Adenocarcinoma with signet ring cells of the axilla showing apocrine features: a case report

A 74-year-old Japanese man developed a reddish, indurated plaque composed of multiple nodules on his right axilla. Histopathologic examination showed a solid tumor that extended from the upper dermis into the subcutis, with both inter- and intracellular lumen formation, cellular arrangement in single files, a fibrotic reaction around the tumor cells, and the presence of mucinous material in the cytoplasm. There was both nuclear and cytoplasmic pleomorphism. Both lysozyme and GCDFP-15 were identified in the tumor cells. Electron microscopic examination showed periluminal condensation of the cytoplasm. Because thorough clinical and laboratory examinations were unremarkable, we regarded this to be a case of primary adenocarcinoma with signet ring cells of the axilla. The neoplasm might have differentiated toward the apocrine sweat glands or the mammary glands. Radiation therapy was effective to some degree. This seems to be the first reported case in which adenocarcinoma with signet ring cells of the skin affected a site other than the eyelids.

Analysis of factors affecting long-term treatment results of adenoid cystic carcinoma of the nose and paranasal sinuses

At Akita University Hospital (from 1971 to 1987) and at Chiba University Hospital (from 1983 to 1988), 17 patients with adenoid cystic carcinoma of the nose and paranasal sinuses were treated by en bloc tumor resection followed by primary reconstruction of the maxilla. Pre- and postoperative radiation was combined in 5 and 6 patients, respectively. Ten-year cancer-free survival rates were 59.3% in the 12 patients with maxillary sinus tumors and 50% in the 4 patients with nasal tumors. One patient with a sphenoid sinus tumor died within 5 years. Ten-year cancer-free survival was affected markedly by grade of tumor extension. Among T1N0M0 and T2N0M0 patients (of which there were 1 and 7, respectively), only 1 died of unrelated causes, and 6 patients survived cancer-free for more than 10 years. However, 4 of the 6 T3N0M0 patients died, and the cause of death was distant metastasis in 2, intracranial tumor extension in 1, and unrelated causes in 1. All 3 T4N0M0 patients died, 2 due to intracranial tumor extension and 1 of unrelated causes. The cause of death was distant metastasis in 3, local recurrence in 3, 2 of whom had intracranial tumor extension, and unrelated causes in 2. Prevention of distant metastasis and intracranial tumor extension was considered to be crucial for improving treatment results after en bloc tumor resection. Preoperative radiation was thought to decrease incidence of distant metastasis. In 5 patients who had preoperative radiation. 4 survived cancer-free for more than 10 years, and only 1 patient died of unrelated cause. However. of the 6 patients who had postoperative radiation, 2 died of distant metastasis and another 2 died of intracranial tumor extension. Of the 6 patients who did not have radiation therapy, the causes of death were local recurrence in 1, distant metastasis in 1 and unrelated causes in 1. Preoperative radiation in 5 patients showed histopathologically moderate or marked degeneration and necrosis of tumors in all patients. Although the number of patients in this study is too small to allow statistical analysis of the data, our present modality of treatment for adenoid cystic carcinoma of the nose and paranasal sinuses is routine combination of preoperative full dose radiation, en bloc tumor resection and primary reconstruction, including en bloc resection of the cranial base in selected T4 patients.

Metastasis of renal cell cancer to the ethmoid sinus

The origin of metastatic tumors in the nasal or paranasal sinuses is often renal cancer, and metastasis to the nasal or paranasal sinuses sometimes takes a long time after nephrectomy. The present paper deals with one patient with metastasis of renal cancer to the ethmoid sinus 2 years after nephrectomy. Even though many metastatic tumors originating from renal cancer develop in multiples, most metastatic tumors in the nasal or paranasal sinuses are single and treated surgically. However, even if multiple tumors are found in the nasal and paranasal region and other organs, surgery will be effective in preventing epistaxis and subsequent anemia. Also, when removing a tumor it will be effective to identify the feeding arteries of the tumor, perform embolization therapy, and clip the necessary arteries.

