The differential diagnosis of pancreatic cysts by MR imaging

BACKGROUND/AIM

The usefulness of magnetic resonance imaging (MR imaging) in the differential diagnosis of cystic lesions of the pancreas was assessed.

METHODS AND MATERIALS

Pseudocyst was present in 9 patients, retention cyst in 4, simple cyst in 2, serous cystadenoma in 1, mucinous cystadenoma in 6, mucinous cystadenocarcinoma in 6. The relative signal intensity (SI) of each cystic lesion on MR imaging was assessed in comparison with that of the liver.

RESULTS

It was difficult to distinguish the cystic types from each other based on the SI on MR images. Insofar as mucinous cystic tumors, those containing gelatinous mucin showed higher SI on T1-weighted images than those containing mucinous but watery fluid. five of the 6 mucinous cystic tumors containing gelatinous mucin were histologically malignant, whereas all except one those containing watery fluid were benign.

CONCLUSIONS

Our results suggest that the SI on T1-weighted images may be useful in distinguishing malignant from benign mucinous cystic tumors.

Echo-Doppler evaluation of reverse flow sign in the intrahepatic portal branches after surgery

OBJECTIVE

The author's evaluated the clinical significance of the development of reversed portal flow after abdominal surgery other than portosystemic shunt procedure.

SUMMARY BACKGROUND DATA

There have been several reports in regard to reversed portal flow demonstrated by pulsed Doppler ultrasonography, most of which were related to portal hypertension. To the authors' knowledge, this is the first report in which reversed portal flow also is present in patients who have undergone abdominal surgery other than portosystemic shunt procedure.

METHODS

Preoperative and postoperative pulsed Doppler ultrasonographic examinations were performed in 126 patients who underwent abdominal surgery. Postoperatively, the portal flow direction was assessed in the right portal branch or the umbilical portion of the left portal branch.

RESULTS

Of the 126 patients, reversed portal flow developed in 10 after surgery; 9 of them died of liver failure.

CONCLUSIONS

The postoperative development of reversed portal flow is considered to have grave prognostic significance, indicating that the degree of postoperative liver damage is extremely critical.

Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency, duct size, and leakage

BACKGROUND

A soft pancreas with a main pancreatic duct (MPD) with normal diameter has been considered a high risk for pancreatic anastomotic leakage because of a relatively high output of pancreatic juice, but data are lacking.

METHODS

An attempt was made to assess the relationship between the consistency of the pancreas, MPD diameter, pancreatic juice output, and pancreatic leakage after partial pancreatoduodenectomy. The pancreatic parenchyma was classified as of soft, intermediate, and hard consistency in 70 consecutive patients undergoing operation (groups 1, 2, and 3, respectively) by one surgeon. The MPD diameter was determined by means of endoscopic pancreatography or abdominal ultrasonography. Pancreatic juice output was measured for 21 days after operation by using a catheter inserted into the MPD. Anastomotic leakage was identified radiologically by using contrast medium.

RESULTS

The mean (SD) pancreatic juice output during a period of 10 days (postoperative days 5 to 14) was 1554 (1073) ml in group 1 (n = 29), 1513 (1060) ml in group 2 (n = 13), and 187 (220)ml in group 3 (n = 28) (groups 1 and 2 versus group 3, p < 0.0001). The MPD diameter was 3.0 (1.6) mm in group 1, 5.9 (2.5) mm in group 2, and 6.6 (2.6) mm in group 3 (group 1 versus groups 2 and 3, p = 0.0001). Anastomotic leaks occurred in four (14%) patients in group 1, three (23%) in group 2, and none in group 3 (p < 0.05).

CONCLUSIONS

Patients with a pancreatic parenchyma with an intermediate or normal consistency produced more pancreatic juice and had a higher leak rate.

Flunitrazepam effects on human sleep EEG spectra: Differences in NREM, REM and individual responses

Flunitrazepam (FNZ) (4mg), an intermediate type benzodiazepine (BDZ) hypnotic, was administered orally to five healthy male subjects (Ss) for seven consecutive nights. Sleep EEG from the baseline night (BLN), the initial drug night (IDN), the fourth and the seventh drug nights (4DN, 7DN) was subjected to fast Fourier transform (FFT) analysis. During NREM sleep of 4DN and 7DN the sigma band (11.0-12.5 Hz) activity was similarly enhanced in every S. In REM of 4DN and 7DN beta band (23.0-29.0 Hz) was enhanced, but with larger variations among Ss. High intra-individual consistency of the relative EEG power patterns on 4DN and 7DN was observed. These results suggest that 1) EEG responses to FNZ are different in sleep states; explorations of these differences may provide better understandings of sleep mechanisms, and 2) individual variations in EEG responses may reflect individual variations of the BDZ receptor system. These methods may be useful for exploring receptor changes in neuropsychiatric disorders.

Cervical osteoplastic laminotomy using autogenous bone

Cervical foraminotomies are performed from the fifth to the eighth cervical nerve roots on both sides. On the side with more marked radiculopathies the laminae are osteotomized to the full extent, but not so completely on the other side. The mass of laminae from C-3 to C-7 is lifted up using the incompletely severed side of the laminae as the fulcrum. The removed spinous processes of C-6 and C-7 are adjusted and fixed between the articular joints and the lifted laminae from C-4 to C-6. This procedure prevents extradural scar formation, there are no complications caused by foreign bodies, postoperative neuroimaging is possible because no metallic artifact is formed, and extensive decompression is achieved for the cervical cord and nerve roots.

