[Long-term survival following multimodality treatment of metachronous metastases (parotid gland, adrenal gland, brain and mediastinal lymph node) after resection of non-small cell lung cancer; report of a case]

We describe a case of long-term survival following multimodality treatment of metachronous metastases (parotid gland, adrenal gland, brain and mediastinal lymph node) after resection of non-small cell lung cancer. A 72-year-old man had a past history of right upper lobectomy for pT3N0M0 tubular adenocarcinoma of the lung 12 years ago and left lower lobectomy for pT3N1M0 papillary adenocarcinoma of the lung 42 months ago, and left parotidectomy and irradiation to the neck for parotid metastasis 20 months ago. A progressive increase in serum CEA level during the follow-up period revealed a 5 cm left adrenal mass and small (1 cm or less) multiple brain metastases, and a 2 cm mediastinal lymph node. He underwent adrenalectomy and gamma knife surgery and received irradiation to the mediastinum, and was administered gefitinib as first-line chemotherapy for about a year. Brain metastases recurred despite 4 more rounds of gamma knife surgery and 4 cycles of docetaxel hydrate as second-line chemotherapy, and 1 cycle of vinorelbine ditartrate as third-line chemotherapy. He died of multiple brain metastases 65 months postoperatively. We confirm the possibility of long-term survival following multimodality treatment even though multiple organ metastases were found after resection of non-small cell lung cancer.

Application of the liquid coil as an embolic material for arteriovenous malformations

SUMMARY

The purpose of this paper is to clarify advantages and disadvantages of platinum liquid coils as an embolic material for AVMs. During the last eight years, 50 endovascular procedures using liquid coils were conducted in our institute for 19 cases with AVMs, 15 of which were located in the eloquent area. All but one presented with haemorrhage, the exception demonstrating repeated ischemic symptoms. Only liquid coils were used as the embolic material to obliterate the nidus and feeders. In ten of the 15 patients with AVMs located in the eloquent area and one case rejecting surgery, liquid coil embolization was applied one to 11 times (average 3.5 times) to achieve decrease in size and this was then followed by radiosurgery. The remaining eight AVM patients underwent total removal after liquid coil embolization. No complications were encountered during the peri-embolization period. In all cases, the purpose of embolization was to diminish the size to facilitate radiosurgery and decrease bleeding during surgery. The liquid coil has advantages as a material for embolization of AVMs; it is non-toxic and bioinart material; it seldom occludes normal minute vascular channels; when it used in a nidus, it seldom to migrates in the venous direction, and it has good radio-opacity and offers good marking for surgery. Appropriate applications include preoperative embolization or pre-radiosurgical embolization of AVMs, especially when staged embolizations are performed to reduce risk of perfusion pressure breakthrough in patients which are large or located in the eloquent area.

Differential gene-expression profiles associated with gastric adenoma

Gastric adenomas may eventually progress to adenocarcinomas at varying rates. The purpose of the present study was to identify gene-expression profiles linked to the heterogeneous nature of gastric adenoma as compared to adenocarcinoma. Suppression subtractive hybridisation analysis was performed to extract relevant genes from two cases of low- and high-grade gastric adenomas. The identified genes were quantified by RT-PCR in 14 low-grade adenoma, nine high-grade adenoma and nine adenocarcinoma samples, followed by hierarchical clustering analysis to separate tumours into groups according to their gene-expression profiles. Nine genes previously implicated in carcinogenesis in a variety of organs, including three genes related to gastric adenocarcinoma, were identified. The overexpression of these genes in gastric adenoma has not been reported previously. The clustering analysis of these nine genes across 32 cases identified three groups, one of which consisted primarily of adenocarcinomas, whereas the other two groups consisted of adenomas. One group of adenomas, characterised by larger tumour size, exhibited gene-expression profiles of an intestinal cell lineage implicated in the pathogenesis of an intestinal-type gastric adenocarcinoma. Another adenoma group consisting of low-grade adenomas with smaller tumour size exhibited a unique expression profile. In conclusion, clustering analysis of expression profiles using a limited number of genes may serve as molecular markers for gastric adenoma with different biological properties. Although the prognostic values of these gene-expression profiles need to be evaluated in further follow-up study of adenoma cases, these findings add new insights to (a) our understanding of the pathogenesis of gastric tumours, (b) the development of specific tumour markers for clinical practice, and (c) the design of novel therapeutic targets.

