[A case of acute mediastinitis with pyothorax secondary to peritonsillar abscess]

A 41-year-old man was admitted to a hospital elsewhere because of tonsillitis with high grade fever. On the 9th day of hospitalization, the patient complained of dysphagia and dyspnea. A chest X-ray film and a CT scan showed right pleural effusion and pericardial effusion, and he was referred to our hospital. Immediately after admission, he underwent pericardiotomy to relieve cardiac tamponade, and a right thoracic tube was inserted for pyothorax. Next day, mediastinal drainage was accomplished through a cervical incision and a right thoracotomy. Eight drainage tubes were left in place. Cultures revealed alpha-Streptococcus, Neisseria and group F Streptococci. Continuous closed irrigation with diluted Isodine (povidone iodine) solution was performed. The last extubation of the drainage tube was done on the 140th day after operation. He was cured and discharged on the 162nd day after operation. In patients with extensive acute mediastinitis secondary to deep cervical infection, early complete mediastinal drainage via a cervical and a transthoracic incision is essential.

Endoscopic injection sclerotherapy for esophageal variceal hemorrhage in a patient with idiopathic myelofibrosis

A 74-year-old female with idiopathic myelofibrosis (IMF) was admitted to our hospital because of massive hematemesis and melena. Immediate upper gastrointestinal endoscopy revealed an intermittent spurting hemorrhage from extensive esophageal varices. Endoscopic injection sclerotherapy (EIS) was carried out and the bleeding ceased. After five courses of EIS, all the esophageal varices were eradicated. About 15 months later, the patient died, due to a cerebral hemorrhage, without further variceal bleeding. A postmortem examination was carried out and the portal hypertension was considered to be due not only to extramedullary hematopoiesis in the sinusoids, but also to increased splenic blood flow. We are confident that EIS is an effective therapeutic procedure for patients with IMF showing esophageal variceal hemorrhage. EIS should be the preferred choice of treatment for esophageal varices in patients with IMF, since it is less invasive than splenectomy.

Comparison of serum hepatitis C virus RNA concentration by branched DNA probe assay with competitive reverse transcription polymerase chain reaction as a predictor of response to interferon-alpha therapy in chronic hepatitis C patients

A study was carried out to assess the correlation between the serum concentration of hepatitis C virus RNA (HCV-RNA) in patients with chronic hepatitis, as measured by competitive reverse transcription polymerase chain reaction (cRT-PCR) and branched DNA probe assay (bDNA), and response to interferon-alpha (IFN alpha) therapy. The serum HCV-RNA concentration was evaluated by both cRT-PCR and bDNA in 54 patients who had received a total dose of 480 MU of IFN alpha. HCV subtypes were also identified in all patients. The measurement of serum HCV-RNA concentration by bDNA correlated significantly with that of cRT-PCR. The concentration of HCV-RNA in subtype 1 patients was significantly higher than that in subtype 2 patients when measured by bDNA, but not when measured by cRT-PCR. The correlation of HCV-RNA concentration between bDNA and cRT-PCR was associated with both subtypes 1 and 2. The difference in serum HCV-RNA concentration between complete and incomplete responders was more significant when measured by bDNA probe assay than by cRT-PCR. Moreover, only 1 of 26 patients with a HCV-RNA concentration of more than 1 x 10(6) eq/ml as measured by bDNA probe assay attained a complete response, while 19 of 28 patients with that of less than 1 x 10(6) eq/ml achieved it. Measurement of serum HCV-RNA concentration by bDNA probe assay was a better predictor of clinical response of IFN alpha therapy than measurement by cRT-PCR.

Effect of daily administration period of natural alpha-interferon in patients with chronic hepatitis C

OBJECTIVE

A randomized, controlled trial was performed to study the effect of the period of daily administration of interferon therapy in patients with chronic hepatitis C.

PATIENTS AND METHODS

Sixty-three patients were administered a total dose of 480 MU of natural alpha-interferon, 6 MU each day. In 32 cases, interferon was given daily for 2 wk, followed by intermittent administration (three times a week) for 22 wk. The other 31 patients received daily administration for 8 wk, followed by intermittent administration (twice a week) for 12 wk. The responses were based on the normalization of ALT and the clearance of hepatitis C virus.

