Hepatocellular carcinoma: efficacy of transcatheter oily chemoembolization in relation to macroscopic and microscopic patterns of tumor growth among 100 patients with partial hepatectomy

PURPOSE

To evaluate the efficacy of transcatheter oily chemoembolization (TOCE) for hepatocellular carcinoma (HCC) on the basis of microscopic and macroscopic findings postembolization.

METHODS

HCCs ranging in size from 0.5 to 13 cm (mean 3.6 cm) were obtained from partial hepatectomies of 100 consecutive patients who had undergone TOCE between 20 and 246 days (mean 59.5 days) prior to surgery. The efficacy of TOCE was assessed on the basis of the necrotic to live cell ratio of the tumors. The microscopic pattern of tumor growth was grouped into expanding type (complete capsule formation) and replacing type (incomplete or no capsule). There were five types of macroscopic groupings: single nodule, single nodule with extranodular growth (SNE), contiguous and noncontiguous multinodular, and massive growth type.

RESULTS

Among 79 cases with the expanding type, 29 (37%) had 100% HCC necrosis, but none with 100% necrosis were in the replacing type. By macroscopic grouping, the efficacy of TOCE decreased from the single nodule type (50% of patients had 100% necrosis) to the SNE type (21%), and the other types (9%).

CONCLUSION

TOCE appears to be most efficacious for HCC with the expanding growth pattern and HCC forming single nodules. Poor results are to be expected in HCC of replacing growth type and multinodular or massive growth types.

[A case of post-biopsy arterio-venous fistula in a renal allograft]

We report here a case of post-biopsy arterio-venous fistula in a renal allograft which was successfully embolized. Percutaneous needle biopsy of renal allograft is performed when the cause of deteriorating renal function is clinically difficult to diagnose, and the pathological diagnosis obtained by it determines the therapy. An easy and safe biopsy encourages the clinician, but some complications occur after the procedure. Arterio-venous fistula is one of the complications after percutaneous needle biopsy of renal allograft. Color-coded ultrasonography is effective to find it, and transarterial embolization should be tried first to treat it.

Contrast-enhanced MR imaging of intrahepatic cholangiocarcinoma: pathologic correlation study

The authors describe the enhanced magnetic resonance (MR) imaging appearance of intrahepatic cholangiocarcinoma. The MR images of eight patients with intrahepatic cholangiocarcinoma who underwent MR examination within 3 weeks before partial hepatectomy were retrospectively studied. The MR images, including a dynamic study, were compared directly with pathologic and histologic findings. The peripheral region of the medullary subtype of cholangiocarcinoma, with many tumor cells, showed greater enhancement relative to liver parenchyma in the early phase. The peripheral region of the scirrhous subtype, with fewer tumor cells showed less enhancement in the early phase. In one patient, the thin rim of the medullary tumor showed less enhancement in the late phase, and this rim corresponded to the peripheral region of the medullary tumor with many tumor cells. The central region of tumors with a large amount of fibrous tissue showed prolonged enhancement in the late and delayed phases. The thin rim of liver parenchyma around the tumor showed less enhancement in the early phase and greater enhancement in the late phase; this rim corresponded to congestive liver parenchyma with dilated sinusoids. Intrahepatic cholangiocarcinoma shows various enhancement patterns, which depend on both the histologic subtype and the degree and distribution of fibrosis within the tumor.

[Diagnostic value of tissue polypeptide antigen in pleural effusions with malignant pleural mesothelioma]

There are no known tumor makers of malignant pleural mesothelioma. We measured the concentration of TPA in the pleural effusions from patients with malignant pleural mesothelioma and from patients with other pleural diseases, evaluate its clinical usefulness. The concentration of TPA was more than 7,000 U/l (mean: 18,600 +/- 9,867 U/l, n = 5) in all patients with malignant pleural mesothelioma, but it was less than 4,000 U/l in those with benign asbestos pleurisy and other benign pleural effusion (benign asbestos pleurisy 1,598 +/- 570, n = 5: p < 0.01, tuberculous pleurisy 1.37 +/- 759, n = 11: p < 0.01, others 2,497 +/- 2,152 n = 3: p < 0.05). The concentration of TPA in the pleural effusions was not significantly different between malignant pleural mesothelioma and lung cancer (12,287 +/- 17,070 U/l). However, in all patients with lung cancer and high TPA concentrations, cytologically malignant cells were detected in the pleural effusions. TPA was high in all five patients with malignant pleural mesothelioma, but cytologically malignant cells were detected in only one patient. Only in malignant pleural mesothelioma (not in other benign disease or in lung cancer) was the concentration of TPA more than 4,000 U/l, and no evidence of malignancy was obtained by cytological methods. These findings suggest that assessing TPA in the pleural effusion might contribute to the diagnosis of malignant pleural mesothelioma.

Infralabyrinthine approach to vestibular neurectomy in Menière's disease

The infralabyrinthine approach to vestibular neurectomy was performed in 9 patients with unilateral Menière's disease. According to the AAOO (1972) criteria, 7 of 9 cases were graded as class B and the remaining 2 cases as class C. Otherwise, according to the AAO-HNS (1985) criteria, 6 patients who could be followed over 2 years were all graded as 'complete' at the vertigo control. The compensation of the spontaneous vestibular signs was rapid in the first 2 postoperative weeks, though an occasional imbalance on movement persisted even 3 years after the operation. No specific caloric reaction was elicited in any patient after warm or cold water irrigation of the operated side in any postoperative period. There have been no serious complications except a delayed facial palsy that appeared in one case one week after surgery. This approach offers access to the vestibular nerve with minimal risk and morbidity.