Superselective arterial chemotherapy for inoperable metastases in the dura mater and cranium

SUMMARY

Diffuse metastases to the cranium and dura mater of the bilateral hemisphere do not allow surgical intervention. We describe an excellent case which was treated by intra-arterial chemotherapy using Epirubicine (Farumorbicine). A 58-year-old woman treated for breast cancer ten years ago was admitted to our hospital with headache and frontal mass lesions.Magnetic resonance (MR) imaging on admission revealed a remarkable enhanced lesion of the bilateral dura mater and cranium, and bilateral brain edema in the frontal lobe. Angiography disclosed a vascular rich tumour supplied by bilateral external carotid artery branches.We successfully treated the lesion using superselective intra-arterial chemotherapy with a minimal dose of Epirubicine followed by embolization of bilateral external carotid artery branches. Followup MR imaging two years after the endovascular treatment showed disappearance of the enhanced lesion and remodeling of the skull bone. The patient is neurologically free of symptoms.

The efficacy of coil embolization at the dissection site of ruptured dissecting vertebral aneurysms

SUMMARY

Proximal occlusion of the parent artery has been widely used for treatment of vertebral dissecting ruptured aneurysms, but this does not always completely prevent re-rupture. In this series, the efficacy of occlusion at the dissection site using detachable coils was compared with proximal balloon occlusion. Over a five year period, 25 patients suffering from subarachnoid hemorrhage with dissecting vertebral aneurysms were treated by endovascular surgery. The first three of these 25 patients were treated with proximal balloon occlusion of the parent artery. The remainder underwent platinum coil occlusion at the affected site as early as possible after the diagnosis. In two of the three cases treated with proximal balloon occlusion, clipping or coating surgery were added because of progressive dissection. In all 22 cases of coil embolization, the intervention was successfully performed without complication. In one case with a dissection involving bilateral vertebral arteries, minor rebleeding from a contralateral dissection occurred after embolization. In the other 21 cases, rebleeding was not apparent (clinical follow-up: mean 24 months). Radiological findings showed complete occlusion of the dissection site and patency of the non affected artery (follow-up: mean ten months). We conclude that detachable platinum coil embolization at the dissection site is more effective than proximal occlusion for treatment of ruptured vertebral dissecting aneurysms because of immediate cessation of blood flow to the dissection site. However, in cases with bilateral dissections or hypoplastic contralateral vertebral arteries, preceding bypass surgery or stent treatment to preserve the affected vertebral artery may be needed.

Multiple arteriovenous malformations with hemorrhage

BACKGROUND

A rare case of a left temporal arteriovenous malformation (AVM) with bleeding 10 days after removal of another hemorrhagic AVM in the frontal lobe is reported.

METHOD

A 47-year-old man had an attack of headache and vomiting and was admitted to our hospital. On admission, a CT scan showed subcortical hemorrhage in the left frontal lobe. Left carotid angiography revealed four AVMs and a vertebro-basilar angiogram demonstrated a vascular malformation.

FINDINGS

First, a hemorrhagic AVM was removed with a hematoma. Following the operation, left carotid angiograms continued to show, AVMs, particularly a temporal AVM with increased blood flow, and after 10 days this hemorrhaged. This was surgically resected and the remaining small AVMs were treated by stereotactic radiosurgery.

INTERPRETATION

The patient had a high risk of hemorrhage. Adding hemodynamic stress to this situation, hemorrhage would have been expected to occur at an early time after the initial intervention for hemorrhagic AVM. Considering the risk of hemorrhage, other AVMs should undergo surgery as soon as possible after resection of hemorrhagic AVM.

Rupture of pial arteriovenous malformation associated with early thrombosis of the draining system following stereotactic radiosurgery--case report

A 50-year-old man was treated with stereotactic gamma knife radiosurgery for an incidentally detected small callosal arteriovenous malformation (AVM) with stenosis of the main draining pathway. He suffered two episodes of intraventricular hemorrhage at 4 and 14 weeks after the radiosurgery. Radiological studies demonstrated that the anterior portion of the draining system including a varix, which had been irradiated, was thrombosed before the obliteration of arteriovenous shunts. Stereotactic radiosurgery is an accepted treatment for selected small and medium AVMs, but this procedure may increase the risk of bleeding. Early occlusion of a part of the draining pathway after stereotactic radiosurgery might have induced AVM rupture. An impaired venous outlet, either consisting of one draining vein or with stenosis, present before treatment may be develop thrombosis in response to high-dose irradiation.

