[Emergency cardiopulmonary bypass for cardiopulmonary-cerebral resuscitation]

Cardiopulmonary bypass (C-P bypass) was performed on two patients who had not responded to conventional cardiopulmonary resuscitation (CPR). The first patient, a 56-y-o male, with bilateral pulmonary thromboembolism repeatedly underwent cardiac massage and electric defibrillation for recurrent ventricular fibrillation. A veno-arterial bypass route was prepared during cardiac massage, and bypass circulation was started 3 hours after the onset of the first ventricular fibrillation. Soon after the initiation of C-P bypass, the physical status and EEG of the patient improved. The patient regained consciousness within a few hours and later underwent open chest pulmonary embolectomy. The second patient, a 44-y-o male, developed refractory cardiogenic shock near the end of aortocoronary bypass graft operation. Under closed chest massage, a femoro-femoral cardiopulmonary bypass operation was started. Soon after the initiation of the bypass circulation and IABP, peripheral circulation improved markedly, and consciousness returned within several hours. Though the first patient finally died from far advanced pulmonary embolism, he was conscious as long as the C-P bypass was continued for two days. In the second patient, the cardiac function gradually improved after the 3rd day. C-P bypass was tapered and discontinued on the 5th day. Emergency veno-arterial bypass for CPR is effective means to maintain life until the cardiopulmonary and cerebral functions are restored. Recent advances in emergency C-P bypass are introduced and a new acronym extracorporeal lung and heart assist, ECLHA, is proposed. Emergency ECLHA with veno-arterial cannulations through percutaneous puncture will become a promising adjunct of cardiopulmonary-cerebral resuscitation in the near future.

[Porphyria cutanea tarda in a chronic hemodialysis patient]

About 3 years after commencing hemodialysis for chronic renal failure, a 39-year-old man developed cutaneous lesions of the face and hands which were compatible with porphyria cutanea tarda (PCT) clinically and histologically. There was no evidence of familial PCT, excessive alcohol consumption, iron overload, chronic liver disease. It was impossible to measure urinary porphyrins because of anuria. Fecal and erythrocytic porphyrins were within normal limits. Plasma porphyrins, however, were markedly elevated, and in an assay using high performance liquid chromatography, uroporphyrin accounted for 72% and 7-carboxyl porphyrin for 24%. Review of past reports of PCT associated with hemodialysis revealed that the most characteristic feature was a significant increase of plasma porphyrins, mainly uroporphyrin. This increase is difficult to explain by accumulation due to failure of adequate clearance. Participation of factors affecting uroporphyrinogen decarboxylase activity seems likely.

[An analysis of factors influential in improving the survival rate of patients with ovarian cancer]

[OBJECTIVES OF STUDY] This presentation deals with an analysis of factors to improve the survival of patients with ovarian cancer. Some 1051 patients with malignant ovarian tumors who were treated in this group, were divided into two groups for their period of treatment. Of these, 460 patients were treated 1974-1979 (retrospective group) and 591 patients treated 1979-1984, (prospective group) because chemo-immunotherapy was determined by a certain protocol in the group. [RESULTS] The survival rate of the two groups were compared, and the 5-year survival rate of prospective group was 20% higher than in the retrospective group. However, there were no significant differences of any clinical stages between retrospective group and prospective group, and the difference in 5-year survival rate was about 20% in any stages. The survival rate was also compared in accordance with histological types. The most dominant progression was seen in serous adenocarcinoma and when the cases were divided into two groups by their clinical stage; one was the early stage (Stage I) cases. The 5-year survival rate of serous ca, mucinous ca and embryonal ca (Higuchi, Kato) made remarkable progress in recent several years, but, mesonephroid ca made little progress. The other was the late stage (stage II, III, IV) cases, patients with mucinous ca when she had had surgery recurrently on relapse, resulting in prolonged survival period. As to the comparison of age groups, younger patients less than 40 years old showed a progression in their survival period, whereas patients in their sixties had no such progression. In order to evaluate the effect of treatment with due comparable counterpart of ovarian carcinoma, cases were quantified with 3 years survival prediction score which was calculated retrospectively by multivariate statistical analysis. The first evaluation was done with an MFC combination chemotherapy and a CAP combination. The results indicated that a CAP combination had improved the survival rate of ovarian cancer, and statistically significant differences were proved. Z value was 2.24 and P value was less than 5%. The second evaluation was done on the significance of second look operation. The prediction score of patients who underwent second look operation and matched pair control of prediction score without reoperation, were compared. The results indicated that second look operation improved the survival rate of ovarian cancer with statistically significant differences. Z value was 2.37 and P value was less than 5%. [CONCLUSION] According to the present study, the treatment of malignant ovarian tumors showed an improved survival rate of about 20%, regardless of the cl

