Endomyocardial biopsy findings in patients with atrioventricular block in the absence of apparent heart disease

The purpose of this study was to examine the histopathological findings of right ventricular endomyocardial biopsies from ten patients less than 60 years of age (47 +/- 9.8 (mean +/- SD) years) with documented atrioventricular block but without apparent heart disease. They underwent electrophysiological testing, echocardiography, coronary angiography, and right ventricular endomyocardial biopsy. Biopsy specimens were assessed for morphologic changes in myocyte diameter, fibrosis, disarray, and degeneration. Electrophysiological testing demonstrated atrioventricular nodal block in 2, intra-His bundle block in 2, and infra-His bundle block in 6 patients. Histology revealed evidence of myocardial fibrosis with either myocyte hypertrophy or disarray in 7 of the 10 patients. The results of electrophysiological testing did not correlate with the histopathological findings or severity. In one patient, heart failure appeared during the follow-up period. We conclude that patients with atrioventricular block of unknown etiology have histological abnormalities of the ventricular endomyocardium in addition to the conduction system disturbances. We consider such cases as constituting one of the disease groups of cardiomyopathy, and suggest that it is necessary to follow up the clinical course in these patients.

[A case of multiple liver metastases from colon cancer successfully operated after intraarterial chemotherapy performed in home]

A 60-year-old male patient had unresectable multiple liver metastases from a sigmoid colon cancer that had been resected, and thus hepatic arterial infusion therapy was planned. A heparin coated catheter was inserted from the left thoracoacromial artery to the proper hepatic artery. 5-fluorouracil (1,000 mg) was administered via the catheter 24 hours/week using an implantable vascular device and a small disposable pump in his home. After 59 weeks, the metastatic liver tumors had decreased remarkably in size, and all tumors could be resected completely through surgery. Three weeks after the operation, the same intraarterial chemotherapy was restarted to prevent the recurrence in the liver. However, the patient died of lymph node recurrences. The intraarterial chemotherapy is thought to be useful for neoadjuvant therapy in patients with inoperable liver metastasis from colon cancer.

[A case of successful management of nonresectable advanced cholangiocellular carcinoma by intermittent hepatic arterial infusion at home]

An 82-year-old female was referred to our hospital because a 16 x 8 cm tumor detected in her liver by abdominal ultrasonography (echo, hereafter) and CT. The patient was diagnosed as having highly advanced cholangiocellular carcinoma (CCC) by abdominal angiography. Since excision of the tumor was impossible due to the patient's age, a reservoir was indwelled for intra-arterial injection into the liver. Continuous injection of 1,000 mg 5-FU over 24 hours was performed every 2 weeks using a portable disposable pump 70 times. The tumor has been markedly reduced since the start of chemotherapy, with a reduction rate (PR) of 98% over the 3 years until the present. Since the frequency of administration was low, only twice a month, the patient had few side effects despite her old age, and injections could be performed in the outpatient department. Usually, the prognosis for CCC is poor. However, the patient has maintained a good QOL with the periodic intra-arterial injection of the carcinostatic into the liver, and this treatment has had a strong antitumor effect. This chemotherapy is thus considered useful for CCC which can not be resected.

Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy

OBJECTIVE

The purpose of this study was to compare the outcomes after sleeve lobectomy and pneumonectomy for patients with non-small cell lung cancer distributed according to their nodal involvement status.

METHODS

Of 1172 patients in whom primary non-small cell lung carcinoma, including mediastinal lymph nodes, was completely excised, 151 patients underwent sleeve lobectomy and 60 underwent pneumonectomy. For bias reduction in comparison with a nonrandomized control group, we paired 60 patients undergoing sleeve lobectomy with 60 patients undergoing pneumonectomy by using the nearest available matching method.

RESULTS

The 30-day postoperative mortality was 2% (1/60) in the pneumonectomy group and 0% in the sleeve lobectomy group. Postoperative complications occurred in 13% of patients in the sleeve lobectomy group and in 22% of those in the pneumonectomy group. Local recurrences occurred in 8% of patients in the sleeve lobectomy group and in 10% of those in the pneumonectomy group. The overall 5- and 10-year survivals for the sleeve lobectomy group were 48% and 36%, respectively, whereas those for the pneumonectomy group were 28% and 19%, respectively (P =.005). Multivariable analysis showed that the operative procedure, T factor, and N factor were significant independent prognostic factors and revealed that survival after sleeve lobectomy was significantly longer than that after pneumonectomy (P =.03).