Development of a compact, highly efficient, totally implantable motor-driven assist pump system

We have developed a compact, highly efficient, totally implantable assist pump system, which consists of a motor-driven assist pump and a transcutaneous energy and optical information transmission system. The motor-driven assist pump consists of a.d.c. brushless motor and a specially designed miniature ball screw. A magnetic coupling mechanism between the blood pump and an actuator provides active blood filling via mild suction force. The controller consists of a PID follow-up controller using an 8-bit one-chip microcomputer. The volume of the pump is 350 ml, and its controller is 210 ml. Pump outflow of 5.8 L/min was obtained against a mean after-load of 100 mm Hg. The pump showed a high efficiency rate and good durability. An efficiency rate of 19-21% (pump output/motor input) was obtained during 87 days of continuous pumping. No mechanical trouble occurred for an accumulated period of 6 months.

Transthoracic percutaneous ethanol injection into the liver

RATIONALE AND OBJECTIVES

The feasibility of the new transthoracic approach of percutaneous ethanol injection through the lower lung to the subphrenic region of the liver was evaluated in normal rats.

METHODS

Fourteen normal rats received percutaneous ethanol injection. A 22-gauge fine needle was inserted into the liver via the thoracic cage and through the lower lung parenchyma under computed tomographic (CT) guidance. After ethanol (0.1-0.2 mL) was injected, three follow-up CT scans were performed: immediately after, 1 day after, and 1 week after the initial injection. All animals were killed 1 week after injection to evaluate macroscopic changes of the diaphragm and pleura.

RESULTS

No major complications were observed. Minor complications were observed in six rats; these included one pneumothorax (7%) and five band-like and streaky shadows (presumably pulmonary hemorrhages) (35%) on the CT scan obtained immediately after the procedure. However, all complications had disappeared spontaneously in the follow-up CT scan obtained 1 day after the procedure. At autopsy, no pleural changes were seen.

CONCLUSIONS

This study demonstrates that percutaneous ethanol injection through the lower lung parenchyma is achievable. Although this study was performed only in normal rats, the transthoracic approach can be a complementary method of ultrasound-guided percutaneous ethanol injection for tumors in the subphrenic region of the liver. Further study will be needed in abnormal livers and then in human subjects to verify the safety and efficacy of this procedure.

MR imaging of mixed hepatocellular and cholangiocellular carcinoma

Two patients with mixed hepatocellular and cholangiocellular carcinoma underwent partial hepatectomy after magnetic resonance (MR) imaging. Correlation is made with the histopathologic manifestations. In both cases the tumors showed relative low signal intensities on T1-weighted spin-echo (SE) images and high signal intensities on T2-weighted SE images. Dynamic MR imaging showed the enhancement from the periphery of the tumor to the inner area gradually and the enhancement continued into the delayed phase. With both cases fibrosis was marked in the inner area of the tumor compared to the peripheral area. The extent and degree of fibrotic tissue is considered to reflect the enhancement on dynamic MR imaging.

[Doses of epirubicin used in oily chemoembolization of hepatocellular carcinoma]

Epirubicin (EPIR), an anticancer agent, has recently been used with increasing frequency in transcatheter oily chemoembolization (TOCE) of hepatocellular carcinoma. We conducted a dose-finding study of EPIR with regard to its safety. One hundred thirty-four patients were divided into five groups according to the EPIR doses (mg/m2), Group A (< 30 mg/m2), Group B (> or = 30 - < 40 mg/m2), Group C (> or = 40 - < 50 mg/m2), Group D (> or = 50 - < 60 mg/m2), and Group E (> or = 60 mg/m2). The number of leukocytes decreased at 2 weeks but recovered at 4 weeks with no significant differences among the groups. However, there were significantly fewer leukocytes in Group E than in Groups A to D. There were no significant differences among the groups in either the number of erythrocytes or platelets. The number of platelets tended to remain at increased levels even at 4 weeks. Liver function as represented by GOT, GPT, LDH, and total bilirubin was not aggravated, but tended to improve. GOT and LDH in Groups D and E, in particular, improved significantly at 4 weeks, probably because of the antitumor effect of TOCE. These results suggest that EPIR can be administered up to 50 mg/m2 for TOCE.

Characterization of the calcium influx induced by depolarization of guinea pig cochlear spiral ganglion cells

We examined dynamic changes in intracellular calcium ion concentrations ([Ca2+]i) in isolated cochlear spiral ganglion cells (SGCs) of the guinea pig using digital imaging microscopy and the Ca(2+)-sensitive fluorescence dye fura-2. [Ca2+]i in SGCs was 83 +/- 22 nM (n = 50, means +/- SD) in cell somata at the resting state. Reversible increases in [Ca2+]i were elicited during membrane depolarization by high K+ (150 mM). This increase in [Ca2+]i was not observed under conditions of depolarization in Ca(2+)-free medium containing 1 mM EGTA. In addition, these increases in [Ca2+]i were sensitive to L-type calcium channel ligands, viz., antagonized by nifedipine (50 microM), verapamil (10 microM) and enhanced by BAY K 8644 (1 microM). These observations suggest that increases in [Ca2+]i of cochlear SGCs induced by high K+ are due to an influx of extracellular Ca2+, probably through voltage-gated L-type calcium channels.

[Responsiveness of lymphocytes from patients with M. avium-intracellulare complex (MAC) infection to PPDs as measured by IFN-gamma production]

We investigated the responsiveness of peripheral blood lymphocytes (PBLs) from patients with M. avium-intracellulare complex (MAC) infection to the stimulation with PPDs by measuring their IFN-gamma producing ability. PBLs were obtained from MAC patients at active stage (culture-positive after three-month chemotherapy), those at inactive stage (culture-negative for three months after or during chemotherapy), and healthy donors. PPDs used were PPD-S prepared from M. tuberculosis, PPD-B from M. intracellulare, and PPD-Y from M. kansasii. PBLs from active MAC patients did not produce IFN-gamma to a significant extent by stimulation with any of three PPDs, while PBLs from inactive MAC patients showed higher responses to each PPD compared to those from active patients. In inactive MAC patients, the maximal response was observed to PPD-B among three PPDs. On the other hand, PBLs from healthy controls produced different levels of IFN-gamma in response to three different PPDs, and their response was most remarkable to PPD-S. These results indicated that the responsiveness of patients' PBLs to PPDs was impaired during active stage of MAC infection and restored on recovery from the disease.