Lower mortality in patients with the DD genotype of the angiotensin-converting enzyme gene after acute myocardial infarction

OBJECTIVE

The angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism has been associated with different serum ACE concentrations and cardiac ACE activity. We assessed whether the ACE gene I/D polymorphism influenced cardiac mortality in Japanese patients with acute myocardial infarction.

METHODS AND RESULTS

The ACE gene I/D polymorphism was determined in 441 consecutive patients with a first myocardial infarction. There were 69 patients (16%) with the DD genotype, 194 patients (44%) with the ID genotype, and 178 patients (40%) with the II genotype. During a mean follow-up of 9.4 months, there were 49 cardiac deaths (DD, n = 4; ID, n = 26; II, n = 19). The DD genotype was significantly associated with a lower mortality than the other genotypes (p = 0.0363) by Cox regression analysis adjusted for age, sex, site of myocardial infarction, Killip functional class, reperfusion therapy during acute phase, ACE inhibitor use, and beta-blocker use.

CONCLUSIONS

In a selected cohort of Japanese patients, the DD genotype was associated with a significantly lower cardiac mortality after a first myocardial infarction.

Prevalence and mortality of the Brugada-type electrocardiogram in one city in Japan

OBJECTIVES

We sought to study the prevalence and mortality of subjects exhibiting the Brugada-type electrocardiogram (ECG) in a community-based population in Japan.

BACKGROUND

The Brugada syndrome has been associated with sudden death in subjects without structural heart disease. Hospital-based studies showed 11% to 38% annual fatal arrhythmic events in patients with the Brugada syndrome.

METHODS

Prevalence and mortality of the Brugada-type ECG were studied in subjects who had ECGs during a health examination in Moriguchi, Osaka, Japan. Information about death and relocation from Moriguchi city was obtained prospectively.

RESULTS

The Brugada-type ECG was found in 98 of 13,929 study subjects (0.70%, 95% confidence interval [CI]: 0.57% to 0.86%). The typical coved-type with an rsR' pattern in V(1) lead ("typical" Brugada-type) was found in 0.12% of subjects (95% CI: 0.07% to 0.20%). The prevalence for male subjects with the Brugada-type ECG (81%) was significantly higher than it was for those without (26%, p < 0.0001). In male subjects, the Brugada-type ECG was found in 2.14% (95% CI: 1.70% to 2.66%), and the "typical" Brugada-type was found in 0.38% (95% CI: 0.21% to 0.64%). After 2.6 +/- 0.3 years of follow-up, there was 1 death (1.0%, 95% CI: 0.03% to 5.6%) of a subject with the Brugada-type ECG, whereas there were 139 deaths (1.0%, 95% CI: 0.85% to 1.2%) of those without the Brugada-type ECG (p = 0.9943, log-rank test).

CONCLUSIONS

A substantial number of the Brugada-type ECG were observed in subjects in a community-based population in Japan, especially in men. The total mortality of subjects with the Brugada-type ECG did not differ from the mortality of those without the Brugada-type ECG in a community-based population.

Analysis of differentially expressed genes in human hepatocellular carcinoma using suppression subtractive hybridization

The genetic basis of hepatocellular carcinoma (HCC) has not yet been fully understood. Although various methods have been developed to detect differentially expressed genes in malignant diseases, efficient analysis from clinical specimens is generally difficult to perform due to the requirement of a large amount of samples. In the present study, we analysed differentially expressed genes with a small amount of human HCC samples using suppression subtractive hybridization (SSH). Total RNA were obtained from the hepatitis C virus-associated HCC and adjacent non-HCC liver tissues. cDNA was synthesized using modified RT-PCR, and then tester cDNA was ligated with 2 different kinds of adaptors and hybridized with an excess amount of driver cDNA. Tester specific cDNA was obtained by suppression PCR and the final PCR product was subcloned and sequenced. We identified 7 known genes (focal adhesion kinase, deleted in colon cancer, guanine binding inhibitory protein alpha, glutamine synthetase, ornithine aminotransferase, M130, and pepsinogen C) and 2 previously unknown genes as being overexpressed in HCC, and 1 gene (decorin) as suppressed in HCC. Quantitative analysis of gene expression using quantitative RT-PCR demonstrated the differential expression of these genes in the original and other HCC samples. These findings demonstrated that it is possible to identify the previously unknown, differential gene expression from a small amount of clinical samples. Information about such alterations in gene expression could be useful for elucidating the genetic events in HCC pathogenesis, developing the new diagnostic markers, or determining novel therapeutic targets.

