Retroperitoneal sarcoma: a 10-year follow-up analysis using hospital-based cancer registry data in Japan

OBJECTIVES

We sought clinical characteristics, survival outcomes, and prognostic factors for overall survival of retroperitoneal sarcoma in Japan.

METHODS

A Japanese hospital-based cancer registry database with a pivotal 10-year follow-up was used to identify and enroll patients, registered from 106 institutions, diagnosed with retroperitoneal sarcoma in 2008-2009. Treating hospitals were divided by hospital care volume; high-volume hospitals and low-volume hospitals were defined as ≥ 4 and < 4 cases/year, respectively.

RESULTS

A total of 91 men and 97 women were included, with a median age of 64 years. The most common histological type was liposarcoma in 101 patients, followed by leiomyosarcoma in 38 patients. The 5-year and 10-year overall survival rates were 44.1 and 28.3%. The majority of patients (n = 152, 80.9%) were treated at low-volume hospitals. High-volume hospital patients had higher 10-year overall survival rates than low-volume hospital patients (51.2% vs 23.2%, P = 0.026). Multivariate analysis revealed age over 60 years, treatment in low-volume hospitals and chemotherapy were independent predictors of unfavorable survival while treatment with surgery was an independent predictor of favorable survival.

CONCLUSIONS

The possibility of surgical removal was suggested to be the most important prognostic factor for retroperitoneal sarcoma. Better survival was shown in patients treated at high-volume hospitals in our series.

Variant allele frequency changes in TP53 predict pembrolizumab response in patients with metastatic urothelial carcinoma

Prognoses for patients with metastatic urothelial carcinoma (mUC) have improved with pembrolizumab treatment, an immune checkpoint inhibitor, but clinical benefits are limited to a subset of patients. Therefore, a non-invasive biomarker to predict pembrolizumab response is required. The present study retrospectively examined genomic alterations in 25 plasma circulating tumor DNA (ctDNA) samples using targeted sequencing of 77 genes from 16 patients with mUC during pembrolizumab treatment. A total of 11 (68.8%) patients demonstrated ≥2 genomic alterations, including TP53 mutations (as defined by ctDNA-positive status). The proportion of responders to pembrolizumab in the ctDNA-positive group was higher compared with that in the ctDNA-negative group (72.7 vs. 20.0%). Furthermore, among all detected genomic alterations, variant allele frequency decreases in TP53 during pembrolizumab treatment were mainly associated with therapeutic response. Collectively, these data suggest that profiling of ctDNA in plasma, particularly TP53, may be useful for predicting and monitoring therapeutic responses to pembrolizumab in patients with mUC.

Improved survival of poor-risk non-seminomatous germ cell tumor patients: real-world data from a single institute in Japan

OBJECTIVES

The International Germ Cell Cancer Collaborative Group Update Consortium showed the improved survival of patients with a non-seminomatous germ cell tumor. We updated the survival data of the non-seminomatous germ cell tumor patients treated at our hospital.

PATIENTS AND METHODS

We analyzed the outcomes of 138 patients treated in 1981-2018. We compared the survival of the patients treated in the early (1981-99) and later (2000-18) periods and determined the groups' progression-free survival and overall survival using the Kaplan-Meier method. We used a web-based application of the International Germ Cell Cancer Collaborative Group Update model to calculate each patient's predicted 3-year progression-free survival.

RESULTS

The 5-year progression-free survival rates of the good, intermediate and poor prognosis groups were 91, 83 and 64%, and their 5-year overall survival rates were 97, 89 and 82%, respectively. There were no significant differences in the progression-free survival or overall survival of the good and intermediate prognosis groups by treatment year. The 5-year progression-free survival of the poor prognosis group was almost identical in both treatment year (60 and 65%, respectively). By contrast, the 5-year overall survival in the later period (85%) was higher than that in the early period (70%). The median-predicted 3-year progression-free survival rates of the good, intermediate and poor prognosis groups were 92, 83 and 51% (P < 0.01), respectively. The concordance index for the good, intermediate and poor prognosis groups were 0.56, 0.79 and 0.67, respectively.

CONCLUSION

The survival of our poor prognosis non-seminomatous germ cell tumor patients improved over time. The 5-year overall survival of patients treated in 2000-18 reached 85%.