[Relationship between nutritional depletion and cell-mediated immune function in active pulmonary tuberculosis]

A survey on the nutritional status and cell-mediated immune function of 47 hospitalized patients with active pulmonary tuberculosis and healthy controls was conducted. In the patients group: 1) Anthropometric measurements, such as %ideal body weight (%IBW), %arm circumference (%AC), %arm muscle circumference (%AMC) and %triceps skin fold (%TSF), were significantly reduced. 2) Visceral proteins including serum albumin (Alb), transferrin (Tf), prealbumin (PA) and retinol binding protein (RBP) were significantly reduced. 3) The imbalance of plasma amino acids, which was characterized by the depression of Fischer ratio, a molar ratio of branched chain amino acids (BCAA) to aromatic amino acids (AAA), was observed. Fischer ratio was significantly correlated with anthropometric measurements (%IBW, %AC and %AMC). Delayed-type hypersensitivity to DNCB (2,4-dinitrochlorobenzene) and lymphocyte transformation to phytohemagglutinin (PHA) and concanavalin A (Con A) were significantly impaired in the patients group, whereas NK cell activity was higher than that of controls. Alb, PA, RBP and Fischer ratio were significantly lower in the patients with reduced DNCB reaction than in those with normal responses. Lymphocyte transformation was significantly correlated with Fischer ratio, and NK cell activity was significantly correlated with Alb, PA, RBP. These data may suggest that the imbalance of plasma amino acids represented by the reduction of Fischer ratio and the depletion of visceral proteins are closely related to the impairment of lymphocyte function in the patients with active pulmonary tuberculosis.

[Tumor necrosis factor alpha in bronchoalveolar lavage fluid and its production by alveolar macrophages with asbestos exposure]

It is generally accepted that asbestos exposure causes pulmonary fibrosis and carcinogenesis. Several studies have suggested that TNF alpha is produced principally by mononuclear phagocytes and that it may play a role in inflammation, fibrosis and anti-tumor activity. We studied TNF alpha production by alveolar macrophages and the TNF alpha concentration in bronchoalveolar lavage fluid harvested from asbestos-exposed subjects and healthy controls. TNF alpha production by alveolar macrophages was significantly higher in the asbestos-exposed subjects than in healthy controls (3696 +/- 1606, 1938 +/- 753 pg/ml; p < 0.01). The period from first exposure correlated inversely with TNF alpha production (r = -0.6; p < 0.05). The TNF alpha concentration in bronchoalveolar lavage fluid was also significantly higher in the asbestos-exposed subjects than in healthy controls. These results suggest that abnormal TNF alpha production by alveolar macrophages may be related to fibrosis and carcinogenesis due to asbestos.

[Usefulness of 3DFT-FISP MR imaging in differential diagnosis of liver tumor]

Dynamic 3-dimensional Fourier transformation (3 DFT)-FISP MR imaging was performed in 30 patients with 49 liver tumors (hepatocellular carcinoma 26, hemangioma 13, cholangiocellular carcinoma 2, metastatic liver tumor 8) to evaluate characteristic enhancement patterns. MR images of 3 DFT-FISP (TR/TE/flip angle/slab thickness/partition/slice thickness, 20 msec/8 msec/30 degree/21-75 mm/7 or 15/3-5 mm) were obtained before, just after (early phase), 1 min after (late phase 1) and 2-4 min after (late phase 2) the administration of 0.1 mmol/kg of Gd-DTPA. Twenty-three of the 26 (88%) hepatocellular carcinomas showed total hyperintense enhancement relative to surrounding liver parenchyma in the early phase, and isointense or total hypointense enhancement in the late phase. Eleven of 13 (85%) hemangiomas showed peripheral hyperintense enhancement in the early phase, and peripheral or total hyperintense enhancement in the late phase. Cholangiocellular carcinomas were enhanced gradually from the early to the late phase. Metastatic liver tumors showed doughnut-like ring enhancement in all 8 lesions in the early phase. We concluded that 3 DFT-FISP dynamic MR imaging was useful in the differential diagnosis of liver tumor.

[Anorexia nervosa complicated with pulmonary tuberculosis]

A study was made on a patient with anorexia nervosa complicated with pulmonary tuberculosis treated with intravenous hyperalimentation (IVH). A 24-year-old female was admitted to our hospital because of progressive loss of body weight during medication for pulmonary tuberculosis at another hospital. She was diagnosed as having anorexia nervosa. After the nutritional assessment IVH was performed. As a result of IVH, her body weight increased and her nutritional deprivation, (i.e., low visceral proteins, low branched amino acids, etc.) recovered. Nutritional support was effective upon treating pulmonary tuberculosis.

3DFT-FISP MRI with gadopentetate dimeglumine in differential diagnosis of small liver tumors

OBJECTIVE

We assessed the value of dynamic sequential three-dimensional Fourier transformation (3DFT) MRI in differentiating various types of small liver tumors.

MATERIALS AND METHODS

Forty-seven patients with 65 liver masses < 3 cm in size (42 hepatocellular carcinomas, 11 hemangiomas, 12 metastatic tumors) were studied by 3DFT fast imaging with steady-state precession (FISP) MRI [TR(ms)/TE(ms)/flip angle (degree): 20/8/30]. The slab thickness was 21-35 mm, and there were seven partitions. The 3DFT-FISP MR images were obtained immediately after 0.1 mmol/kg of gadopentetate dimeglumine was administered intravenously over 2-3 s (early phase), 60 s after (late phase I), and 120 s after (late phase II).

