[Clinical study of 8 cases of spontaneous esophageal rupture]

Among 8 patients with spontaneous esophageal rupture, mean age was 46.5 years, and there was only one female. Vomiting after drinking was the main cause of onset. In 4 patients who underwent drainage of the thoracic cavity or initial treatment by surgery within 24 hrs after onset, closure after layer-layer suture of the site of rupture was made in two patients in whom definitive diagnosis was obtained at the first medical examination and early discharge was possible. A definitive diagnosis was obtained after drainage of the thoracic cavity in the other two patients, and esophagectomy without thoracotomy was performed on the 55th day after onset in one and the other patient received only conservative treatment without surgery, both patients were discharged. Of 4 patients who underwent treatment after 24 hrs, two patients who recovered included one who received only conservative treatment and another who underwent closure by suture of the site of rupture and covering with a pedicled omental flap 12 days after onset. The other two patients died of MOF after operation. We propose the following guidelines for treatment of this condition; In patients in whom surgical treatment is possible within 24 hrs after onset, closure by layer-layer suture of the site of rupture may be indicated. In cases in which more than 24 hrs has elapsed after rupture spontaneous closure sometimes can be expected in patients with a rupture would less than 2 cm. In patients accompanied with progressing mediastinitis or pyothorax with drainage procedure surgical treatment is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis and surgical treatment of small papillary carcinomas of the thyroid gland

The preoperative and pathological findings of 38 cases of small papillary carcinoma of the thyroid gland measuring < or = 10 mm in diameter and 74 cases of large papillary carcinoma measuring more than 10 mm were compared. In the small carcinoma cases, the sensitivity of palpation, ultrasonography, and fine-needle aspiration biopsy (FNAB) was higher than that of computed tomography and soft tissue roentgenography of the neck. Therefore, palpation, US, and FNAB should be instituted as reliable diagnostic methods, but other examinations seem unsuitable as methods for preoperative qualitative diagnosis. No definite correlation was found between the intraglandular dissemination and the size of the carcinoma, and the frequency of metastasis was relatively high even in the small carcinoma cases. If the patient elects to undergo surgery, subtotal thyroidectomy with lymph node dissection should be performed for small thyroid carcinomas as well as large carcinomas.

Frequency of spontaneous p53 mutations (CpG site) in breast cancer in Japan

Sixty-five tumors of invasive ductal carcinoma of the breast were examined for p53 alteration by the reverse transcription-polymerase chain reaction-single strand conformation polymorphism (RT-PCR-SSCP) method and sequencing analysis. In total, 16 samples (24.6%) showed p53 gene alteration. Sixteen of these alterations were evaluated by sequencing analysis, and 15 showed missense point mutations while one showed a 9-base pair deletion. In the 15 point mutations, G:C to A:T transitions constituted the majority (53%), and five tumors (33%) had a transition at the CpG site, which are mutational patterns not commonly found in breast tumors from Europe and America. On the other hand, there were no G:C to T:A transversions in our cases, which were frequently observed transversions in Europe and America. These p53 mutation patterns in breast cancer in Japan are not similar to those in Europe and America reported by Hollstein et al. and Coles et al.. These findings suggest that there are some differences between mechanisms of breast cancer in Japan and in Europe and America.

Replacement of dendritic cells in the airways of rat lung allografts

It is unknown whether dendritic cells are able to migrate normally from the recipient into the allogeneic lung graft. Using monoclonal antibodies to major histocompatibility complex class II antigens (OX6 for both donor and recipient types; HIS19 for recipient type), we studied the replacement of donor dendritic cells by recipient type cells in rat lung allografts that are indefinitely accepted with a short course of cyclosporine early after transplantation. The recipient dendritic cells started to migrate into lung allografts early (by 1 wk) after transplantation. Donor dendritic cells in the grafts were replaced by recipient cells during the first 2 months after transplantation. Dendritic cells in the perivascular tissue were replaced quickly, most of them within 1 wk, whereas those in the alveolar septa were replaced slowly. In the lung allograft surviving 2 or more months, the normal phenotypic heterogeneity of dendritic cells was preserved. Recipient dendritic cells accumulated in dense peribronchial aggregates that remained 6 months. The dendritic aggregates were associated with late airway changes in allografted lungs. The abnormal accumulation of dendritic cells peribronchially might be related to an abnormal mucosal immune response or a chronic rejection process.

