[Comparative study on the macroscopic and histopathological diagnosis of lymph node metastases in cancer patients]

Macroscopic diagnosis for lymph node metastases was compared with histopathological diagnosis in 444 patients with carcinoma of the esophagus, stomach, colon, thyroid and breast. The former indicated lymph node metastases in 181 patients. In all of them, none or less than five node metastases were proven by routine histopathological diagnosis. Detailed histological study revealed lymph node metastases in 25 out of 263 patients with macroscopically negative nodes, the rate of false negative being 9.5 per cent. The study also demonstrated no lymph node metastases in 51 of 181 patients with macroscopically positive nodes. Three additional specimens were obtained from originally examined 693 lymph nodes and reexamined microscopically in these 51 patients. Involvement by cancer cells was detected in 9 nodes (1.3 per cent) in 8 patients. Metastases were found from additional specimens in 7 of 9 nodes, indicating that metastatic carcinoma had been overlooked in the remaining two nodes. Additional specimens or embedding-techniques were recommended in such cases as macroscopic metastases were strongly suspected or lymph vessel invasions were remarkable. In 24 patients with esophageal cancer, one to one correspondence was available in the analysis of macroscopic diagnosis. Seventy-eight out of 108 involved nodes were macroscopically judged as involved (sensitivity; 72.2 per cent), and 1166 out of 1260 nodes without macroscopical metastases were judged as cancer-free (specificity; 92.5 per cent). Overestimation of macroscopic diagnosis was due to thickened capsule, fibrosis, inflammation and enlargement in size more than 10 mm in diameter of the nodes. Underestimation was observed in case of nodes with metastatic area less than one-third and with smaller size less than 5mm in diameter.

[Pre-operative staging in advanced gastric cancer by ultrasound; with special reference to para-aortic lymph node metastases]

Extraluminal cancer spreadings such as peritoneal dissemination, liver metastases, lymph node metastases and infiltration to surrounding organs were examined in 236 patients with gastric cancer by ultrasound (US). Peritoneal dissemination was found in 36 of 236 cases. Ascites, nodules in the cul-de-sac and thickened wall of the transverse colon could be detected by US in 24 of 36 cases (sensitivity of 67%). Liver metastases were detected in 18 out of 23 cases (78%). Infiltration to the surrounding organs, mainly to the pancreas, was impossible to demonstrate by US. Sensitivity was 44% (17/39). Lymph node metastases in the region around the celiac axis were indicated in 30 of 40 cases (75%) by US. Para-aortic nodal metastases were also detected in 27 of 34 cases (79%). Ultrasonic images of para-aortic lymph node metastases were classified into four figures: plate type, sandwich type, unilateral multiple type, unilateral solitary type. These types were not necessarily the same in indication of laparotomy, selection of combined or adjuvant therapy, significance of nodal dissection and also prognosis. Solitary involved para-aortic node near the left renal vein should be removed in a case free from peritoneal dissemination or liver metastases. Ultrasound could be very useful in screening patients with gastric cancer for peritoneal dissemination, liver metastases and lymph node metastases.

Step response analyses of the cardiovascular system and their application to the measurement of systemic and pulmonary vein compliances