[Cardiocirculatory disturbances after surgery of carcinoma of the thoracic esophagus]

From 1976 to 1985, 277 cases of carcinoma of the esophagus were resected in the Second Department of Surgery, Tohoku University School of Medicine. Postoperative cardiocirculatory disturbances occurred in 114 cases (41.2%), arrhythmia being the disturbance most frequently observed (86.8%). Low cardiac output syndrome occurred in 8 cases and myocardial infarction occurred in 3 cases. The majority of the cases were treated successfully, but 5 patients died within one month after operation. Causes of death were as follows: myocardial infarction, constrictive pericarditis, cardiac tamponade, non-occlusive mesenteric ischemia and acute cardiac failure. Postoperative arrhythmia occurred mainly up to the third postoperative day. Low cardiac output syndrome occurred just after operation or on the first postoperative day. All cases of myocardial infarction occurred on the first postoperative day. The rate of occurrence of cardiocirculatory disturbances in aged patients (greater than or equal to 70) was significantly higher than other group (less than or equal to 69), (56.7%:38.1%, p less than 0.05). The rate of occurrence of cardiocirculatory disturbances in patients who had a history of hypertension or in patients with abnormal preoperative electrocardiographic findings were relatively higher than those in patients who had no history of hypertension or in patients with no abnormal preoperative electrocardiographic findings. The rate of occurrence of cardiocirculatory disturbances in patients who had undergone total resection of the thoracic esophagus was significantly higher than that in patients who had undergone partial resection of the thoracic esophagus (42.8%:23.8%, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of hypertension on asymmetrical septal hypertrophy: an echocardiographic study]

The effect of hypertension on asymmetrical septal hypertrophy was studied by echocardiography to differentiate idiopathic asymmetrical septal hypertrophy (ASH) from ASH with hypertension. One hundred eight patients with ASH proven by echocardiography were categorized in two groups; 53 patients with hypertension (greater than 160 systolic, greater than 95 diastolic) (hypertensive group: HT) and 55 patients with normal blood pressure (normotensive group: NT). Septal hypertrophy was classified as mid-portion (M-type), diffuse (D-type), and basal (B-type) hypertrophy by the long-axis view, and also diffuse (I-type), anterolateral (II-type), anteroseptal (III-type), and anterior septal (IV-type) by the short-axis view, respectively. Endomyocardial biopsy and left ventriculography were performed in 50 patients (18 hypertensives and 32 normotensives). In the hypertensive group, 45%, 30%, and 25% of cases had diffuse, basal and mid-portion hypertrophy, respectively. There was no case in the basal hypertrophy whose biopsy findings were compatible with hypertrophic cardiomyopathy. In the normotensive group, 78% and 22% of patients had midportion and diffuse hypertrophy, respectively, but none of them had the basal hypertrophy. Type IV was seen in only six patients in the normotensive group.

Total parathyroidectomy with forearm autograft for secondary hyperparathyroidism in chronic renal failure

One hundred twenty-eight patients with chronic renal failure and secondary hyperparathyroidism underwent total parathyroidectomy with forearm autograft. Postoperative clinical improvement was remarkable. In all cases, the grafted tissue functioned well, and reimplantation of the cryopreserved parathyroid tissues was unnecessary. Intact 1-84 parathyroid hormone was more sensitive than C-terminal parathyroid hormone in parathyroid hormone level (PTH) gradient assays of grafted and nongrafted forearm. The study of hypocalcemia was also helpful in obtaining more distinct PTH gradients. Five of 119 patients had supernumerary parathyroid glands (4.2%), which preoperative noninvasive image diagnosis of parathyroid glands was helpful in detecting.