Clinicopathological features of adrenal malignancies: Analysis of hospital-based cancer registry data in Japan

OBJECTIVE

To identify the clinicopathological features of adrenal malignancies and analyze the prognoses of patients with adrenal cortical carcinoma (ACC) and malignant pheochromocytoma (MPCC).

PATIENTS AND METHODS

We used a hospital-based cancer registry data in Japan to extract cases of adrenal malignancies that were histologically confirmed, diagnosed, and initially treated from 2012-2015. For survival analysis, we used data from the 2008-2009 cohort to estimate 5-year overall survival (OS) by the Kaplan-Meier method.

RESULTS

A total of 989 adrenal malignancies were identified in the 2012-2015 cohort. The most common histologies were ACC (26.4%), diffuse large B-cell lymphoma (DLBCL; 25.4%), neuroblastoma (22.2%), and MPCC (11.9%). While most ACC and MPCC patients were in their 60s, DLBCL patients accounted for 61.5% of adrenal malignancies in the over-70 cohort. Among ACC patients with clinical staging data, 46.3% of patients were stage IV. Although surgery was a chief strategy for all stages, younger patients tended to receive combination therapy, including surgery and chemotherapy or hormone therapy. In the 2008-2009 cohort, the 5-year OS rates of ACC (n = 49) and MPCC (n = 23) patients were 56.2% and 86.4% while ACC patients without surgery had 1- and 2-year OS rates of 25.0% and 12.5%.

CONCLUSION

In Japan, DLBCL accounted for the majority of adrenal malignancies in older patients. Despite advanced staging, ACC patients were mainly treated with surgery and their prognosis was not satisfactory. Such epidemiological data may be useful in considering initial management strategies.

ELOVL2 promotes cancer progression by inhibiting cell apoptosis in renal cell carcinoma

Renal cell carcinoma (RCC) is an aggressive genitourinary malignancy which has been associated with a poor prognosis, particularly in patients with metastasis, its major subtypes being clear cell RCC (ccRCC), papillary PCC (pRCC) and chromophobe RCC (chRCC). The presence of intracellular lipid droplets (LDs) is considered to be a hallmark of ccRCC. The importance of an altered lipid metabolism in ccRCC has been widely recognized. The elongation of very-long-chain fatty acid (ELOVL) catalyzes the elongation of fatty acids (FAs), modulating lipid composition, and is required for normal bodily functions. However, the involvement of elongases in RCC remains unclear. In the present study, the expression of ELOVL2 in ccRCC was examined; in particular, high levels of seven ELOVL isozymes were observed in primary tumors. Of note, elevated ELOVL2 expression levels were observed in ccRCC, as well as in pRCC and chRCC. Furthermore, a higher level of ELOVL2 was significantly associated with the increased incidence of a poor prognosis of patients with ccRCC and pRCC. The CRISPR/Cas9-mediated knockdown of ELOVL2 resulted in the suppression of the elongation of long-chain polyunsaturated FAs and increased LD production in renal cancer cells. Moreover, ELOVL2 ablation resulted in the suppression of cellular proliferation via the induction of apoptosis in vitro and the attenuation of tumor growth in vivo. On the whole, the present study provides new insight into the tumor proliferation mechanisms involving lipid metabolism, and suggests that ELOVL2 may be an attractive novel target for RCC therapy.

PLD1 promotes tumor invasion by regulation of MMP-13 expression via NF-κB signaling in bladder cancer

Invasion of bladder cancer (BC) cells from the mucosa into the muscle layer is canonical for BC progression while phospholipase D isoform 1 (PLD1) is known to mediate development of cancer through phosphatidic acid (PA) production. We therefore used in silico, in vitro and in vivo approaches to detail the effect of PLD1 on BC invasion. In BC patients, higher levels of PLD1 expression were associated with poor prognoses. PLD1 knockdown significantly suppressed cellular invasion by human BC cells and matrix metalloproteinase-13 (MMP-13) was observed to mediate this effect. In our mouse bladder carcinogenesis model, the development of invasive BCs was suppressed by PLD1 knockout and a global transcriptomic analysis in this model indicated MMP-13 as a potential tumor invasion gene with NF-κB (nuclear factor-kB) as its transcriptional regulator. Furthermore, PA administration increased MMP-13 expression in line with NF-κB p65 phosphorylation levels. Collectively, we demonstrate that PLD1 promotes tumor invasion of BC by regulation of MMP-13 expression through the NF-κB signaling pathway and that PLD1 might be a potential therapeutic target to prevent clinical progression in BC patients.