Analysis of long-term results of our combination therapy for squamous cell cancer of the maxillary sinus

Seventy-four patients between 1971 and 1982 in Period I and 32 patients between 1982 and 1987 in Period II with maxillary sinus squamous cell cancer were treated by combination therapy consisting of preoperative LINAC X-ray irradiation with 5-flourouracil intra-arterial chemotherapy followed by maxillectomy and primary reconstruction. In Period II, 21 patients received preoperative cisplatinum (CPPP) microcapsule chemoembolization and pepleomycin (PEP) i.m. and or postoperative CDDP i.v. with PEP i.m. in addition to the combination therapy administered in Period I depending on systemic conditions, tumor stage and histopathological type. Five and 10-year crude survival rates were 68.9% and 55.4%, respectively, for Period I and 71.9% and 56.3% for Period II, with no significant difference between the two trials. In 21 selected patients in Period II, who had additional chemotherapy with preoperative CDDP chemoembolization and/or postoperative i.v. infusion of CDDP with pepleomycin i.m., 5 and 10-year survival rates were 85.7% and 61.9%, respectively.

Pirmenol hydrochloride-induced QT prolongation and T wave inversion on electrocardiogram during treatment for symptomatic atrial fibrillation

Pirmenol hydrochloride is a new orally effective, long-acting antiarrhythmic agent currently used in patients with supraventricular and ventricular tachyarrhythmias. We report on a 56-year-old female who exhibited drug refractory paroxysmal atrial fibrillation, in which marked prolongation of the QT interval and T wave inversion on electrocardiogram was demonstrated reproducibly shortly after the administration of oral pirmenol therapy. The plasma concentration of pirmenol was at a subtherapeutic level and the lymphocyte stimulation test was positive in this patient. Thus, an immunological mechanism might be involved in the mechanism of pirmenol-induced QT prolongation and T wave inversion on the electrocardiogram.

Effect of sex hormones on eosinophilic inflammation in nasal mucosa

We examined the effects of sex hormones on the functions of eosinophils. Treatment of eosinophils with beta-estradiol significantly enhanced the eosinophil adhesion to human mucosal microvascular endothelial cells (HMMEC), and eosinophils stimulated by a combination of beta-estradiol and progesterone showed significant induced degranulation. On the other hand, testosterone significantly reduced the eosinophil adhesion to HMMEC and eosinophil viability. The experiments from the series of studies might provide a partial explanation for the aggravation of asthma and some forms of rhinitis that occurs during pregnancy.

Is dobutamine-induced sinus node deceleration a marker of significant stenosis of the right coronary artery?

STUDY OBJECTIVES

Sinus node deceleration during exercise is a highly specific marker for significant stenosis of the right coronary artery. Prior studies of dobutamine-induced sinus node deceleration have contained relatively few patients, and the purpose of this study was to determine if sinus node deceleration is an accurate marker of right coronary artery disease in a much larger study population.

DESIGN

Dobutamine stress echocardiography was performed in a cohort of patients, and submaximal exercise testing and coronary angiography were performed in most of the patients.

SETTING

A university hospital.

PATIENTS AND INTERVENTIONS

Dobutamine stress echocardiography was performed in 757 patients, and symptom-limited submaximal treadmill ECG was also performed in 571 of those patients. Sinus node deceleration was defined as a decrease in the heart rate at peak stress compared with that at the previous stage. Coronary angiography was performed in 631 patients, 184 of whom were found to have significant right coronary artery stenosis.

