Factors affecting postoperative prognosis in the solitary-nodule type of hepatocellular carcinoma: experience of 132 cases in our institute

A retrospective analysis of clinical and pathological factors was performed on 132 surgical cases with solitary-nodule type HCC in our hospital. The overall cancer-free survival rates after 1, 3 and 5 years were 82.2%, 42.3% and 26.5%, respectively. With univariate analysis, the significant prognostic factors for survival were tumor size, cancer cell infiltration of the fibrous capsule of the tumor (fc-inf), invasion into portal vein (vp), and intrahepatic metastasis (im), while significant prognostic factors for non-recurrence were tumor size, fc-inf, vp, im, Edmondson-Steiner's classification and perioperative blood transfusion. With multivariate analysis for recurrence, significant factors were vp, clinical stage (CS), and perioperative blood transfusion. Therefore, prognostic factors for long-term survival in surgical cases of HCC are thought to be good hepatic function, absence of portal invasion, and avoidance of perioperative blood transfusion if possible.

A case of oophoritis detected by gallium-67-citrate scintigraphy

A 39-year-old woman with fever of unknown origin was admitted to our hospital. Whole body scintigrams with 67Ga-citrate showed an abnormal accumulation of radioactivity in the pelvic cavity. Cystadenocarcinoma of the ovary was suspected on the basis of findings obtained by abdominal computed tomography and magnetic resonance imaging. Left oophorectomy was performed, and oophoritis was diagnosed. We would like to propose that 67Ga-citrate scintigraphy may be useful for the diagnosis of oophoritis as well as gynecologic malignant tumors.

Medullary thyroid carcinoma with a paraganglioma-like pattern and melanin production: a case report with ultrastructural and immunohistochemical studies

We report a case of medullary thyroid carcinoma with a paraganglioma-like pattern and melanin production. Macroscopically, a rectangular black area within a gray-white background was seen on the cut surface of the tumor. Histologically, the tumor was found to have a trabecular or nestlike architecture with many pigmented dendritic cells, resembling the "sustentacular cells" of paraganglioma, scattered among nonpigmented polygonal tumor cells. Fontana-Masson staining and bleaching with potassium permanganate and oxalic acid revealed that this pigment was melanin, which was also confirmed by electron microscopy. Immunohistochemically, pigmented dendritic cells were positive for calcitonin, as were the surrounding typical medullary thyroid carcinoma cells. These cells were also positive for S100 protein but not for HMB-45, compatible with sustentacular cells. These findings suggest that this tumor could be considered to bridge the gap between two variants of medullary thyroid carcinoma, the melanin-producing (pigmented) type and the paraganglioma-like type.

Studies of postoperative transarterial infusion chemotherapy for liver metastasis of colorectal carcinoma after hepatectomy

BACKGROUND/AIMS

The aim of this study was to evaluate the efficacy of postoperative transarterial infusion chemotherapy (PTIC) for the prevention of metastatic liver cancer recurrence after hepatectomy following curative surgery for colorectal carcinoma.

METHODOLOGY

Thirty-eight patients who underwent curative hepatectomy for metastatic liver cancer from colorectal carcinoma were studied. Ten out of the 38 patients received PTIC (experimental group) and 28 patients did not receive chemotherapy (control group). PTIC was performed with an intrahepatic indwelling catheter, which was set-up for 3 weeks and repeated 3 times in two monthly intervals.

RESULTS

In the control group, no significant differences were observed in the survival between patients with a single hepatic nodule and those with multiple hepatic nodules. Between patients with hepatic tumors of more than 3 cm in diameter and those with tumors less than 3 cm, and between patients with tumors located at H1 and H2, no significant differences were seen, either. However, the 5-year survival rate of the patients with metachronous liver metastases was 90% which was significantly better than for those patients with synchronous liver tumors (p < 0.05). The 100% of 3- and 100% of 4-year survival rates of the experimental group were significantly better than the 60% and 47% respectively of the control group (p < 0.05). The non-recurrence rate in the remnant liver was also significantly better in the experimental group than that in the control group (p < 0.01). The adverse effect of this protocol was negligible.

CONCLUSION

We conclude that PTIC improved the survival and non-recurrence rate in the remnant liver of the patients with liver metastases from colorectal cancer after hepatectomy, and was considered to be safe and an important protective factor for the prevention of recurrence of liver metastases after hepatectomy.

[Eighty cases of minimally invasive direct coronary artery bypass grafting]

Between March 1996 and November 1997, 80 patients with a mean age of 70 years (45-89) have undergone minimally invasive direct coronary artery bypass grafting via anterior minithoracotomy or subxiphoid incision with left internal thoracic artery and right epigastric artery using local coronary occlusion on a beating heart. Cardiac-related hospital mortality was 2.5% (2/80). Routine angiographic assessment of anastomotic patency showed an overall patency. rate of 94.6%, but demonstrated the severe stenosis at the anastomotic site in 8 patients. Further study is required to establish the efficacy of minimally invasive direct coronary artery bypass grafting and combination therapy with PTCA.

