Long-term prognosis of surgical patients with hepatocellular carcinoma

We reviewed 139 resected patients with hepatocellular carcinoma at our clinic between 1963 and 1987, and using the 118 cases for the period between 1963 and 1986, we analyzed the prognostic factors that influenced the long-term prognosis by comparing the survival curves. Significant differences in the survival patterns were noted when analysed on the basis of the preoperative indocyanine green maximal removal rate (greater than 0.4 mg kg-1 min-1 versus less than 0.4 mg kg-1 min-1), tumor size (greater than 5 cm versus less than 5 cm, etc.) and the existence of tumor capsule. The recurrence of carcinoma was the main cause of death of 32 patients (56%), who died after being discharged from hospital. To improve the prognosis of patients with surgically treated hepatocellular carcinoma, postoperative multidisciplinary treatment is mandatory.

[Origin of the capsule of a chronic subdural hematoma--an electron microscopy study]

To understand the early stage of subdural neomembrane (SN) formation, we examined 23 outer SNs and two inner SNs of chronic subdural hematomas in surgical specimens. Ultrastructurally, the cellular component of the outer SN was fibroblasts, myofibroblasts, smooth-muscle cells (in four cases), blood vessels and blood-born cells. Dural border cells were observed only in limited areas. Namely, the outer SN is a simple granulation tissue which originates from multiple sources of mesenchymal cells in dura mater, and dural border cells are only one of constituent sources for SN formation. The inner SN was simply composed of slender spindle cells which were mostly fibroblasts and some were recognized as dural border cells. Our results showed that the subdural hematoma is actually an "intra" dural hematoma which is formed within the split dural border cell layer. The dura mater with rich vascular supply forms thick granulation tissue, that is outer SN and a few dural border cells on the underlying arachnoid membrane form thin fibrous inner SN.

Calcium pyrophosphate dihydrate crystal deposition disease in the cervical ligamentum flavum

The authors describe three cases of cervical radiculomyelopathy caused by calcium pyrophosphate dihydrate crystal deposition disease (CPPDcdd). Radiological investigations revealed nodular calcifications, 5 to 7 mm in diameter, in the cervical ligamentum flavum compressing the spinal cord. Light microscopic, scanning electron microscopic, and x-ray diffraction studies were performed on all three surgical specimens obtained by laminectomy. In two of the cases x-ray microanalysis and transmission electron microscope studies were also performed. This study defined the presence of two patterns of crystal deposition in the ligamentum flavum. One is a nodular deposit, in which hydroxyapatite crystals are seen in the central part of the nodules, with calcium pyrophosphate dihydrate (CPPD) being distributed thinly around them. The other pattern is a linear deposit seen in multiple ligaments and composed of pure CPPD, which causes minimal thickening of the ligaments. A transitional pattern between the two types was also observed. This study revealed details of the nodular deposition of crystals in the ligamentum flavum and demonstrates that CPPDcdd and so-called "calcification of the ligamentum flavum" are the same disease: namely, CPPDcdd. Hydroxyapatite is assumed to have been transformed from CPPD.

A new instrument for hepatic resection

A new instrument for hepatic resection was designed and developed. Use of the hepatic comb during hepatic resection is described. It is very simple in shape, easy to handle and inexpensive. Using the instrument has made mandatory rapid hepatectomy in poor risk patients possible. The hemostatic effect of the procedure with this instrument is excellent, which is an important consideration in surgical treatment of the liver.

The effect of nifedipine, a calcium channel blocker, on liver ischemia in dogs

This study was undertaken in order to determine whether the administration of nifedipine, a calcium channel blocker, could protect the liver from ischemic damage and to investigate its effect on the hepatic cellular energy status and cardio-vascular system after 60 minutes of hepatic ischemia in dogs. The ischemia was induced by temporarily clamping the portal vein and hepatic artery. One group of animals (n = 17) received nifedipine (5 micrograms/kg body weight) intravenously 15 minutes before the induction of liver ischemia, which was continued at a dose of 0.2 microgram/kg body weight/min throughout the ischemic period, and for an additional 30 minutes afterwards. Control dogs (n = 16) were not given nifedipine and survival was observed over seven days. The survival rate was 83 per cent in the nifedipine treated animals and 0 per cent in the control animals. Serum glutamic oxaloacetic transaminase levels were greatly increased following ischemia, and they were significantly lowered with the nifedipine treatment. The hepatic energy charge decreased remarkably during the hepatic ischemia, however it increased gradually after declamping but did not returned to its preoperative value in either group until one hour later and then it was higher in the nifedipine treated animals than in the control animals. Cardiac index and portal venous blood flow ratio remained higher in the nifedipine treated animals than in the control animals, after the ischemic period. These results suggest that nifedipine may have a powerful cytoprotective effect and that the period of warm hepatic ischemia could be prolonged with its use.