Intractable chest pain in a patient whose postpneumonectomy space was managed with sulfur hexafluoride

A 50-year-old man who had undergone right pneumonectomy 1 year previously was referred to our department following the sudden onset of severe chest pain. Since the operation, his postpneumonectomy space had been managed with sulfur hexafluoride. On admission, the pressure in the postpneumonectomy space was found to be more than +60 cmH2O. The chest pain was relieved after the sulfur hexafluoride had been drained and the pressure released. Thus, it is advisable to inject sulfur hexafluoride stepwise into the postpneumonectomy space of patients with long-standing fluid accumulation.

Incidence of ultrasonographically-detected thyroid nodules in healthy adults

We studied the incidence of thyroid nodules in healthy adults, who had no history of thyroid disease, in Tokushima, Japan, where goiter is not considered endemic. Examination was performed by palpation and using a 10-MHz real-time sonographic scanner. Palpable thyroid nodules were present in two (0.9%) of 227 men and in four (1.8%) of 224 women. On the other hand, nodules were detected by ultrasonography in 42 men (18.5%) and 47 women (21.0%). There was no significant difference in the incidence detected by ultrasonography between men and women in any of the age groups, except in men above 60 years old. It is concluded that thyroid nodules are not an uncommon disorder even in men. Since, clinically, the incidence of nodularity appears to be higher in women than in men, there may be difference between men and women in the development of nodules until they become clinically detectable.

Management of postpneumonectomy syndrome by intrapleural injection of sulfur hexafluoride. Case report

Left postpneumonectomy syndrome was managed by injection of sulfur hexafluoride (SF6) into the pleural space. This measure permitted irradiation of a contralateral, second primary lung cancer without resulting pulmonary fibrosis. Such use of SF6 may be an option for prophylaxis against postpneumonectomy syndrome.

A study of the electrical bio-impedance of tumors

A new system of impedance measurement over a frequency range of 0 to 200 kHz was developed by a three-electrode method. In this study, the electrical impedances of various tumors were measured in vivo in 54 patients with breast disease (31 breast cancers, 13 fibroadenomas, and 10 fibrocystic diseases) and 57 patients with pulmonary disease (44 lung cancers, 5 metastatic pulmonary tumors, 4 pulmonary tuberculoses, and 4 organized pneumonias). On the basis of those impedance measurements and the equivalent circuits in vivo, we calculated the extracellular resistance (Re), intracellular fluid resistance (Ri), and cell membrane capacitance (Cm) in tissues, all of which were compared among the various diseases. It was found that Re and Ri were significantly higher in breast cancers than in benign tumors and normal breast tissues and that Cm was significantly lower in breast cancers than in other tissues. On the other hand, Re and Ri were significantly higher, and Cm was significantly lower, in normal lung tissues than in pulmonary masses. Re and Ri were significantly higher, and Cm was significantly lower, in malignant tumors than in organized pneumonias. The results showed that these parameters (Re, Ri, and Cm) exhibit significant differences among various tissues and tumors, suggesting possible applications in tumor diagnosis.

Late airway changes caused by chronic rejection in rat lung allografts

Airway disease after lung or heart-lung transplantation is one of late major complications, affecting the prognosis of the transplants. Little is known about the causes of airway changes. We performed rat lung transplantation and investigated the late airway changes of the long-term surviving lung grafts: allografts, BN to Lewis; isografts, BN to BN rat. All recipients were treated with CsA. We found airway changes, i.e., mucosal ulceration, granulation, submucosal fibrosis, which was located in the large airways, in four of five allografted lungs. The lung isografts showed no pathological abnormalities. Immunopathological studies disclosed the localized expression of MHC class II antigens on the bronchial epithelium of the large airways where recipient type dendritic cells accumulated in the submucosa and CD4 positive predominant lymphocytes infiltrated. These findings support the idea that the late airway changes in lung transplants are caused by immunologically mediated chronic rejection.