The liposome of trehalose dimycolate extracted from M. bovis BCG induces antitumor immunity via the activation of dendritic cells and CD8+ T cells

Intravesical Bovis bacillus Calmette-Guérin (BCG) therapy is the most effective immunotherapy for bladder cancer, but it sometime causes serious side effects because of its inclusion of live bacteria. It is necessary to develop a more active but less toxic immunotherapeutic agent. Trehalose 6,6'-dimycolate (TDM), the most abundant hydrophobic glycolipid of the BCG cell wall, has been reported to show various immunostimulatory activities such as granulomagenesis and adjuvant activity. Here, we developed cationic liposomes incorporating TDM purified from Mycobacterium bovis BCG Connaught, and we investigated the antitumor effect of the cationic liposome TDM (Lip-TDM). Lip-TDM exerted an antitumor effect in bladder cancer, colon cancer, and melanoma-bearing mouse models that was comparable or even superior to that of BCG, with no body weight loss or granuloma formation. The antitumor effect of Lip-TDM disappeared in two types of mice: those with depletion of CD8⁺ T cells, and those with knockout of macrophage-inducible C-type lectin (Mincle) which recognize TDM. Lip-TDM treatment enhanced the maturation and migration of dendritic cells in the tumor microenvironment in a Mincle-dependent manner. Our results elucidate mechanisms that underlie Lip-TDM treatment and suggest that Lip-TDM has potential as a safe and effective treatment for various cancers.

The arterial blood supply of the conducting system in normal human hearts

The distributing artery of the conducting system of the heart is occasionally injured in cardiac surgery. The aim of this study was to define the anatomic characteristics of the principal arterial source of the sinu-atrial node and atrioventricular node. Furthermore, the morphology of the tendon of Todaro was clarified. Thirty hearts were studied by gross anatomic methods, and the exact area of the conducting system was supported by histologic observations of four hearts. The sinu-atrial node was supplied by the right coronary artery more frequently (73% of cases) than by the left (3%), and in 23% of cases this node was supplied by both coronary arteries. The atrioventricular node was supplied by the right coronary artery (80% of cases) more than by the left (10%), and in 10% of the cases this node was supplied by both coronary arteries. The atrioventricular bundle branch arose from the right coronary artery in 10% of cases, the left coronary artery in 73%, and both coronary arteries in 17%. Most of the blood to the right bundle (the moderator band) was supplied by the interventricular septal branches of the anterior interventricular branch from the left coronary artery. Finally, all the arteries of the right bundle and left bundle were defined to be derived from left coronary arteries.

An anatomical and clinical study of the dorsal intercostal cutaneous perforators, and application to free microvascular augmented subdermal vascular network (ma-SVN) flaps

We report a two-part anatomical and clinical study whose aim was to map the dominant dorsal intercostal cutaneous perforators (DICPs), which are useful for microvascular augmentation of flaps raised from the skin of the back called subdermal vascular network (SVN) flaps, and to test their reliability in the clinical setting. In the anatomical arm of the study, using preserved cadavers, we macroscopically confirmed the location of DICPs, and performed micro-angiography of the dorsal skin to find each dominant DICP. In the clinical arm of the study, we confirmed the location of the dominant DICP during microvascular augmented SVN flap transfer. Postoperatively, posteroanterior radiographs of the chest were taken to locate vessel clips used to ligate the DICPs. The combined study results showed that the dominant DICP is the sixth or seventh in most instances, but there are some anatomical variations. If no dominant DICP is found in the sixth or seventh spaces, at least one DICP that is of sufficient calibre for microvascular augmentation can usually be found in the general vicinity, such as the fifth, eighth or ninth spaces. The clinical application of microvascular augmented SVN flaps, both pedicled and free, is presented.