[Enzyme immunoassay of drug in blood (serum)]

Antiepileptic drugs, cardiac glycosides (digoxin, etc.), theophylline, antiarrhythmic agents (quinidine, procainamide, lidocaine, etc.) and aminoglycosides have narrow therapeutic range and large interindividual variations have been reported for their pharmacokinetics. Therefore, to obtain the appropriate therapeutic effects without undesirable effects, monitorings of above drug concentrations are useful (therapeutic drug monitoring). There are many assay methods (high-performance liquid chromatography, immunoassay, enzyme immunoassay, etc.) to determine drugs in serum. In those assays various enzyme immunoassays, enzyme-multiplied immunoassay technique (EMIT), enzyme-linked immunosorbent assay (ELISA), apoenzyme reactivation immunoassay (ARIS), radial partition immunoassay (RPIA), etc., are developed and widely used in many clinical laboratories. These assay systems offer convenience and great rapidity of assay and satisfactory accuracy and reproducibility but lack a little specificity of antibody.

Increased in vitro and in vivo tumoricidal activity of a macrophage cell line genetically engineered to express IFN-gamma, IL-4, IL-6, or TNF-alpha

Genetically engineered monocytes and macrophages may have potential as effector cells for the adoptive immunotherapy of cancer. As a first step, we have transfected the genes encoding either mouse interferon (IFN)-gamma, human interleukin (IL)-6, mouse IL-4, or mouse tumor necrosis factor (TNF)-alpha into the mouse macrophage cell line, J774A.1 cells using retroviral vectors. In vitro activation of J774A.1 cells by gene modification was assessed by morphological changes, proliferative activity was determined by [3H]-TdR uptake, and cytolytic activity was assessed using an 18-hour chromium-51 (51Cr) release assay. In vivo tumoricidal activity was studied by means of local adoptive immunotherapy using intratumoral injection of transfected effector cells. IFN-gamma gene-transfected J774A.1 [J7(IFN-gamma)] cells developed filamentous processes, increased doubling times, and enhanced tumoricidal activity against three tumor cell lines: the TNF-sensitive fibrosarcoma line WEHI 164 and the TNF-alpha-resistant cell lines B16 melanoma and C1300 neuroblastoma. IL-6-, TNF-alpha-, and IL-4-gene-transfected J774A.1 cells also had augmented tumoricidal activity but did not display any changes in morphology or growth. Cytolytic activity was markedly reduced after the addition of anti-TNF-alpha antibodies. Cytolytic J7(IFN-gamma) cells showed upregulated expression of TNF-alpha messenger RNA. After intratumoral injection of J7(IL-4) and J7(IFN-gamma) cell mixtures, 50% of established B16 melanomas were rejected by C57BL/6 mice, thereby demonstrating synergistic killing. Further studies on gene-transfected macrophages should better define their potential usefulness in tumor immunotherapy.

Event-related changes of background electroencephalogram during contingent negative variation paradigm

The autoregressive model was applied to the background electroencephalogram during the tone(S1)-tone(S2)-respond contingent negative variation paradigm under eyes-open condition. The EEG data were obtained at the scalp sites of Fz, Cz, and Pz in seven normal males. During the first half of the interstimulus interval (ISI) of 2.5 s, Fz-dominant excitatory process was suggested in concordance with an orienting response to stimulus 1. In the second half of the ISI, Pz-dominant inhibitory process was considered. The stimulus 2 presentation and the required motor response promoted the Pz-dominant process.

Adenosquamous carcinoma of the gall-bladder with gastric foveolar-type epithelium

An 80 year old Japanese man had adenosquamous carcinoma of the gall-bladder characterized by an adenocarcinoma (AC) in the gall-bladder lumen and a squamous cell carcinoma (SCC) in the invaded region of the liver. In the AC, the tumor cells consisted of atypical columnar epithelium with pseudostratification, mimicking gastric foveolar epithelium, while atypical signet-ring cells were scattered within the SCC. There was an abrupt transition between the AC and SCC areas. The tumor cells in the AC area were intensely positive for galactose oxidase-Schiff staining, and paradoxical concanavalin A staining revealed these tumor cells to have Class II mucins. Immunohistochemically, the tumor cells in foveolar-type adenocarcinoma were diffusely positive for cathepsin D. Flow cytometrical analysis of DNA content showed the AC area to be diploid and the SCC area to be aneuploid. The S-phase fraction of the SCC area (46.9%) was larger than that of the AC area (19.5%). The positive rate of immunostaining for proliferating cell nuclear antigen in the SCC area (mean 50.627%) was larger than that of the AC area (mean 3.048%, P < 0.01). These results suggest that the AC area of this tumor, histochemically and immunohistochemically, showed gastric foveolar-type characteristics, the SCC component was squamous cell metaplasia of the pre-existing AC, and that the SCC area had a greater proliferating capacity than the AC area.

