We report a 64-year-old woman who developed nausea, headache, and consciousness disturbance. She was well until four years before the onset of her neurologic illness when (April of 1990 at her 59 years of the age) she was found to have an early cancer in her anterior wall of the lower stomach. Subtotal gastrectomy was performed and the operative result was reported as curative. Four years after the surgery (December of 1994 at her 64 years of the age), she noted suboccipital headache and nausea which had become progressively worse and she was admitted to our service on May 24, 1995. On admission, she appeared chronically ill but general physical examination was unremarkable with normal vital signs. Neurologically she was alert and not demented, and the higher cerebral functions were intact. Cranial nerves were also unremarkable. She was able to walk in tandem and on heels. No motor weakness or ataxia was noted. Deep tendon reflexes were moderately increased, however, no Babinski sign was noted. Although she had headache, no meningeal signs were seen. Slight superficial and vibratory sensory loss was noted in both feet. Routine blood work was again unremarkable except for slight increase in CEA to 8.3 ng/dl (N < 5 ng/dl). The opening pressure of lumbar CSF was 180 mm H2O and the CSF contained 39 cells/microliter, 79 mg of protein, and 10 mg/dl of glucose. Approximately half of the cells were atypical malignant cells. Plain CT was unremarkable, however, tentorial border showed enhancement after contrast infusion. FGS showed no malignant tumors in the stomach. She was treated with intravenous glycerol and whole brain radiation, however, she continued to complain of severe headache, and her sensorium started to be disturbed one month after the admission. Follow-up cranial CT scan revealed enlargement of the lateral and the third ventricles. Her consciousness progressively deteriorated and she became comatose three months after the admission. Repeated cranial CT scan showed enlargement of the ventricles, but no mass lesions were seen within the brain. She developed respiratory arrest on September 25 of the same year. She was discussed in a neurological CPC and the chief discussant arrived at the conclusion that the patient had a gastric cancer with meningeal seeding developing meningeal carcinomatosis. The cause of deep coma was ascribed to damage of cerebral cortical areas secondary to metastatic carcinoma cells and fibrinous materials in the surface of the brain. Postmortem examination revealed thickening and clouding of leptomeninges of the cerebral convexity. On histologic observation, patchy areas of fibrous thickening were seen in the cerebral leptomeninges; in such areas, adenocarcinomatous cells were seen scattered. The basal meninges were free of carcinoma cells, however, leptomeninges of the cerebellum and brain stem tegmentum contained scattered carcinoma cells. The lateral and the third ventricles were enlarged, however, insides of the brain were free of pathologies; the ependymal layer were intact. In the stomach no carcinoma cells were remaining. Pneumonic changes were seen in the right upper and the left lower lobes which appeared to be the direct cause of her death. No evidence of tentorial herniation was noted. The cause of her deep coma was not clearly determined, however, combination of hydrocephalus and cortical malfunction due to leptomeningeal carcinoma cell infiltration and fibrinous material accumulation appeared to have played a role.