A theoretical analysis of the step response in the closed cardiovascular system induced by a sudden shift of the right cardiac output curve predicted that if the relations of the right heart output (COr) and the total systemic capillary flow (CFs) to the systemic venous pressure (Psv) are linear, then the time course of Psv change will become monoexponential with a time constant T given by T = Csv/(Gr + Gs), where Csv is the systemic vein compliance and Gr and Gs are the conductances of the transient COr-Psv and CFs-Psv relationships. A similar prediction was obtained for the time constant T of the pulmonary vein pressure (Ppv) response to the step change in the left cardiac output (COl) curve, pulmonary vein compliance (Cpv) and the conductances of the COl curve, and the pulmonary capillary flow (CFp) curve against Ppv. The actual Psv or Ppv changes following sudden alteration of the COr or COl curve by inflation and deflation of the balloon in the right or left atrium revealed monoexponential time courses. Semilogarithmic plots of the transient vein pressure changes yielded correlation coefficients of -0.995 +/- 0.006 (means +/- SD) in 11 curves for Psv and 0.977 +/- 0.017 in 16 curves for Ppv (P less than 0.01). The assumed linearity of dynamic COr and COl curves was confirmed by beat by beat COr-Psv and COl-Ppv relationships during the step responses, except for the first few beats immediately after the balloon maneuver. The linearity of the dynamic CFs curve was examined by measuring CFs with a double-step balloon maneuver so as to cause rapid equilibrium between COr and CFs at varied moments of the transient process. The correlation coefficient between CFs and Psv thus obtained was 0.98 +/- 0.04 (P less than 0.01). A similar linearity of the dynamic CFp-Ppv relationship was suggested from their steady-state curves. The values of Csv calculated from the experimental data were 1.70 +/- 0.12 ml/mmHg/kg body wt in 11 curves and those of Cpv were 0.13 +/- 0.03 ml/mmHg/kg in 15 curves. These results are mostly consistent with those previously reported.

[Thyroid nodules; evaluation of malignancy by ultrasonography]

Preoperative ultrasonic examination was correlated to final pathological diagnosis in 102 cases which underwent thyroidectomy in our clinic from 1979 to May 1985. Preoperative ultrasonic diagnosis was as follows: Sensitivity was 78% (45/58 cases), and specificity was 86% (38/44 cases). Four factors in ultrasonic image were considered: Shape, boundary, internal echo and margin were featured, and correlated to malignancy in 75 cases with mainly solid nodules. Among 34 nodules with irregular shape, 33 (97%) were pathologically malignant and 40 of 42 (95%) with rugged boundary were also malignant. Whether internal echo was even or not could not be used as a diagnostic criteria. Similarly, whether a nodule had well defined margin or not was found not to be a significant criteria in order to differentiate malignant from benign lesions. In 15 of 34 cases with lymph node metastases, metastatic lymph nodes were detected by ultrasonography. Lymph node metastases must be also evaluated by ultrasonography preoperatively in thyroid diseases. Each of these factors must be considered individually in the diagnosis of thyroid nodules. By evaluation of the ultrasonography findings the pathological characteristics may be inferred, and consequently being possible to reach a correct diagnosis.

Vitamin D status after total gastrectomy

Serum levels of 25-hydroxyvitamin D, 24,25-dihydroxyvitamin D, 1,25-dihydroxyvitamin D, immunoreactive parathyroid hormone, and urinary excretion of nephrogenous cyclic AMP were measured in 25 patients after total gastrectomy. Two types of reconstruction after total gastrectomy were also compared. Serum 25-hydroxyvitamin D levels were significantly decreased and serum 24,25-dihydroxyvitamin D levels were markedly reduced, whereas serum 1,25-dihydroxyvitamin D levels were significantly increased in the patients. Although serum levels of immunoreactive parathyroid hormone did not show a significant difference, serum alkaline phosphatase levels and urinary excretion of nephrogenous cyclic AMP were significantly increased in the patients. The results suggest that defective vitamin D storage and enhanced vitamin D action coexist in patients after total gastrectomy and that the enhanced vitamin D action, possibly derived from slightly increased parathyroid function, would be a compensatory mechanism to sustained calcium deficiency. No substantial difference of vitamin D status was observed between the two types of reconstruction which differed in passage through the duodenum.

Venous occlusive RN plethysmography: comparison with electrical admittance plethysmography

A venous occlusion plethysmography using radionuclide (RN) was introduced for the measurement of the limb blood flow. This technique, called RN plethysmography, can be carried out in a subject who has been previously administered RN intravenously for the routine angiographic examination. The blood flow is calculated from the initial slope of the RN count rate change (RN accumulation curve) due to venous occlusion. In this study, this method was compared with electrical admittance plethysmography. The blood flow values determined by these two methods correlated well with each other.