Recurring encephalopathy abolished by gastrorenal shunt ligation in a diabetic hemodialysis patient

A 57-year-old man was admitted to our hospital for hepatic encephalopathy. He previously had undergone a partial gastrectomy for gastric ulcer, and also had been on maintenance hemodialysis because of diabetic nephropathy. Despite treatment with branched-chain amino acids and lactulose, encephalopathy occurred repeatedly. The findings of his laboratory examinations, computed tomography, and liver biopsy were not suggestive of chronic liver damage. Angiography revealed a portal-systemic shunt from the superior mesenteric vein via the left gastric vein to the left renal vein. A ligation of the gastrorenal shunt was performed. After the shunt ligation, hepatic encephalopathy no longer recurred, and no medication was required to prevent it. The insulin requirements also decreased, the plasma ammonia concentration then decreased, and serum concentration of several amino acids related to the ammonia metabolism also decreased. The molar ratio of branched-chain amino acids to aromatic amino acids increased. The ligation of the portal-systemic shunt was thus considered to be the key to the successful treatment of hepatic encephalopathy in this unusual case.

A rare case of hepatic injury associated with ovarian hyperstimulation syndrome

A 26-year-old married woman was admitted to our hospital because of massive ascites and hepatic injury. The patient had been treated with human menopausal gonadotropin and clomiphene citrate to prevent recurrence of spontaneous abortions. About 1 month later, she developed upper abdominal pain and noticed dark urine. On admission, she had elevated concentrations of serum transaminases with an asparate aminotransferase of 127 IU/L and alanine aminotransferase of 194 IU/L. An abdominal ultrasound showed massive ascites. Her serum concentration of estradiol was high at 12,100 pg/mL, which was much greater than the value of early stage of pregnancy (2,279-7,353 pg/mL). She was thus diagnosed as having ovarian hyperstimulation syndrome. Following a period of bed rest, her liver function normalized and the ascites disappeared. Based on the above findings, the patient was considered to have suffered from ovarian hyperstimulation syndrome, complicated by hepatic injury.

Impaired in vivo tumor growth of human pancreatic carcinoma cells retrovirally transduced with GM-CSF gene

We have examined the antitumor effect of human pancreatic carcinoma cells (AsPC-1) retrovirally transduced with mouse granulocyte macrophage-colony stimulating factor (GM-CSF) gene in nude mice. Growth retardation of the subcutaneous tumors of GM-CSF-producing AsPC-1 cells was observed, although their in vitro proliferation was not different from that of wild-type cells. Histological examination revealed infiltration of monocytic cells into the tumor of GM-CSF-producing cells, and they were shown to be mainly CD11b positive cells by immunohistochemical staining. The survival of the mice inoculated intraperitoneally with GM-CSF- producing AsPC-1 cells was significantly prolonged compared with that of the mice inoculated with wild-type AsPC-1 cells. Thus, the expression of GM-CSF gene in human pancreatic cells induced an antitumor effect in vivo even in the mature T cell-deficient condition.

Light-induced extracellular changes of calcium and sodium concentrations in the Planarian ocellus

Ion-selective double-barreled microelectrodes inserted into a planarian ocellus were used to monitor the ocellus potential and the changes in extracellular concentrations of Ca2+ (Ca(o)) and Na+ (Na(o)) caused by a 0.5-sec light flash or sustained (120s) illumination. Ca(o) and Na(o) were slightly decreased following a flash. Sustained illumination caused a biphasic change in Ca(o) (a rapid decrease followed by a slow increase) and a tonic decrease in Na(o). When Na+ in the planarian saline was replaced by Li+ or choline+, the increase in Ca(o) was prevented: sustained illumination induced only a decrease in Ca(o). These results suggest that illumination induces influxes of both Ca+ and Na+ into planarian photoreceptors, and that the Ca2+ influx is rapidly followed by a Na-dependent Ca2+ efflux due to Na-Ca exchange.

[A case of retinochoroidal optic neuropathy]

The patient was a 59-year-old male with impaired left vision. Before he was referred to this hospital, he was diagnosed as having optic nerve injury due to the trauma of a severe bruise on his left eye caused by a traffic accident, and relative afferent pupillary defect (RAPD) was negative. On his first examination in this department, RAPD was negative and funduscopy of the left eye demonstrated hyperemia of the optic disc and mild opacification at the posterior pole. Fluorescein fundus angiography showed circular hyperfluorescence around the optic disc and transverse linear hyperfluorescence appearing above and below the macula. From these findings a diagnosis of choloidal rupture was made. The form of choloidal rupture suggested an early stage of evulsion of the optic nerve. The impairment of visual acuity seemed to be caused by choloidal circulatory disturbance. The patient was therefore, had traumatic retinocholoidal optic neuropathy complicated by the rupture of the choloidal around the optic disc, disturbance of the optic disc, and opacification of the retinochoroid.