[Preoperative assessment of risk for gastroenterological operations in patients with hepatic cirrhosis]

In order to devise an easy and available method to assess the surgical risk of cirrhotic patients, we reviewed 52 cirrhotic patients who underwent gastroenterological operations at Tokyo Kosei Nenkin Hospital between 1968 and 1982, by means of multivariant discriminant analysis. Utilizing presence of ascites, serum albumin, ICG R15, prothrombin time and platelet count, we estimated the surgical risk as Risk Score. Furthermore, our method predicted short-term survival of other 150 cirrhotic patients who underwent gastroenterological operations at the First Surgical Department The University of Tokyo between 1968 and 1985. We conclude that our method is easily available, and that cirrhotic patients with Risk Score less than or equal to 2.5 tolerate all the gastroenterological operations except hepatic major resection, and that those with Risk Score of residual liver less than or equal to 2.5 tolerate well hepatic major resection.

[New knowledge on the calcium pyrophosphate dihydrate (CPPD) crystal deposition disease in the cervical ligamentum flavum]

A case of 64-year-old Japanese woman with cervical radiculomyelopathy caused by the deposition of both calcium pyrophosphate dihydrate (CPPD) and hydroxyapatite crystals in the cervical ligamentum flavum is reported. The patient developed paresthesia in her both hands and gait disturbance in the previous six months. Neurological examination revealed generalized hyperreflexia and hypesthesia in the C7 region. Neuroradiologically, two nodular opacifications were shown in the C3-4 and C5-6 level. CT scan revealed linear and symmetrical calcifications in the C3-4 and nodular calcifications in the C5-6 level. En bloc laminectomy was performed and the patient was discharged from the hospital with improvements of neurological symptoms. Specimens of the spinal laminae and ligamenta flava were studied by light microscopy, scanning electron microscopy (SEM), energy dispersive X-ray microanalysis (X-MA) on SEM, and an X-ray diffraction study was carried out on the crystals. The results showed A. CPPD crystal depositions throughout the ligamenta flava together with a minimal thickening of the ligaments. The deposition was seen in the midzone of the ligaments forming a plate-like distribution and forming lines in the cut surface, the latter coincided well with the CT finding at the C3-4 level. B. The nodule (7 X 6 X 6 mm in size) at the C5-6 level was composed of two crystals, CPPD and hydroxyapatite, the latter being encased by the former. The thickness of the CPPD layer was quite thin varying from 10 to 100 mu. Myelographically, the spinal cord was most severely compressed by the C5-6 nodule. C. Because of the absence of family histories and predisposing factors, the case was considered one of primary or idiopathic CPPD crystal deposition disease. The origin of the deposition of mixed crystals was discussed and it appeared likely that the central part of CPPD crystal deposition had transformed to hydroxyapatite at the C5-6 level. In the literature a considerable number of cases have been reported under the title, "Calcification of the Ligamentum Flavum", and some of them have been shown to have hydroxyapatite deposition. Considering the great similarities in clinical, radiological and histological findings between the so-called "calcification of the lig. fl." and CPPD crystal deposition disease, the present case was the first to clearly indicate that these two conditions belong to a single category, i.e. CPPD crystal deposition disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Hepatic resection for hepatocellular carcinoma. Clinical features and long-term prognosis