Origin of the thoracic duct and pancreaticoduodenal lymphatic pathways to the para-aortic lymph nodes

We investigated the afferent and efferent connections of the para-aortic lymph nodes (group 16 nodes) relative to the origin of the thoracic duct in 85 postmortem cadavers. The origin was usually restricted to groups 16b1-inter and -latero nodes (type I; 90.6%), regardless of whether the union of their efferents occurred at the abdominal or thoracic level. We also occasionally observed thick collecting vessels originating from the dorsal aspect of the pancreaticoduodenal region, running along the right side of and superficial to the celiac plexus and emptying into group 16b1 nodes. The thoracic duct originated occasionally not only from group 16b1 nodes but also from group 16a2 nodes (type II; 9.4%). Moreover, in all 85 specimens, the group 16a2-inter node often received afferents from the celiac plexus itself or the tight connective tissue between the plexus and diaphragmatic crus, or both. The results support the reliability of the extended D2 lymphadenectomy (D2 + group 16b1 nodes + group 16a2-inter node) for curative cancer surgery in the pancreaticoduodenal region.

Anatomical bases for paravertebral anesthetic block: fluid communication between the thoracic and lumbar paravertebral regions

An injection of a local anesthetics in the paravertebral region produces an analgesic field on the same side of the body, a paravertebral block. One point in question about this block is whether the local anesthetic spreads from the thoracic to the lumbar level of the paravertebral region. The purpose of this study was to find how the anesthetic fluid traveled to the lumbar paravertebral region, if at all. Twelve cadavers were used in this study. 15 ml of crimson dye was injected into the paravertebral region at the 11th thoracic level. The viscerae were removed so that we could examine the dye spread. While the crimson dye spread in the endothoracic fascia posterior to the parietal pleura, it also spread downward in the fascia mostly along the splanchnic nerves. At the upper surface of the diaphragm the dye spread laterally in the fascia, and entered the abdominal cavity through the medial and lateral arcuate ligaments. In the abdominal cavity, the dye was found to have spread so widely in the transversalis fascia that the subcostal, iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous and femoral nerves were involved. We concluded that the dye in the thoracic paravertebral region can enter the abdominal cavity through the medial and lateral arcuate ligaments. This study explained possible fluid communication between the thoracic and lumbar paravertebral regions and confirmed our former clinical observations. The result is important for the future clinical application of paravertebral anesthesia.

A single-injection, multi-segmental paravertebral block-extension of somatosensory and sympathetic block in volunteers

BACKGROUND

It is our experience that a deposition of an anesthetic solution in the ventral area of the paravertebral space near the parietal pleura and the sympathetic trunk produces extended unilateral block. Because sympathetic block effects in this extended paravertebral block are not reported yet, we undertook this singly blinded, controlled study on the sympathetic change in volunteers.

METHODS

A total of 22 ml 1% lidocaine was injected at the T11 level into the ventral area of the right-sided paravertebral space in 16 volunteers. The distribution of analgesia, heart rate, blood pressure and body temperature (measured by 12 skin sensors) was monitored. On a later occasion the volunteers underwent a control injection of saline.

RESULTS

Unilateral analgesia (with no contralateral element) was induced in every subject injected with lidocaine, contrasted with no block induction with saline. Loss of pin-prick sensation was observed within 10 min after injection and involved a mean of 12 (range 8-13) dermatomes. A sympathetic block was indicated by cutaneous temperature increase within at least 6 dermatomes. Increase of arterial blood pressure was obtained in all volunteers with no change in pulse rate. No side effects or complications occurred. Epidural spread of the local anesthetic was unlikely because of the absence of contralateral cutaneous analgesia and temperature increase.

CONCLUSION

One-sided extended analgesia (sensory loss) follows the paravertebral injection of lidocaine. A large ipsilateral sympathetic block is observed without change in pulse rate and with no hypotension. These are all characteristics of an optimal regional block.

