavity mass is the most common clinical finding. The authors describe an exceptionally rare case in which the patient presented with massive intracranial extension and exhibited confusion as an initial symptom. He subsequently underwent combined radical surgery and radiation therapy and has remained free of disease for 31 months. The surgical approach to the lesion, histological features, and clinical course are detailed.

Surgical removal of a cavernous sinus chondroma.

BACKGROUND: Chondromas at the base of the skull are most commonly found in the parasellar and sellar regions, and present varying degrees of involvement of the cavernous sinus. However, those confined mainly to the cavernous sinus are rare, and only a few reports show detailed radiological and surgical findings. MATERIALS AND METHODS: This 40-year-old woman experienced sudden right orbital pain followed by right third and sixth cranial nerve palsies. Computerized tomography scan and magnetic resonance image depicted a well-circumscribed mass in the right cavernous sinus. A frontotemporal craniotomy with orbito-zygomatic osteotomy was used to approach this lesion intradurally. We drilled away the anterior clinoid process using a high-speed air drill extradurally, exposed the intrapetrous carotid artery, and dissected the right sylvian fissure from the distal, fully exposing the surface of the right cavernous sinus. The soft and grayish tumor was easily removed using sucker and tumor forceps; the venous bleeding from the sinus itself was easily controlled. RESULTS: The tumor was successfully removed via a superior triangle. Intradural invasion of the tumor and heavy venous bleeding from the sinus were not observed. Histologically, the mass was diagnosed as a mature chondroma. The tumor was presumed to originate from the right posterior clinoid process. The lesion was totally removed, and postoperative right ophthalmoplegia had fully disappeared within 6 months after surgery. CONCLUSION: Successful surgical attack of lesions in the cavernous sinus requires comprehensive and precise knowledge of the microsurgical anatomy and neuroradiology.

Revascularization of the anterior cerebral artery using a free superficial temporal artery graft: a case report.

BACKGROUND: Various bypass procedures have been used to treat occlusive cerebrovascular diseases. Most procedures were performed to prevent further ischemia in the territory of the middle cerebral artery, while only a few of the papers discuss the anterior cerebral artery (ACA) territory. METHOD AND RESULTS: A patient who initially presented with several episodes of transient monoparesis in the left leg was found to have severe stenosis of the right A2-A3 junction. A free superficial temporal artery (STA) graft was anastomosed between the right A2 and A3 portion intracranially. Transient ischemic attacks immediately disappeared after surgery and subsequent cerebral angiography revealed good anterograde filling from the A2 to A3 portion via the free STA graft. CONCLUSION: Revascularization using a free STA graft is useful for reconstruction of a local stenotic lesion, especially in the ACA territory.

Osteoregenerative lateral suboccipital craniectomy using fibrin glue.

This report describes a simple technique of cranioplasty for suboccipital craniectomy and the results of a clinical study to assess the effects of fibrin glue on regeneration of the skull. Cranioplasty using a mixture of autologous bone chips and human allogenic fibrin glue was performed in 31 patients who received lateral suboccipital craniectomy. Long-term observations with three-dimensional CT showed satisfactory reconstruction of the mastoid-occipital bone plate in 25 patients (81%); among them, a nearly complete reconstruction of the occipital bone (plate) was found in 14 patients. Regeneration of the bone began 6 months after surgery on the inner surface, adjacent to the dura mater. In conclusion, the present technique provides a new simple method to restore an autologous bone plate in a cranial defect made by piecemeal craniectomy.

[Sealing effect of fibrin glue spray on protection of cerebrospinal fluid leakage through the dura mata].

Fibrin glue, a biologic adhesive, is made with highly concentrated human fibrinogen and clotting factors. It has become used frequently in neurosurgical procedures, in particular in the closure of the dura mata to prevent cerebrospinal fluid leakage. This report evaluates sealing effects of the fibrin glue on cerebrospinal fluid leakage through the dura. (1) Three manipulations for application of fibrin glue were used; i.e., layer, mixture and spray methods. These methods were compared to estimate their sealing effects on water leakage through a 1.2mm pore in an artificial dura. The burst pressure was significantly higher when the spray method was used than when the other two methods were used. (2) Dural incision was made and then sutured at intervals of 2mm, 3mm, 4mm, 6mm, and 8mm. Fibrin glue was applied by a spray method on the sutured dura. The burst pressure of the fibrin plate was over 80cmH2O on every interval of dural suture. (3) Dural defects 2mm, 4mm, 6mm, and 8mm in diameter were made, and then spray of fibrin glue was used to shield the defects. The fibrin clot spreading to the inner and outer surfaces of the pore defect was plug-shaped. The fibrin plug tolerated water pressure over 200cmH2O, in every size of pore. In conclusion, the optimal method for using fibrin glue on the surface of the dura was a spray method. Fibrin plate/clot made by the spray method sealed the dural tear or pore so well that it sustained a water pressure of over 80cmH2O, which is far higher than normal pressure of the intracranial cerebrospinal fluid.

Vacuolated meningioma with secretory features: a case report.

We report a case of meningioma with secretory features in a 47-year-old woman. The left frontal tumor mass had already eroded the overlying bone at the time of presentation. When respected, the mass showed a gelatinous appearance. Histologically, marked vacuolar change was seen in the stroma. Whorls, psammoma bodies, and pavement arrangement of nuclei were also noted. Periodic acid-Schiff stain revealed cytoplasmic granules, which were digested with diastase. Alcian blue diffusely stained the cytoplasm of the tumor cells. Electron microscopy showed numerous small vacuoles and cored vesicles in the cytoplasm. Glycogen granules were poorly observed. These features indicate the mild secretory nature of this vacuolated meningioma.

[Clinical effects of NK 631, a new bleomycin derivative, in treatment of oral cancer (author's transl)].

We used only NK 631, a new bleomycin derivative, for 10 cases of primary oral cancer, and obtained following results. (1) Anti-cancer effects were immediate and as follow: remarkably good in 1 case, efficacious in 8 cases, and none in 1 case. (2) In clinical examination, peripheral blood, function of kidney, liver, etc. were normal. But attention must be payed to blood gas. (3) Loss of hair, stomatitis and exanthema were noticed as side effects more clearly than regular bleomycin, but no fever. As the result of the above, NK 631 is better than regular bleomycin in anti-cancer effect and activity, but more attention should be payed to the side effect.