Ninety-eight hepatic resections for hepatocellular carcinoma were performed on 94 patients from 1963-1985. HBs antigen was positive in 17% of patients, preoperative serum alpha-fetoprotein was more than 20 ng/mL in 70% of patients, and liver cirrhosis was present in 75% of patients. Hospital mortality rate was 19%, and the volume of operative blood loss was the most decisive factor that affected the short-term prognosis. Excluding the 19 hospital deaths, the long-term survival rates of 75 patients were 73%, 42%, and 25% for 1, 3, and 5 years, respectively. Prognostic factors that influenced the long-term prognosis were investigated by comparing the survival curves. Significant differences of survival patterns were noted when analyzed on the basis of preoperative alpha-fetoprotein level (less than or equal to 200 vs. greater than 200 ng/mL), tumor size (less than or equal to 5 vs. greater than 5 cm), and tumor capsule. The recurrence of carcinoma was the main cause of death in 56% (42 patients) who died after discharge from the hospital. The development of effective prevention and treatment against recurrent tumors is necessary to improve long-term prognosis.

A study on so-called novel inclusion body in human hepatocyte

The so-called novel inclusion body (NIB) is an intrahepatocytic structure which is frequently observed in human cirrhotic liver. It resembles very much to, but definitely differs from Hepatitis B surface antigen (HBsAg) morphologically. The age distribution of liver cirrhosis cases positive for NIB is similar to that positive for HBsAg, except for an existence of a time lag in mean age. One of the best staining methods to demonstrate NIB, for example, is to exhibit it as a reddish body stained by Luna, with a contrast of HBsAg counterstained purple in color by aldehyde fuchsin after thiosulfation. Electron microscopy of the liver obtained from a patient, negative for both HBsAg and Hepatitis B e antigen (HBeAg) but positive for Hepatitis B core antibody (HBcAb) and Hepatitis B surface antigen antibody (HBsAb) clinically, revealed some unfamiliar, tubular and cisternal arrays showing a network pattern and ring-shaped structure at the site exactly corresponding to NIB localization. These are considered to have been induced from the endoplasmic reticulum by an unknown agent, for which non A non B hepatitis virus (NANBV) is rationally postulated as one of the possibilities. A close relation between NIB and NANBV is highly suspected because of much similarities in histology, histochemistry, age distribution, and electron microscopy. The true nature of NANBV should be rescrutinized, especially in relation with Hepatitis B virus infection, since NIB is quite often observed also in cirrhotic liver positive for HBsAg.

Cyclosporine and partial liver allotransplants in a simplified rat model

We designed a simplified rat model to assess the effects of cyclosporine (CsA) on liver transplants. Auxiliary liver grafts consisting of 20 per cent of the whole liver were supplied with portal inflow and the bile was drained into the stomach. The cuff technique was used routinely for both end-to-end and end-to-side venous anastomoses. The host liver was totally deprived of portal inflow. Two inbred strains of rats, LEW and F344, were used for isograft (LEW----LEW) and allograft (F344----LEW). All survivors were killed at the end of the fourth week after transplantation. During four weeks, the isografts increased by 108 per cent in wet liver weight. Animals with allograft were treated with CsA given i.m., in a daily dose of 20 and 40 mg/kg for the first ten days post transplantation. The CsA-treated rats were free from parenchymal destruction of the allograft, as was characteristic of the allograft controls. The rats given CsA in the dose of 40 mg/kg showed a 173 per cent increase in the wet liver weight of the transplant, such being greater than allografts in rats on 20 mg/kg of CsA (100 per cent) and even than isografts. These results indicate that auxiliary partial liver grafts benefit from the use of CsA not only through suppression of allorejection but through a potential "hepatotrophic effect" of the agent.

Plasma somatostatin level during natural and interrupted nocturnal sleep in man

The plasma levels of somatostatin (SRIF), growth hormone (GH) and thyrotrophin (TSH) in 4 normal men were measured during nocturnal sleep on 6 nights. In the waking state, the fluctuation of plasma SRIF level was within +/- 2.1 pg/ml (SD) of the mean value for each individual (range of mean value, 10.7 pg/ml-15.4 pg/ml). A marked episodic surge of GH release (peak value, 24.4 +/- 6.3 ng/ml (mean +/- SD] was noted in the initial period of slow wave sleep (SWS) in all subjects, but no significant negative correlation was observed between SRIF and GH in the plasma during either increase or decrease in the GH surge. There was no relation between the distribution of the plasma SRIF concentration and the stage of sleep, including the period before sleep, judged by electroencephalography (EEG). A small, but significant, increase of plasma TSH (10.0 muU/ml) independent of the SWS-related GH burst was detected in 1 of 4 subjects, but in that period the plasma SRIF level did not change. Even when the GH surge was suppressed by interruption of SWS, the plasma levels of SRIF and TSH did not show any significant change. From these findings, it is concluded that SRIF in the peripheral plasma does not fluctuate during the sleeping period as in the waking state and that, whatever its source, it is not related to the plasma GH or TSH level in the systemic circulation.