CONCLUSIONS

These data suggest that sleeve lobectomy should be performed instead of pneumonectomy in patients with non-small cell lung cancer regardless of their nodal status whenever complete resection can be achieved because this is a lung-saving procedure with lower postoperative risks and is as curative as pneumonectomy.

Clonal expansion in evolution of chronic hepatitis to hepatocellular carcinoma as seen at an X-chromosome locus

Clonal analysis has shown that hepatocellular carcinoma arises from a single cell. However, the clonality of precancerous lesions and adjacent nonneoplastic tissues is not clear. We analyzed a human androgen receptor locus to elucidate the clonal state of liver tissues including post-hepatitic lesions associated with hepatocarcinogenesis. The analysis was based on a restriction fragment length polymorphism involving an androgen receptor locus on the X chromosome, taking advantage of physiologic random inactivation by methylation of 1 of 2 X chromosomes in females during embryogenesis. Clonality was assessed in 79 randomly located tissue samples microdissected from noncirrhotic liver, including a total of 40 morphologically normal sites in 4 normal livers and 39 sites from a single HCV-infected liver. In addition, 51 regenerative nodules, 4 areas of adenomatous hyperplasia, and 18 hepatocellular carcinomas were sampled. All samples were obtained from livers involved by various neoplasms. Eight of forty samples (20.0%) from the four normal livers and 20 of the 39 samples (51.3%) from the single HCV-infected liver showed a monoclonal pattern. Moreover, 30 of 51 regenerative nodules (58.9%) showed a monoclonal pattern. No histologic differences were evident between mono- and polyclonal nodules. On the other hand, the 18 carcinomas and 4 areas of adenomatous hyperplasia all were monoclonal. Mean calculated monoclonal areas of normal liver and liver with chronic hepatitis were 1.1 and 3.3 mm(2). Our results suggest that areas representing a single clone of hepatocytes are present in normal liver, and these progressively expand as changes advance from chronic hepatitis to hepatocellular carcinoma.

Malignant endocrine carcinoma of the stomach

Small cell carcinoma and small portions of poorly differentiated adenocarcinoma of the stomach sometimes differentiate into secretory cells. We experienced a pure endocrine carcinoma of the stomach. The patient, who had a giant mass in the greater curvature of the body of the stomach and regional lymph node metastasis, underwent total gastrectomy. Immunohistologic staining of the resected specimens revealed that the tumor was an endocrine carcinoma. The tumor cell shape in the present case was polygonal or oval and the cell size was relatively large. The cell nucleus was coarse chromatic and nucleoli were seen, whereas, the nucleus of small cell carcinoma often shows a fine chromatic pattern and nucleoli are not seen. On the basis of these findings, the present case was considered to be a pure endocrine carcinoma which was not classified as a small cell carcinoma.

Pharmacological characterization of an 18-kDa protein associated with the peripheral-type benzodiazepine receptor in salivary glands

Pharmacological characterization of peripheral type benzodiazepine receptors in rat, rabbit, mouse and human salivary glands was determined by receptor binding and photoaffinity labeling analysis using [3H]PK14105 (1-(2-fluoro-5-nitrophenyl)-3-isoquinolinecarboxylic acid). [3H]PK14105 bound to the membranes of salivary glands in rats, rabbits, mice and humans with high affinity at the nanomolar level. The rank order of receptor density in submandibular glands among several species was as follows: human > or = rat > or = mouse > rabbit. Competitive potency of receptor ligands against [3H]PK14105 was as follows: PK1195 > or = Ro5-4864 > diazepam > clonazepam > Ro15-1788. The rank order of potency against calcium channel ligands and co-transport inhibitors was as follows: nitrendipine > BAY K 8644 > bumetanide > furosemide. Pretreatment with nitrendipine or BAY K 8644 decreased the affinity of [3H]PK14105 binding to rat parotid gland membranes, without changing the density. The photoaffinity labeling with [3H]PK14105 indicated the presence of the 18-kDa protein in all salivary glands of our experiment. The inhibition of photolabeling by some receptor ligands was the same results as the receptor binding assay. In conclusion, the peripheral type benzodiazepine receptors include the 18-kDa protein photolabeled with [3H]PK14105 in salivary glands of rat, mouse, rabbit and human.