Overexpression of interferon gamma-inducible protein 10 in the liver of patients with type I autoimmune hepatitis identified by suppression subtractive hybridization

OBJECTIVE

To clarify gene expression profiles in the liver may elucidate the pathogenesis of type I autoimmune hepatitis (AIH). Using suppression subtractive hybridization (SSH), we identified genes overexpressed in the liver of AIH.

METHODS

A small liver biopsy sample from a patient with definite AIH was available to be analyzed in our system. By mixing cDNA synthesized from this sample as a 'tester' and cDNA from a normal liver as a 'driver,' we subtracted cDNA to enrich genes overexpressed in AIH. After polymerase chain reaction (PCR) amplification and subcloning, we identified subtracted genes by sequencing 50 randomly selected clones.

RESULTS

Only one cDNA fragment, which is identical to interferon inducible protein 10 (IP-10), was overexpressed by > 10 times in the liver of AIH, as compared with control. We confirmed IP-10 overexpression in all eight patients with AIH by reverse transcription PCR. Immunohistochemical analysis demonstrated increased IP-10 expression in hepatocytes in the liver of AIH. Reverse transcription PCR analysis of 63 liver biopsy samples with various liver diseases revealed that IP-10 expression was significantly higher in AIH (p = 0.025) and chronic hepatitis C (p = 0.0043) than in other liver diseases. Interestingly, the amount of IP-10 mRNA expression was correlated with serum ALT values in AIH (p = 0.0006), but not in chronic hepatitis C (p = 0.43).

CONCLUSION

These results indicate the IP-10 expression in the liver might be used as a preferential marker of AIH, and that IP-10 has some pathophysiological roles in the liver damage of AIH.

Sequences in the NS5A protein of hepatitis C virus and the serum alanine aminotransferase response to interferon therapy in Japanese patients

BACKGROUND AND AIMS

Chronic hepatitis C is a slowly progressive disease and eventually causes hepatocellular carcinoma in many patients. Although interferon (IFN) therapy has been used for viral eradication, its success rate is only about 30%. In patients in whom it has failed (non-responders), there are several patterns of serum alanine aminotransferase (ALT) values, and detection of serum HCV-RNA during and after IFN therapy and improved long term prognosis were reported in patients whose serum ALT values were normalised by IFN therapy even if HCV viraemia persisted. The present study sought to clarify the virological characteristics contributing to these differences.

METHODS

Complete or partial length dominant sequences of hepatitis C virus genotype 1b (HCV-1b) were determined by direct sequencing. Firstly, the complete sequences of HCV-1b genomes were determined in six non-responders; three showed normalisation of serum ALT values during IFN-alpha therapy and the other three did not. Subsequently, the amino acid residues that were different in the two groups were further analysed retrospectively in another 82 patients.

RESULTS

Comparison of the sequences suggested an association between amino acids 2154-2172 of HCV-1b and serum ALT normalisation. A retrospective analysis of 82 patients revealed that the number of amino acid substitutions in this region was the only statistically significant variable associated with ALT normalisation (odds ratio 31.0; 95% confidence interval 5.0-286) in multivariate analyses.

CONCLUSIONS

A HCV genomic region that correlates with the ALT response to IFN therapy appears to be present in virologically IFN ineffective patients.

Radiation therapy in combination with transcatheter arterial chemoembolization for hepatocellular carcinoma with extensive portal vein involvement

AIM

The aim of this study was to examine the effectiveness and toxicity of radiation therapy in combination with transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with extensive portal vein tumor thrombus (PVTT).

METHODS

The combined therapy was performed in 24 HCC patients with extensive PVTT. External radiation targeted for PVTT (50 Gy in 2 Gy fractions) was performed in combination with repetitive TACE for intralobar lesions using 30-60 mg epirubicin every 3 months, and associations of the following variables with the survival rate were evaluated: gender, age, viral etiology, Child's class, performance status, extrahepatic metastasis, size and number of HCC, and location of PVTT.