MEASUREMENTS AND RESULTS

The prevalence of dobutamine-induced sinus node deceleration (54 [7%] of 757 patients) was significantly higher than that induced during treadmill ECG (3 [0.5%] of 571 patients; p<0.001). The prevalence of inferior ischemia by echocardiography did not differ between patients with dobutamine-induced sinus node deceleration (26%) and those without (30%). There was also no significant difference in the prevalence of right coronary artery stenosis between the two groups (27% vs 29%). The specificity of dobutamine-induced sinus node deceleration for detecting significant stenosis of the right coronary artery (92%) was higher than that of echocardiography (84%; p<0.00), but the positive predictive value was lower (28% vs 64%; p<0.001).

CONCLUSIONS

Although sinus node deceleration during dobutamine stress echocardiography is a relatively more common finding, it does not always accompany significant stenosis in the right coronary artery. The mechanism for its induction is postulated to be vagal activation caused by multiple factors.

Essential light chain exchange in smooth muscle myosin

The exchange of 17-kDa essential light chain (LC17) in smooth muscle myosin was carried out by incubating myosin with a 10-fold molar excess of exogenously added LC17 over the corresponding endogenous light chain in the presence of trifluoperazine and 4.5 m ammonium chloride. Porcine aorta myosin contains two kinds of LC17 isoform, LC17nm and LC17gi, while chicken gizzard myosin contains only one kind of LC17 isoform. As LC17gi can be separated from LC17nm and gizzard LC17 by urea-gel electrophoresis, LC17nm in aorta myosin and LC17 in gizzard myosin were exchanged with LC17gi and LC17gi in aorta myosin was exchanged with LC17nm, and the degree of exchange was estimated by urea-gel electrophoresis. Under the optimal conditions (6 and 10 degrees C for aorta and gizzard myosin, respectively), nearly 90% of exchange, which is close to the theoretical value, was achieved for the former combinations, and a slightly lower exchange was obtained for the latter. The LC17-exchanged myosins contained stoichiometric amounts of the heavy and light chains and retained the original nature in the phosphorylation-dependent actin-activated ATPase activity, 6S-10S conformational transition, and filament assembly.

[Ultrasonographic diagnosis of the parotid gland tumors--experience with 310 patients]

The diagnostic value of ultrasonography of parotid gland tumors is to determine if the tumor is benign or malignant. In the period from 1984 to 1995, ultrasound examinations were performed on 310 patients with a space-occupying lesion of the parotid gland, using real time 3.75 MHz, 5 MHz and 7.5 MHz transducers. From a histological standpoint, there were 246 benign tumors, namely 144 pleomorphic adenomas, 35 adenolymphomas, 23 other adenomas, 14 cysts, 9 neurinomas, 3 lymphomas, 9 hemangiomas, 3 lymphangiomas and 6 lymph nodes. Another 64 were malignant tumors, namely, 7 mucoepidermoid carcinomas, 7 acinic cell carcinomas, 7 adenoid cystic carcinomas, 15 adenocarcinomas, 7 squamous cell carcinomas, 4 undifferentiated carcinomas, 10 carcinomas in pleomorphic adenoma, 3 malignant lymphomas, 2 metastatic carcinomas and 2 other carcinomas. According to our criteria for ultrasonographic diagnosis of the parotid gland tumors, the benign or malignant pattern was determined by the following findings; shape, boundary echo, internal echo and posterior echo. But in some cases we could not differentiate the two echogram patterns, and we call them the intermediate pattern. The total accuracy rate of the diagnosis of the 310 patients was 79.0%. (The intermediated pattern was found in 39 patients and these cases were considered to be misinterpreted.) In 268 primary parotid gland tumors (210 benign and 58 malignant tumors) excluding recurrent cases, lymph nodes, hemangiomas and so on, the sensitivity was 62.1%, the specificity was 91.4% and the total accuracy rate was 85.1%. The accuracy of sonography in determining whether a tumor was benign or malignant was affected by the tumor size; tumors smaller than 2 cm in diameter showed a tendency to be diagnosed as benign and tumors larger than 6 cm in diameter as malignant. In the 268 cases, the importance of the pattern of the boundary echo and the internal echo in differentiating benign and malignant tumors was examined retrospectively. In the 210 primary benign tumors, the benignity of the tumors was assessed correctly in 84.3% by the boundary echo and 85.7% by the internal echo. In the 58 primary malignant tumors, the malignancy was assessed correctly in 58.6% by the boundary echo and 43.1% by the internal echo. Strong echos, which are the signs of a malignant pattern, were seen in 14.8% of the benign tumors, and in 51.7% of the malignant tumors. It can be concluded that ultrasonography is very reliable for the examination of parotid gland tumors.