The basic helix-loop-helix transcription factor, dHAND, is required for vascular development

Reciprocal interactions between vascular endothelial cells and vascular mesenchymal cells are essential for angiogenesis. Here we show that the basic helix-loop-helix transcription factor, dHAND/Hand2, is expressed in the developing vascular mesenchyme and its derivative, vascular smooth muscle cells (VSMCs). Targeted deletion of the dHAND gene in mice revealed severe defects of embryonic and yolk sac vascular development by embryonic day 9.5. Vascular endothelial cells expressed most markers of differentiation. Vascular mesenchymal cells migrated appropriately but failed to make contact with vascular endothelial cells and did not differentiate into VSMCs. In a screen for genes whose expression was dependent upon dHAND (using subtractive hybridization comparing wild-type and dHAND-null hearts), the VEGF(165) receptor, neuropilin-1, was found to be downregulated in dHAND mutants. These results suggest that dHAND is required for vascular development and regulates angiogenesis, possibly through a VEGF signaling pathway.

Different responses of polyploidized V79 cells after removal of two drugs, demecolcine and K-252a

To examine whether or not cells polyploidized by different mechanisms behave in a different manner after drug removal, V79 Chinese hamster cells were assessed by flow cytometry (FCM) after their polyploidization by demecolcine and K-252a, inhibitors of spindle-fiber formation and protein kinase, respectively. Cell cycle analysis of DNA histograms of V79 cells before and after the drug release was performed. With both drugs, the ploidy of V79 cells increased just after the drug removal and was maintained for a week. A difference was evident 10 days after the release. Tetraploid cells were the main population from 10 to 18 days after the release of K-252a, but not demecolcine. Cell cycle parameters were almost the same in pseudo diploid and tetraploid V79 cells, except for the tetraploid S phase which was 2h longer.

[A case of intra-right atrial thrombus adhering to an intravenous hyperalimentation catheter]

We reported a clinical case of intra-right atrial giant thrombus adhering to an intravenous hyperalimentation(IVH) catheter. The patient was a 63 years-aged male, and was indwelled the IVH catheter for one month from right subclavian vein to right atrium to improve a malnutrition due to his advanced gastric cancer. Intra-cardiac mass was found in the right atrium by routine transthoracic echocardiography for the preoperative inspection; the giant mass(22 x 20 mm) had a low-echo density with a portion of high-echo density. In transesophageal echocardiography, the portion of high-echo density was found to be an IVH catheter and intra-right atrial mass was pierced by that catheter; however, it was difficult to determine whether the mass was either a vegetation or thrombus. The mass was removed by operation, and was diagnosed as a giant thrombus by histopathological examination. Thrombus should be taken into account as a possible cause of intra-right atrial mass when an IVH catheter was indwelled in the right atrium.

Angiotensin blockade inhibits SIF DNA binding activities via STAT3 after myocardial infarction

The in vivo activation of transcription factors, which is important for cell regulation by gene expression, has not been well examined in myocardial infarcted heart. The purpose of this study was to determine whether myocardial signal transducer and activator of transcription (STAT) pathway is activated as sis-inducing factor (SIF) in infarcted heart, and to assess the angiotensin blockade on SIF activity in ischemic and non-ischemic myocardium of rat. Myocardial infarction was made by ligation of the coronary artery in Wistar rats. In electrophoretic mobility shift assay, myocardial SIF DNA binding activities gradually increased and reached to peak at 1 week in infarcted and non-infarcted regions after myocardial infarction. Imidapril and candesartan cilexitil significantly prevented the increase in SIF DNA binding activity in infarcted and non-infarcted regions. This increased SIF DNA complex was supershifted by specific anti-STAT3 antibody, indicating that increased SIF complex at least contained activated STAT3 proteins in myocardial infarcted heart. Furthermore, immunoprecipitation-Western blot analysis revealed that STAT3 of infarcted and non-infarcted regions were tyrosine-phosphorylated at 1 week after myocardial infarction. Imidapril and candesartan cilexitil prevented the increase in phosphorylated STAT3. Thus, the transcriptional activation of STAT3 through AT1 receptor may be partially involved in cardiac remodeling after myocardial infarction.