RESULTS

Eighty-six percent of small hepatocellular carcinomas showed hyperintense enhancement relative to the surrounding liver parenchyma and iso- or hypointense enhancement with or without capsular enhancement in the late phase. Eighty-two percent of small hemangiomas showed peripheral globular enhancement in the early phase and total hyperintense or peripheral enhancement in the late phases. Ninety-two percent of the small metastatic liver tumors showed doughnut-like ring enhancement in the early phase.

CONCLUSION

By dynamic 3DFT-FISP MRI, we were able to accurately evaluate the hemodynamics and morphological findings of each type of small liver tumor.

Five-year survival after transcatheter chemoembolization for hepatocellular carcinoma

The 5-year cumulative survival rate of 443 patients who underwent transcatheter chemoembolization (TCE) for non-resectable hepatocellular carcinoma (HCC) before December 1986 was 8.0%, and 29 patients survived for 5 years or more. Of these 29 patients, 25 were men and 4 were women; their mean age was 63.9 years. Macroscopic classification showed lesions of the single nodular type in 16 cases, the multiple nodular type in 10 cases, and the massive type in 3 cases; 12 of the single nodular lesions measured 5 cm or less in size. The TNM classification showed lesions of stage I in 3 cases, stage II in 14 cases, stage III in 6 cases, and stage IV in 6 cases. Lesions classified as Child A were found in 23 patients, and they were thus much more common than Child B lesions (2 patients) and Child C lesions (1 patient). The response was analyzed in relation to the use of iodized oil (Lipiodol). It was used in 215 of the patients, and the 5-year cumulative survival rate of those patients was 12.9% (23 of them survived for 5 years or more). Lipiodol was not used in 228 patients, and they showed a 5-year cumulative survival rate of 3.4%, with 6 patients surviving for 5 years or more. The 6 patients with stage III disease and the 6 with stage IV disease received Lipiodol. TCE with Lipiodol thus contributed greatly in prolonging the survival of patients with HCC complicated by intrahepatic metastases or intraportal tumor thrombi.

[An autopsy case of atypical mycobacteriosis accompanied with chest wall deformity]

An autopsy case of 63-year old male of atypical mycobacteriosis with severe scoliosis was reported. He was diagnosed as atypical mycobacteriosis in 1981 and controlled by antimycobacterial treatment. But since 1989, dyspnea and sputum have been increasing, new abnormal shadow in company with progression of curvature of the scoliosis was revealed on the chest roentgenogram. In spite of various treatments for mycobacteriosis, he died of respiratory failure. The aggravation of this mycobacteriosis brought on advancement of malnutrition and impairment of cell mediated immunity. Findings of autopsy showed the remarkable chest wall deformity and tuberculous change of the lung parenchyma. In this case, chest deformity was thought as the major risk factor of onset of mycobacterial mycobacteriosis.

[Clinical features of primary and secondary atypical mycobacteriosis]

A clinical investigation was carried out in 39 patients with atypical mycobacteriosis (AM). The patients at our hospital diagnosed as having AM during an 11-year period from 1981 to 1991 were reviewed in this study. The incidence of AM among all of mycobacterial infections has been increasing since 1988. The atypical mycobacteria detected included M. avium complex (MAC) in 79%, M. kansasii in 26%, and other organisms in 5%. Patients who had primary infection without underlying respiratory disease were compared with those who had secondary infection. In secondary infection, MAC was detected in the sputum of a high percentage of patients and was positive for more than 6 months despite therapy. Gamma globulin levels were also increased in patients with secondary infection. Cell mediated immunity was examined by the DNCB reaction and the detection of CD4- and CD8- positive T lymphocytes. The DNCB skin reaction was positive in 6 out of 26 patients with secondary infection. The percentage of CD8- positive T lymphocytes was higher in patients with secondary disease. Fischer's ratio (indicating the balance of plasma amino acids) was also examined as an index of the nutritional status. It was significantly lower in secondary infection compared with primary infection. Moreover, secondary infection was associated with a lower positive rate for the DNCB skin reaction and a lower Fischer's ratio when compared with pulmonary tuberculosis. Thus impairment of cell-mediated immunity, malnutrition, and a poor prognosis were significantly more common in secondary infection compared with primary infection.

Display of MR angiograms: maximum intensity projection versus three-dimensional rendering

OBJECTIVE

The purpose of this study is to clarify the most useful technique of MR imaging in demonstrating the collateral venous pathways due to portal hypertension.

SUBJECTS

Twenty-eight cirrhotic patients with collateral venous pathways due to portal hypertension and three patients without them were studied. We evaluated the detectability of collateral vessels of flow-enhanced transverse MR images by time of flight effect, projection MR angiography using the maximum intensity projection technique and three-dimensional (3D) computer graphic images, by using the arterial portography as the standard.

RESULTS

Flow-enhanced transverse MR images showed 98% of the collateral vessels detected by angiography, however, the connection of each vessel was obscure. Fully 81% of the collateral vessels were seen by projection MR angiography, and 98% of them by the 3D computer graphic images.

CONCLUSION

The detectability of collateral vessels of 3D computer graphic imaging was better than that of the projection MR angiography and was as accurate as that of transverse MR imaging. 3D Computer graphic images provided complex anatomical information in a more easily understood fashion than either transverse MR images or projection MR angiography.