Effects of a newly synthetized calcium antagonist, cyclopropylmethyl 4-(3-nitrophenyl) 1,4-dihydro-2,6-dimethylpyridine-3,5-dicarboxylate (MPC-2101), on action potentials of rabbit's myocardial tissues in vitro

Electrophysiological effects of cyclopropylmethyl 4-(3-nitrophenyl) 1,4-dihydro-2,6-dimethylpyridine-3,5-dicarboxylate (MPC-2101), a newly synthetized compound, were examined in the rabbit SA node and papillary muscle, using a conventional microelectrode technique in vitro. In the SA node, MPC-2101 (10(-8) - 10(-6) M) showed dose-dependent negative chronotropic effects by depressing the slope of slow diastolic repolarization without significant effects on maximum diastolic potential and action potential duration. MPC-2101 (10(-7) - 10(-5) M) had no significant effects on the resting membrane potential, the amplitude and dV/dt of action potentials in papillary muscles, but induced a statistically significant reduction of the plateau phase of the action potential duration measured at 20% repolarization at a concentration of 10(-5) M. MPC-2101, at concentrations lower than 10(-6) M, had no significant effects on the amplitude, dV/dt, or duration of slow action potentials induced in 18 mM (K+]o and histamine at 10(-6) M, but at 3 x 10(-6) M significantly depressed all parameters of the slow action potentials. In higher Ca2+ solution, dose-response curves for MPC-2101 on dV/dt of slow action potentials were shifted to the right. MPC-2101, at a concentration of 3 x 10(-6) M, showed frequency-dependent depression in dV/dt of the slow action potentials. MPC-2101 showed less potent actions than nicardipine on electrophysiological activities of the SA node and papillary muscle.

Successful treatment of primary endodermal sinus tumor of the endometrium

Endodermal sinus tumor (EST) arising in the endometrium is an extremely rare malignant neoplasm. To the authors' knowledge, this is only the second report of an EST arising in this location. The tumor was exophytic, 2.4 cm in diameter, and was located in the fundus uteri. It had infiltrated the circumambient endometrium slightly. Preoperative serum alpha-fetoprotein (AFP) levels were markedly elevated, 1580 ng/ml. The patient received a simple abdominal hysterectomy and bilateral salpingo-oophorectomy followed by combination chemotherapy consisting of vincristine, actinomycin D, and cyclophosphamide. To date, there has been no evidence of tumor recurrence, and serum AFP titers, which had returned to normal 7 weeks after surgery, continue to remain within normal limits. We believe this is the first successful treatment of a documented case of primary EST of the endometrium.

Glucagonoma syndrome

A 53-year-old Japanese man with a skin eruption characteristic of glucagonoma syndrome had had misdiagnoses for 10 years. The plasma glucagon level was not abnormally high on the first admission, and 4 years later the level was elevated as determined by the 30 gm arginine tolerance test. An alpha cell carcinoma detected in the tail of the pancreas was associated with a lymph node metastasis; the skin eruption cleared up 10 days after the partial pancreatectomy with lymphadenectomy. The clinical features of glucagonoma syndrome should be given attention.

Preservation of ovarian function and reproductive ability in patients with malignant ovarian tumors

In a study designed to determine the merit of preserving ovarian function and childbearing capability in women with unilateral malignant ovarian tumors, the results of radical surgery (n = 86) and conservative surgery (n = 106) were compared. The mean length of survival was slightly but not significantly shorter following conservative surgery. There were 15 recurrences (14%) and 11 deaths among the conservative surgery group. The incidence of metastasis to the preserved ovary was high. In the most cases restoration of normal menses was fairly rapid after initial treatment, but this appeared to depend on whether or not chemotherapy was given postoperatively, the specific agents used, and the duration of their administration. Hypergonadotropic hypogonadism was the most common finding among the anovulatory patients. Sixteen women experienced a total of 27 pregnancies and 18 normal infants were born. Abortion was induced when conception occurred during a course of chemotherapy. These findings are encouraging in terms of the feasibility of preserving childbearing capability in ovarian cancer patients. However, they also underscore the necessity for close, long-term follow-up, which will be improved as new technologies become available.

[Indications and limitations of laser treatment for early gastric cancer and palliative treatments for malignant obstruction of the esophagus and stomach]