[A case report of a metaplastic carcinoma of the breast diagnosed by the preoperative needle biopsy]

A case of the metaplastic carcinoma, a rare type of the breast cancer, was reported. A 49-year-old woman noticed the left breast lump. Ultrasonography revealed a well circumscribed hypoechoic mass measuring 3 cm in diameter. The preoperative needle biopsy showed the invasive carcinoma with chondrometaplasia. The modified radical mastectomy along with the lymph node dissection was performed. There have been few reports of the metaplastic breast carcinoma diagnosed preoperatively.

Relationship between peripheral portal blood flow and liver function in patients with liver cirrhosis. Pulsed Doppler ultrasonographic study

BACKGROUND

The relationship between portal hemodynamics and liver function in patients with liver cirrhosis remains unclear.

METHODS

Using pulsed Doppler ultrasonography, we investigated portal hemodynamics in the trunk and the intrahepatic peripheral vessels and its relation to liver function in cirrhotic patients.

RESULTS

The portal blood flow in the right anterior branch (RAB) in cirrhotic patients (n = 40) was significantly lower (p < 0.01) than that in normal subjects (n = 40). In the cirrhotic patients the portal blood flow in the RAB was significantly correlated with the values of serum albumin, total bilirubin, cholesterol, cholinesterase, prothrombin time, and ICG R-15, and that in group C (Child's grading) was significantly decreased (p < 0.01) compared with that in group A. No such difference was found in the main portal vein, the right posterior branch, or the umbilical portion of the left portal vein.

CONCLUSIONS

The decrease in blood flow in the RAB is closely related to the impairment of liver function in cirrhotic patients.

[Carpal tunnel syndrome: clinical experience of 61 cases]

Carpal tunnel syndrome (CTS) is the most frequent entrapment neuropathy. Appropriate diagnosis and therapy contribute to obtaining good results. We performed carpal tunnel release in 61 patients including 8 cases with chronic renal failure. They included 18 males and 43 females. Age distribution was from 28 to 76 years of age among the males, and from 29 to 82 years of age among the female patients. Bilateral operations were performed in 13 cases (male 5, female 8). Operations were carried out with local anesthesia in all cases except one. The skin incision was about 5 cm on the palmar skin. Hypertrophy of the transverse carpal ligament was found in all cases, with a thickness of 4 mm on the average. Usually, the ligament was as hard as gum in consistency. There were also hypertrophy of the subcutaneous connective tissue and palmar aponeurosis or aberrant muscle in some cases. In CTS following long-term hemodialysis for chronic renal failure, the ligament was very hard and appeared to be partly calcified. All patients improved clinically after the operation. We should understand the characteristic clinical symptoms and signs of CTS. Clinical worsening was prominent at night and/or early in the morning. Definite diagnosis was performed by electrophysiological means. Operative indications are 1) cases whose daily activities are disturbed due to severe symptoms with progressive aggravation, 2) cases with muscle weakness in the distribution of the median nerve, 3) cases with thenar atrophy, 4) cases which, electrophysiologically, are suspected of demyelination of the median nerve. As there were many unpredictable anomalies and variations among the lesions, correct decompression of the median nerve under direct vision is necessary during surgery.

Decreased cyclosporin A absorption after treatment with GoLytely lavage solution in rats

Recently we observed a case in which the cyclosporin A absorption decreased after treatment with GoLytely lavage solution in a kidney transplant patient. In this study, we confirmed the decrease of the blood concentration of cyclosporin A after oral administration by GoLytely (Macrogol 3350) based on experiments with rats. The peak blood cyclosporin A concentration, and the area under the blood drug concentration-time curve from 0 to 24 h in the GoLytely-administered group were significantly lower than the control group. In the case of gastrointestinal dysfunction such as diarrhoea, or in treatment with laxatives such as GoLytely lavage solution, whole blood cyclosporin levels must be carefully monitored, and intravenous cyclosporin A may be more suitable for providing adequate immunosuppression.

Three synchronous carcinomas of the papilla of Vater, common bile duct and pancreas

Multiple carcinomas of the pancreatico-biliary tree are rare. A 53 year old Japanese man was diagnosed as having an adenocarcinoma in the papilla of Vater. During the operation, he was also found to have a polypoid mass in the common bile duct. While cutting the operative specimen into stepwise sections, a small tumor was also detected incidentally in the main pancreatic duct of the pancreatic head. Histologically, all three tumors proved to be papillary adenocarcinomas and were restricted to the mucosa. Immunohistochemically, all three tumors were positive for carcinoembryonic antigen, carbohydrate antigen 19-9, chromogranin A and serotonin, while they were negative for somatostatin. Immunoreactivity to the tumor suppressor gene p53 protein (PAb 1801) was found in all three tumors. A flow cytometric analysis of the cellular DNA content revealed all three tumors to be aneuploid. The above results suggested that these three tumors from different sites all had the same histological, immunohistochemical and flow cytometrical characteristics.