We report a 29-year-old man with diabetes insipidus and cerebellar ataxia who developed spinal cord swelling 15 years after the onset. He was well until 14 years of the age when he noted dizziness. Two years after there was an onset of gait disturbance and slurred speech. He also noted polydipsia and polyuria. He was evaluated at the neurosurgery service of our hospital when he was 17 years of the age. Neurologic examination at that time revealed memory loss, horizontal nystagmus, cerebellar ataxic gait, dysmetria and decomposition more on the left. Cranial CT scan revealed a mass lesion involving the left subthalamic region and the head of the caudate area. Spinal fluid was unremarkable, however, human chorionic gonadotropin was increased to 27 mIU/ml. He was treated by radiation therapy (3,000 rads for total brain area and 5,460 rads for focal region). His CT scan and memory loss improved, however, cerebellar ataxia was unchanged. Three years after the radiation, he started to show choreic movement in his neck and left upper extremity. He was admitted to our service in August 14, 1995 when he was 29 years of the age. On admission, he was alert but disoriented to time; calculation was also poor. Higher cerebral functions were intact. The optic fundi were normal without papilledema. Visual field appeared intact. Gaze nystagmus was observed in all the directions, but more prominent in the horizontal direction. Speech was slurred. Otherwise, cranial nerves were unremarkable. Motor wise, he showed marked truncal and gait ataxia; he was unable to walk because of ataxia. Muscle atrophy and marked weakness was noted in both upper extremities more on the left side. Deep tendon reflexes were diminished in the upper extremities but active in the lower extremities. He was polyuric; urinary specific gravity was low. Spinal fluid contained 6 cells/cmm and 113 mg/ dl of protein; Queckenstedt was positive. MRI revealed swelling of the cervical cord; in addition, the entire cervical region and the medullar oblongata appeared as high signal intensity areas. No mass lesion was noted in the supratentorial structures but the third ventricle was markedly enlarged. Surgical biopsy was performed on the cervical lesion. The patient was discussed in neurologic CPC, and the chief discussant arrived at the conclusion that the patient had germinoma with syncytiotrophoblastic giant cells in the diencephalic region which appeared to have been cured by radiation therapy; he thought that the cervical lesion was the seeding of germinoma. Cerebellar ataxia was ascribed to the remote effect of germinoma. Most of the participants thought that the original tumor was germinoma and the cervical lesion was its spread. Some participants thought that his ataxia was caused by germinoma cells involving the medulla and the inferior cerebellar peduncles. Histologic observation of the biopsied tissue from the spinal cord revealed the typical two cell patterned germinoma. Most of the tumor cells were not stained for an antibody against HCG, but some tumor cells were positively stained. Germinoma is very radio-sensitive; this patient showed T2 high signal lesion involving the medulla oblongata and cervical cord continuously. Probably, tumor cells in the lower brain stem escaped radiation, and gradually spread to the spinal cord over many years. At the time of operation, the surface of the spinal cord was free from tumor cells. Therefore, tumor cells invaded the spinal cord continuously from the medulla oblongata. He was treated with cervical radiation, and his neurologic as well as radiologic findings showed marked improvement.

We report an autopsy case of atypical presenile dementia. Shibayama, Kosaka and others had reported similar autopsy cases. These cases had the following common pathologic characteristics: circumscribed cerebral atrophy, diffuse neurofibrillary tangles (NFTs) noted in the cerebral cortex with few senile plaques (SPs), and pathological calcification. We propose the term "dementia with cerebral calcification and tangles" (DCCT) for this atypical presenile dementia. Our patient, who was female and died at the age of 65 years, also exhibited these characteristics. Her clinical diagnosis was Alzheimer's disease. She had developed apparent dementia at the age of 55. Psychological and neurological symptoms such as memory impairment, speech disturbance and abnormal behavior slowly progressed. Gradually, she had become bedridden in her own home. When she was 65 years old, she was admitted because of pneumonia, and died soon after. In the pathologic examination of our patient, the brain weight was 850 g, and severe cerebral atrophy predominant in the temporal lobe was noted. Microscopically, diffuse and numerous NFTs were also found in the cerebral cortex and brain stem. Some NFTs were observed in the dentate nucleus of the cerebellum. However, SPs were seldom noted. Calcifications were also found in the putamen, globus pallidus and cerebellar cortex. NFTs in our case had developed without the formation of SPs. The degree of the NFT formation was correlated to the extent of cerebral cortical atrophy and neuron loss. Therefore, we suspect that NFTs with neuron loss strongly contribute to clinical symptoms such as dementia. The distribution of NFTs resembles that in patients with Alzheimer's disease, they are more prominent in the temporal lobe in our case. Although there has not been any discussion about the findings of glial cells and neuropils in DCCT, our detailed examination showed argyrophilic structures in glial cells and in neuropils. Most of the glial cells appeared to be oligodendrocytes. Calcification is also a prominent characteristic of DCCT. Using analytical electron microscopy, we examined the area of calcification in the globus pallidus and cerebellum, and found an accumulation of both Fe and Ca. The role of calcification in the pathogenesis, however, remains unclear. It is very important to examine cases of atypical presenile dementia clinicopathologically, in order to study the correlation between NFTs and SPs in neurological disease, and to understand their pathogenetic significance.