[Effects of TNM extension and histopathological type of the tumor on long-term survival rates of parotid and submandibular gland cancer]

The effects of TNM extension and histopathological type of the tumor on 5 and 10-year survival rates were analysed in 1,147 cases of parotid cancer and 271 cases of submandibular gland cancer which had been registered from 152 institutes throughout Japan since 1978. Advance of stage decreased the prognosis significantly, and the decrease was more pronounced in submandibular gland cancer. Facial paralysis also decreased the prognosis of parotid cancer significantly. The prognosis was also affected significantly by the histopathological type of the tumor. The 5-year survival rates of adenocarcinoma, epidermoid carcinoma and undifferentiated carcinoma were only about 30% in parotid cancer and about 20% in submandibular gland cancer. In treatment of salivary gland cancer, the therapeutic approach should be individualized in accordance with the tumor extension and its histopathological type. Improvement of accuracy in preoperative diagnosis of salivary gland cancer is of the utmost importance.

Acute myocardial infarction in a patient during dobutamine stress echocardiography

We report the case of a patient who developed an acute anteroseptal and inferior myocardial infarction during dobutamine stress echocardiography. The proposed mechanism for this event is discussed based on results obtained during emergency coronary angioplasty and subsequent clinical findings.

Contralateral external carotid-middle cerebral artery bypass for carotid artery resection

Resection of the common carotid or internal carotid artery is occasionally unavoidable in cases of advanced head and neck carcinoma with carotid artery involvement. To prevent the consequent decrease in cerebral perfusion, we have developed a contralateral external carotid-middle cerebral artery bypass grafting technique. From 1990 through 1995, six patients with advanced head and neck cancer involving the carotid artery underwent total tumor resection combined with vascular reconstruction using the contralateral external carotid- middle cerebral artery bypass grafting. No bypass-related complications occurred in any patient postoperatively. Cerebral hemodynamics after surgery indicated that this bypass graft worked steadily over a long term and supplied sufficient volume of blood to the cerebral cortex on the opposite side in every case.

Crosslinking of telokin to chicken gizzard smooth muscle myosin

Telokin, which is a candidate for one of the factors stabilizing dephosphorylated myosin filaments in smooth muscle cells, was subjected to a chemical crosslinking study to determine its binding location on the myosin molecule. Telokin labeled with 5-iodoacetamidofluorescein (Fl-telokin) retained the nature of unlabeled telokin: it bound to dephosphorylated gizzard myosin with a stoichiometry of 1 mol/mol myosin and induced filament assembly. The carboxyl groups of Fl-telokin were activated with 1-ethyl-3-(3-dimethyl-amino-propyl) carbodiimide and N-hydroxysuccinimide and then crosslinked to myosin. The production of three fluorescent peptides was observed on an SDS-gel, accompanying a decrease in the amount of regulatory light chain (LC20). The molecular weights of these products estimated to be > 200, 62, and 41 kDa. When unlabeled telokin was crosslinked to myosin of which LC20 was exchanged with 5-[[2-[(iodoacetyl)amino]ethyl]amino]-naphthalene-1-sulfonic acid-labeled LC20, the 62- and 41-kDa bands were also fluorescent. These results suggest that the > 200, 62, and 41-kDa species are telokin crosslinked with a heavy chain, with 2 LC20, and with 1 LC20, respectively. Myosin crosslinked with unlabeled telokin showed an extra structure with a small projection at the head-rod junction on electron microscopy and this structure was proved to be telokin by decorating it with anti-telokin antibodies. In addition, dephosphorylated myosin crosslinked with Fl-telokin was incapable of folding into the 10S conformation at 0.2 NaCl in the presence of MgATP, and assembled into filaments at 0.15 M NaCl in the presence of MgATP. Thus, telokin may bind to LC20 and a heavy chain region at the head-rod junction and suppress folding into the 10S conformation, leading to the assembly of myosin into filaments.