Two stages of excitability change of pontine pause neurons in the cat

Spikes of single pontine pause neurons (PNs) in the cat were recorded extracellularly and identified by observing cessation of tonic discharges before and during the fast phase of vestibular nystagmus. PNs were antidromically activated from the excitatory burst neuron area. Antidromic spikes were abolished or their peak latencies were prolonged during particular periods within a nystagmic cycle. The excitability change in PNs indicated by alteration of the antidromic responses occurred with two stages; i.e. a moderate decrease in excitability before the onset of the fast phase and an abrupt, intense decrease starting form the beginning of the fast phase.

Superficial carcinoma of the esophagus

Nine cases of superficial carcinoma of the esophagus were described. Although 3 patients complained of abdominal sensations on swallowing or dysphasia, 6 patients did not present with any symptoms related to the esophageal lesion. The radiologic diagnosis is particularly difficult in cases with superficial type esophageal cancer, and no definitive findings were obtained in three such cases. However, esophagoscopy using Lugol spray was far more effective for the recognition of these superficial lesions. Although surgical resection of the esophagus is technically easier in these cases, the indications of surgery should be carefully evaluated. One operative death occurred in our series. In cases that are good indications, however, wide lymph node dissection should be carried out, since metastases occur even to distant lymph nodes, particularly in cases with cancer invasion of the submucosal layer. The histopathologic diagnosis was squamous cell carcinoma in 8 cases, but in one case it was adenocarcinoma of mucus-secreting gland origin in the mid-thoracic esophagus.

[Vascular-volume compensation method for noninvasive measurement of instantaneous arterial blood pressure: its usefulness in psychological research]

A new method of measuring blood pressure proposed previously by us (1980) was examined to evaluate its usefulness and applicability for psychological research. In this method, beat-to-beat systolic and diastolic pressures and pressure waveforms of the human finger are measured noninvasively by the use of a volume-servocontrol system, in which vascular volume changes, associated with intraarterial pressure and photo-plethysmographically detected, are compensated by an applied counterpressure (cuff pressure) to maintain a proper value corresponding to the unloaded vascular volume. At this state, the servocontrolled cuff pressure follows the intraarterial pressure instantaneously. Comparative data with direct measurement from the brachial artery were analyzed in a normotensive and a hypertensive subjects, and fairly valid regression coefficients as well as highly significant correlation coefficients were obtained between these two methods in each subject under various conditions. The present system can be used without any discomfort for the measurement of instantaneous arterial pressure for more than one hour, since the blood circulation in the finger is maintained. This system, therefore, was found to be an useful and practical means to study human subjects in various fields of psychology.

[Successful treatment in an adult case of congenital esophagobronchial fistula]

A case of congenital esophagobronchial fistula in a 46-year-old woman was described. The patient had presented with repeated attacks of pulmonary infection from her childhood and had been diagnosed pneumonia at least five or six times after the age of 18 years. Preoperative examinations including esophagogram by barium swallow revealed the existence of a fistula between middle thoracic esophagus and left B6 bronchus. The fistula was recognized as Type II of Braimbridge and Keith's classification, and successfully resected with left lower pulmonary lobe. Sixty-eight cases with congenital esophagobronchial fistula in adult including our own case have been reported in Japanese literature and about 70 cases in the literature of western countries. From the analysis of these cases, diagnostic basis on congenital origin of the fistula, useful diagnostic methods, types of the fistula and appropriate surgical procedures were discussed.