Comparison of CNS effects of propofol and thiopentone in cats

Using cats with chronically implanted brain electrodes, we have compared the effects of propofol on CNS electrical activities with those of thiopentone. Ten cats were allocated to receive either propofol (n = 5) or thiopentone (n = 5). Cats were anaesthetized initially with 4% halothane in oxygen. The trachea was intubated and the lungs ventilated mechanically. A femoral artery and a vein in a forepaw were cannulated for arterial pressure monitoring and fluid infusion. After the inspired concentration of halothane was maintained at 0.5%, EEG in the cortex, the amygdala and the hippocampus, somatosensory evoked potential (SEP) and reticular multi-unit activity (R-MUA) were recorded. Incremental doses of propofol or thiopentone were administered i.v. at 5-min intervals during 0.5% halothane anaesthesia. The cumulative doses of propofol and thiopentone were 2, 5, 10 and 20 mg kg-1, and 4, 10, 20 and 40 mg kg-1, respectively. Arterial pressure was maintained in excess of 100 mm Hg systolic by infusion of phenylephrine. All cats in the propofol group survived, but two in the thiopentone group died after the administration of thiopentone 40 mg kg-1. Changes observed in CNS activity were dose-related in all cases. The EEG changed with the increments of doses of propofol or thiopentone, from fast, small amplitude to complexes of fast and slow, large amplitude activities, burst suppression and flat EEG. SEP latency was prolonged by both agents: the peak latency of N1 changed from 15 (SD 2) ms to 20 (5) ms with propofol 20 mg kg-1, and from 14 (1) ms to 27 (2) ms with thiopentone 40 mg kg-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of viable tumor cells in hepatocellular carcinoma following transcatheter arterial chemoembolization with iodized oil. Pathologic correlation with dynamic turbo-FLASH MR imaging with Gd-DTPA

To evaluate the effect of transcatheter arterial chemoembolization (TACE) with iodized oil for hepatocellular carcinoma (HCC), dynamic turbo-fast low angle shot (turbo-FLASH) (TR/TE/flip angle/TI, 8.5/4.6/10/200) MR imaging with gadopentetate dimeglumine was performed in 10 patients with HCC after TACE with iodized oil and before partial hepatectomy. Immediately after 0.05 mmol/kg b.w. of gadopentetate dimeglumine was administered intravenously, 10 images were obtained in the first 20 s (early phase). Then, one image every 30 s from 1 to 3 min (late phase), and images at 5 min and 7 min (delayed phase) were obtained serially. In the early phase, HCC showed no enhancement in 5 patients, partial hyperintense enhancement in 4, and total hyperintense enhancement in one. Viable regions of the tumor, evaluated at histopathology, showed hyperintense enhancement relative to the surrounding liver parenchyma in the early phase, while necrotic regions showed no enhancement. Both viable and necrotic regions showed lower signal intensities than the surrounding liver parenchyma in both late and delayed phases. By using dynamic turbo-FLASH MR imaging, we were able to accurately evaluate the effect of TACE with iodized oil for HCC in 8 of the 10 patients. In 2 patients, in whom small viable cells were seen in the HCC, viable regions could not be detected with our technique. It is concluded that turbo-FLASH dynamic MR imaging was useful for evaluating the effect of TACE for HCC.

[Transthoracic percutaneous ethanol injection for the liver]

Fourteen normal rats were received with percutaneous ethanol injection (PEI) in the subphrenic region of the liver, using a 22G fine needle, via the thoracic cage. The procedure was successful in all rats. Minor complications were observed in 3 rats: these included pneumothorax, hemorrhage, and pleural effusion. However all complications had disappeared in the follow up CT one week after the procedure. The transthoracic approach is a useful and safe method of PEI for the subphrenic region of the liver.

Treatment of hepatocellular carcinoma by chemoembolization: evaluation with 3DFT MR imaging

OBJECTIVE

We evaluated the usefulness of an MR imaging technique that used dynamic three-dimensional Fourier transformation (3DFT) fast imaging with steady-state precession (FISP) with gadopentetate dimeglumine for detecting viable regions of hepatocellular carcinoma following transcatheter arterial chemoembolization with iodized oil (Lipiodol). Images obtained with the 3DFT FISP technique were directly correlated with hepatectomy specimens.

SUBJECTS AND METHODS

Dynamic 3DFT FISP MR imaging was performed after transcatheter arterial chemoembolization and before partial hepatectomy in 10 patients with 10 tumors of hepatocellular carcinoma. Imaging parameters were 20/8/30 degrees (TR/TE/flip angle) with a slab thickness of 21-75 mm and seven or 15 partitions. 3DFT FISP images were obtained at the slice level where a tumor had been detected on T1- and/or T2-weighted spin-echo MR images before, just after (early phase), and 1 and 2 min after (late phase) IV administration of gadopentetate dimeglumine (0.1 mmol/kg). We directly compared the dynamic MR images of the 10 patients with the gross and microscopic findings.

RESULTS

On early-phase images, tumors of hepatocellular carcinoma showed no enhancement in three patients and partial intense enhancement in seven. Viable regions of the tumor showed intense enhancement relative to the surrounding liver parenchyma in the early phase, whereas necrotic regions showed no enhancement in either the early or the late phase. Both viable and necrotic regions had lower signal intensities than did the surrounding liver parenchyma in the late phase. By using dynamic 3DFT MR imaging, we were able to accurately assess the effect of transcatheter arterial chemoembolization with iodized oil in nine of the 10 patients. However, in one patient in whom microscopically viable cells were seen in the capsule of the carcinoma, viable regions could not be detected with our technique.

CONCLUSION

Dynamic 3DFT MR imaging was useful in differentiating viable regions of hepatocellular carcinoma from necrotic regions following transcatheter arterial chemoembolization with iodized oil.

[An experimental study of a new embolic material--Lipiodol suspension of water-absorbent particle]

A water-absorbent particle (a polymer of polyacrylic acid soda) was investigated as a new embolic material. The size of a single particle is 200 microns (N-100) or 10 microns (NP-1010). A particle absorbs 100 times its own weight of physiologic NaCl solution within a few seconds. The particles have no acute or chronic toxicity or immunogenicity. This material suspended by Lipiodol was evaluated in an in vitro study using an AVM model composed of a plastic syringe and polyurethane sponge. The AVM model was perfused by physiological NaCl solution at a pressure of 150 mmHg. The swollen polymer worked as an adequate embolic material in the AVM model, using a minimum quantity. The embolic effect depended upon the quantity and concentration of the suspension. Restoration of flow was not observed within a period of ten minutes. The embolized part was clearly visualized due to the retention of Lipiodol. This material is a promising agent for arterial embolization.