Adenosquamous carcinoma of the gallbladder: a clinicopathological, immunohistochemical and flow-cytometric study of twenty cases

Twenty patients (7.4%) with adenosquamous carcinoma of the gallbladder were selected from 271 surgically resected gallbladder cancers. The 20 patients were composed of 8 men and 12 women with a mean age of 66.9 years. Histologically, all twenty tumors showed an abrupt transition between the adenocarcinoma (AC) and squamous cell carcinoma (SCC) areas, and well differentiated AC was also found in the peripheral area of the tumor. A histochemical and immunohistochemical study using alcian blue, periodic acid-Schiff, cytokeratins, involculin and tissue polypeptide antigen disclosed a different nature of the two components. DNA heterogeneity between the components was detected in 5 of 7 cases by flow cytometry. The positive rate of immunostaining for proliferating cell nuclear antigen in the SCC areas (mean 20.55%) was larger than that of the AC areas (mean 11.40%) (P = 0.0029), which indicated that the SCC areas had a greater proliferative capacity than AC areas. These results suggest that the SCC component of adenosquamous carcinoma of the gallbladder arose by a stepwise molecular progression of the pre-existing AC. Furthermore, the prognosis of adenosquamous carcinomas of the gallbladder (mean survival: 10 months) in the advanced stage (pTNM 2-4) was less favorable than those of papillary and well differentiated AC (mean survival: 99 months and 86 months) (P < 0.0001).

Small-cell carcinoma combined with adenocarcinoma of the gallbladder. A case report with immunohistochemical and flow cytometric studies

A small-cell carcinoma combined with adenocarcinoma of the gallbladder was detected in a 71-year-old Japanese woman. A nodular mass measuring 4.0 x 5.0 cm was located in the fundus of the gallbladder, in which a tiny depressed lesion measuring 2 mm in diameter was macroscopically and stereomicroscopically observed. Histologically, the depressed area revealed small-cell carcinoma that consisted of atypical cells with small, round to oval nuclei and scanty cytoplasm and was surrounded by ordinary well-differentiated adenocarcinoma. Immunohistochemically, the tumor cells in an adenocarcinomatous area were diffusely positive for carcinoembryonic antigen and showed an interspersed positivity to serotonin and gastrin, while the tumor cells in the small-cell carcinoma area were negative for both antigens. The nuclear DNA content of the tumor cells of both components was aneuploid; however, the first G0/G1 peak of the small-cell carcinoma was much smaller than that of the adenocarcinoma. These results indicated that the tumor revealed a divergence in functional differentiation, and this feature suggested an initial phase of composite small-cell carcinoma and adenocarcinoma in the gallbladder.

Biomechanical studies on shape effect of hydroxyapatite artificial root upon surrounding jawbone

To study the shape effect upon surrounding tissue of artificial dental root made of synthetic hydroxyapatite, this paper deals with the numerical analysis of the artificial root on functioning jawbone with the aid of the finite element method (FEM). The stress distribution around artificial roots in the shape of a cylinder, a cone, and three types of corrugated cone, including the newly tailored type implanted in the mandibular molar region, was analyzed in the plane strain state. The numerical results showed that the stress distribution was sensitive to the artificial root shape, and that the stress state was distributed in mitigatory way around the roots of the newly tailored form. The pattern of osteogenesis in the animal experiment and the finite element analysis (FEA) pattern showed a close correlation. Osteogenesis was assumed to occur in the weak or moderate stress distribution zone. The principal stress trajectory pattern in the lamina dura around the tailored artificial root was indicated as being either parallel or normal to the root surface. From this study, the biomechanical property of the tooth can be identified as a vehicle of mastication forces which disperse stresses moderately and equally upon surrounding tissues. Also, the periodontal ligament can be identified as a converting system of principal stress trajectories.

Undifferentiated spindle cell carcinoma of the gallbladder: a clinicopathologic, immunohistochemical, and flow cytometric study of 11 cases

Eleven primary spindle cell carcinomas (SpCCs) of the gallbladder are reported. They occurred in eight women and three men ranging in age from 59 to 80 years (mean age, 66.5 years). Histologically, the tumors showed interlacing bundles of atypical spindle cells with eosinophilic cytoplasm, oval to elongated nuclei, and conspicuous nucleoli. Eight SpCCs contained tiny foci of neoplastic glands similar to those seen in adenocarcinoma, and two of these cases also had small foci of neoplastic squamous epithelium. A gradual transition between the squamous cell carcinoma and the spindle cell component was observed in one tumor. Immunohistochemically, all SpCCs were positive for at least one of the epithelial markers (epithelial membrane antigen, nine cases; AE1/AE3, nine cases; carcinoembryonic antigen, three cases; and EAB 903, one case), and the tumor cells also were immunoreactive to mesenchymal marker (vimentin, eight cases), muscle markers (alpha-smooth muscle actin, one case; desmin, one case), and histiocytic marker (HAM 56, one case). Abnormalities in tumor suppressor gene p53 expression also were found in two of the 11 SpCC cases using monoclonal antibody PAb 1801. In six cases for which data were available flow cytometry revealed aneuploidy in three SpCCs (50%). The survival curve of the SpCC cases (mean survival, 9 months) was less favorable than that of 224 cases of adenocarcinoma of the gallbladder (mean survival, 81 months) (P = .0011). These results indicate that SpCC of the gallbladder is an epithelial tumor with sarcomatoid components and its prognosis is unfavorable.