Myocardial Depolarizing Response to Glutamate in the Myogenic Heart of the Branchiopod Crustacean Triops longicaudatus

Fine structure of the heart and the effects on the heartbeat of some transmitter candidates in crustacean cardioregulatory system were examined in the myogenic heart of the branchiopod crustacean Triops longicaudatus. Electron microscopy revealed that, in each myocardial cell, myofibrils are confined in the part facing the epicardium and intercalated disks are present between the myofibrillar regions of adjacent myocardial cells. No neural elements were found in the heart, suggesting lack of extrinsic cardioregulatory nerves from the central nervous system. Gamma aminobutyric acid and acetylcholine produced no detect-able changes in the myogenic activity of the heart at concentrations up to 10(-3) M, respectively. Glutamate induced a depolarizing membrane response in the cardiac muscle with a threshold concentration of approximately 1x10(-5) M. The amplitude of the depolarizing response was concetration-dependent and saturated at approximately 1x10(-4) M. The myogenic activity of the heart increased in frequency with glutamate of less than approximately 3x10(-5) M. With higher dose of glutamate, action potential adaptation occurred in the cardiac muscle and the heart exhibited a systolic arrest.

Errors in the spleen-blood partition coefficient for water in C15O2 steady-state PET

The aim of this study was to clarify if the value of 0.93, determined for patients with normal livers, is useful as a pathological spleen-blood partition coefficient for water when the splenic blood flow is quantified by the C15O2 steady-state method. A steady-state PET scan with continuous inhalation of C15O2 and a dynamic PET scan with a H(2)15O bolus injection were performed. From 157 patients, 392 slices were chosen as having planes that encompassed the spleen and provided regions of interest with full signal imaging. A comparison of the results of the steady-state and dynamic methods was performed. When 0.93 was adopted as the spleen-blood partition coefficient for water, an error of about 25% was seen in the splenic blood flow of patients with cirrhosis. When measuring splenic blood flow, the H(2)15O dynamic method is necessary. However, a rough estimate of splenic blood flow is possible by the C15O2 PET steady-state method, if this error is known.

Polarized secretion of transgene products from salivary glands in vivo

Previously (Kagami et al. Hum. Gene Ther. 1996;7:2177-2184) we have shown that salivary glands are able to secrete a transgene-encoded protein into serum as well as saliva. This result and other published data suggest that salivary glands may be a useful target site for vectors encoding therapeutic proteins for systemic delivery. The aim of the present study was to assess in vivo if transgene-encoded secretory proteins follow distinct, polarized sorting pathways as has been shown to occur "classically" in cell biological studies in vitro. Four first-generation, E1-, type 5 recombinant adenoviruses were used to deliver different transgenes to a rat submandibular cell line in vitro or to rat submandibular glands in vivo. Subsequently, the secretory distribution of the encoded proteins was determined. Luciferase, which has no signal peptide, served as a cell-associated, negative control and was used to correct for any nonspecific secretory protein release from cells. The three remaining transgene products tested, human tissue kallikrein (hK1), human growth hormone (hGH), and human alpha1-antitrypsin (halpha1AT), were predominantly secreted (>96%) in vitro. Most importantly, in vivo, after a parasympathomimetic secretory stimulus, both hK1 and hGH were secreted primarily in an exocrine manner into saliva. Conversely, halpha1AT was predominantly secreted into the bloodstream, i.e., in an endocrine manner. The aggregate results are consistent with the recognition of signals encoded within the transgenes that result in specific patterns of polarized protein secretion from rat submandibular gland cells in vivo.

Dobutamine-stress electrocardiographically gated positron emission tomography for detection of viable but dysfunctional myocardium

PURPOSE

This study was performed to determine whether low-dose dobutamine stress electrocardiography (ECG)-gated fluorine-18 fluorodeoxyglucose (FDG)-positron emission tomography (PET) can assess wall motion and identify myocardium without contractile reserve despite preserved FDG uptake.

METHODS

Fifty-three patients with myocardial infarction and normal sinus rhythm underwent ECG-gated FDG-PET and transthoracic echocardiography. Wall motion of 10 segments of the left ventricle was graded as normal, hypokinetic, or akinetic/dyskinetic.