RESULTS

Although ALT normalized in 37 patients during the administration of interferon, it relapsed after the end of interferon therapy in 20 patients. The other 17 patients achieved sustained normalization of ALT and clearance of hepatitis C virus RNA. Responses did not differ according to the administration period of interferon.

CONCLUSIONS

Prolonged daily administration did not improve the responses to interferon therapy when the total dose was the same.

Estimation of usefulness of N-butyl-2-cyanoacrylate-lipiodol mixture in transcatheter arterial embolization for urgent control of life-threatening massive bleeding from gastric or duodenal ulcer

We estimated the usefulness of a mixture of N-butyl-2-cyanoacrylate (NBCA) with lipiodol for transcatheter arterial embolization (TAE) used to control massive bleeding from gastric or duodenal ulcer. Thirty patients who had gastric or duodenal ulcers and massive bleeding that was uncontrollable by endoscopic procedures were included in this study. All patients were subjected to TAE (without NBCA in 23 and with NBCA in seven patients). Coils and/or gelfoam were also used. The achievement of haemostasis, occurrence of rebleeding and the time taken for TAE were compared between patients who received TAE without and with NBCA. Eighteen of 23 patients (78.3%) who received TAE without NBCA and six of seven patients (85.7%) who underwent TAE with NBCA achieved complete haemostasis without rebleeding. The time for TAE was significantly shorter in patients who received NBCA compared with those who did not (P = 0.0095). TAE using NBCA or a combination of NBCA and coils achieved a rapid, complete embolization regardless of vascular distribution or arterial diameter. Thus NBCA is considered to be useful as a secondary embolization material in TAE that is urgently conducted to control massive bleeding from gastric or duodenal ulcers.

Long-term administration of natural interferon-alpha in patients with chronic hepatitis C: relationship to serum RNA concentration, HCV-RNA genotypes, histological changes and hepatitis C virus

To virologically assess the efficacy of interferon therapy in chronic hepatitis C, either 5 or 10 MU/day natural interferon-alpha (IFN alpha) was administered to 57 patients with chronic hepatitis C for 38 weeks. A complete and sustained response (CR-SR), as evidenced by the absence of serum hepatitis C virus (HCV)-RNA during the administration period and at 6 months after the final administration of IFN alpha and normal GPT level at 6 months after final administration, occurred in 42.6% (23/54) of subjects. Liver tissue was histologically evaluated using the histological activity index (HAI) score before and after the administration period. In CR-SR cases, significant improvements (P < 0.01) occurred in periportal necrosis, intralobular necrosis, portal inflammation and total score. A comparison, by HCV genotypes, revealed that CR-SR occurred in 60% (9/15) of subjects with type 2a and 30.3% (10/33) of subjects with type 1b. A comparison by virus concentration revealed that CR-SR occurred in 71.4% (15/21) of those subjects having a virus concentration of < 10(5) copies/mL, but in only 24.2% (8/33) of those having a virus concentration of > 10(5) copies/mL. Analysis by a multiple logistic model revealed a strong correlation between the therapeutic effect of interferon therapy and the pre-administration virus concentration (P = 0.0061) and genotype (P = 0.0015). These results suggest that the pre-administration virus concentration and genotype are both key factors affecting the therapeutic effect of interferon therapy in chronic hepatitis C and that the therapeutic effect of interferon is satisfactorily high, irrespective of virus concentration, in subjects with type 2a HCV, but varies depending on virus concentration in subjects with type 1b.

[The clinical evaluation of hepatic arterial infusion chemotherapy in patients with liver metastases from colorectal cancer employing an implanted port system]

Between 1986 and 1994, 66 patients with unresectable liver metastases from colorectal cancer were treated by repeated hepatic arterial infusion chemotherapy employing an implantable port system. In this study, 44 patients who received intermittent hepatic arterial infusion of high dose 5-FU (1000mg/m2) were analysed according to a response rate, survival rates, developments of extrahepatic lesions, periods of hepatic arterial infusion, and the rates at home. Two cases (4.5%) achieved a complete response (CR) and 27 cases (61.4%) a partial response (PR). The overall one-year and two-year survival rates were 56.7% and 37.8% respectively. The 50% survival time for all patients was 17.2 months. During the course of observation, extrahepatic lesions developed in 16 of the 39 patients (41.0%) and many responders died due to deterioration of extrahepatic lesions. The over all rates at home were more than 85%. Hepatic arterial infusion of the 5-FU at 1000mg/m2 every week showed a high response rate in colorectal cancer patients with hepatic metastases, and the responders showed a low rate of death due to the hepatic metastases. However, in many patients the prognosis-determining-factor was extrahepatic lesions. Thus, countermeasures were necessary for extrahepatic lesions.