Intraductal papillary neoplasm of the pancreas

BACKGROUND

In 1989, Morohoshi et al. reported an intraductal papillary neoplasm of the pancreas (IPNP), which was a morphologically distinct, but rare tumor.

METHODS

Two cases with IPNP were analyzed by immunohistochemical and DNA flow cytometric methods.

RESULTS

The patients included a 67-year-old man and a 71-year-old woman. Both tumors were characterized by a well-defined papillary growth in the cystically dilated main pancreatic ducts, associated with papillary and nonpapillary hyperplasia. Immunohistochemically, the tumor cells of both cases were positive for the epithelial markers (AE1/AE3 and CAM 5.2), and in one of the two cases, the tumor cells and hyperplastic cells surrounding the tumor conspicuously revealed multiple hormonal markers such as serotonin, somatostatin, glucagon, gastrin, and pancreatic polypeptide. The nuclear DNA content of the tumor cells of the first case, which showed moderate cellular atypia, was considered to be diploid, whereas that of the second case, which revealed severe atypia, was aneuploid.

CONCLUSIONS

These results suggested that these tumors arose from multipotential stem cells capable of epithelial and neuroendocrine differentiation, and results of the flow cytometric study was related to the degree of cellular atypia of the tumors.

"CT angiogram sign" in obstructive pneumonitis and pneumonia

OBJECTIVE

The "CT angiogram sign" in dynamic pulmonary CT consists of enhanced branching pulmonary vessels in a homogeneous hypoattenuating consolidation of lung parenchyma and is reportedly useful for diagnosing lobar bronchioloalveolar cell carcinomas.

MATERIALS AND METHODS

To identify cases exhibiting the CT angiogram sign, we retrospectively reviewed the reports of 5,500 dynamic incremental CT examinations of the chest.

RESULTS

We identified the CT angiogram sign in five patients with obstructive pneumonitis due to lung tumors and four patients with pneumonias.

CONCLUSION

The CT angiogram sign can be observed in pulmonary consolidation of varying etiologies.

Papillary cystic tumor of the pancreas. Is it a hormone-dependent neoplasm?

In order to attempt to examine the question of whether papillary cystic tumors (PCT) of the pancreas represent a hormone-dependent neoplasm or not, three cases of PCT were biochemically and immunohistochemically investigated. The patients included a 27-year-old man, a 14-year-old girl and a 21-year-old female. Two of the three patients showed measurable biochemical levels of progesterone receptor in the tumors by the dextran-coated charcoal (DCC) method, and an immunohistochemical study revealed that the nuclei of the tumor cells in all the three cases were diffusely positive for progesterone receptor. In the literature, there have been more than 300 female patients of PCT with a significant minority of only twenty male patients, and the mean age of the cases with PCT in men (31.4 years old) is higher than that in women (25.5 years old) (P < 0.05). These results therefore suggest that PCT is a sex hormone-dependent neoplasm.

Papillary cystic tumours of the pancreas: an analysis by nuclear morphometry

Papillary cystic tumour (PCT) is a rare, low-grade malignant pancreatic neoplasm, in which the histological criteria for malignancy are still uncertain. We performed a histological examination of 3 metastasizing PCTs, while comparing them with 18 non-metastasizing PCTs, using a computed image analyser. The mean maximum nuclear diameter, the mean standard deviation (SD) of the nuclear diameter, the mean nuclear area and the nuclear-nonnuclear (N/NN) ratio obtained by the image analyser of the metastasizing PCTs (7.23 microns, 2.21 microns, 30.45 microns2, 36.41%) were all significantly larger than those of the non-metastasizing PCT (6.34 microns, 1.59 microns, 23.66 microns2, 23.74%; P < 0.005, P < 0.005, P < 0.005, P < 0.001 respectively). However, there were no statistical differences in either the nuclear ellipsoidity or nuclear regularity. These results suggested that nuclear morphometry might be a useful parameter to define metastatic potential, in addition to histological variables such as venous invasion, nuclear grade and mitotic rate.

Carcinoma of the ampulla of Vater

A consecutive series of 36 Japanese patients with ampullary carcinoma who underwent a pancreatoduodenectomy at the Department of Surgery I, Kyushu University Hospital during the past 20 years were reviewed clinicopathologically to study prognostic factors. A univariate generalized Wilcoxon test showed that preoperative serum carcino-embryonic antigen (CEA) concentration, venous invasion, lymphatic permeation and perineural invasion were significant parameters. A multivariate Cox regression analysis showed that venous invasion was the only significant variable. In a sequential serum CEA follow up of 10 patients, an elevation of serum CEA levels was seen to correspond to the clinical development of a recurrence in six, while a high concentration of serum CEA was not evident despite the clinical manifestation of a recurrence in two, and serum CEA levels remained within the normal limits with no evidence of a recurrence in two others. According to the death certificates of 15 patients, where an exact site of metastasis was available, 11 died from liver metastasis, three from lung metastasis and one from peritoneal dissemination. These findings support the theory that a histologic invasion of the venous space is an independent prognostic factor and close attention should be paid to any signs of haematogenous metastasis, such as to the liver and lung, as well as to a serial serum CEA follow up.