Veins of the lumbar spinal ganglia in human adults and fetuses

To obtain a fundamental knowledge of the morphological relationship between nerve root symptoms and circulatory disorders, the distribution pattern of the veins in the lumbar spinal ganglia from the first to fifth vertebrae was investigated in 5 adult human cadavers (mean age 69.6 years) and 5 human fetuses (mean age 6.6 months). The following results were obtained: 1) In the adults the veins perforating from the outer surface of the fifth lumbar spinal ganglion were smaller in number than those perforating from the first to fourth ganglia. In contrast, in the fetuses the number of such veins was increased in the lower lumbar spinal ganglia. In each of the ganglia, the number of veins emerging through the dorsal side was much higher than the number perforating from the outer surface of the ventral sides. The veins perforating through the outer surface of the ganglion formed weak venous networks (periganglionic venous plexus) surrounding the dorsal ramus of the spinal nerve. 2) The veins communicating with the tributaries from the periganglionic venous plexus were classified into three types. Type 1 veins flowed into the intervertebral veins (the frequency ranged from 9.2 to 18.2 in the adults and from 22.4 to 37.0 in the fetuses). Type 2 veins coursed in the spinal cord along the dorsal root fibers and penetrated the dura mater on the way (the frequency ranged from 0.4 to 4.8 in the adults and from 1.2 to 2.2 in the fetuses). Type 3 veins opened directly into the internal vertebral plexus (the frequency ranged from 0.4 to 1.8 in the adults and from 0 to 0.4 in the fetuses). Type 1 veins were the most frequent among the three types of veins in both adults and fetuses. Few type 3 veins were observed in either group. 3) In the first and second lumbar vertebrae in the adults, three-quarters of each spinal ganglion was situated in the vertebral canal. In the lower lumbar region (L3-L5), three quarters of each spinal ganglion lay on the outside of the vertebral canal. In the fetuses, approximately one half to three-quarters of each lumbar spinal ganglion was located in the vertebral canal.

Extended unilateral anesthesia. New technique or paravertebral anesthesia?

BACKGROUND AND OBJECTIVES

The authors previously reported a case in which injection of local anesthetic posterior to the endothoracic fascia at the T11 vertebral level gave rise to extended analgesia in thoracic and lumbar dermatomes. They now report a study in which this type of anesthesia was used in patients undergoing herniorrhaphy.

METHODS

A 12-mL dose of 2% mepivacaine was injected at the T11 level posterior to the endothoracic fascia in 15 patients.

RESULTS

On average, seven dermatomes could be blocked with this dose and with a single injection. Nine patients experienced adequate analgesia and underwent operation with no additional sedation. In three patients the block resulted in inadequate analgesia, and additional sedative drugs were used. Three patients experienced no analgesia and were given general anesthesia

CONCLUSION

Injection of local anesthetic posterior to the endothoracic fascia resulted in extended unilateral anesthesia that was adequate for herniorrhaphy in 9 of the 15 patients (60%) studied.

[Angles among main cranial sutures in Japanese]

To examine a relation of angles among the coronal, sagittal and lambdoid sutures to the size of the calvaria as well as to the remains of the metopic suture, 158 adult Japanese calvae or calottes were observed. The calvae used consisted of four groups: group M composed of 74 male calvae without the metopic suture; group F, of 41 female calvae without the same suture; group Un, of 27 sex-unknown calvae without the same suture; and group Um, of 16 sex-unknown calvae with the same suture. The angles among the sutures were measured at both bregma and lambda. The size of the calvaria was represented by bistephanic arc and breadth (distance between the stephanions), and by parietal sagittal arc and chord (distance from the bregma to the lambda). Results obtained were as follows. The distances both between the stephanions and from the bregma to the lambda were larger in M than in F, though these distances in M, F and Un were much the same as those in Um. The bistephanic index (breadth/arc) was higher in Um than in F, whereas the sagittal parietal indices (arc/chrod) in M, F and Um were similar to one another. Apical angle of the frontal squama was larger in M than in F, and was larger in Um than in M and F. However, apical angle of the occipital squama showed no difference among M, F and Um.(ABSTRACT TRUNCATED AT 250 WORDS)

[Endothoracic anesthesia for artificial anus formation in rabbits]

We succeeded in maintaining anesthesia for artificial anus formation in rabbits using a new anesthetic technique of endothoracic anesthesia. The drug injection through a catheter, which was inserted into the endothoracic fascia at the level of the 11th thoracic vertebra, caused an unilateral anesthesia from the chest down to the lower limb. Artificial anus formation was possible by this endothoracic anesthesia with a help of medetomidine and nitrous oxide.