Allogeneic bone marrow transplantation (BMT) can cure some hematologic and solid malignancies, but its success depends on the prompt identification of a suitable donor and the avoidance of severe graft-versus-host (GVH) disease. Transplantation using hematopoietic stem cells from umbilical cord blood may overcome these problems. Over the past several years, cord blood transplantation (CBST) from siblings and unrelated donors has been performed in more than 300 patients. The probability of event-free survival was almost similar to that for BMT. This review described the recent status of CBST in USA, Europe and Japan, and the outlook for CBST.

Stem cell-fed maturational lineages have long known to exist in rapidly proliferating tissues such as bone marrow, gut and epidermis. Recent studies support the hypothesis that stem cell-fed maturational lineages occur also in quiescent tissues. In this review is presented evidence for this hypothesis using liver as one of the model systems representative of quiescent tissues. In addition, studies are summarized indicating that control of growth and tissue-specific gene expression is dependent on maturational lineage mechanisms operating dynamically and sometimes synergistically in combination with gradients of regulatory signals that include hormones, growth factors and extracellular matrix components. Tissue engineering for optimal maintenance of cells and tissues ex vivo and for the development of bioartificial organs will depend on use of cells at specific maturational lineage stages, seeding them onto substrata of specific mixtures of extracellular matrix components, and culturing them in hormonally and nutritionally defined media.

Healthy elderly people are mildly anemic peripheral blood data on 3,583 healthy elderly people (1,590 men and 1,993 women aged 65 years or older) from among those undergoing medical examinations at our hospital in the 8 years from 1988 to 1995 were compiled into 5-year age groups. For both men and women the mean values of red blood cell count, hemoglobin, and hematocrit were slightly lower among older subjects. The main causes of this apparent reduction may be a decrease in the number of hematopoietic stem cells and regression of the hematopoietic microenvironment. Observation of arteries in specimens of hematopoietic bone marrow obtained from the spines of elderly people showed arteriosclerotic changes such as greater hypertrophy of the media than of the intima, and adventitial fibrous hypertrophy. The number of venous sinuses was low and the amount of adipose tissue was high compared to the bone marrow of younger people. The cell density and the ratio of hematopoietic tissue to fat tended to be lower in older subjects. The number of erythroid burst-forming units formed after 14 days in culture medium containing erythropoietin was 28 +/- 19 in 32 healthy elderly people, which was significantly lower than the number in 30 young people 54 +/- 30, (p < 0.005). The value for erythroid colony-forming units was 170 +/- 67 in eight healthy people, which was much lower than in young people, 276 +/- 54. In the elderly subjects, the plasma iron disappearance time (PIDT/2) was 60-80 min (mean: 71.9 min), which was similar to that in the young, but the percent red cell iron utilization was 67.6%-84.9% (mean: 79.7%), which was slightly lower than in younger people. When the diagnostic criterion for anemia in the elderly was set at a hemoglobin value of 11.0 g/ dl, about 13% of outpatients who came to our Geriatrics department were found to have anemia, and in most of them the anemia had resulted from another disease. In conclusion, anemia in the elderly is likely to be affected by reduction in the function of various organs and by the decreased reserves associated with aging. The causes of anemia are complex and diagnosis is often difficult. The present article gives a general outline of the diagnosis and treatment of common types of primary and secondary anemia in the elderly.

In the process of bone remodeling or modeling, the balance between bone formation and bone resorption maintains normality of function and structures of bone. Major bone-resorbing cells, osteoclasts, are terminally differentiated from hematopoietic stem cells and multinucleate cells. However, direct effects of osteotropic factors on osteoclast function have been unclear. Attempts to obtain isolated mammalian osteoclasts of high purity have been unsuccessful so far. Initially we succeeded in isolating osteoclasts of high purity using tissue culture dishes because of their high affinity for the tissue culture dishes, but the shortcoming of this method is that it was impossible to detach osteoclasts from the dishes. Therefore, we could not estimate bone-resorbing activity of mature osteoclasts on mineralizing substratum without any influence of bone-cells other than osteoclasts. Recently we developed a method to avoid the defect in the above-described method by the use of collagen gel. Our new method may shed new light on our understanding of the cellular and molecular mechanisms of osteoclasts.