Accumulation of vanadium during embryogenesis in the vanadium-rich ascidian, Ascidia gemmata

It is a remarkable and previously unrecognized fact that ascidians, which are known to contain high levels of vanadium in their blood cells, begin to accumulate vanadium during embryogenesis. This study revealed that the accumulation starts quite dramatically 2 wk after fertilization, and 2 mo later, the amount of vanadium in larvae is 600,000 times higher than that in the unfertilized egg. These results were obtained by neutron activation analysis, a highly sensitive method for determining levels of vanadium, in the Ascidia gemmata, the ascidian that contains the highest known levels of vanadium and accumulates vanadium at 150 mM in its blood cells, a concentration that corresponds to 4,000,000 times the concentration in seawater.

Mutations in the P53 tumour suppressor gene in primary lung cancer in Japan

The reverse transcription-polymerase chain reaction-single strand conformation polymorphism (RT-PCR-SSCP) analysis and sequencing were used to examine p53 gene alterations in 18 surgical specimens of primary lung cancers obtained in Japan. Somatic mutations resulting in amino acid changes were found in eight of the 18 cases (44%). Seven missense mutations were located in amino acid-conserved domains or their vicinities (codons 110 to 307). Most mutations were found at G-C pairs, suggesting that specific carcinogens are involved in the etiology of lung cancer. The p53 mutations showed a significant association with a history of smoking (P = 0.0294). We suggest that the p53 mutations may be associated with smoking-induced lung carcinogenesis.

Intra-arterial adriamycin chemotherapy in combination with radiotherapy for advanced bladder cancer

A total of 38 patients with locally advanced bladder cancer (T2, n = 14; T3, n = 14; T4, n = 10) were treated with intra-arterial Adriamycin chemotherapy in combination with radiotherapy. The clinical as well as the pathological efficacy of this treatment was evaluated in all patients. Clinically, 23 (60.5%) of the 38 patients achieved a complete remission (CR), 12 (31.6%) achieved a partial remission (PR), and 3 (7.9%) remained stable (NC). The pathological efficacy was evaluated according to the criteria of Shimosato et al., with 20 (52.6%) of the 38 patients being categorized as grade IV; 2 (5.3%), as grade III; 12 (31.6%) as grade II; and 4 (10.5%), as grade 0. The 5-year actuarial survival as a function of clinical stage amounted to 91.6% for T2, 50.0% for T3, and 37.4% for T4 (T2 vs T3, P less than 0.05; T2 vs T4, P less than 0.01). The 5-year actuarial survival determined according to the clinical and the pathological efficacy of treatment were 74.1% for CRs, 56.2% for PRs, and 0 for NCs (CR vs NC, P less than 0.01; PR vs NC, P less than 0.01). Surgery for preservation of the bladder was performed in 30 of the 33 patients who achieved clinical and pathological CRs or PRs. The 5-year actuarial survival of these 30 patients was 73.2%. These results demonstrate that this therapy is a useful method for the treatment of locally advanced bladder cancer and that preservation of the bladder might be feasible in patients who achieve clinical and pathological CRs or PRs during this treatment.