Role of substance P in the vascular response of nasal mucosa in nasal allergy

The effects of topically administered substance P (SP) on nasal blood flow and nasal airway resistance (NAR) were evaluated in 11 subjects with perennial nasal allergy. The change in NAR induced by SP was compared with those induced by nasal challenge with histamine, leukotriene D4 (LTD4), and antigen. In doses > or = 16 nmol, SP caused a significant increase of nasal blood flow within 5 minutes that lasted for less than 20 minutes. In doses > or = 16 nmol, SP caused a dose-dependent, short-lasting, significant increase in NAR. The magnitude of the increase in NAR was LTD4 > SP > histamine when compared on a molar basis. Our results may suggest that SP released from C fiber terminals is partially involved in an early nasal vascular response after antigen challenge by acting on adjacent vascular smooth muscle to cause a transient vasodilatation of both resistance and capacitance vessels only while sensory stimulation persists in subjects with nasal allergy.

Autoantibody against a 78 kDa membrane protein of HepG2 cell in the sera of patients with alcoholic liver diseases

Sera from 14 normal control subjects, 30 patients with alcoholic liver diseases (fatty liver, n = 8; hepatitis, n = 13; liver cirrhosis, n = 9), 7 controls with chronic hepatitis B, and 8 controls with chronic hepatitis C were masured for their concentrations of antibodies against HepG2 membrane protein by a binding assay utilizing 125I-labeled protein A. When the cut-off level was set as the mean value plus 2 SD of normal control subjects, the incidence of positivity was 75%, 69.2%, and 77.8% in patients with alcoholic fatty liver, alcoholic hepatitis, and alcoholic cirrhosis, respectively. Both the mean serum antibody values and the positive incidence were significantly higher in patients with alcoholic liver diseases than in either the normal controls or in the control patients with chronic hepatitis. Sodium dodecylsulfate polyacrylamide gel electrophoresis of 125I-labeled HepG2 membrane protein precipitated with IgG from patients with alcoholic liver diseases revealed an immunoreactive band at a molecular weight of 78,000 daltons (gp78). The antibody activity remained after immunoabsorption by human liver-specific lipoprotein (LSP) but decreased when HepG2 cells were pre-treated with trypsin or neuraminidase. Consequently, gp78 appears to be a glycoprotein distinct from LSP, and is specifically recognized by IgG from patients with alcoholic liver diseases. This assay may provide a new system to measure autoantibody to hepatocytes in alcoholic liver diseases.

Differential diagnosis of pulsatile neck masses by Doppler color flow imaging

A pulsatile neck mass (PNM) requires careful judgment in its evaluation, and it is difficult and inaccurate to diagnose a PNM only by physical examination, even though a thrill or bruit is present. Doppler colorflow imaging (DCI) was performed as an initial evaluation in nine patients with PNMs. Intravenous digital subtraction angiography, intra-arterial angiography, X-ray computed tomography, and magnetic resonance imaging were performed in selected cases. The DCI revealed seven vascular masses (three tortuosities of the common carotid artery, two tortuosities of the brachiocephalic artery, one pseudoaneurysm, and one traumatic arteriovenous fistula) and two nonvascular masses (one neurofibroma and one metastatic lymph node). The clinical diagnoses of all the vascular masses were defined by DCI. In nonvascular masses, fine-needle aspiration biopsy could be performed relatively safely and accurately by monitoring the feeding artery or the common carotid artery by DCI. This method was quite useful for the initial evaluation in the differential diagnosis of PNMs.