Papillary cystic tumors of the pancreas. Assessment of their malignant potential

BACKGROUND

Although the biologic characteristics of papillary cystic tumors (PCT) generally indicate a good prognosis, a malignant form has been reported.

METHODS

Twenty-two examples of PCT were examined to assess their malignant potential by histologic, flow cytometric, and immunohistochemical studies.

RESULTS

Three had hepatic, peritoneal, and/or lymph node metastases (metastasizing tumors [MT]); the other 19 PCT had no such metastatic features (nonmetastasizing tumors [NMT]). Venous invasion was detected in all three MT and two NMT. Compared with the 19 NMT, the MT had a higher nuclear grade and more prominent necrobiotic nests characterized by aggregates of cells with pyknotic nuclei and eosinophilic cytoplasm. In the flow cytometric analysis of cellular DNA content, one MT was aneuploid, and eight NMT were diploid. Immunohistochemically, there was no difference between the MT and NMT.

CONCLUSIONS

These results support the assumption that venous invasion, nuclear grade, and prominent necrobiotic nests are useful as histologic parameters to detect the malignant potential of PCT.

The effects of liver and renal disease on stereoselective serum binding of flurbiprofen

Stereoselectivity in the serum binding of flurbiprofen, a non-steroidal anti-inflammatory drug which is highly bound to albumin, was studied in patients with liver and renal disease. Subjects with renal disease or liver disease with ascites had significantly lower serum albumin concentrations than normals, resulting in higher free fractions of both the R(-) and S(+) enantiomers of flurbiprofen as determined by equilibrium dialysis. The ratio (+/- s.d.) of R/S-flurbiprofen free fractions was lower in the subjects with ascites (0.714 +/- 0.298) than in those without ascites (0.796 +/- 0.090) (P < 0.05).

Papillary cystic tumors of the pancreas. Assessment of their malignant potential

BACKGROUND

Although the biologic characteristics of papillary cystic tumors (PCT) generally indicate a good prognosis, a malignant form has been reported.

METHODS

Twenty-two examples of PCT were examined to assess their malignant potential by histologic, flow cytometric, and immunohistochemical studies.

RESULTS

Three had hepatic, peritoneal, and/or lymph node metastases (metastasizing tumors [MT]); the other 19 PCT had no such metastatic features (nonmetastasizing tumors [NMT]). Venous invasion was detected in all three MT and two NMT. Compared with the 19 NMT, the MT had a higher nuclear grade and more prominent necrobiotic nests characterized by aggregates of cells with pyknotic nuclei and eosinophilic cytoplasm. In the flow cytometric analysis of cellular DNA content, one MT was aneuploid, and eight NMT were diploid. Immunohistochemically, there was no difference between the MT and NMT.

CONCLUSIONS

These results support the assumption that venous invasion, nuclear grade, and prominent necrobiotic nests are useful as histologic parameters to detect the malignant potential of PCT.

Composite glandular-endocrine cell carcinoma of the extrahepatic bile duct: immunohistochemical study

A composite glandular-endocrine cell carcinoma of the extrahepatic bile duct in a 64 yr old Japanese man is reported. A nodular polyp measuring 1.9 x 1.1 cm was located in the confluence of the extrahepatic bile duct. Histologically, the tumor was composed of well differentiated tubular adenocarcinoma and small cell neuroendocrine carcinoma with a transition between the 2 components. The 2 areas of the tumor immunohistochemically revealed a clear-cut difference in functional differentiation. Tumor cells in the glandular component were immunoreactive to both carcinoembryonic antigen (CEA) and CAM 5.2, while those in the small cell area were immunoreactive to neuroendocrine markers such as neuron specific enolase (NSE), chromogranin A and serotonin. These results suggest that the tumor arose from a multipotential stem cell capable of differentiation in 2 directions.

Studies on peri-root tissue formation around new type artificial root made of dense hydroxyapatite

The aim of this study was to examine the wound healing process and tissue development around a new type of artificial root made of dense hydroxyapatite. The newly tailored artificial roots, which have characteristic corrugated configurations with smooth root surfaces, were implanted immediately after extraction of the premolars of adult dogs. After preliminary experiments, the following studies were carried out: for the observation of tissue formation around the artificial root, artificial root with surrounding tissue were extirpated after fixed periods (6-32 weeks) of implantation; to study tissue formation at the artificial root surface, undecalcified specimens with polished surfaces for microanalysis and decalcified specimens for light microscopic observation were prepared after 72 weeks of implantation. The following results were obtained: around the artificial roots in the jawbone, fibrous tissue formation with angled orientation, bone formation resembling alveolar bone proper, and calcified substance formation attaching to the root surface were observed.