[Thyroid function in patients with Yusho: 28 year follow-up study]

To evaluate chronic effect of polychlorinated biphenyl (PCB) on thyroid functions, thyroid hormone levels and thyroidal autoantibodies were studied in 81 patients with Yusho in 1996. Serum level of thyroid stimulating hormone (TSH) was elevated in 7 cases (8.6%). All of them showed normal triiodothyronine (T3), thyroxine (T4) and free T4 levels, and regarded as latent hypothyroidism. There were no significant correlations between blood PCB concentrations and TSH levels, T2 levels, T4 levels or free T4 levels. Thyroglobulin antibodies were detected in 8 cases (19.5%) of 41 Yusho patients with high PBC concentration (higher than 3.0 ppb), and in only one case (2.5%) of 40 patients with low PBC concentration (lower than 2.9 ppb). We conclude that thyroglobulin antibody in patients with Yusho is not frequent and it may be associated with blood PCB concentration.

Electron-beam CT angiography for thoracic aortic aneurysm and dissection: application of continuous volume scan and electrocardiographically triggered scan

PURPOSE

To assess the diagnostic value of CT angiography of thoracic aortic aneurysm and dissection with electron-beam CT.

MATERIALS AND METHODS

Electron-beam CT angiography was used for the evaluation of thoracic aortic aneurysm (n = 15), and aortic dissection (n = 15). Continuous volume scan (CVS), permitted by continuous X-ray exposure with table incrementation, was performed in all patients. An additional electrocardiographically triggered scan was obtained in four patients. Three-dimensional surface display and multiplanar reformations were obtained and compared with digital subtraction angiography.

RESULTS

Motion artifacts and the resulting degradation of three-dimensional image quality were frequent in the ascending aorta of CVS images. Electrocardiographically triggered sections improved the image quality of the ascending aorta. In the aortic arch and descending aorta, excellent three-dimensional images competitive in quality with digital subtraction angiography were obtained in all patients. For patients with aortic dissection, multiplanar reformation was useful to demonstrate the intimal flap and entry sites.

CONCLUSION

The use of electron-beam CT angiography is feasible for the diagnosis of thoracic aortic aneurysm and dissection.

[Matured mediastinal teratoma with high levels of tumor markers in cystic fluid]

A 42-year-old woman was admitted to Gifu Municipal Hospital because of an abnormal mediastinal shadow on a chest X-ray film. The serum CA125 level was slightly high 38 U/L, normal: < 35 U/L. Preoperative examination of fluid from a cyst revealed a high level of carcinoembryonic antigen (550 ng/ ml). The tumor resected was 11 x 9 x 5 cm. Microscopic examination revealed a matured teratoma containing pancreatic cells, collagenous tissues, squamous epithelia, and hair follicle-like tissues. Biochemical analysis of the cystic fluid revealed high levels of eight tumor markers: carcinoembryonic antigen, CA125, CA19-9, SLX, Ferritin, NSE TPA, and elastase 1. Samples stained positively for the tumor markers carcinoembryonic antigen CA125, CA19-9, and NSE by ABC immunohistochemical staining. The serum carcinoembryonic antigen levels had decreased to the normal level within two weeks after the surgery. The high levels of tumor markers and materials in the cystic fluid may have been related to the biological characteristics of the various cell components in this matured teratoma.

Accumulation of Tc-99m HMDP in hepatic metastasis from colon carcinoma without detectable calcification

A 51-year-old man was found to have hepatic metastasis from colon carcinoma. Bone scintigraphy with 99mTc-hydroxymethylene diphosphonate showed a ringlike accumulation corresponding to the hepatic mass, which was without calcification on computed tomography. Treatment with chemotherapeutic agents was started. After 4 months, computed tomography showed that the mass was smaller than before and that the margin was calcified. The extraosseous accumulation of the radionuclide may be evidence supporting earlier speculation on calcification that could not yet be detected by computed tomography.