[The pharmacokinetics of the glycyrrhizin and glycyrrhetic acid after intravenous administration of glycyrrhizin for the patients with chronic liver disease caused by type C hepatitis virus]

Glycyrrhizin had been used widely for the patients with chronic liver disease. We examined the pharmacokinetics of the glycyrrhizin and glycyrrhetic acid in the blood stream after intra-venous administration of glycyrrhizin. The stream concentration of glycyrrhizin in the patients of liver cirrhosis tend to be kept higher than that of chronic hepatitis but there were no significant difference between them except for after a half hour from the administration. There was negative correlation between ICG R15 and the speed of excretion of glycyrrhizin from the serum. On the other hand, the concentration of the glycyrrhetic acid was kept higher in the patients with liver cirrhosis than that of chronic hepatitis, but there were no significant difference between them except for after a half hour from the administration. These findings suggested that the accumulation of glycyrrhizin and glycyrrhetic acid in the patients of liver cirrhosis can be seen by long term administration.

[A case of tricuspid regurgitation due to blunt chest trauma]

A case of tricuspid regurgitation due to blunt chest trauma is presented. A 35-year-old man was in good health until he sustained blunt chest trauma in a traffic accident 17 years ago (in 1972). After that easy fatiguability developed. In 1977, slight tricuspid regurgitation was detected, but he was clinically well and no treatment seemed necessary. In October 1989, he was admitted due to right heart failure. The chest X-ray film showed marked cardiomegaly and ECG revealed atrial fibrillation and complete right bundle branch block. Two-dimensional echocardiogram showed a flail anterior leaflet of the tricuspid valve and severe tricuspid regurgitation. In December 1989, he underwent tricuspid valve replacement with Carpentier-Edwards bioprosthesis. The chordae tendineae to the anterior leaflet of the tricuspid valve were ruptured. Furthermore, an artificial cardiac pacemaker was implanted because of slow atrial fibrillation. His postoperative course was uneventful.

[Clinical evaluation of a recurrent mode after treatment in patients with small hepatocellular carcinoma]

A total of 96 patients with small hepatocellular carcinoma (HCC) with a maximal diameter of below 2 cm were analyzed according to recurrent factors and recurrent modes after the first treatment. In this study, recurrences were divided into two groups based on the style of recurrences provisionally: intrahepatic metastases (IM, 35 cases) and multicentric recurrences (MC, 22 cases). In patients with IM, the majority of recurrences were observed within 2 years after the first treatment and the primary HCC lesions had strong relation to the degrees of malignancy. On the other hands, there were no association with recurrent intervals and the degrees of malignancy, although the recurrent rate was high in patients with anti-HCV in MC group. The prognosis after the second treatment in MC group was superior to that in IM group (p < 0.05). These results indicate MC group have a good prognosis if early detection and the second accurate treatment are performed.

Serum levels of soluble interleukin-2 receptor in chronic hepatitis C treated with interferon-alpha

BACKGROUND

Serum levels of soluble interleukin-2 receptor (sIL-2R) seem to serve as a marker for the activation of T lymphocytes. The aim of this study was to evaluate the clinical significance of such levels in patients with chronic hepatitis C (CHC) treated with interferon.

METHODS

We measured serum levels of sIL-2R in 37 patients with CHC before and after treatment with recombinant interferon-alpha. Serum receptor levels were then compared with the response of the hepatitis C virus (HCV)-RNA level in serum after interferon.

RESULTS

Receptor levels were significantly higher in the patients with chronic persistent hepatitis and chronic active hepatitis than in normal controls (p < 0.01). There was a weak correlation between serum sIL-2R and alanine aminotransferase (ALAT) levels (r = 0.14, p = 0.010). Patients were then classified into three groups on the basis of the effect of interferon treatment on HCV-RNA levels in serum: sustained response (SR; n = 21), non-sustained response (NSR; n = 14), and nonresponse (NR; n = 2). Before and during interferon treatment the serum sIL-2R level remained increased in the SR group and in the combined groups with NSR or NR. However, after interferon was withdrawn, the serum sIL-2R decreased in the SR group but remained significantly increased in the combined response group (p < 0.01-0.05).