[Pharmacokinetics of a new antitumor antibiotic, neothramycin, after intrapleural administration]

In 5 patients with malignant pleural effusion, neothramycin (NTM) was intrapleurally administered at a dose of 30 mg in 3 cases and 40 mg in 2 cases and the pharmacokinetics was studied by using compartment models. The results were as follows: 1) Pleural levels of NTM were described by a mono-exponential equation and the half-life ranged from 3.45 to 6.48 hr. 2) The time to reach the maximum plasma level was 1 to 2 hr after pleural administration. The maximum levels were 54 to 106.4 ng/ml with the 30 mg dosage and 74.7 to 79.2 ng/ml with the 40 mg dosage, followed by a slow decline, with T1/2 ranging from 6.54 to 17.80 hr. 3) The elimination half-life of NTM in the plasma after intrapleural administration was much longer than that after intravenous administration. This phenomenon can be explained by a "flip-flop model": in this case, the rate of transfer from the pleural space to the plasma was much slower than that of the elimination from the plasma. 4) The parameters, K1 and K2, which were obtained by the deconvolution method, seemed to reflect the transfer of NTM between the pleural space and the plasma. 5) In 3 out of the 4 evaluable cases, an extreme decrease in the pleural fluid volume and suppression of reswelling were observed, including a case found to be negative for tumor cells upon cytodiagnosis.

[Leiomyoma and leiomyosarcoma of the esophagus: report of 9 cases and review of the Japanese literature]

Seven cases of leiomyoma and two cases of leiomyosarcoma of the esophagus were presented. Review of the Japanese literature revealed a total of 260 cases of the former and only 35 cases of the latter, including our own cases. They occurred more frequently in males than females, by a ratio of 1.6:1 and 1.8:1, respectively. The patients with leiomyosarcoma distributed in higher age groups. The most frequent symptom was dysphagia in both groups of the cases, but in cases of leiomyosarcoma the incidence was much higher and the duration of the symptom was shorter. About 20% of the patients with leiomyoma were asymptomatic. Although the size of leiomyosarcoma tended to be larger, giant leiomyomas more than 10 cm in diameter were found in 18% of the cases. The lower third of the esophagus was the site of both tumors in over half of the cases, the middle third being the next frequent. The surgical removal by enucleation was the procedure of choice for leiomyoma. However, when either the tumor is densely adherent to the mucosa for considerable length or accidental extensive mucosal tear occurs, esophageal resection is recommended. Postoperative morbidity was minimal and results were generally excellent. On the contrary, esophageal resection including the tumor was indicated for leiomyosarcoma. The long-term results were poor particularly in cases of infiltrating-type lesions, though survival data could not be fully evaluated.

Functional organization of premotor neurons in the cat medial vestibular nucleus related to slow and fast phases of nystagmus

Extracellular spikes were recorded from secondary vestibular neurons in the cat medial vestibular nucleus (MVN) and were identified as type I or II neurons by horizontal rotation. Type I neurons were further classified as excitatory or inhibitory premotor neurons on the basis of their axonal termination in the contralateral or ipsilateral abducens nucleus, demonstrated by spike-triggered averaging of abducens nerve discharges, or by antidromic activation using systematic microstimulation within the abducens nucleus. Both excitatory and inhibitory premotor type I MVN neurons exhibited a rhythmic modulation of their firing rate in association with nystagmus elicited by rotation or electrical stimulation of the vestibular nerve. Their tonic activity during the slow phase was suppressed at the quick phase directed to the ipsilateral side. Excitatory type I MVN neurons terminating in the contralateral abducens nucleus sent collateral axons to the contralateral MVN. These commissural neurons also showed a nystagmus-related discharge pattern. Type II MVN neurons activated at short latency by stimulation of the contralateral vestibular nerve exhibited burst discharges when the activity of ipsilateral type I neurons was suppressed at the quick phase. These type II neurons made monosynaptic inhibitory connection with type I neurons as shown by the post-spike average of the membrane potential of secondary MVN neurons triggered from spikes of single type II neurons. Thus, the inhibitory action originating from burst activity of type II MVN neurons contributes to suppression of type I premotor MVN neurons during fast eye movements.