The long-term effect of endoscopic laser treatment for early gastric cancer as a local curative procedure was reported. Forty-seven patients with endoscopically diagnosed early gastric cancer whose surgical risk was critical or who refused surgery were treated by either photocoagulative Nd: YAG laser (YAG) or photodynamic therapy (PDT) with argon dye laser and hematoporphyrin derivatives (HpD) or both and followed-up for more than 3 years. Thirty-one patients were initially treated by YAG. One patient was lost to follow-up. Sixteen of 30 cases (53%) treated by YAG were negative for cancer on biopsy for 9 to 73 months (mean 3 years and 7 months) after the initial treatment. Sixteen cases were initially treated by PDT. Eight of 14 cases (57%) treated by PDT with argon dye laser were negative for cancer on biopsy for 19 to 35 months (mean 1 year and 7 months). Ten of 13 cases treated by combined laser therapy were negative for cancer on biopsy for 12 to 77 months (mean 3 years and 2 months). Curative effect of YAG and PDT was expected in lesions of superficially elevated mucosal cancer (type) IIa less than 20mm and well demarcated superficially depressed mucosal cancer (type IIc) less than 10mm. PDT was superior to YAG in treating early gastric cancer, particularly when the margin of lesion is unclear, and depth of cancer invasion is estimated to be submucosal. Risks of lymph node metastasis in these lesions are reportedly minimal as well. Quality of life scores did not decrease when the patients were treated by lasers, but did so statistically significantly in the surgically treated group of patients. Therefore, we conclude that the endoscopic laser is the treatment of choice of treatment for early gastric cancer as a local curative procedure in the aged if they have a curable lesion as mentioned above. As a palliative treatment, 34 patients with neoplastic obstruction of the esophagus and stomach were treated by dilators with or without intubation of prosthesis tube and laser recanalization. Functional efficacy (ability to eat solid or semi-solid diet which could not be eater before treatment) was noted in 64% of 11 cases treated by dilators alone, 75% of 12 cases treated by intubation of prosthesis tube and 45% of 11 cases treated by lasers. There was a greater complication rate in the intubation group also. Patients with malignant stricture due to mediastinal lymph node metastasis were at higher risk of perforation.

Sex differences in [3H]nitrendipine binding and effects of sex steroid hormones in rat cardiac and cerebral membranes

The sex differences and regulation by sex steroid hormones in calcium channels were studied by using [3H]nitrendipine binding to cardiac and cerebral membranes in 15-week old spontaneously hypertensive rats (SHRs). The maximal number of binding sites (Bmax) in the hippocampus of female SHRs increased by 24.1% over that in male SHRs. In the females, the Bmax values in the cardiac, striatal, thalamic and hippocampal membranes from ovariectomized SHRs decreased by 34.7, 29.9, 29.3 and 26.9%, respectively, compared to normal SHRs. This phenomenon, except for the hippocampus, was inhibited by estradiol but not by testosterone. In the male, the Bmax values in cardiac and cerebral membranes showed almost no changes after orchidectomy or treatment with estradiol or testosterone. After gonadectomy, the Bmax values in the cardiac, striatal and thalamic membranes of females decreased by 30.2, 33.0 and 35.6%, respectively, compared to those in males. The changes in apparent dissociation constant (KD) values were less remarkable than those in the Bmax values. These findings suggest that sex differences exist in the calcium channels of the heart, striatum, thalamus and hippocampus, and they suggest that estradiol, but not testosterone, may play a part in the regulation of the calcium channels in female SHRs.

Structure and expression of a human class pi glutathione S-transferase messenger RNA

We have used a rat glutathione S-transferase P (GST-P) complementary DNA as a probe to screen a human placenta complementary DNA library constructed in the lambda gt11 vector. One of the positive clones contained the complete coding region (630 base pair) and the entire 3'-noncoding region (78 base pair) of the putative human glutathione S-transferase pi (GST-pi) subunit mRNA. From the nucleotide sequence we deduced the complete amino acid sequence of the GST-pi subunit. It contained 209 amino acids with the relative molecular mass of Mr 23,224. Comparison of the amino acid sequences between GST-pi and GST-P subunits suggests that they are the corresponding enzymes in these species. GST-pi and GST-P both consist of 209 amino acids and differ in only 30 amino acids (85.6% homology). The difference in amino acid composition can explain the large difference in isoelectric point between GST-pi subunit (pI 5.5) and GST-P subunit (pI 6.9). The expression of GST-pi mRNA in some normal and cancerous tissues, including some hepatoma cell lines, hepatoma, and colon carcinoma specimens was determined using complementary DNA as a probe. The results indicate that the mode of the expression of GST-pi in humans is different from that of GST-P in rats.

[Significance of tumor markers in the treatment of patients with ovarian malignancies]

Seven tumor markers (CA125, CA19-9, TPA, IAP, CEA, ferritin, LDH) were measured in 24 patients with ovarian cancer. The positive rates in untreated cases of ovarian cancer were 87.5% for CA125, 35.5% for CA19-9, 10% for CEA, 77.8% for IAP, 63.6% for TPA, 28.6% for LDH and 35.3% for ferritin. Among these, CA125 was the most available marker for detecting tumor growth or regression during each respective clinical course by serial measurement. Serial changes in serum alpha-fetoprotein (AFP) levels during treatment were studied among 27 patients with ovarian embryonal carcinoma. AFP decreased with a half-life of about 7 days, and was restored to the normal range within 10 weeks after the initial surgery and chemotherapy (VAC) in all cases. In subsequently fatal cases, AFP rose again during 10 to 30 weeks after the initial treatment.