[Cesarean section under spinal anesthesia for a patient with chronic renal failure]

A 37-year-old primipara was scheduled for cesarean section under spinal anesthesia in the 38th gestational week because of cephalo-pelvic disproportion. She had suffered from chronic renal failure since 27 years of age, and had been undergoing hemodialysis three times per week. The frequency of hemodialysis was increased to 4-6 times per week during pregnancy to maintain blood urea nitrogen and serum creatinine concentration below 60 mg.dl-1 and 6.0 mg.dl-1, respectively. Since she had no bleeding tendency, spinal anesthesia with 8 mg of tetracaine was successfully performed after hemodialysis eliminating only solute but not water in the morning of surgery and after infusion of 500 ml of acetated Ringer solution. Blood pressure and heart rate were stable during surgery. Monitoring of central venous pressure was useful for fluid management. A baby weighing 2,575 g with an Apgar Score of 8 at one minute and 9 at five minutes was delivered five minutes after the beginning the surgery. The mother recovered uneventfully and returned to regular hemodialysis on the first postoperative day. These findings suggest that with careful fluid management, spinal anesthesia can be safely performed for cesarean section, for patients undergoing hemodialysis.

Coronary artery fistula to bronchial artery on contralateral side of coronary atherosclerosis and myocardial insufficiency. A case report

Among coronary vessels anomalies is the rare coronary artery fistula. Myocardial insufficiency resulting from fistula steal phenomenon can not be clinically distinguished from that of coronary atherosclerosis, if these conditions coexists in the same patient. The authors present a case of extracardiac left coronary artery fistula connecting the circumflex branch and left bronchial artery, with inferior wall myocardial insufficiency attributable to the right coronary artery atherosclerosis.

[Intratumoral LPD deposition within hepatocellular carcinoma without arterial tumor staining]

The dissociation of intratumoral LPD deposition and arterial tumor staining was investigated in 20 cases of hepatocellular carcinoma (HCC) without arterial tumor staining. The intratumoral deposition of LPD injected from the hepatic artery was observed in nine cases of HCC and coincided with the decrease in tumor vascular bed evaluated by photomicroscopic study and arterial portography. LPD deposition was not observed within the 11 other tumors, which were diagnosed as well differentiated HCC. Infusion angiographic CT revealed that the arterial and portal vascular beds were separated from each other. Therefore, arterial tumor staining was insufficient for accurate evaluation of the tumor vascular bed. The vascular bed in cancerous and noncancerous tissue was accurately evaluated by the addition of the contrast enhancements from the hepatic artery and the portal vein.

[Coronary artery bypass grafting in cases with the atherosclerotic ascending aorta]

Among 172 cases of coronary artery bypass grafting, 9 cases (5%) revealed severely atherosclerotic ascending aorta. In 3 of the 9 cases, total aortic cross-clamping in the distal anastomoses of saphenous vein graft (SVG) and partial aortic clamp in the proximal anastomoses of SVG were performed. In 1 case with this technique, cerebral infarction was occurred. In 4 cases, total aortic cross-clamping in the distal and proximal anastomoses of SVG was performed. In 2 of these cases with this technique, cerebral infarctions were occurred. Hypothermic circulatory arrest was performed in 2 of the rest. In one case that was predicted to have atherosclerosis of ascending aorta prior to operation, the left internal thoracic artery was anastomosed to the left anterior descending, and SVG to the right coronary artery with hypothermia and ventricular fibrillation. And during the proximal anastomoses of SVG, hypothermic circulatory arrest without aortic clamping was initiated. In another case, atherosclerosis of ascending aorta was noted after aortic cross-clamping. Then the aorta was declamped, hypothermic circulatory arrest was established, the aorta was opened, the diseased segment was resected, and proximal anastomoses of SVG was performed to Dacron patch which was implanted for aortic wall. There were no cerebral infarction in last two patients.

[Experimental study on early detection of alloxan-induced pulmonary injury by magnetic resonance imaging]

We studied the early detection of alloxan-induced pulmonary injury by magnetic resonance imaging in vivo. Permeability edema was induced in ten rats by intravenous injection of alloxan at 100 mg/kg. T1-and T2-weighted images were acquired in five rats every 30 min for 120 min after alloxan injection. Five rats served as controls. The rats were sacrificed immediately after imaging and examined microscopically. CT images were also acquired in five rats every 30 min for 120 min after alloxan injection. Five rats served as controls. The rats were sacrificed immediately after imaging, and the wet-to-dry ratio of the lung was measured. In T1-weighted images, relative signal intensity from the lung with permeability edema rose from 30 min to 120 min, and was greater than that from normal lung every time. In T2-weighted images, there was no statistically significant difference in relative signal intensity of the lung between permeability edema and the control during 120 min. In CT images, there was also no statistically significant difference in lung density between permeability edema and the control during 120 min. There was no statistically significant difference in the wet-to-dry lung ratio between edematous lung and normal lung. In histological study, mild congestion and interstitial edema were observed in edematous lung. These results suggest the potential capability of MR imaging in detecting the early phase of permeability pulmonary edema.