RESULTS

The local response confined to PVTT was complete response (CR) in four patients, partial response (PR) in eight patients, no change (NC) in eight patients, and progressive disease (PD) in four patients. By using the stepwise Cox's regression analysis, only Child's class was associated with the survival rate. The survival rates after 1 and 2 years were 73 and 21% in Child's A, 10 and 0% in Child B or C, and 61 and 21% in patients in whom the local response was CR or PR, and 19 and 9% in those in whom the local response was NC or PD, respectively. By using the multiple logistic regression analysis, Child's class was the only factor associated with the local response (P = 0.006).

CONCLUSIONS

The combined therapy is feasible and may be useful to reverse PVTT in patients with good hepatic function reserve.

Prevention of Complications during Endovascular Surgery on the External Carotid Arteries, with Special Reference to Use of Nitropaste and the Lidocaine test

SUMMARY

PURPOSE

To examine all complications of endovascular procedures on the external carotid arteries and to ascertain how to reduce their number.

METHODS

In 93 consecutive patients, 137 endovascular procedures on the external carotid arteries were performed during the last 6 years.

RESULTS

We encountered no neurologic complications in these patients. In eight (9%) of the 93 patients who underwent lidocaine tests of the external carotid branches, nine transient cranial nerve palsies occured, seven of 67 vessels (10%) involving the middle meningeal artery and two of 18 vessels (11%) the ascending pharyngeal artery. However, they soon disappeared and successful embolisations were achieved. Vasospasm that prevented endovascular procedures occurred in only two cases of this series as a result of the application of isosorbide dinitrate.

CONCLUSIONS

The lidocaine test effectively provoked cranial nerve palsies without false negatives. The complication rate of endovascular surgery will decrease as long as awareness of complications such as cranial nerve palsy is maintained.

Investigations of the Dose of Heparin and Whole Blood Coagulation Time during Endovascular Surgery

SUMMARY

We chronologically determined whole blood coagulation time during continuous heparin administration, and investigated optimal doses of heparin in thirty-seven vascular surgery cases. ACT was determined with Hemochron 401. Heparin (2000 IU) was administered by bolus injection at the beginning of intravascular surgery, which was followed by continuous injection of 20 to 160 IU/kg/h. ACT determined before and 30 minutes after heparin administration were compared. There were no complications. ACT was maintained at a nearly constant level by continuous heparin administration. The dose of heparin required to maintain ACT at a level 1.5 to 2 times the initial level was 20 to 60 IU/kg/h. ACT was prolonged by more than three times in two of the ten subjects who were given heparin at a dose of 70 IU/kg/h or more. Continuous administration of heparin allowed maintenance of ACT at a nearly constant level during intravascular surgery. ACT was maintained within the range which is believed to be effective for prevention of thrombus formation (approximately 1.5 to 2.0 times larger than the initial level) by continuous administration of 20 to 60 IU/kg/h of heparin. ACT was, however, prolonged to more than three times the initial level in some subjects who were given 70 IU/kg/h or higher doses, suggesting the risk of a bleeding tendency. Accordingly, it is ideal to continue heparin administration at appropriate doses, while measuring ACT. The results of our study should serve as a useful standard for meeting this goal.

Modified Devine exclusion for unresectable pancreatic head carcinoma

BACKGROUND/AIMS

Gastrojejunostomy is generally performed for unresectable pancreatic head carcinoma. However, in the case of conventional gastrojejunostomy, the bypass does not always function effectively.

METHODOLOGY

For unresectable pancreatic head carcinoma accompanied by severe duodenal stenosis, conventional gastrojejunostomy was performed in 5 cases, and modified Devine exclusion was performed in 7 cases. There were no significant differences between the groups regarding their backgrounds.

RESULTS

There were no significant differences between the two groups for the average operation time, the days before peroral ingestion and the hospital stay. The state of peroral ingestion showed better results for modified Devine exclusion. The discharge rates were better for modified Devine exclusion, showing a significant difference (P = 0.028). The 50%-survival periods were 65 days and 159 days, respectively. The bleeding from the tumor occurred in 2 patients from the conventional gastrojejunostomy group, but none in modified Devine exclusion group.

CONCLUSIONS

Modified Devine exclusion is a simple and effective technique for unresectable pancreatic head carcinoma.