[An analysis of 117 cases of patients who died from tumor recurrence or from the progression of ovarian malignancies]

Out of 403 patients with ovarian with malignancies during 1978 to, 1985, 117 (29.0%) died from the progression of a non-curative cancer (56 cases, 47.9%) or from a cancer recurrence (61 cases, 52.1%). The mean survival rate 117 cases was 13.4 months, of which 103 (88.0%) cases concerned patients who died within 2 years and 114 (97.4%) who died within 3 years. A histological analysis revealed that patients with a serous or an endometrial cancer had a longer survival rate than others. Among 61 recurrent cases, 59 (96.7%) fell into recurrence within 2 years. Regarding the relationship between a recurrent of cancer and its prognosis, patients with a recurrence of an ascitic or a metastatic disease had a poorer prognosis than patients with a pelvic or an abdominal mass. An aggressive operation, such as a resection of a recurrent tumor, even if small in volume, led to a better prognostic result than no therapy.

The clinical usefulness of preoperative CEA determination in gastric cancer

Between 1980 and 1984, preoperative serum carcinoembryonic antigen (CEA) was determined in 468 patients with gastric cancer to evaluate its clinical usefulness. The positive rate of preoperative CEA was 20.9 per cent in these 468 patients. A significantly higher CEA positive rate was obtained in those patients with liver metastasis (69.2 per cent), n3-4 (40.0 per cent), stage IV gastric cancer (37.0 per cent) and Pap, Tub1 histological type (26.3 per cent) (p less than 0.01). It is interesting that the positive rate of the 49 unresectable patients was 51.0 per cent, which was significantly higher than 17.4 per cent of the 419 resectable cases (p less than 0.01). CEA levels in 16 of the 39 patients with liver metastasis were more than 100 ng/ml. In contrast, serosal invasion and peritoneal metastasis were less correlated to the CEA positive rate. In the 419 resected cases, the 5 year survival rate in the higher CEA group of more than 50 ng/ml (35 cases) was 4.4 per cent, which was significantly lower than 64.0 per cent in the negative group (346 cases) (p less than 0.01). These results show that CEA determination in patients with gastric cancer is useful for the prediction of prognosis, as well as for a diagnostic tool to discover the presence of liver or lymph node metastasis.

The usefulness of CEA as an indicator for early detection and a guide to the treatment of recurrent gastric cancer

The usefulness of carcinoembryonic antigen (CEA) as an indicator for recurrence and a guide to the treatment was evaluated from a retrospective analysis of 88 patients with recurrent gastric cancer. Sixty-two of these patients (70.5 per cent), 25 of whom had a preoperative positive assay, and 37 a negative assay, had elevated levels of CEA after disease progression. Averaged CEA level in patients with liver metastasis was significantly higher (872 ng/ml) than in those with peritoneal metastasis (68 ng/ml), with lymph node metastasis (103 ng/ml) or with local metastasis (93 ng/ml) (p less than 0.01). An elevation of CEA was found prior to the clinical manifestation of recurrence, and the average lead time was 4 months. In 25 patients with a lead time of more than 4 months, survival time after CEA elevation was 13.3 months, which was longer than the 6.5 months of 28 patients with less than 4 months. Thirty-seven of the 88 patients were treated after recurrence. The average survival period after the detection of recurrence was 9.4 months in patients with surgical treatments followed by chemotherapy, 5.9 months in those with chemotherapy alone and 3.8 months in those with surgery alone. The average survival period of 26 patients with positive CEA assays in recurrence was 5.1 months longer than of patients with negative assays. This fact suggested that early detection of recurrence followed by various treatments, in the elevated CEA group, contributes to favorable results.

[Usefulness of esophageal prosthesis in inoperable esophageal cancer]

Radiotherapy of inoperable esophageal cancer provided palliation for dysphagia in only 40% of the patients treated over the past 5 years at our hospital. The remaining patients were unable to eat a regular diet even after radiotherapy and to provide them with nourishment, a gastrostomy and/or IVH were required. We feel that the release of the patient from a medical environment will lead to a better quality of remaining life. From our experience with a prosthesis tube for palliation of a malignant esophageal stricture, 4 patients showed excellent results with this way of improving their oral intake.