Oligodendroglioma-like cells (clear cells) in ependymoma

A brain tumor of a 22-year-old man was composed mostly of round cells with perinuclear halos (clear cells), forming clusters intersected by small blood vessels. In some areas, the tumor cells showed perivascular arrangement and epithelial pattern. Phosphotungstic-acid hematoxylin stain and immunoperoxidase stain for glial fibrillary acidic protein (GFAP) technique failed to stain the clear cells. Electron microscopy of the clear cells revealed them to be classical ependymoma cells with well developed intercellular junctions, microvilli and cilia. As no reporters in the past showed the evidence to clarify the nature of the clear cells, this case is considered a good example to support the viewpoint that the clear cells (oligodendroglioma-like cells) commonly observed in ependymomas are in reality ependymoma cells. It is stressed that the diagnosis of "mixed glioma" or "oligoependymoma" should be made with sufficient caution despite the recent advances of GFAP technique.

Contiguous malignant astrocytoma and Wilms'-like tumor in the brain

A case of primary brain tumor composed of two contiguous neoplasms in presented. At operation, a nodular tumor was embedded in the infiltrating tumor within the brain parenchyma. With light and electron microscopy, the nodular tumor was similar to Wilms' tumor (nephroblastoma). The infiltrating tumor was malignant astrocytoma. Autopsy revealed, besides the recurrence of malignant astrocytoma in the brain and its subarachnoid dissemination, extracranial metastases to the abdominal cavity, liver, lung, and bone marrow. Recurrent and metastatic tumors were glioblastoma multiforme, which was more malignant than the surgical specimen. The possibility of metastatic Wilms' tumor from the kidney was completely ruled out by extensive autopsy survey. The authors present an extremely rare tumor including detailed observations on the electron microscopic appearance of the tumor; the histogenesis of these tumors is briefly discussed.

Studies on the gonadotropin secretion during sleep in patients with abnormal sexual development--the role of the CNS in the onset of puberty

In order to evaluate the secretory patterns of luteinizing and follicle-stimulating hormones in various forms of abnormal sexual development, plasma levels of these hormones were measured every 20-30 minutes during sleep in 9 patients with true precocious puberty and 2 patients with primary hypogonadism. Seven patients with idiopathic precocious puberty and 2 patients with organic CNS lesion-related precocious puberty exhibited fluctuating plasma concentrations of these hormones that resembled findings in normal pubertal subjects who had significantly increased concentrations of plasma luteinizing hormone during sleep. Two patients with primary hypogonadism also showed episodic fluctuation of both hormones and augmented luteinizing hormone concentrations during sleep. These results suggest that the pubertal sleep-related gonadotropin secretion is dependent on the sleep-entrained CNS mechanism, and that the central nervous system plays an important role in sexual maturation.

Hypothalamic-pituitary function in patients with congenital malformations accompanied by central nervous system disorders

In 20 patients with congenital brain disorders, the influence of the CNS maldevelopment on the neuroendocrine system was investigated by assessment of the hypothalamic-pituitary function through measurements of the secretory reserve of pituitary hormones (GH, PRL, TSH, LH and FSH) in response to injections of insulin, TRH and LH-RH, and of the secretion of sleep-dependent pituitary hormones with polygraphic recording. The subjects consisted of 9 patients with midline anomalies of the brain and face, 3 patients with hydrocephalus, hydroencephalodysplasia or microcephalus, and 8 patients with the malformation syndrome associated with mental retardation. Ten of the 18 patients examined showed normal responses of GH secretion in the loading test (secretory peaks: greater than 10 ng/ml). But only 4 of these patients were found normal in respect of GH secretory peaks of more than 10 ng/ml during sleep. Of these 17 children, 5 showed abnormal values for basal secretion of PRL, and/or the secretory peak of PRL on injection of TRH. Two children showed hypersecretion of PRL during sleep. One patient out of the 19 examined was unresponsive in gonadotropin secretion to injection of LH-RH and 2 patients displayed excessive responses. During sleep, 4 of the 13 patients studied were found to be hypersecretory and 2 hyposecretory of gonadotropin. These results suggest that abnormalities in pituitary hormone secretion are frequently present in patients with CNS maldevelopment, and growth disturbances and abnormal sexual development may in some instances be due to endocrine abnormalities.