[A case report of hemiparesis due to compression of the medulla oblongata by an elongated vertebral artery]

The authors report a case of a 53-year-old woman who developed symptoms and signs of compression of the left medulla oblongata by the elongated and curved left vertebral artery with normal diameter. Twelve days before admission to the hospital, the patient suddenly noticed severe occipital-nuchal headache and nausea with vomiting, while she was unloading a burden. Neurological examination revealed left facial hyperalgesia, right hemihypesthesia and mild right hemiparesis. Hoarseness was observed, but the movement of the uvula and tongue was normal. Hypertension was noticed (180/100). Cerebral and vertebral angiography revealed no aneurysm, but demonstrated an elongated and curved V4 portion of the left vertebral artery with normal diameter. Coronal plain of T2 weighted image of MRI and CT scan with metrizamide administered into the CSF, clearly demonstrated an elongated and curved left vertebral artery compressing the ventro-lateral portion of the left medulla oblongata, neurovascular decompression of the V4 from the medulla oblongata was performed. Through the operating microscope, it was observed that the elongated and curved V4 portion of the left vertebral artery with normal configuration was compressing the left medulla oblongata ventro-laterally, making a compression notch at the outlets of the cranial nerves IX and X. Transposition of the V4 portion was impossible. Some pieces of Taflon felt, thick enough to prevent the pulsatile movement of the V4 from compressing the medulla oblongata, were inserted between the V4 and the medulla oblongata. Two months after the operation, the patient's right hemiparesis and sensory disturbances were gradually improving and her blood pressure had become normal. The authors emphasize that, among patients with symptoms and signs of compression of the medulla oblongata, there is at least one patient for whom neurovascular decompression was an effective treatment.

Coil embolization for the treatment of ruptured dissecting vertebral aneurysms

BACKGROUND AND PURPOSE

Proximal occlusion of the parent artery has been widely used for treatment of vertebral dissecting ruptured aneurysms, but this does not always completely prevent rerupture. We retrospectively studied 24 consecutive patients for clinical characteristics and/or for efficacy of occlusion with detachable coils at the site of dissection.

METHODS

During a 45-month period, 24 of 242 patients with aneurysms associated with subarachnoid hemorrhage had dissecting vertebral aneurysms identified at angiography. Eighteen of the 24 patients were treated with platinum coil occlusion at the affected site as early as possible after diagnosis, two patients were treated conservatively, and four others were not eligible for treatment owing to intractable elevation of intracerebral pressure and severe brain stem dysfunction.

RESULTS

The rate of aneurysmal rupture in the posterior fossa was high, at 56 (23%) of the 242 aneurysms, including 24 (10%) vertebral dissecting aneurysms. Subsequent rupture occurred in 14 (58%) of the patients, all within 24 hours after the first attack and three during transportation to the hospital. In all 18 patients, coil embolization at the affected site was successful, with no complications. Radiologic findings showed complete occlusion of the dissection site and patency of the unaffected artery (mean follow-up, 9 months). Among the six patients who did not undergo embolization, only one survived with a good outcome, the others died of repeat hemorrhage.

CONCLUSION

A high rate of vertebral artery dissecting aneurysms may be expected in patients with subarachnoid hemorrhage, especially in those with early repeat hemorrhage. Detachable platinum coil embolization may be more effective than proximal occlusion for treatment of ruptured vertebral dissecting aneurysms because of immediate cessation of blood flow to the dissection site; however, in patients with bilateral dissections or hypoplastic contralateral vertebral arteries, prior bypass surgery orstent placement to preserve the artery will be needed.

Long-term observation after transjugular intrahepatic portosystemic stent-shunt in two patients with hepatocellular carcinoma

Two patients with hepatocellular carcinoma (HCC) were treated with transjugular intrahepatic portosystemic stent-shunt (TIPS) and followed for 22 and 58 months thereafter. HCC was well controlled by transcatheter arterial chemoembolization. Hepatic failure or metastasis, especially in the lung, was not observed in the long-term observation. TIPS seems to be useful even in patients with HCC, provided HCC is controlled.