A 18-year old female with acute myelogenous leukemia (AML), M2 had translocation: t(6;9) (p23; q34). The patient entered into hematological complete remission after two courses of BHAC-DMP chemotherapy with disappearance of cytogenetic abnormality. However, minimal residual disease (MRD) detected with DEK/CAN chimeric m-RNA by reverse transcription polymerase chain reaction (RT-PCR) was continuously observed, although decreased quantitatively, following several courses of consolidation and intensification chemotherapies. MRD was detected also in the harvested peripheral blood stem cells (PBSC). Leukemia relapsed with the reappearance of t(6;9) 2 months after the subsequent peripheral blood stem cell transplantation (PBSCT). Leukemia became refractory to chemotherapy, and the patient died 5 months thereafter.

In this study, we investigated CDw90 (Thy-1) expression in CD34+ cells and hematopoietic colony-forming ability in purified CD34+ Thy-1+ and CD34+ Thy-1 fractions in the peripheral blood at the PBSCH. The high proliferative potential colony-forming cells (HPP-CFC), which are considered to be more primitive hematopoietic stem cells, were found more frequently in the purified CD34+ Thy-1+ fraction than in the purified CD34+ Thy-1- fraction. Thus, it is useful to decide the optimal time of PBSCH to measure the CD34+ Thy-1+ cells as well as CD34+ cells in the peripheral blood by flow-cytometry. In CD34+ acute myeloblastic leukemia (AML) cells, the co-expression rate of CD34 and Thy-1 was negative, suggesting that it may be possible to estimate the contamination of CD34+ AML cells by the Thy-1 expression rate in CD34+ cells at PBSCH.

Recent results from molecular biology have shown that lung cancer is characterized by multiple, sequentially appearing molecular changes that include genetic and epigenetic alterations. Among all types of lung cancer, small cell lung cancer (SCLC) is associated with the lowest rate of 5-year survival. In this symposium, we introduce our findings regarding the c-kit oncogenes in SCLC. We found that the c-kit gene is strongly expressed in SCLC. The c-kit gene was not expressed in normal bronchial epithelial cells, which indicates that this gene is abberantly transcribed in SCLC. In addition, c-kit-positive cases of SCLC showed autophosphorylation in response to recombinant human stem cell factor. Furthermore, adding rh stem cell factor of SCLC cell lines induced a significant chemotactic response and moderate in vitro cell growth. These results strongly suggest that abnormal expression of the c-kit gene may be involved in the pathogenesis of SCLC by autocrine/paracrine stimulation via the c-kit/SCF signal pathway. To overcome drug resistance, we assessed the efficacy of a chimeric toxin targeted to c-kit receptors.

Severe anemia A 37 year-old male with therapy resistant multicentric Castleman's disease (MCD) anemia was treated by subcutaneous injection of erythropoietin. Although immunoglobulin and CRP concentration increased, anemia obviously improved with hemoglobin levels increasing from 4.8 g/dl to 8.5 g/dl without any side effects. Colony assay revealed that the bone marrow mononuclear cells responded to erythropoietin in a dose dependent manner. The mechanism of anemia of MCD is not clearly understood, and treatment is sometimes very difficult. There is no other previous report concerning erythropoietin as a treatment for anemia in MCD.

A 54-year-old woman with leukocytosis, was referred to our clinic in February 1982. Based on findings of pancytosis, high NAP score, high serum vitamin B12, increase in total red cell volume and splenomegaly, she was diagnosed as having polycythemia vera (PV). Since then, she has been treated with pipobroman, hydroxycarbamide and phlebotomy. Leukocytosis with increase in blastic cells and thrombocytopenia was noted in August 1995, and she was admitted to our hospital. Since the blastic cells were CD10(+)19(+)20(+), she was diagnosed as having acute lymphoblastic leukemia and treated with vincristine and prednisolone, resulting in remission. This case suggests that PV is a disease of multipotent stem cells including those with a lymphoid lineage.