[Involvement of lymph nodes and neural plexus in carcinoma of the pancreas]

We studied 428 lymph nodes attached to the head of the pancreas (13,14,17) in 18 patients with ductal carcinoma of the pancreatic head. These were classified into the small size of the lymph nodes less than 5mm (group S), the moderate size of the lymph nodes (group M) and the large size of the lymph nodes more than 10 mm (group L). The metastases were seen in 76 nodes, which consisted of 49 with group S, 14 with group M and 13 with group L. The lymph node involvement in group (14) S was found in 7 of 18 patients (38.9%), that in group (14) M was in 4 (22.2%) and that in group (14) L was in 2 (11.1%). In these involved cases, the primary tumors tended to be locate in the portion near the superior mesenteric artery, such as in the uncinate process. Invasion of extrapancreatic neural plexus was noted in 9 of 18 patients (50%). There was no significant correlation between nerve plexus invasion and lymphatic invasion by Spearman's rank correlation. In addition, any close relationship between plexus invasion and primary tumor location could not be indicated. These results suggested that neural invasion in pancreatic carcinoma is independent of lymphatic invasion, and the routes of cancer spread via the neural plexus are different from those via the lymphatic vessels. Those without liver metastases survived longer than those with liver metastases, which were characteristically multiple.

Solitary pancreatic metastasis of malignant fibrous histiocytoma treated by distal pancreatectomy

A tumor in the body of the pancreas was detected in a 31-year-old man who had undergone a resection of a malignant fibrous histiocytoma (MFH) of the left distal femur 2 years before. The patient underwent a distal pancreatectomy with regional lymph node dissection. The surgical specimen revealed MFH metastatic to the pancreas. He is alive without recurrence or metastasis at 1 year after pancreatectomy. This case seems to be the first report of successfully resected pancreatic metastasis of a malignant fibrous histiocytoma in the published literature, as far as we can determine.

Relationships between epinephrine, waking time, and self-estimates for naps at night

In a previous study, we established a basal regression line between epinephrine excretion and percent of waking time in bed-rested humans under conditions involving minimal stress. We suggested that this regression line might be clinically useful for observing insomnia. The present study was undertaken to examine whether epinephrine excretion during short-duration sleep, such as naps, is influenced by a transient insomniac state. Polysomnograms during a 2-hour nap from 0000 to 0200 were recorded three times for six healthy male subjects. Epinephrine excretion levels during sleep were found to increase along the basal regression line when percent of waking time went up. The subjects with over 30% waking time during this 2-hour period reported that their sleep was light and not satisfactory at all. These results support our position that the regression line can be useful for observing a transient insomniac state.

Long- and short-term survivors after pancreatoduodenectomy for ampullary carcinoma

Out of 36 consecutive patients who underwent a pancreatoduodenectomy for carcinoma of the ampulla of Vater, eight patients (long-term survivors) survived more than 5 years after surgery, while eight other patients (short-term survivors) survived less than 12 months after intervention. Both the eight long-term survivors and eight short-term survivors were compared clinicopathologically. The long-term survivors did have some preferable factors such as a high value of peripheral lymphocytes, a low concentration of carcinoembryonic antigen, a small protruding tumor, a shallow depth of invasion, a well-differentiated histopathologic type, an infrequent venous invasion, and no perineural infiltration. However, these differences were not significant. A multivariate regression analysis regarding the 18 prognostic variables showed that both perineural invasion and the grade of histopathologic differentiation were significant parameters. Out of the eight long-term survivors, three patients lived more than 10 years while another died from ampullary carcinoma 74 months after surgery. Pancreatoduodenectomy not only produces long-term survivors but can also effect a complete cure in patients with ampullary carcinoma. A long clinical follow-up of more than 5 years after surgical intervention is thus warranted.

LONG SURVIVORS AFTER PANCREATODUODENECTOMY FOR PANCREAS HEAD CARCINOMA

Twelve Japanese patients with pancreas head carcinoma who survived 3 years or more after a pancreatoduodenectomy and 50 who survived less than 12 months were reviewed clinicopathologically. The 12 patients who survived for greater than or equal to 3 years exhibited more favourable prognostic factors: a higher incidence of jaundice; a smaller mass; a higher prevalence of an earlier stage tumour and adenocarcinoma of differentiated type; and a lower incidence of venous invasion, lymph node metastasis, and cancer cells at the surgical margins. However the difference was not significant. Univariate log-rank analysis regarding 13 prognostic variables showed that histologic type was a significant factor but multivariate Cox regression analysis failed to reveal an independent significant parameter. Nine of the 12 long-term survivors showed lymph node metastasis and six of the 12 revealed cancer cells at the surgical margins. Six of the 12 long-term survivors died from local recurrence and/or distant metastasis 37-78 months after operation. Only two patients survived more than 5 years after the operation. At the time of writing, one of them was still alive and another was dead 78 months after the operation. Pancreatoduodenectomy for pancreas head carcinoma infrequently offers a permanent cure for the patients with pancreas head carcinoma but sometimes produces a worthwhile long-term survival, even if the resected margins were affected by malignant cells or the lymph node metastasis was evident.