[Absorption, excretion and clinical trials of cefroxadine in the field of pediatrics (author's transl)]

A study was made with the newly developed cefroxadine (CXD) dry syrup by measuring the serum level, urine excretion and recovery rate in 10 children who were orally administered 5, 10 and 20 mg/kg at 1 hour after meals and the following results were gained. Also, its clinical efficacies and side effects were investigated in the following cases who were treated with a mean dose of 33 mg/day divided into 3 to 4 portions for a period of 9 days on the average; viz. a total of 151 cases consisting of 9 cases of pharyngitis, 39 of tonsillitis, 11 of streptococcal infection, i.e. scarlet fever, 7 of bronchitis, 6 of pneumonia, 1 of otitis media, 6 of purulent lymphadenitis, 1 of purulent parotitis, 1 of subcutaneous abscess and 3 of impetigo. 1. The serum level tends to reach its maximum level within 1 hour after administration. The mean concentrations of 5, 10 and 20 mg/kg dose in the foregoing time were 6.35, 9.12 and 21.62 mcg/ml respectively and dose response was observed. CXD showed higher concentration than CEX, CED and CFT. The mean half-life periods of the 3 dose were 72, 84 and 66 minutes respectively and variations were observed, but the drugs maintains a satisfactory serum level. 2. The time which showed highest urine excretion was mainly in the 0 to 2 hours bracket and the average concentrations of 5 , 10 and 20 mg/kg dose in the foregoing time were 381.2, 771.7 and 1,577.7 mcg/ml respectively. The dose response was more evident than in the serum concentrations. The average recovery rates within 6 hours were 93.6, 88.3 and 94.3% respectively and they were similar to those of CEX, CED and CFT. 3. The clinical effects were evaluated were in 148 cases out of the total of 151 and 136 cases, or 91.9% showed good or excellent efficacy response. 4. The daily dose groups of less than 30 mg/kg and 31 to 40 mg/kg formed the majority and there was no difference in the comparison of the clinical effectiveness in these 2 groups. Administration of a daily dose of 20 to 40 mg/kg is sufficient for the treatment of the aforementioned mild diseases except for pneumonia. 5. The clinical effects were compared between the 3 and 4 times a day treatment groups, but there was no difference between these two groups with regard to the foregoing daily dose. The 3 times a day treatment is acceptable, but the 4 times a day treatment is preferable when pharmacokinetics if taken into account. 6. The bacteriological effects in 41 cases, or 97.6% out of the 42 cases were above the efficacy base line and a high efficacy rate was achieved. 7. With regard to side effects, diarrhea developed in 4 cases and eosinophilia in 6 cases, abnormal simultaneous increases in GOT and GPT in 1 case and 1 case each for abnormal values in LDH and BUN were seen in the clinical test values. The foregoing results show that CXD has high efficacy and safety and it can be said that it is a drug required in the pediatric field.

[Clinical trials of cefroxadine on skin and soft tissue infections in the field of pediatrics (author's transl)]