CONCLUSION

This finding seems to reflect the disappearance of HCV-RNA from the serum of the patients with an SR, and monitoring of sIL-2R levels may therefore be of value as an adjunct to the measurement of serum ALAT and HCV-RNA in evaluating the response to the interferon therapy for CHC.

The efficacy of continuous local arterial infusion of 5-fluorouracil and cisplatin through an implanted reservoir for severe advanced hepatocellular carcinoma

There is not yet an effective standard therapy for severe advanced hepatocellular carcinoma (HCC). We attempted continuous local arterial infusion chemotherapy using 5-fluorouracil (5-FU) and cisplatin (CDDP) with an implanted reservoir for these patients, and evaluated its efficacy. Twenty-one HCC patients received continuous arterial infusion of 5-FU and CDDP for 1 week, followed by a 1-week no-infusion period; this regimen was repeated 1-32 times, and patients were observed for 36-549 days. The 1-year survival rate was 61.1%, and alpha fetoprotein levels decreased in 13 patients. All could continue as outpatients for 94.0% of the entire course of therapy. Because CDDP amplifies the effect of 5-FU as a biochemical modulator, and because continuous infusion strengthens the effect of 5-FU and reduces the side effects of CDDP, we consider this therapy to be effective for patients with severe advanced HCC, prolonging survival and improving the quality of life.

Treatment of chronic hepatitis C with interferon-alpha: sustained absence of hepatitis C virus RNA from serum after four courses of therapy

A patient with chronic hepatitis type C, confirmed by the detection of hepatitis C virus RNA (HCV RNA) in the serum and by histological examination of the liver biopsy specimen, was treated with four courses of interferon-alpha (IFN-alpha). For the first three courses of IFN-alpha the patient's serum alanine aminotransferase (ALT) level normalized during the administration of IFN-alpha but rose again after its cessation; similarly, HCV RNA was absent from the serum by the end of each course of treatment but could be detected once again after treatment stopped. The fourth course of IFN-alpha therapy, however, produced a sustained normalization of the ALT level and sustained absence of HCV RNA from the serum for 20 months after the end of treatment. This case suggests that patients with the potential for an eventual complete response to IFN-alpha therapy may show a normalization of serum ALT levels during IFN-alpha administration and the absence of HCV RNA in the serum by the end of each course of treatment (even if that particular course of treatment does not produce a sustained response).

[Mass-screenings for osteoporosis using computed X-ray densitometry (CXD): in a mobile unit]

The early diagnosis and treatment of osteoporosis is considered to be important for the prevention of fractures which often cause elderly to become bed-ridden. Computed X-ray densitometry (CXD), a method to measure bone mineral content in the metacarpus II utilizing a simple X-ray image, has been used for mass-screening of osteoporosis, because of its utility and reliability. However, due to its requiring adequate X-ray equipment, this method is often unsuitable for use in small facilities in a remote mountain areas. The use of CXD for osteoporosis screening, was attempted in a mobile unit for tuberculosis screening, by our public health center. The results showed that it is possible to use CXD in combination with a mobile unit, correcting the obtained values according to the radiographic conditions. With this set-up, CXD was used for mass-screening of osteoporosis in a total of 1150 subjects living in mountainous areas of Yoshino-gun, Nara prefecture, and CXD was found to be convenient and effective for mass-screening. The use of CXD in a mobile chest X-ray unit can be expected to be useful for mass-screening of osteoporosis especially in remote mountainous areas having inadequate X-ray equipment.

Transcatheter arterial embolization for massive bleeding from duodenal ulcers not controlled by endoscopic hemostasis

BACKGROUND AND STUDY AIMS

We evaluated the efficacy of transcatheter arterial embolization (TAE) in patients in whom endoscopic hemostasis of a massively bleeding duodenal ulcer failed.