Non-icteric pancreas head carcinoma fares worse than icteric pancreas head carcinoma

A total of 22 patients with non-icteric pancreas head carcinoma were retrospectively compared with 61 patients with icteric pancreas head carcinoma. No significant difference was found regarding age, sex, greatest diameter, macroscopic type, microscopic type, stage, lymphatic permeation, perineural infiltration, venous invasion, lymph node metastasis, and the presence of cancer cells at the surgical margins. The main location of pancreas head carcinoma could be divided into two sites: the superior (pericholedochal), and inferior or distal (excholedochal) areas of the pancreas head. Sixteen (73%) of the 22 non-icteric pancreas head carcinomas were located in the inferior or distal area (excholedochal), while 28 (46%) of the 61 icteric pancreas head carcinomas were situated in the superior portion (pericholedochal) (P less than 0.05). One (5%) of the 22 non-icteric pancreas head carcinomas was small pancreas carcinoma, compared with 11 (18%) of the 61 icteric pancreas head carcinomas. The cumulative 2-year and 4-year survival rates of the 22 patients with non-icteric pancreas head carcinoma were significantly worse than those of the 61 patients with icteric pancreas head carcinoma [7.9% vs. 24.6% (P less than 0.05) and 0% vs. 13.4% (P less than 0.01)]. These findings suggest that non-icteric pancreas head carcinomas normally arise in an area far from the biliary tree, and include a greater number of large tumors. Any resulting difficulty and delay in the diagnosis and treatment of this disease will usually lead to a worsening of the clinical course of non-icteric pancreas head carcinoma.

Sensitive determination of cystathionine and assays for cystathionine beta- and gamma-lyase, as well as cystathionine beta-synthase, using high-performance liquid chromatography

Cystathionine was cleaved into 2-ketobutyric acid, cysteine and ammonia by cystathionase. 2-Ketobutyric acid was converted into 3-ethyl-2-hydroxy-6,7-dimethoxyquinoxaline (EHDQ) by reaction with 1,2-diamino-4,5-dimethoxybenzene. When EHDQ was measured in a mobile phase of pH 2.1 using high-performance liquid chromatography with ultraviolet detection, 250 pmol of L-cystathionine in 250 microliters of the reaction mixture could be determined. Because EHDQ has a strong fluorescence in a mobile phase of pH 6.5 at 447 nm, on excitation at 365 nm, as little as 2.5 pmol of cystathionine in 250 microliters of the reaction mixture could be determined by high-performance liquid chromatography with fluorimetric detection. Cystathionase activity was assayed on the basis of the same principle by determining cystathionine in as little as 63 ng of rat liver by fluorimetric detection. Cystathionine beta-synthase activity was measured by the same method by determining cystathionine formed in only 113 ng of wet weight of rat liver. Using these methods, both cystathionine beta- and gamma-lyase activities in Saccharomyces cerevisiae were determined, because quinoxaline derivatives from pyruvate and 2-ketobutyrate could be measured simultaneously by high-performance liquid chromatography.

[Ossification of the thoracic ligamentum flavum presenting with intercostal neuralgia. Case report]

A 46-year-old female was admitted complaining of progressive, severe girdle pain consistent with the left Th3 dermatome. Neurological examination on admission revealed dysesthesia and radiating pain in the left Th3 territory. Plain X-rays and tomograms of the thoracic spine revealed a beak-like bony excrescence arising from the lamina and projecting moderately to the Th3/4 intervertebral foramen, suggesting ossification of the thoracic ligamentum flavum (OYL). Myelography showed the dural sac compressed from laterally just below the left Th3 pedicle, which suggested that the Th3 nerve root was compressed by the OYL. After Th3 nerve root decompression through hemilaminectomy and foraminotomy, the girdle pain disappeared. OYL is known to cause thoracic radiculomyelopathy, but presentation with intercostal neuralgia only is very rare. The authors review the literature and stress the importance of myelography for diagnosis.

Carcinoma of the cystic duct

Carcinoma of the cystic duct is a rare neoplasm, and we herein report four cases of carcinoma of the cystic duct. The patients consisted of a 69 year old and 71 year old woman and a 61 year old and 93 year old man. They complained of either abdominal pain or abdominal mass. All the tumors were microscopically well-differentiated adenocarcinoma, mostly limited to the wall, that showed no lymph node or distant metastasis. Three patients who had undergone resection were doing well 20 days, 67 months, and 125 months after the operation, respectively. These findings may suggest that not only the early development of symptoms caused by obstruction of the narrow lumen of the cystic duct, but also slow growth and late metastasis produce a favorable clinical course in patients with carcinoma of the cystic duct.

The anti Mac-1 monoclonal antibody inhibits neutrophil sequestration in lung and liver in a septic murine model

We investigated the mechanism by which leukocytes adhere to the pulmonary and liver microvascular endothelium in a septic murine model. After C57BL/6 mice were intraperitoneally (ip) injected with lipopolysaccharide (LPS), a striking peripheral leukocytopenia occurred as neutrophils accumulated rapidly in the lung and liver. When the anti-Mac-1 monoclonal antibody (mAb) was administered intravenously (iv) 2 hr before the ip administrated LPS, leukocytopenia and neutrophil accumulation in the lung and liver were inhibited significantly at 3 hr after the LPS injection. An immunofluorescence study revealed that Mac-1 expression on leukocytes from LPS-injected mice were greatly increased when compared to that of controls. Additionally, an in vitro assay demonstrated that LPS-activated serum increased neutrophil Mac-1 expression and neutrophil adhesion to the endothelial monolayer and that these phenomena are inhibited by pretreatment of neutrophils with anti-Mac-1 mAb. These results indicate that a marked increase in Mac-1 antigen expression by leukocytes plays a crucial role in striking neutrophil attachment to the vascular endothelium and is likely to be the cause of neutrophil accumulation in the lung and liver during endotoxemia.