Dural arteriovenous malformations associated with cerebral aneurysms

Only limited information is available concerning dural arteriovenous malformations (AVMs) found in association with cerebral aneurysms. The present report focuses on six such cases, concentrating attention on clinical characteristics and significance. Of a total of 46 dural AVMs encountered over a given period, six (13%) were linked with cerebral aneurysms. Particularly strong associations were noted for dural AVMs in the anterior cranial fossa (three of four cases) and convexity (all of three cases). With dural AVMs in the anterior cranial fossa, subarachnoid haemorrhage is common, so that where this is encountered the possibility of a complicating aneurysm should be considered in order to select an appropriate treatment.

The effect of encephalo-myo-synangiosis on abnormal collateral vessels in childhood moyamoya disease

Child patients with Moyamoya disease initially present with ischemic symptoms. However, the long-term risk of intracranial hemorrhage for childhood Moyamoya disease is unknown. Hemodynamic overload to the fragile collateral vessels has been considered to cause hemorrhage. We reviewed angiograms to evaluate the effect of encephalo-myo-synangiosis (EMS) on abnormally dilated collateral vessels in 13 child patients with Moyamoya disease. EMS was performed on 24 sides in 13 patients ranging from 5 to 14 years of age. Post-operative angiography (6-88 months after surgery) revealed good revascularizations through EMS (larger than one-third of the middle cerebral artery (MCA) distribution) in 18 sides (75%) and smaller revascularizations in 6 sides (25%). In cases with a good revascularization through EMS, reduction of the abnormal collateral vessels was observed not only in the basal Moyamoya vessels (94% of sides) but also in the medullary arteries derived from the choroidal arteries (62% of sides), which are considered to cause intraventricular hemorrhages in adult patients. It is suggested that EMS may reduce the hemodynamic load on dilated collateral vessels and, subsequently, the long-term risk of intracranial hemorrhage in childhood Moyamoya disease.

The influence of vascular pressure and angiographic characteristics on haemorrhage from arteriovenous malformations

BACKGROUND

The present study was designed to determine whether there is a physiological explanation for the predisposition of patients with certain angiographic characteristics to haemorrhage from cerebral arteriovenous malformations (AVMs).

METHODS

Intra-operative measurement of feeding artery pressure (FAP) and intravascular pressures in the draining venous system [draining vein pressure (DVP) and cranial sinus pressure (SP)] were performed for 30 AVM cases using direct puncture of the vessels. The correlation between pressures and previously described angiographic characteristics predisposing to haemorrhage were evaluated.

FINDINGS

Small nidus size and only one draining vein increased the risk of haemorrhage. FAP and DVP are both inversely related to the number of draining veins and the size of the AVMs. DVP was significantly higher in AVMs with haemorrhage (23.1+/-8.7 mmHg) than in those without (13.5+/-4.4), as was FAP (58.6+/-12.8 as opposed to 38.7+/-4. 7) (p<0.05). Moreover, the difference between systemic blood pressure and the FAP with haemorrhagic AVMs (17.0+/-9.5 mmHg) was significantly lower than that in nonhaemorrhagic cases (33.7+/-5.5) (p<0.05). The pressure difference between the feeding artery and draining vein was not significant between the haemorrhagic and nonhaemorrhagic groups. There was no significant difference of SP between haemorrhagic and nonhaemorrhagic patients.

INTERPRETATION

The present study suggests that a high DVP probably induced by high resistance in the venous drainage system, as well as a high FAP, may contribute to the development of haemorrhage from AVMs, and physiologically supports previous reports that small AVMs and AVMs with only one draining vein are susceptible to haemorrhage.

Basaloid-squamous carcinoma of the esophagus: report of a case

We report herein the case of a 69-year-old man with basaloid-squamous carcinoma (BSC) of the esophagus. To the best of our knowledge, this is the 60th case of BSC of the esophagus to be reported in Japan, and a review of the other 59 cases is presented after this case report. In our patient, endoscopic findings revealed a circumferential erosion in the middle intrathoracic esophagus (Im), and a protruding tumor with friable ulceration in the center of the erosion. A biopsy suggested that it was moderately differentiated squamous cell carcinoma (SCC), and a thoracoscopic total thoracic esophagectomy was performed. Histologically, the protruding-type lesion with ulceration was composed of BSC, and the circumferential 0 -I + IIc type lesion was composed of moderately differentiated SCC. The immunohistochemical findings of these resected specimens led us to suspect that the basal-layer-type SCC had transformed into BSC by undergoing differentiation and expansive proliferation.