PATIENTS AND METHODS

TAE was performed in 11 patients with endoscopically uncontrollable massively bleeding duodenal ulcers, and the results and long-time outcome were studied. Two additional cases of failed endoscopic hemostasis were treated surgically without TAE. The entire group of 13 patients represented 5% of endoscopically treated duodenal ulcers and 0.6% of all cases with upper gastrointestinal bleeding who underwent emergency endoscopy (n = 2073). All but one of these 13 patients had concomitant disease.

RESULTS

Arteriograms performed before TAE revealed extravasation of contrast material around the gastroduodenal artery (GDA), the anterior superior pancreaticoduodenal artery (ASPD), or the posterior superior pancreaticoduodenal artery (PSPD) in six of 11 cases. We failed to stop the bleeding in one patient, in whom only the common hepatic artery side of the GDA bleeding site was embolized; this patient died. TAE was successful in the other ten patients, in whom the long stretch of the GDA, including the ASPD and PSPD, was embolized around the bleeding site. Two surgically treated patients died within a week.

CONCLUSIONS

Our findings indicate that TAE may induce hemostasis in 90% of patients with serious concomitant diseases who have endoscopically uncontrollable massive bleeding from duodenal ulcers.

Impaired high-shear-stress-induced platelet aggregation in patients with chronic renal failure undergoing haemodialysis

We investigated shear-induced platelet aggregation (SIPA) in 30 patients with chronic renal failure (CRF) undergoing haemodialysis. 26 patients showed a significant decrease in SIPA at high shear stress but no change in SIPA at low shear stress. The former reaction reflects the interaction between plasma von Willebrand factor (vWF) and its platelet receptors, glycoprotein (GP) Ib-IX and IIb/IIIa complex, whereas the latter is assumed to involve the binding of plasma fibrinogen to GP IIb/IIIa complex. These SIPA profiles in CRF patients after haemodialysis showed almost no change compared to those before haemodialysis. The ratio of ristocetin cofactor/vWF antigen in plasma was slightly lower in CRF patients than in controls (P < 0.01). However, the level of GPIb antigen in the platelets of these patients was significantly reduced (42.1 +/- 20.3% of normal platelets), with partial destruction of GPIb antigen. The number of vWF receptors on the GPIb molecule was quantitated using the GPIb-binding protein alboaggregin-B (AL-B), purified from the snake venom of Trimeresurus albolabris. AL-B bound to GPIb at a total of 48,760 +/- 9944 molecules per normal platelet and a Kd of 85.44 +/- 15.70 nM at saturation. In contrast, binding in CRF platelets was 22,980 +/- 6395 molecules per platelet and Kd was 50.08 +/- 13.83 nM. Taking these results together, we conclude that the impaired SIPA found in CRF patients is due to both abnormalities in plasma vWF and in its platelet GPIb receptor.

Soluble P-selectin in the plasma of patients with connective tissue diseases

We measured the soluble P-selectin (sP-selectin) in plasma of 54 patients with connective tissue diseases and 12 normal controls by a 2-step sandwich enzyme immunoassay. Our purpose was 2-fold: to determine (1) whether the level of sP-selectin of such patients is higher than normal, and (2), if it is, whether it correlates with any of the laboratory data currently available. The mean levels in patients with systemic lupus erythematosus (SLE), mixed connective tissue disease (MCTD) and rheumatoid arthritis (RA) were 306, 1,048 and 844 ng/ml, respectively, compared with 220 ng/ml for controls. The mean levels in patients with SLE and nephropathy, MCTD and either nephropathy or thrombosis, and malignant RA were 351, 1,116 and 1,721 ng/ml, respectively. No correlation was found between the levels of sP-selectin and other laboratory data (WBC, CRP, ESR, antinuclear antibody, RF, aCL) except the number of platelets (y = 0.057, r = 0.37). In the clinical course of patients with lupus nephritis and MCTD with nephropathy, sP-selectin became a sensitive parameter. Thus, the level of sP-selectin is higher than normal in patients with connective tissue diseases, especially when complications exist, and it does not correlate with any of the laboratory data currently available except the number of platelets. Measurement of sP-selectin levels should be included in the laboratory tests of patients with connective tissue diseases, especially when complicated by nephropathy or thrombosis.

Retreatment of chronic hepatitis C with interferon

OBJECTIVE

We analyzed the retreatment of chronic hepatitis C with interferon to get the standpoint for the selection of patients to receive it.