[Three cases of intramural cyst of the esophagus with ciliated epithelium]

We had 3 cases of intramural cyst of the esophagus with ciliated epithelium. In Case 1, 13-year-old man, the cyst was lined with ciliated columnar epithelium and had a smooth muscle layer. In Case 2, 37-year-old female, the cyst was lined with ciliated stratified epithelium and had some layers of smooth muscle. In Case 3, 42-year-old male, the cyst was lined with ciliated columnar epithelium and had a smooth muscle layer. In all cases, cartilaginous tissue was not found. They had no complaints and the abnormal shadow was found by chance Chest X-ray film. When the cyst did not have typical diagnostic criteria, clear division into esophageal cyst or bronchogenic cyst is difficult. The bronchus and the esophagus are of the foregut origin, so we suppose the middle type cyst, between esophageal and bronchial, may exist. In Case 2, the cyst was diagnosed as esophageal, because it had some muscle layers. But in Case 1 and Case 3, as the cyst did not have typical diagnostic criteria, we diagnosed them as the inclusion cyst of the esophagus, not as esophageal, not as bronchogenic.

Extrathymic malignancy in patients with myasthenia gravis

The presence of extrathymic malignancies was investigated in 296 thymectomised myasthenia gravis (MG) cases. In 5 of the 296 cases, extrathymic malignant tumours were observed. 4 of the 5 cases had thymomatous MG. 3 cases had malignant fibrous histiocytoma. Extrathymic malignancies were observed more frequently in thymomatous MG than in non-thymomatous MG. 59 cases (60 tumours), including our 5 cases, who had MG and extrathymic malignant tumours were compiled from the literature. In the 60 extrathymic malignancies, leukaemia and reticulo-endothelial sarcoma were the most frequent types.

Morphologic activation of lymphocytes in blood during rejection of heart and lung grafts in rats

We investigated morphologic activation of lymphocytes in blood in a standardized, infection-free rat model and compared lymphocyte activation during rejection of heart grafts and that of lung grafts with other parameters of rejection. For heart grafts the other parameters were histology and palpation, and for lung grafts they were histology, bronchoalveolar lavage, and chest roentgenography. During acute rejection of heart grafts, lymphocyte activation in blood increased when histology of the heart grafts showed already moderate-to-severe rejection with myocyte necrosis. Lymphocyte activation in blood detected acute heart rejection clearly later than histology but somewhat earlier than palpation. During acute rejection of lung grafts, lymphocyte activation in blood increased when histology of the lung grafts showed the (early) vascular phase of rejection, without apparent tissue damage. Lymphocyte activation in blood detected acute lung rejection only slightly later than histology, at approximately the same time as bronchoalveolar lavage and earlier than chest roentgenograms. Lymphocyte activation was higher during acute lung rejection than during acute heart rejection. During "chronic" rejection of long-surviving heart grafts and lung grafts, lymphocyte activation in blood did not increase consistently. The early and strong increase of morphologic activation of lymphocytes in blood during acute lung rejection may imply for clinical transplantation that monitoring of lymphocyte activation in blood is more useful for early detection of acute rejection after lung transplantation than after heart transplantation.

[Chemotherapy of thymoma]

Thymoma is a low malignant, slow growing tumor and rarely metastasizes hematogenously or lymphogenously. Therefore, the local treatment by surgery or irradiation has been the main therapy for this tumor. In this paper, we reviewed the chemotherapy for thymoma in literature. Cis-platinum, doxorubicin, vincristine, cyclophosphamide and corticosteroid are mainly used by various dosages and various combinations. Papers concerning the chemotherapy for thymoma were reports of a single or a few cases. The chemotherapy is now effective for some kinds of malignant tumor. The chemotherapy for thymoma should be systematically studied.

[Intra-arterial infusion chemotherapy in bladder cancer]

Between 1976 and 1985, 35 patients with bladder cancer were preoperatively treated with intra-arterial doxorubicin (ADM) chemotherapy. We separated these patients into 2 groups according to regimen: A) 1-3 shots of ADM infusion with or without radiotherapy, and B) 3-day courses of ADM infusion with low-dose radiotherapy. The 5-year actual survival rate according to stage (T category) was 100% in T1-2, 37.5% in T3 and 23.3% in T4. In T1-2, bladder preservative operations were done on 50% of the patients in group A and 100% in group B. In T3-4, the 5-year actual survival rate in group A was 22.5%, while in group B it was 52.8% (p less than 0.01). The bladder preservative operations were done on 33.3% of the patients in group A and 73.3% in group B. The patients who received ADM intra-arterial chemotherapy combined with low-dose radiotherapy for bladder cancers, who achieved complete or partial remission, might be able to preserve their bladder.