RESULTS

In 365 (76%) of 480 segments, assessment of wall motion was concordant between the 2 modalities. In 30 patients dobutamine-stress ECG-gated FDG-PET was performed. In 13 (50%) of 26 dysfunctional segments with normal FDG uptake, 16 (36%) of 44 dysfunctional segments with mildly reduced FDG uptake and 12 (25%) of 48 dysfunctional segments with moderately reduced FDG uptake, wall motion was improved by dobutamine infusion.

CONCLUSION

Assessment of left ventricular wall motion with ECG-gated FDG-PET is feasible, and dobutamine stress ECG-gated FDG-PET can simultaneously identify metabolic viability and contractile reserve.

Knot formation in a long tube used in the treatment of a post-operative adhesive small bowel obstruction

The complications specific to the management of the nasointestinal long tubes for small bowel obstruction are not generally appreciated. We report here of a case of knot formation of the long tube which was inserted for a 60 year-old male. Because it was difficult to place the tube in the distal stomach despite frequent changes in patient position, two coiled loops were noted at the fornix as the tip of the tube reached the antrum. The tube was gently removed without injury to the esophagus or stomach under fluoroscopic control. This case illustrates that when a long tube is used, the formation of multiple coils in the stomach should be avoided during placement to prevent knotting. Furthermore, a knotted tube can be gently removed non-operatively without esophageal injury. A short tube may be superior to a long tube because most of the complications can be avoided.

Bowel perforation during chemotherapy for non-hodgkin's lymphoma

Bowel perforation in patients with primary malignant lymphoma usually occurs at the site of tumor. A 78 year-old man underwent chemotherapy for malignant lymphoma. He presented with abdominal pain. An emergency operation was performed under a diagnosis of panperitonitis. At laparotomy, an anal-side perforation approximately 20 cm from the Treiz ligament was observed. Drainage and partial resection of the jejunum was performed. Histopathologic examination demonstrated that there was no characteristic finding of malignant lymphoma around the perforation site in the case. Perforation of the small intestine is one of the most critical complications during the chemotherapy for malignant lymphoma. In cases of chemotherapy for malignant lymphoma, especially systemic administration, we should keep in mind the possibility of perforation of the small intestine. Fortunately, emergency surgery saved the patient presented in this report. Early diagnosis and treatment are important to improve prognosis of bowel perforation in patients with primary malignant lymphoma.

[Clinical evaluation of weekly hepatic arterial infusion chemotherapy in patients with unresectable metastatic liver cancer]

Twenty-five cases with unresectable metastatic liver cancers were experienced in our hospital over the past five years who underwent weekly 24-hour continuous hepatic arterial infusion chemotherapy using 5-FU and CBDCA. The response rate was 20%, the median survival was 23 months, and the one/two year overall survival rates averaged 81.3/45.5%. In 77% of patients, this therapy prevented death from hepatic metastases. Moreover, since adverse effects were limited compared with bolus infusion, weekly 24-hour continuous hepatic arterial infusion chemotherapy was thought to be a favorable method.

Extended sleeve lobectomy for lung cancer: the avoidance of pneumonectomy

OBJECTIVE

We have tried atypical bronchoplasties in patients with noncompromised lung function with centrally located cancers to avoid pneumonectomy. We evaluated the efficacy of extended sleeve lobectomy in such patients.

METHODS

Among 157 patients undergoing bronchoplasty for primary non-small cell lung carcinoma, 15 patients underwent extended sleeve lobectomy.

RESULTS

According to the mode of reconstruction, the 15 patients were classified into 3 groups: (A) anastomosis between the right main and lower bronchi with resection of the upper and middle lobes (n = 6), (B) anastomosis between the left main and basal segmental bronchi with resection of the upper lobe and superior segment of the lower lobe (n = 4), and (C) anastomosis between the left main and upper division bronchi with resection of the lingular segment and lower lobe (n = 5). The tumors were completely resected in all patients. Pulmonary angioplasty was carried out in 8 patients. Bronchial reconstruction was successful in all patients. Pulmonary vein thrombosis resulting from overstretching of the inferior pulmonary vein occurred in 1 patient of group A and was relieved by completion pneumonectomy. There was neither operative mortality nor local recurrence. Although all patients with stage IIB disease and half of patients with stage IIIA disease were alive without recurrence (12-106 months), half of the patients with stage IIIA disease died of distant metastases within 1 year.