METHODS

A complete response was defined as continuous normalization of the serum alanine aminotransferase (ALT) level and continuous disappearance of serum hepatitis C virus RNA (HCV-RNA) during interferon administration and more than 6 months after. Patients without complete response were classified as noncomplete responders. From August 1990 to May 1993, we retreated 23 noncomplete responders on initial treatment with interferon and studied the factors that alter the effectiveness.

RESULTS

Complete response was achieved in eight (34.8%) patients; the other 15 patients did not achieve this degree of response. Three patients were of genotype II and five were of genotype III in these eight complete responders. All complete responders were patients with relapse who had had normalized serum ALT levels during the initial administration and undetectable HCV-RNA at the end of the period. No patient who failed to achieve normalization of the serum ALT level on initial treatment achieved a complete response on retreatment. HCV-RNA concentrations before retreatment were significantly less than before initial treatment in the eight complete responders.

CONCLUSION

Interferon retreatment of patients who do not achieve a complete response may be effective in relapsed cases with undetectable HCV-RNA at the end of initial treatment. Selection of patients to receive interferon retreatment requires careful review and consideration of genotype, HCV-RNA concentration, and the clinical response on initial treatment.

[Analysis of methods of administration on local arterial infusion chemotherapy for severe advanced hepatocellular carcinoma]

Between 1986 and 1994, hepatic local arterial infusion chemotherapy with implanted reservoir was performed for 51 patients with hepatocellular carcinoma (HCC) who were not indicated for surgery, PEIT and/or TAE because of the advanced stage of tumors and impaired liver function. We compared direct effects, survival rates, and rates of outpatients by dividing these 51 patients into 3 groups according to the methods of administration--repeated one-shot arterial infusion group, continuous arterial infusion group and intermittent high-dose arterial infusion group. There were no significant differences among these three groups in terms of background factors. The continuous infusion group had significantly better survival rates than the repeated one-shot infusion group, and the survival rate of the intermittent high-dose infusion group was similar to that of the continuous infusion group, although there were no significant differences in effectiveness among the three groups. Patients in the continuous infusion group and intermittent high-dose infusion group could receive almost all of their treatment as outpatients. Furthermore, more patients in the intermittent high-dose infusion group could receive whole treatment without hospitalization than patients in the continuous infusion group. Because intermittent high-dose arterial infusion of 5-FU showed about the same survival rate as continuous arterial infusion and because it can maintain high quality of life, it is suggested to be a standard method for local arterial infusion of 5-FU for severe advanced HCC.

[Two cases of asymptomatic primary biliary cirrhosis (PBC) accompanied with CREST syndrome]

Two cases of asymptomatic primary biliary cirrhosis (PBC) combining CREST syndrome. We have had encountered two primary biliary cirrhosis (PBC) patients overlapped with CREST syndrome. Case 1 was a 51-year-old female, who was suffering from Raynaud's phenomenon, esophageal dysmotility and sclerodactyly. Case 2 was a 67-year-old female, who was suffering from Raynaud's phenomenon, esophageal dysmotility, sclerodactyly and telangiectasia. They were free from itching and icterus. The histology of their biopsied liver specimen should stage I-II of Scheuer's classification. Their immunological findings showed anti-centromere antibody, (ACA) at a high titer (1 : 1280 dilution) and anti-mitochondrial antibody (AMA) at a low titer (1 : 40 dilution) positive in both. HLA DR types included DR2 and DRW8 in case 1, and did DR1 and DRW6 in case 2. Both patients are having good prognosis.

[A case of systemic lupus erythematosus in late component (C9) complement deficiency]