CXD was administered orally at an average dose of 28.6 mg/kg (18.3 approximately 42.3 mg/kg) for an average 6 days (3 approximately 12 days) to a total of 99 pediatric cases with skin and soft tissue infections (impetigo 89, abscess 7 and furuncle 3) ranging from 3 months to 9 years old. The drug was given twice to 4 times per day after meals. The clinical and bacteriological effects and adverse reactions of CXD as well as the susceptibility of the causative organisms against CXD and CEX were studied, and the results obtained are as described below: 1. According to judgement of the attending doctors, CXD had a high global efficacy rate of 90.9%. 2. Analysis of the attending physicians' evaluations of the clinical effects on impetigo revealed that a dose of CXD 20.5 approximately 30.4 mg/kg t.i.d. can produce satisfactory responses. 3. According to the assessments by Evaluation Committee, the global clinical effects after 3, 5 and 7 days were 81.4, 91.2 and 94.6%, respectively. This indicates that clinical responses increased with prolongation of the treatment period, viz. better responses obtained after 5 and 7 days. This suggests that a minimum of 5 days administration is required for treating these infections. 4. As for impetigo having the largest number of patients in this study, a dose of CXD 20.5 approximately 30.4 mg/kg per day seemed to produce satisfactory clinical effects. 5. As for dose per day, the t.i.d. regimen of CXD 20.5 approximately 30.4 mg/kg seemed to exhibit satisfactory clinical responses, as already mentioned. Because of quite a small number of patients on the q.i.d. regimen of higher doses, however, the question of whether the t.i.d. treatment with 20.5 approximately 30.4 mg is adequate or not should be determined by a comparative study between the q.i.d. and t.i.d. treatments. 6. As for bacteriological responses, a high global effect of 87.1% was obtained with CXD against S. aureus and S. pyogenes isolated from 74 and 1 cases, respectively. 7. As for impetigo with predominant number of cases, CXD was highly effective bacteriologically at a daily dose of 20.5 approximately 30.4 mg/kg t.i.d. As an appropriate comparative evidence with the q.i.d. treatment was lacking, however, therapeutic validity of the t.i.d. treatment could not be determined definitely. 8. Utility was evaluated by the attending physicians on the total 99 cases, and CXD showed as high as 88.9%. 9. There were neither non-compliances nor adverse reactions to this treatment. 10. CXD showed a distribution of antimicrobial activity similar to that of CEX, against 74 isolates of S. aureus with the MICs of CXD ranging from 1.56 to 25 mcg/ml and those of CEX ranging from 0.78 to 25 mcg/ml, with peak MIC being 3.13 mcg/ml for both drugs. As for S. pyogenes, only one isolate from the same species, CXD was antimicrobial activity at 0.2 mcg/ml and CEX was antimicrobial at 0.39 mcg/ml. The above findings suggest that CXD is highly effective against acute skin and soft tissue infections in pediatrics.

[A case of pleomorphic xanthoastrocytoma (Kepes) (author's transl)]

A case of pleomorphic xanthoastrocytoma, the first case in Japan, is reported. This is a 25-year-old woman with a history of convulsive seizures which were initiated on her left arm 13 years prior to admission, On admission, physical and neurological examinations revealed no abnormalities. CT-scan disclosed a large well-defined low density area in the right fronto-temporal region. A small peripheral portion of the low density area was enhanced by contrast media. The high density area located immediately beneath the inner table of the skull. Right carotid angiogram showed a large avascular area corresponding to the cystic lesion. At the operation, there was a mural nodule in the frontal cortex involving the leptomeninges. The tumor was relatively soft and was milky-white in color. Under this tumor was a large cyst containing xanthochromic fluid. The mural nodule was totally removed and the cyst was widely opened. Postoperative course was uneventful and she received a radiation therapy (5500 rads). She was discharged without any neurological deficits. Histologically, the tumor was highly cellular. The tumor cells were markedly pleomorphic showing bizarre giant cells and multinucleated cells. However, tumor necroses and mitotic figures were absent. With immunoperoxidase method and PTAH stain, these tumor cells were confirmed to be astrocytic. In some areas, tumor cells were surrounded by reticulin fibers. Many tumor vessels presented marked hyalinous degeneration. By electron microscopy, many tumor cells contained lipid droplets. This case was considered to be pleomorphic xanthoastrocytoma (Kepes). Pleomorphic xanthoastrocytoma was designated by Kepes et al in 1979 as a new tumor entity. They described clinical and pathological characteristics of this tumor as follows. The age of the patients were young and the tumors were frequently cystic. The tumors were superficially located in the brain and involved the leptomeninges. Despite marked nuclear pleomorphism, mitotic figures of the tumor cells or necroses were rare. In contrast to their pleomorphic cytology, the biological behavior of this tumor appeared to be favorable. The authors stressed the clinical and pathological significance of this tumor. Because, this is the tumor with malignant appearance in light microscopy, but with favorable prognosis.