CONCLUSIONS

We suggest that this extended sleeve lobectomy, which is technically demanding, should be considered in patients with centrally located lung cancer, because this lung-saving operation is safer than pneumonectomy and is equally curative.

[Five cases of cerebral and/or cerebellar embolism after insertion of a heparin-coated catheter from the left thoracoacromial artery]

We reported five cases of cerebral and/or cerebellar embolism after insertion of a heparin-coated catheter from the left thoracoacromial artery for multiple liver metastases. They were one patient with multiple liver metastases from the angiosarcoma of the scalp, and 4 others with gastrointestinal cancer liver metastases. The first case suffered a cerebeller embolism just after removal of a catheter that had been obstructed. In this case, it is possible that the thrombus quickly migrated into a cranial vessel from around the catheter. In the others with patent catheters, the cerebral embolisms occurred more than a month after insertion of the catheters. In the latter cases, it is thought that embolisms did not occur because of catheter insertion maneuver. However, a thrombus that grew around the catheter migrated into the left common carotid artery or the left vertebral artery. The anti-coagulation therapy should be considered for prophylactic treatment.

Preventive influence of inhaled nitric oxide on lung ischemia-reperfusion injury

In lung transplantation, lung ischemia-reperfusion injury is a serious problem when using long-term preserved grafts. A warm ischemic lung model was prepared using rabbits. NO was administered by inhalation (group I, n = 9). The control group was not administered NO (group II, n = 8). Severe ischemia-reperfusion injury occurred as evidenced by hypoxia and lung edema. PaO2 at 120 min after reperfusion was 325 +/- 41 mmHg in group I and 40 +/- 6 mmHg in group II. The pulmonary blood flow of the left lung at 120 min after reperfusion was 51% +/- 3% in group I and 20% +/- 5% in group II. The wet-to-dry weight ratio was 5.5 +/- 0.2 for the right lungs, 5.8 +/- 0.8 for the left lung in group I, and 6.1 +/- 0.4 for the left lung in group II. Histopathologically, marked hemorrhage, hyaline membrane formation, and leukocyte infiltration were observed in group II but not in group I. These data suggested that inhaled NO reduced warm ischemia-reperfusion injury in the lung, and also contributed to a better preserved lung function.

Histatin 3-mediated killing of Candida albicans: effect of extracellular salt concentration on binding and internalization

Human saliva contains histidine-rich proteins, histatins, which have antifungal activity in vitro. The mechanism by which histatins are able to kill Candida albicans may have clinical significance but is currently unknown. Using radiolabeled histatin 3, we show that the protein binds to C. albicans spheroplasts in a manner that is dependent on time and concentration. Binding to the spheroplasts was saturable and could be competed with unlabeled histatin 3. A single histatin 3 binding site with a K(d) = 5.1 microM was detected. Histatin 3 binding resulted in potassium and magnesium efflux, predominantly within the first 30 min of incubation. Studies with fluorescent histatin 3 demonstrate that the protein is internalized by C. albicans and that translocation of histatin inside the cell is closely associated with cell death. Histatin binding, internalization, and cell death are accelerated in low-ionic-strength conditions. Indeed, a low extracellular salt concentration was essential for cell death to occur, even when histatin 3 was already bound to the cell. The interaction of histatin 3 with C. albicans, and subsequent cell death, is inhibited at low temperature. These results demonstrate that the candidacidal activity of histatin 3 is not due exclusively to binding at the cell surface but also involves subsequent interactions with the cell.

A case of hyperosmolar nonketotic coma occurring during chemotherapy using cisplatin for gallbladder cancer

A 61 year-old woman was admitted to our hospital because of an abdominal tumor. She was diagnosed with recurrent gallbladder cancer, and treated with cisplatin (CDDP). On day 6, after the 1st cycle of chemotherapy, she developed confusion and suddenly became comatose. She was diagnosed as having hyperosmolar nonketotic coma (HNC) on day 7. She had no history of diabetes mellitus. She recovered from HNC after 3 days of treatment with continuous infusion of 0.45% saline and moderate amounts of insulin. HNC may be a complication of CDDP chemotherapy in patients with malignancy. Early diagnosis and appropriate treatment is necessary for HNC occurring during chemotherapy for malignant disease.