Testicular metastasis from malignant schwannoma of chest wall

Metastatic malignancy to the testes is unusual. Reports of testicular metastasis of neurogenic tumor are extremely rare. Only 28 cases with testicular metastasis of neurogenic tumor have been reported in the world literature. Cases of primary malignant schwannoma with testicular metastasis have not been reported previously. We present an unusual case of a thirty-seven-year-old man who had a malignant schwannoma of the chest wall with testicular metastasis.

A case of intralobar pulmonary sequestration with calcification and elevated serum values of carcinoembryonic antigen and carbohydrate antigen 19-9

Pulmonary sequestration is uncommon. We report a case with radiographically visible calcification and elevated serum values of the tumor markers carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9.

Lung cancer in chromate workers: high-risk group for multiple lung cancer

We diagnosed eight (8.9%) lung cancer patients in 90 workers exposed to chromate compounds. The duration of exposure ranged from 8 to 31 years, with a mean value of 18 +/- 8 years. The histological classification was squamous-cell carcinoma in seven patients and adenocarcinoma in one patient. The site of origin of the primary tumors was located peripherally in two (25%) and centrally in six (75%). All but one of these patients underwent surgery. In three (37.5%) of these patients, lung cancer foci were detected during the postoperative follow-up by sputum cytology and bronchoscopy. Two of these three patients had multicentric cancer foci: double primary early squamous-cell carcinoma in one and early squamous-cell carcinoma + small-cell lung cancer in the other. In a high-risk group such as chromate workers, we should emphasize early detection of lung cancer by serial sputum cytology, chest x-rays, and bronchoscopy. Lung cancer patients with chromate exposure should be treated with due regard to the possibility of synchronous or metachronous cancer.

Flexible bronchoscopy for foreign body in airway

The flexible bronchoscopy has not yet been popular in the foreign body in the airway, especially in children. We performed the flexible bronchoscopy for 27 patients with foreign bodies in the airway including 22 patients who had not been removed foreign bodies by the rigid bronchoscopy. Nineteen of 27 patients were children. The success rate of flexible bronchoscopy was 81% (22/27 cases) in all patients, 77% (17/22 cases) in patients failed by the figid bronchoscopy, and 82% (9/11 cases) in young children of 2 years old or less. For the removal of foreign bodies under the flexible bronchoscope, a biopsy forceps and a Fogarty balloon catheter were effective. The flexible bronchoscope is useful for foreign bodies in the airway, even in young children.

CEA and CA 19-9 in benign pulmonary or mediastinal cystic lesions

Serum carbohydrate antigen (CA) 19-9 was present at high levels in pulmonary sequestration, mediastinal bronchogenic cysts, and mediastinal mature teratomas. The fluid in the cysts of the lesions contained a high level of CA 19-9. After operation, the titer of serum CA 19-9 returned to normal ranges. Histological studies showed that mucosal epithelium stained positively for CA 19-9. We speculate that CA 19-9 concentrated in the cystic lesion might flow into the peripheral blood. Carcinoembryonic antigen (CEA) was also present at high levels in the cyst fluid. CEA was positively stained in the epithelial cells using a polyclonal antibody but not a monoclonal antibody. The CEA detected at high concentration in the fluid was considered to be immunologically cross-reacting CEA.