Regional blood flow volume in the eustachian tube

Measurements of regional blood flow around the pharyngeal orifice of the Eustachian tube were carried out after topical administration of various inflammatory mediators in 14 mongrel dogs by the hydrogen clearance method. Histamine and platelet-activating factor (PAF) resulted in a significant alteration of blood flow volume. Histamine was found to induce a dose-response related increase, whereas blood flow volume tended to decrease in each concentration range in the series of PAF administration. There was no significant difference in blood flow between topical application of leukotriene C4 and leukotriene D4. It is likely that in upper respiratory tract inflammation, such as in otitis media and in nasal allergy, activated histamine and PAF affect the microcirculation of the tubal orifice. These results suggest that disturbance of the microcirculatory system in the Eustachian tube mucosa could be involved in the pathogenesis of chronic otitis media with effusion.

Surgical anatomy for infralabyrinthine approach to the internal auditory canal

Surgical anatomy for infralabyrinthine approach to the internal auditory canal was evaluated using human temporal bone in order to understand advantages and disadvantages of this approach. The procedure is extracranial without any damage of labyrinth. Lateral exposure of the internal auditory canal allows for easy separation of the cochlear and vestibular nerves. There are some potential problems of little importance stemming from anatomical variations, such as high jugular bulb, forward positioned sigmoid sinus and poor pneumatization of the infralabyrinthine space. This approach offers access to the eighth cranial nerve with minimal risk and morbidity.

Effects of acetazolamide on acid-base balance in the endolymphatic sac of the guinea pig

The effects of acetazolamide, a carbonic anhydrase inhibitor, on acid-base parameters in the endolymphatic sac of the guinea pig were investigated using ion-selective microelectrodes. Bicarbonate concentration was reduced and pH shifted to being acidic immediately after administration of acetazolamide. Chloride concentration in the endolymphatic sac increased after carbonic anhydrase inhibition. These findings provide evidence of an active function of carbonic anhydrase in the endolymphatic sac and suggest that carbonic anhydrase activity is involved in the formation of endolymphatic sac fluid.

The usefulness of partial parotidectomy for benign parotid gland tumors. A retrospective study of 306 cases

This retrospective study concerns benign parotid gland tumors in 306 Japanese patients who were treated by partial parotidectomy with preservation of the facial nerve. There were no recurrences in 112 with a pleomorphic adenoma in over a 5-year follow-up. Facial weakness and temporal paresis occurred in 18% of 232 patients and Frey's syndrome in 18% of 93 with longer than a 3-year follow-up. In comparison with reported results of lateral or superficial parotidectomy, partial parotidectomy with preservation of the facial nerve seems preferable for treatment of patients with a benign parotid gland tumor.

Thyroid follicle transplantation by percutaneous injection

We previously reported on the isolation of thyroid follicles from thyroid tissue and their acceptance after allogeneic transplantation under the renal capsule with laparotomy in mice. In the present study, we introduced a new method of autologous transplantation of thyroid follicles accepted in the hosts after percutaneous injection into the spleen or into fat tissue in the peritoneal cavity without laparotomy in rats. This method of thyroid transplantation by a single injection, which induces little stress in the host, is applicable to autologous and allogeneic transplantations and may release patients from the burden of daily life-long administration of thyroxine.

Sympathetic nerve disturbance and fine structure of adrenergic nerve terminals in nasal mucosa after experimentally-induced nasal hypersensitivity

Electron microscopic observations were used to study the relation between the adrenergic nerve terminal and the effector cell in the nasal mucosa of toluene diisocyanate-sensitized and non-sensitized guinea pigs. Adrenergic nerve terminals were abundantly distributed in the adventitia of arterioles, however, no synapse formation was observed in smooth muscle cells of the mesothelium, i.e., effector cells. Adrenergic nerve terminals were observed separated from smooth muscle cells of the mesothelium of the arteriole by distances of 1000 A-3000 A. Neurotransmission by the sympathetic nerve in the nasal mucosa is assumed to be by diffusion of norepinephrine (NE) or by diffusive synaptic conduction. The mechanism of sympathetic hypofunction in the nasal mucosa in nasal hypersensitivity is assumed to be as follows: Released histamine directly stimulates H-1 receptors at the sympathetic nerve terminal, leading to the release of NE. Once released, NE is not readily reabsorbed, and is gradually depleted in the sympathetic nerve terminal, leading to hypofunction of the sympathetic nerve.

Menière's disease and autoimmunity: clinical study and survey

In order to clarify whether autoimmune mechanisms form part of the etiopathogenesis of Meniere's disease, sera and endolymphatic sac tissues from 30 patients with Meniere's disease were analyzed according to the clinical criteria for autoimmune diseases stated by Mackay & Burnet. Several cases showed hyper gamma-globulinemia, antibody elevation to Type II collagen in the serum and endolymph, positive staining to immunoglobulins and C3 or infiltration of immuno-competent cells in the endolymphatic sac, good response to prednisolone and combination with systemic immune disorders. Other examinations showed a significant elevation of OKT 4/8 ratio and a decrease of OKT8-positive cells, and elevated levels of circulating immune complex and antiviral antibody titers. It is suggested that certain cases of Meniere's disease may have an altered immunological background, which may be attributed to an autoimmune mechanism dependent on humoral and/or cellular responses.