Photocontact allergy due to suprofen

A 79-year-old Japanese woman developed edematous erythema on sun-exposed areas 3 months after applying Sulprotin ointment, which contains 1% suprofen (SP), a phenylacetic acid derivative. A patch test with Sulprotin ointment as it was negative, but a photopatch test with Sulprotein ointment as is was positive. A photopatch test with 10-3% SP was positive, as was that obtained with an SP analogue, 3% ketoprofen, but that with the ointment base of Sulprotin was negative. Photopatch tests with other SP analogues such as flurbiprofen, ibuprofen, and pranoprofen were negative. She developed abnormal erythema with monochromatic irradiation in the range from 320 to 380 nm on the uninvolved abdominal skin where 1% SP had been applied 24 hours (h) before irradiation. The action spectrum for this erythema agreed with the absorption spectrum of SP in the range of UVA. The MED after applying SP was below that after applying w. pet. in the range from 250 to 290 nm and from 300 to 320 nm. Positive intracutaneous test results were obtained with an irradiated mixture of human serum albumin (HSA) and SP at 48 and 72 h after injection and negative ones with a mixture of HSA and irradiated SP.

Hemodynamic changes in the head and neck after ligation of the unilateral carotid arteries: a study using color Doppler imaging

For evaluation of the hemodynamics of the collateral circulation to the ligated external carotid artery (ECA) region, we measured the blood flow direction and volume in branches of the ECA in patients with unilateral carotid artery ligation before and during digital suppression of the common carotid artery (CCA) on the ligated and nonligated sides with color Doppler imaging and angiography. The main collateral pathway to the ligated ECA region was the ipsilateral occipital artery through Richter's anastomosis from the vertebral artery in the case of unilateral ECA ligation, and was the contralateral carotid artery in the case of unilateral CCA, ECA, and internal carotid artery resection. The superior and inferior labial arteries were important as the collateral pathway from the contralateral ECA.

Current assessment and proposed improvement to emergency medical information systems in Japan

Most prefectural governments in Japan have been implementing, or planning to implement, emergency medical information systems that take advantage of advanced information-related technologies such as computers and communication systems, in order to improve their emergency medical care systems. We studied the emergency medical information systems to analyse their present status, clarify their purpose, and present the ideal system, in view of community health care requirements. Here the results of the research are examined, and there is a discussion of what is needed to improve the system in the future. The emergency medical information system in Aichi prefecture is taken as an example, to closely survey its present situation and analyse the evaluation of the system by the residents who are the major beneficiaries of the system.

Synovial osteochondromatosis of the temporo-mandibular joint

A rare case of synovial osteochondromatosis of the temporo-mandibular joint is presented. Important diagnostic information can be obtained by CT, MRI, 99m Tc bone scan and aspiration biopsy. Observation using a light microscope showed mild cellular atypia, but the hallmarks characteristic of chondrosarcoma were not found. Observation using an electron microscope showed the mature chondrocytes contained a well-developed rough endoplasmic reticulum. Histological evaluation indicated that the present case was benign synovial osteochondromatosis in an early stage.

Evaluation of radiograph signs for the diagnosis of solitary peripheral pulmonary nodules less than 3 cm

Ten radiograph signs were assessed by two experts for their usefulness in the diagnosis of small solitary peripheral pulmonary nodules less than 3 cm. The ten categories included notching, spicula formation, pleural indentation, vascular convergence, contour, paleness, homogeneity, cavitation, air bronchogram, and calcification. The cases included 134 lung cancers and 44 benign lung lesions resected between 1972 and 1988 at the Second Department of Surgery, Okayama University Medical School. Notching, spicula formation, pleural indentation, vascular convergence, contour, and air bronchogram were useful signs in differentiating lung cancer from benign lung lesions. However, since the radiograph signs exhibited great variation in both lung cancer and benign lung lesions, a diagnostic operation is sometimes inevitable.