A case of bronchogenic cyst with high production of antigen CA 19-9

A 35-year-old man was hospitalized with complaints of retrosternal pain and high fever. A chest radiograph showed a large round mass in the mediastinum. Of the several tumor markers in the serum tested, only CA 19-9 was elevated. Thoracotomy revealed a cystic mass with purulent hemorrhagic materials. Histologically the cyst was lined by bronchial epithelium with no evidence of malignancy. The high level of CA 19-9 in the cystic fluid, and positive immunohistochemical staining of the bronchial glands in the cyst wall for CA 19-9 indicated that the elevated serum level of CA 19-9 originated from the bronchogenic cyst after its infection.

Antitumour potential of pleural cavity macrophages in lung cancer patients without malignant effusion

The present study was undertaken to examine whether the presence of primary lung cancer could affect the antitumour activities of pleural cavity macrophages (PCM) and peripheral blood monocytes (PBM). PCM by pleural lavage and PBM were simultaneously obtained from 14 lung cancer patients not showing invasion of the pleural cavity. PCM and PBM were isolated by percoll gradient centrifugation and adherence. The lavage method yielded about 16.8 +/- 9.6 (s.e.) x 10(6) cells, which consisted of 80.7% PCM, 17.6% lymphocytes and 1.6% other cells. The cytotoxic activities of PCM and PBM against allogeneic melanoma (A375) cells were assessed by a 72h 125I-IUdR release assay. The lavaged PCM showed spontaneously high tumour cytotoxic activity which was dependent on the effector/target ratio. In 13 out of 14 cancer patients, PCM were significantly more cytotoxic to melanoma cells than PBM. In contrast, there were no significant differences in production of tumour necrosis factor (TNF-alpha) or interleukin 1 (IL-1) between PCM and PBM. When the abilities of PCM and PBM of the same patient to produce these monokines were compared, PCM produced much more TNF-alpha than PBM, thus indicating a correlation between the expression of spontaneous macrophage-mediated cytotoxicity and spontaneous TNF-alpha production by PCM. These results suggest that PCM may play an important role in host defence against invasion of the pleural cavity by cancer cells.

Drainage of giant bulla with balloon catheter using chemical irritant and fibrin glue

A simple technique for drainage for a giant bulla with balloon catheter using chemical irritants and fibrin glue is described. This method allows physical and functional improvement without major surgery in compromised patients with giant bullae.

Pulmonary leiomyomatosis showing endobronchial extension and giant cyst formation

A 49-year-old woman who had previously undergone hysterectomy was found to have multiple pulmonary masses and cysts and experienced respiratory failure. Bronchoscopic study revealed an endobronchial mass obstructing the left main bronchus and protruding into the trachea. She was treated with an endoscopic laser to eliminate the airway obstruction. After recovery from the respiratory failure, two-stage thoracotomies were performed at six-month intervals. The endobronchial mass originated from a tumor in the left basal segment. The histologic findings on the cysts and nodules of both lungs were compatible with fibroleiomyoma. The final diagnosis was pulmonary leiomyomatosis with myoma uteri.

Rapidly growing mature teratoma of the mediastinum: do sex hormones affect growth of the tumor?

The case of a 12-year-old girl with an anterior mediastinal tumor is reported. A mass grew rapidly and occupied the anterior mediastinum after menarche. Resected material was diagnosed as a mature teratoma. Both estrogen receptors and progesterone receptors were detected in the resected tissue. The titer of estrogen receptors was 2-11.3 femtomoles per milligram of protein and that of progesterone receptors was 9.5-15.7 fmol/mg protein. Based on these data, it was surmised that sex hormones may affect the growth of the tumor in this case. The change in sex hormones after menarche may have played a role in the rapid growth of this tumor.

The characteristics of thymoma with myasthenia gravis: a 28-year experience

Of 134 patients with thymoma, 79 (59%) also had myasthenia gravis (MG). The thymoma with MG differed from that in the absence of MG in the following aspects: The ratio of lymphocytes to epithelial cells in the tumor was larger, the polygonal cell type was more prominent (i.e., in 83% of the MG patients this cell type predominated), and the differentiation of epithelial cells in the tumor was more advanced in the group with MG than in the group without MG. Furthermore, the clinical stage of thymoma was earlier, the recurrence rate was lower, and the survival curve was better in the group with MG than in the group without MG. These findings suggest that the thymoma with MG is less malignant than that without MG.