[Case study of interleukin-1 beta, tumor necrosis factor alpha and interleukin-6 production peripheral blood monocytes in patients with diabetes mellitus complicated by pulmonary tuberculosis]

Patients with diabetes mellitus (DM) show an increased susceptibility to bacterial infections due to the presence of neutrophil dysfunction. Susceptibility to tuberculosis has also been reported in such patients, however, the reason remains unclear. This study measured the production of interleukin-1 beta (IL-1 beta), tumor necrosis factor alpha (TNF alpha) and interleukin-6 (IL-6) by the peripheral monocytes of patients diagnosed with pulmonary tuberculosis accompanied by DM (TB+DM) and patients without DM complications (TB) using age-matched, healthy control subjects for comparison. Also examined was the relationship between cytokine production and DM control. The results were as follows: (1) The production of IL-1 beta, TNF alpha and IL-6 in TB patients was significantly higher than that observed in the healthy control subjects. (2) The production of IL-1 beta, TNF alpha and IL-6 in TB+DM patients was significantly lower than that observed in the TB patients. (3) The production of IL-1 beta and TNF alpha in TB+DM patients with poor control was significantly lower than that observed in the patients with good control. (4) The TNF alpha production had a significant inverse correlation to HbA1c in the TB+DM patients. This study demonstrated that the production of cytokines is impaired in TB+DM patients and suggests a close correlation between tuberculosis immunity and DM.

[Three cases of young adults advanced pulmonary tuberculosis due to patient's and doctor's delay]

Three young adults advanced pulmonary tuberculosis due to delay of therapy were reported. In case 1 and 3, their delays resulted from difficulty in diagnosis, in case 2, from neglecting medical counseling. Each cases revealed bilateral diffuse shadows on chest roentgenograms on admission, which were typical shadows of advanced pulmonary tuberculosis. Malnutrition might contribute to the development of the diseases, which were improved by anti-tuberculosis therapy and hyperalimentation therapy. These cases were suggested some clinical problems characteristic of pulmonary tuberculosis of young adults.

Alterations of charge barrier in the inner ear following immune reactions

We investigated electron microscopically the changes of anionic sites of a charge barrier in the capillary basement membrane of the stria vascularis and endolymphatic sac following inner ear immune reactions. Hartley guinea pigs were immunized with bovine type II collagen, keyhole limpet hemocyanin, or horseradish peroxidase, with boosted and challenged antigens through the stylomastoid foramen. Animals were killed painlessly from several days up to 56 days after the antigen challenge. Polyethylenimine was used as a cationic tracer in order to observe the localization of anionic sites of the charge. In the animals immunized with bovine type II collagen or horseradish peroxidase, a significant decrease of anionic charge in the stria and the sac was found in the early stage of immunization. However, the keyhold limpet hemocyanin immunization group did not show any remarkable changes in the charge because of its lesser transfer into the inner ear due to of its high molecular weight and negative surface charge. A decrease of the charge under immunologic conditions may induce a hyperpermeability of vessels and a malabsorption of endolymph, and thus may cause endolymphatic hydrops.

A case of intraosseous angioleiomyoma

We report a rare case of expansively growing angioleiomyoma in the proximal tibia of a 64-year-old woman. MRI revealed a well-defined area of low signal intensity on T1-weighted image and high intensity on T2-weighted image. Angiographs showed hypervascularity and vascular poolings. Microscopic examination after incisional biopsy showed an angioleiomyoma with bundles of nerve fibers.

Experimental interruption of the endolymphatic duct and its effect on the DC potential in the endolymphatic sac

The endolymphatic sac (ES) of the guinea pig was isolated from the remainder of the inner ear by means of surgical interruption of the endolymphatic duct (ED). The DC potential in the ES lumen and the morphology of the ES were studied using glass micro-electrodes and a light microscope at various time intervals after the interruption of ED. The DC potential did not significantly change 1 h postoperatively, compared to findings in the non-operated ear, but a significant decrease of the DC potential was observed after 1, 3 and 7 days postoperatively. A histologically-stainable substance in the ES lumen was enhanced on the operated side. The isolated ES shows a disturbance of mechanism(s) maintaining the DC potential and there is a secretion of a stainable substance into its lumen.

[Relation of airway obstruction and respiratory muscle weakness to energy metabolism in pulmonary emphysema]

Resting energy expenditure (REE) was assessed and its relationship to nutritional status, pulmonary function and respiratory muscle function was studied in 25 patients with pulmonary emphysema. The mean value of REE was 1413 +/- 251 Cal and the ratio of REE/REEpred was 1.398 +/- 0.23, suggesting the existence of a hypermetabolic state in these patients. REE/REEpred ratio was inversely correlated with plasma amino acid BCAA/AAA ratio and body muscle mass; and PImax. REE was inversely correlated with FEV1.0%. REE in the patient subgroup with severe hyperinflation (%RV > or = 200) was significantly higher than that in the subgroup with moderate hyperinflation. Malnourished patients showed significantly more severe hyperinflation than well-nourished patients. These findings suggest that augmented REE contributes to malnutrition in patients with emphysema, and that the increase in REE was related to the increase in mechanical work load on the basis of airway obstruction, respiratory muscle weakness and hyperinflation.

[The efficacy of transarterial immuno-embolization therapy in patients with hepatocellular carcinoma]

The efficacy of transarterial immuno-embolization therapy (TIE) was investigated in 7 patients with multiple hepatocellular carcinoma (HCC). We administered OK-432 (10 KE), fibrinogen (30 mg/ml) and thrombin (1 U/ml) as a new treatment for HCC with intrahepatic metastasis. In all patients with a high level of AFP, the AFP level decreased promptly less than the pretreatment level after TIE therapy. High fever in all cases, epigastralgia in 6 cases and appetite loss in 3 cases were observed after TIE therapy. Our results indicate that this therapy may be a safe and effective method in HCC patients with intrahepatic metastasis.