We report on a case of C9 deficiency followed by the onset of systemic lupus erythematosus (SLE). A 51-year-old female patient had suffered from repeated urinary tract infections since 1977. In 1980, at 41 years of age, she had proteinuria and facial erythema along with low level of CH50 less than 12.0 U/ml. She was diagnosed as C9 deficiency (C9D) because of C9 protein less than 0.5 mg/dl, C9 activity 0.03% and C8 activity 94% and also SLE was strongly suspicious. Subsequently, she suffered from repeated urinary tract infections. In 1990, she was diagnosed as SLE because of pleuritis, pericarditis and positive anti-nuclear (1:640) and positive anti-DNA antibody (28.0 U/ml) in addition to proteinuria and facial erythema. From the family study, her two sisters showed homozygous C9D (less than 0.5 mg/dl) with hypergammaglobulinemia (2290 and 2230 mg/dl, respectively) and positive anti-nuclear antibody (1:80) in both. Her father also showed heteropygous C9D (1.7 mg/dl) with anti-nuclear antibody (1:640). These results suggest that healthy carriers of C9D may have some abnormalities in humoral or cell-mediated immunity. The possibility was thought that other unrecognized disease associated loci exist in linkage with the C9 allele like that of C4D was speculated. And repeated infections due to C9D may possibly induce B cell activation followed by the occurrence of SLE or related disorders. This case seems to be very valuable with respect to the onset of SLE under a long-term observation of C9D.

[Clinical study of continuous local arterial-infusion chemotherapy for severely advanced hepatocellular carcinoma (HCC) using reservoir]

We attempted continuous local arterial-infusion chemotherapy using reservoir for patients with severely advanced hepatocellular carcinoma (HCC), with no indications for operation, PEIT or TAE because of the advanced clinical stage, Vp-factor, and so on. Twenty-two HCC patients were given continuous arterial-infusion of 5-FU + CDDP and were observed for 36-443 days from June, 1991 to December, 1992. Until the end of 1992, we had 3 partial response (PR) cases and 3 progressive disease (PD) cases, and the other cases showed no change (NC). Except for a case in which therapy was stopped because of renal failure, no patients were disturbed by side effects, and 68.2% of the patients completed all of their therapy as outpatients. Because CDDP can amplify the effect of 5-FU in addition to its own effect as a biochemical modulator, and because continuous infusion can strengthen the effect of 5-FU and reduce the side effects of CDDP, we consider continuous local arterial-infusion of 5-FU and CDDP to be an effective therapy for severely advanced HCC. This treatment does not cure the carcinoma but helps to slow its progress and assure good QOL.

[The study of continuous local arterial-infusion chemotherapy with 5-FU + CDDP for patients with severely advanced HCC--for the elongation of the life-span and the improvement of QOL]

We tried continuous local arterial-infusion chemotherapy using 5-FU + CDDP with an implanted reservoir, for patients with severely advanced hepatocellular carcinoma (HCC), who had no indications for operation, PEIT or TAE. Arterial-infusion was continued for one week, followed by a one-week no-infusion period, and this treatment was repeated 1-32 times, and patients were observed for 36-549 days. Until the end of April 1993, the one-year survival rate was 61.1%. There were 3 partial remission (PR) cases, 3 progressive disease (PD) cases and the other cases showed no change (NC). Only one patient had any side effects, and all could continue as outpatients for 94.0% of the entire therapy. The patients' evaluation of QOL revealed no differences of QOL according to the length of the whole therapy, the history of rehospitalization during therapy, response to therapy, etc. But PR cases tended to show improved QOL. Therefore we considered this as effective therapy for the elongation of the life-span and the improvement of QOL.

[Hormone therapy of tamoxifen in resected carcinoma of the pancreas]

Greenway et al reported estrogen receptor existed in the carcinoma of the exocrine pancreas in 1981. We followed the study by using immunohistochemical method with monoclonal antibody ER-D5 (Amersham) and found high levels of estrogen receptor in 21 cases out of 27 carcinomas of the pancreas (77.8%). Furthermore, we gave randomly the hormone therapy by Tamoxifen 20 mg per day adding to immuno-chemotherapy (Tegaful, Mitomycin, Krestin, OK-432) to the patients with resected carcinoma of the pancreas. There was no significant difference of the survival rate of pancreatic carcinoma without hormone therapy between 10 cases with estrogen receptor and 4 cases without estrogen receptor at the 6th month and 12th month. However, in cases treated by Tamoxifen, remarkable high survival rate at 12 months of 11 cases with estrogen receptor was obtained to be 85.7% according to Kaplan-Meier method. Two cases without estrogen receptor died within 5 months. One year survival rate of Tamoxifen group (13 cases) was 78.6% and that of non Tamoxifen group (14 cases) was 21.4%. These findings indicated that estrogen receptor existed at the high level in the carcinoma tissues of the pancreas and anti-estrogen treatment might offer a new approach to the treatment of pancreatic carcinomas.