Pulmonary varices: a case report and review of the literature

A case of a 47-year-old woman with pulmonary varix is reported herein. Saccular dilatation of the inferior pulmonary vein resembled a pulmonary perihilar mass which could not be palpated at the time of thoracotomy. Aneurysmal dilatation of the pulmonary vein, otherwise known as pulmonary varix, is rare. Only 71 such cases, including 17 cases in Japan, have been reported. Pulmonary varices may be classified into three types, namely: saccular type, tortuous type and confluent type. Most of the varices seen in patients with valvular disease have been of the confluent type (62 per cent), however tortuous type varices have also been seen in some cases (19 per cent). Pulmonary venous hypertension may be one of the major causes of confluent type pulmonary varices as regression of pulmonary varices after mitral valve replacement has been reported. None of the saccular type cases, however, were accompanied by valvular disease. This indicates that local factors may also be an important cause of saccular type varices.

The role of preoperative intra-arterial doxorubicin chemotherapy in combination with low-dose irradiation for bladder cancer

Twenty patients with bladder cancer (T1, 3 patients; T2, 6 patients; T3, 8 patients; T4a, 3 patients) were preoperatively treated with intra-arterial doxorubicin chemotherapy in combination with low-dose irradiation. The originally scheduled operations were as follows: total cystectomy in 16 patients (T1 + cis, 1 patients; T2, 5 patients; T3, 7 patients; T4a, 3 patients), segmental cystectomy in 2 patients, and transurethral resection in 2 patients. The total dose of doxorubicin ranged from 120 to 540 mg (251.5 +/- 100.2 mg), and that of irradiation was from 4 to 36 Gy (24.4 +/- 7.3 Gy). Clinical and pathological effects were evaluated in all of the cases. Clinically, complete remission (CR) was observed in 14 cases (70.0%), partial remission (PR) was seen in 3 cases, a minor response (MR) occurred in 2 cases, and no response (NR) was seen in 1 patient; non patient showed progressive disease (PD). The pathological effects (according to the criteria of Shimosato et al.) were as follows: grade IV was seen in 10 cases, grade III in 3 cases, and less than grade II in 7 cases; however, viable tumor cell were not seen in 13 (65.0%) of the 20 cases. The bladder was preserved in 13 (81.3%) of the 16 cases for which total cystectomy had been recommended. All of the patients were followed up for periods ranging from 3 to 54 months (26.3 +/- 16.5 months), during which time 6 patients (30.0%) died (3 with cancer, 1 without cancer, and 2 unknown causes). The actual survival rate according to the stage of disease was 100.0% at 50 months in T1-T2 and 40.9% at 54 months in T3-T4a. In T3-T4a, the actual survival rate in pathologically complete responders was 60% (relative rate 68.8%) at 54 months, and the actual survival rate in incomplete responders was 25.0% (relative rate 27.1%) at 36 months. The results of our study are encouraging, especially in T1-T2 and T3-T4a cases, who showed a complete response. It is concluded that doxorubicin intra-arterial chemotherapy combined with low-dose irradiation could be the first treatment of choice for locally invasive bladder cancer.

[Doxorubicin intra-arterial chemotherapy combined with low-dose irradiation in bladder cancer]