A five-year-old boy with acute myelogenous leukemia in relapse was treated by HLA-matched cord blood stem cell transplantation. The patient was preconditioned with 16 mg/kg of busulfan, 15 mg/kg of thiotepa and 90 mg/kg of cyclophosphamide and 2.45 x 10(7)/kg of cord blood mononuclear cells were infused to the patient on October 19th 1995 without the prophylaxis of graft-versus-host disease (GVHD). From the fifth day following the transplant, rG-CSF was administered at a dose of 300 micrograms/m2/day. Hematopoietic recovery was obtained as following; WBC over 1000/microliters was on +18 day, neutrophil over 500/microliters was on +20 day, reticulocyte over 20/1000 was on +28 day and platelet over 50 x 10(2) microliters was on +91 day. Engraftment was confirmed by DNA restriction fragment length polymorphism (VNTR) on +28 day. In spite of absence of prophylaxis of GVHD, the patient did not develop any signs of GVHD, and leukemia relapsed on +105 day. The patient died of leukemia relapse on +251 day. This is the first case of cord blood stem cell transplantation in Japan.

Recently, clonal EBV-DNA and/or EBV-encoded small RNA(EBER1) have been detected in some gastric carcinomas. We reported the first observation of EBV infection in gastric glands with intestinal metaplasia, and characterized the EBV-infected lymphocytes which infiltrated in gastric mucosa. To determine the cellular location of EBV, EBER1 in situ hybridization(ISH) with an EBER1 oligonucleotide probe was applied to paraffin sections of the non-neoplastic gastric mucosa in 80 cases of gastric carcinoma and 49 cases of gastric ulcer. Not only was EBER1 expression detected in the nucleus of gastric cancer cells(5 cases) but also in non-neoplastic gastric epithelial cells(3 cases) and in infiltrated lymphocytes(40 cases). A single or a few shedding non-neoplastic epithelial cells in 2 cases of EBV-associated gastric cancer showed EBER1 expression. In one case, EBER1 was observed in all of the epithelial cells of a few gastric glands with intestinal metaplasia, suggesting that the stem cells of the metaplastic gastric glands were infected with EBV. EBV DNA was also detected in the EBER1-positive metaplastic glands scratched from the paraffin section by a single cell PCR method with a BamHI W primer pair. However, immunohistochemical examination showed that these metaplastic glands lacked expression of EBNA2 and LMP-1. The observation of these rare EBV-infected metaplastic glands reinforces the pre-transformation EBV infection hypothesis for EBV-associated gastric carcinoma. The double staining using ISH and immunohistochemistry revealed that EBER1 positive lymphocytes showed a B cell marker of L26(< 50%) but not T cell markers of UCHL1 and OPD4.

There are now abundant evidence to confirm the role of serotonin (5-HT) and in particular, 5-HT3 receptors in the control of cisplatin-induced emesis. Emesis caused by cisplatin is associated with an increase in the concentration of 5-HT in the intestinal mucosa and in the area postrema. The intestinal mucosa contains enterochromaffin (EC) cells that synthesize and secrete approximately 80% of all 5-HT produced in the body. A selective 5-HT3 agonist, 2-methyl-5-HT, induced a dose-dependent increase in 5-HT level from the ileum. Furthermore, a selective 5-HT4-receptor agonist, 5-methoxytryptamine also induced a concentration-dependent increase of 5-HT level. Both 5-HT3 and 5-HT4 receptors may be involved in intestinal 5-HT release. It is proposed that anticancer drugs cause 5-HT release from the EC cells and that the released 5-HT stimulates the 5-HT3 receptors on the afferent vagal fibers, resulting in their deporalization. Electrical stimulation of the abdominal vagal afferents is capable of inducing emesis, and abdominal vagotomy suppresses cisplatin-induced emesis. These results indicate that the vagus is the major afferent pathway involved in the detection of emetic stimuli.

The inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme-A (HMG-CoA) reductase, pravastatin and simvastatin, are widely used clinically as anti-hypercholesterolemic drugs. To determine whether these drugs affect hematopoiesis, we examined the effect of the drugs on colony formation by human bone marrow cells. Simvastatin strongly inhibited both erythroid and granulocyte-macrophage colony formation by total or CD34-positive bone marrow cells at the concentration of 10 microM, which is about 100-1,000 fold higher than the pharmacologically effective level. On the other hand, the inhibitory effect of pravastatin was much weaker than that of simvastatin. These findings show that these drugs, especially pravastatin have little effect on hematopoiesis.

We evaluated the changes in stem cells in peripheral blood and the optimal timing for harvesting peripheral blood stem cells (PBSCs) following the administration of conventional cancer chemotherapy in patients with urological malignancies.