Evaluation of brain collateral circulation by the transcranial color Doppler-guided Matas' test

For the determination of the indication for reconstruction of the carotid artery in patients with head and neck cancer, a color Doppler-guided Matas' test was performed to examine brain collateral circulation and blood flow of the middle cerebral artery (MCA) and internal carotid artery (ICA). Both SSA-270A convex (3.75 MHz) and linear (3.75 MHz and 2.5 MHz) array probes (Toshiba Co, Ltd) were used for this investigation. A temporary occlusion test (60 seconds) by digital pressure on the common carotid artery was performed on 30 patients with head and neck cancer. The results were classified into four groups according to the relative flow volume (percent blood flow volume before the test) of the MCA: group A, with a flow volume of 87% or more; group B, with a flow volume between 72% and 86%; group C, with a flow volume between 57% and 71%; and group D, with a flow volume of 56% or less. The relative flow volume of the MCA was correlated with the ICA stump pressure and single photon emission computed tomography during a balloon Matas' test (ICA occlusion). This test seems to be useful in predicting the risk of carotid resection without reconstruction and in determining the indication for reconstruction of the carotid artery.

[A contralateral external carotid-middle cerebral artery bypass operation--a new procedure of vascular reconstruction in the treatment of head and neck carcinoma requiring carotid resection]

In the treatment of head and neck carcinoma involving the carotid artery, resection of the carotid artery and direct reconstruction using a vein graft has commonly been employed to reduce the incidence of cerebral ischemic complications. But the procedure of carotid grafting itself carries the risk of preventing complete tumor clearance. And contamination due to salivary fistula, particularly in cases of meso or hypopharyngeal carcinoma, may result in graft rupture or thrombosis. To overcome these difficulties, the authors have developed a new surgical procedure, namely, a contralateral external carotid-middle cerebral artery bypass operation. This bypass system is designed at directly supplying the cerebral hemisphere on the carotid ligation side through a vein graft running entirely outside the cervical operative field. The vein graft is anastomosed end-to side to the external carotid artery of the opposite side. Then it is placed subcutaneously in front of the auricle, above the zygomatic arch, frontal subgaleal space and anastomosed end-to-side to the recipient artery, the ascending branch of the middle cerebral artery, in the Broca area of the carotid ligation side. The neck is incised almost the same manner as in parotidectomy, with a slightly longer cervical extension, and the scalp by bilateral coronal incision of Sutta. A frontotemporal osteoplastic craniotomy of the involved side is performed. The length of the saphenous vein used is about 50cm. This surgical procedure requires no transient internal or external shunt. The common carotid artery can be ligated safely after confirming good post-anastomotic bypass flow using an electro-magnetic blood flow meter.(ABSTRACT TRUNCATED AT 250 WORDS)

[Six cases of primary pulmonary cryptococcosis]

Six patients with asymptomatic primary pulmonary Cryptococcosis are reported. In all of the patients, the disease was detected by annual chest X-ray during mass screening for lung cancer or during follow-up for pulmonary tuberculosis or gastric cancer. The chest X-ray findings consisted of a solitary pulmonary nodule in 4 patients and multiple pulmonary nodules in 2. Only one patient who could not be histologically diagnosed by bronchofiberscopy underwent surgical resection. However, the other 5 patients were histologically diagnosed by transbronchial biopsy with bronchofiberscopy. They were treated with oral antifungal agents, namely flucytosine (5-FC) and/or fluconazole, with marked improvement of chest X-ray findings. These results indicate that transbronchial biopsy with bronchofiberscopy and oral administration of antifungal agents instead of initial surgical resection are useful in the diagnosis and treatment of primary pulmonary cryptococcosis.