[Nutritional assessment and the effect of supplementary oral nutrition in patients with pulmonary emphysema]

Nutritional status and its relation to respiratory function and respiratory muscle strength were assessed in patients with pulmonary emphysema. Energy metabolism was also examined in order to elucidate the mechanism of their malnutrition. BCAA/AAA ratio of plasma amino acid was positively correlated with FEV1.0%. Resting energy expenditure (REE) was negatively correlated with FEV1.0%, and REE/REEpred ratio was also negatively correlated with BCAA/AAA and PImax. These findings suggest that increased mechanical work load, associated with airway obstruction and reduced respiratory muscle efficiency, contribute to the increased energy expenditure and amino acid imbalance. Oral nutritional supplementation using BCAA enriched-elemental diet was found to be effective, as assessed by nutritional parameters, PImax, D.O.E., and QOL index, in malnourished emphysema patients.

[Stage III, IV hepatocellular carcinoma patients surviving more than five years after transcatheter chemoembolization]

Twelve of the patients with advanced (Stage III or IV) hepatocellular carcinoma who received transcatheter chemoembolization survived for more than 5 years. These survivors consisted of 6 Stage III cases and 6 Stage IV cases. Of the 6 Stage III cases, 5 had multiple tumors (larger than 2 cm) in one lobe of the liver, and 1 had tumor invasion into the second portal branch before treatment. Of the 6 Stage IV cases, 4 had had multiple tumors in both lobes, and 2 had had tumor invasion into the main portal branches. Before treatment, 9 of the 12 survivors had been rated as Child's class A. Lipiodol was used in all 12 cases. The results of the present study suggest the usefulness of Lipiodol in treating advanced hepatocellular carcinoma.

[Dynamic 3DFT FISP MR imaging of hepatocellular carcinoma]

Dynamic 3 dimensional Fourier transformation (3DFT) FISP MR imaging was performed in 5 patients with hepatocellular carcinoma before partial hepatectomy. Immediately after 0.1 mmol/kg of Gd-DTPA was administered intravenously, 3DFT FISP images (TR/TE/flip angle/slice thickness, 20 msec/8 msec/30 degrees/2-4 mm) were obtained every 30 seconds until 150 sec. We correlated dynamic MR images of the 5 patients with gross and microscopic findings. Some regions in the tumor corresponding to viable cells showed high intensity enhancement and other regions corresponding to necrotic regions showed no enhancement on the early phase images. We concluded that dynamic 3DFT FISP MR imaging which had good spatial resolution was useful in evaluating the vascularity of the tumor.

Flumazenil does not antagonize halothane, thiamylal or propofol anaesthesia in rats

We have studied the effects of flumazenil on sleep time and EEG in rats anaesthetized with 1.5% halothane, propofol 20 mg kg-1, thiamylal 30 mg kg-1, or combinations of diazepam 5 mg kg-1 and anaesthetic agents. We also studied the effects of flumazenil 0.3, 3 and 30 mg kg-1 on behaviour and EEG. Flumazenil 0.3 and 3 mg kg-1 alone had no effect on behaviour or EEG, but flumazenil 30 mg kg-1 had depressive effects similar to those of diazepam on behaviour and EEG. Flumazenil 0.3, 3 and 30 mg kg-1 i.v., antagonized the effects of diazepam 10 mg kg-1 i.v. on behaviour and EEG. Flumazenil had no antagonistic effect on sleep time induced by anaesthetic agents, but flumazenil 30 mg kg-1 potentiated propofol-induced anaesthesia. Flumazenil did not affect anaesthesia-induced EEG changes. Diazepam 5 mg kg-1 potentiated anaesthesia. Flumazenil antagonism of diazepam potentiation varied with anaesthetic agent: flumazenil 0.3 mg kg-1 antagonized diazepam action in halothane anaesthesia, but 30 mg kg-1 was required in propofol anaesthesia; this large dose was insufficient in thiamylal anaesthesia.

Small-angle x-ray scattering study of metal ion-induced conformational changes in Serratia protease

Metal ion-induced conformational changes in Serratia protease which contains one zinc ion per molecule were investigated by the small-angle x-ray scattering method. The molecule is an elongated ellipsoid of approximately 110 x 40 x 40 A with a large cleft in its central region. Comparisons of the native (zinc-enzyme) with the zinc-free (apoenzyme) enzyme and with the zinc-replated metalloenzyme show small but significant differences in their radii of gyration, maximum particle dimensions, and intraparticle pair-distance distributions. The radius of gyration and maximum particle dimension of the native enzyme are almost the same as those of the cobalt-enzyme but are shorter and longer, respectively, than those of the apo- and cadmium-enzymes. Simulation analysis based on the intraparticle pair-distribution function showed that these modified enzymes are comparable with the native enzyme in overall structure, and, except for the cobalt-enzyme, differ in cleft size. The residual enzymatic activity of the cobalt-enzyme is the same as that of the native enzyme, but the apo- and cadmium-enzymes have considerably less activity. The size of the cleft therefore is strictly controlled to ensure optimal enzyme activity, and the position and coordination behavior of the zinc ion in the cleft appears to be essential both for biological functioning and for the maintenance of the gross tertiary structure.

[Differentiation between hepatoma and hemangioma by inversion recovery snapshot FLASH MR imaging with variable TIs]

To differentiate hepatoma from hemangioma, MR studies were performed for 18 patients with 21 untreated liver tumors (hepatoma 10, hemangioma 11). We obtained inversion recovery snapshot FLASH images of liver tumors with variable TIs (50, 100, 150, 200, 250, 300, 400, and 500 msec). 8 hemangiomas showed higher intensity than liver parenchyma on the images at 150 msec and less of TI, and lower intensity at 200 msec or more TI. In 7, signal intensity of hepatoma became low at 150 msec or less of TI or remained high with prolonged TI. Inversion recovery snapshot FLASH imaging with variable TIs will be useful for differentiating between hepatoma and hemangioma.