Fifteen patients with non-disseminated bladder cancer (T1:2, T2:2, T3:8, T4:3) were preoperatively treated with intra-arterial doxorubicin chemotherapy in combination with low-dose irradiation. The originally scheduled operations had been as follows; total cystectomy in 11, segmental cystectomy in 2, and TUR- or SVR-Bt in 2. The total dose of doxorubicin ranged from 120 to 540 mg/body, with an average of 312.7 mg/body and that of irradiation was from 4 to 34 Gy with an average of 24.0 Gy. Clinically, in the early phase of the study, complete remission (CR) was revealed in 10 (66.7%), and partial remission (PR) in 2 (13.3%). The bladder was preserved in 9 of 11 (81.8%) cases in which total cystectomy had been recommended. Pathological effects according to the criteria presented by Shimosato, Oboshi and Baba, were as follows; grade IV in 6 cases (40.0%), grade III in 2 (13.3%), grade II in 4 (26.7%) and grade I or 0 in 3 (20.0%). Therefore, viable tumor cells were not seen in 8 of 15 (53.3%) cases. Vesical non-recurrent rate in the cases with bladder preservation was 56.2% at 48 months by simple mode and 44.6% by accumulated mode. Survival in 13 cases (T2-T4) by pathological effects was 75.0% at 48 months in the grade IV and III group (n = 8), and 40.0% at 42 months in the grade II or less group (n = 5). The results obtained from this study seem encouraging, especially in the group where the pathological effects were grade IV or III, and leads to the conclusion that doxorubicin intra-arterial chemotherapy, combined with low-dose irradiation, could be a first-choice treatment for locally invasive bladder cancer.

[Carcinoma of the esophagogastric junction with extension to the cervical esophagus]

A 51-year-old woman with adenocarcinoma of the esophagogastric junction (E-G J), which spread from the E-G J to the cervical esophagus, is reported. Only two cases of carcinoma in the E-G J with the extension of the tumor to the upper or middle portion of the intrathoracic esophagus have been reported in the Japanese literature in the past two decades and there have been no previous reports of E-G J carcinoma with extension to the cervical esophagus. At first, the invasion to the esophagus in our case was thought to be continuous. Histological examination, however, revealed that the tumor in the esophagus was discontinuous in some portions and that the lymph vessels were remarkably invaded. These findings suggested that the extension of the tumor to the esophagus was lymphogenous metastasis.

Clinical characteristics and prognosis of myasthenia gravis with other autoimmune diseases

Of 277 patients with myasthenia gravis (MG) who underwent thymectomy, including 78 with thymomatous MG, 33 patients had other autoimmune diseases. The clinical characteristics of MG with other autoimmune disease were investigated. Graves's disease and rheumatoid arthritis were the most common autoimmune diseases seen. The association rate of autoimmune disease in patients with thymomatous MG (3.8%) was significantly lower than that in patients with nonthymomatous MG (15.1%). The positive rate for a germinal center in the thymus was significantly higher in patients with other autoimmune disease than in those without such disease. Thymectomy was effective for MG in patients with an associated disease as well as in those without such a complication. The clinical course of the associated autoimmune disease did not seem to be adversely affected by thymectomy. Therefore, thymectomy should be performed in MG patients with other autoimmune disease.

Prophylactic long-term treatment of bladder tumors with oral chemotherapy (tegafur)

A total of 107 patients with bladder tumor (from Ta to T2) was studied. Patients were treated with or without prophylactic intravesical chemotherapy using mitomycin C or doxorubicin hydrochloride (Adriamycin) after the excision of tumor. After the preliminary treatment, 55 patients were given tegafur 600 mg p.o. daily (study group), and the other 52 patients (control group) were treated without tegafur. Both groups were followed up with periodic cystoscopy every three months. Actuarial nonrecurrence rate of the two groups were examined statistically. The results revealed that tegafur was a good prophylaxis against recurrence of the bladder tumor, significant differences at P from less than 0.001 to 0.025 were noted at every observation period except at six months. A significant difference at P less than 0.005 was also recognized from an overall comparison between two nonrecurrence curves.

[Case of rectal carcinoid associated with carcinomas of the esophagus and ureter]

We report a 71-year-old man with rectal carcinoid accompanying carcinomas of the esophagus and ureter. These were synchronous triple cancers clinically diagnosable and curable. Pathohistologically, positive granules were observed upon Grimelius and Masson-Fontana staining. The production of multiple hormones was indicated by electron microscopy and histochemical studies (PAP method).