[Anatomical consideration of anesthetic dispersion into abdominal cavity causing broad unilateral anesthesia after inadvertent local anesthetic infusion into endothoracic fascia]

Recently we reported a case of inadvertent migration of an epidural catheter into the endothoracic fascia. Anesthetic injection into the fascia brought a broad unilateral analgesia. To clarify the mechanism of anesthesia. We studied how the anesthetic agent spreads into the abdominal cavity from the endothoracic fascia. The crimson dye, the substitute of the anesthetic agent, reached the transversial fascia in the abdominal cavity through medial and lateral arcuate ligament. Subcostal nerve, iliohypogastric nerve, ilioinguinal nerve, genitofemoral nerve and lateral femoral cutaneous nerve were found to be in the course of dye dispersion. The renal adiposal fascia plays a role of a reservoir for the anesthetic agent and prevents the further anesthetic dispersion.

[Morphology of the ganglion cervicale superius in human fetuses and an adult]

Morphology of the ganglion cervicale superius (GCS) was studied on 16 sides of 10 human fetuses and the 2 sides of an adult cadaver with a binocular stereomicroscope. The obtained results were as follows. GCS is fusiform on 8 sides, takes the form of an eggplant on 3 sides, and is weakly constricted on 7 sides. The GCS was symmetrical in 2 cases. The GCS lay slightly above the first cervical vertebra and extended downward to the superior half of the second cervical vertebra on 11 sides of fetuses. The level in the adult is lower than in the fetuses by one vertebra. The nervus caroticus internus (CI), originating from the superior pole of the GCS as a cephalic prolongation, comprises one bundle on 14 sides, and splits into 2 bundles in the original position on 4 sides. The Nn. carotici externi (CE) arise from the medial part of the superior half of the GCS with several roots (the average number of roots: 3.4) on 17 sides. The CE communicates with the Rami pharyngei of the N. vagus and the N. laryngeus superior. The Rr. laryngopharyngei arise from CE on many sides. The N. jugularis originates from the laterosuperior side of GCS with one to three branches. On a few sides, the N. jugularis communicates with the N. vagus and the N. hypoglossus. The communicating branch between the Ggl. inferius of the N. vagus and the GCS was observed in all cases. The communicating branch between the R. ventralis of the Nn. cervicales and GCS is found in all sides, and the lower limit of the branch is at the ansa from C3 to C4. The Rr. laryngopharyngei (RL) arise from the medial part of the GCS with several branches near the CE, or it may arise from the CE or from both the GCS and the CE, and join with the N. laryngeus superior (laryngeal branch of RL:RL1), the Plexus pharyngeus (pharyngeal branch of RL:RL2) and CE (RL1 and RL2). It is found in a few sides that RL directly extends to the pharyngeal and laryngeal portions. The N. cardiacus cervicalis superior (CS), which originates from the anteroinferior portion or the inferior pole of the GCS, was found on all fetal sides. The average number of CS is 2.9. Some nerves, crossing from the CI to the root of CE over the A. carotis interna, were recognized on 15 sides of the fetuses and on both sides of the adult.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of partial absence of the left pericardium]

A rare case of partial absence of the left pericardium was reported. The patient was a seventy-nine year old male and the cause of death was a gastric cancer. The pericardial absence was oval in shape, in egg-size with smooth margin and was located between the superior portion of the left pericardium and the pleural cavity. The pulmonary artery, left auricle and superior part of the left ventricle were visible through the absence. The left phrenic nerve descended along the anterior free margin of the absence.

[The cephalic arterial system in dogs, especially on the anastomoses between the intracranial and extracranial circulations]

The cephalic arterial system with a special reference to the anastomoses between the extracranial and intracranial circulations was investigated by means of the corrosion casts of 30 dogs. We researched into the cephalic arterial system in dogs according to Bugge's theory. His theory is as follows: ontogenetically it is composed of 4 arterial systems (the internal and external carotids, vertebral and stapedial arteries), although these arteries trans-figure from the primitive basic pattern to the adult one with particular anastomoses between the branches in each of the species. The modification of this basic pattern occurs as a result of the obliteration or persistence of certain parts of the 4 original arterial systems when they are accompanied with various anastomoses. And he emphasizes that the mode of the appearance of each anastomosis is constant in each of the species. In this paper the obtained result is as follows. The stapedial artery that occurred in an early stage of embryonic period obliterates the proximal part except for the supraorbital, infraorbital and mandibular branches. Anastomosis X between the vertebral and external carotid arteries is formed in all the cases. Anastomosis Y between the internal carotid and ascending pharyngeal arteries is found at 20% on the right side and 30% on the left. Anastomosis a1 between the internal ophthalmic artery and each of the orbital arteries derived from the supraorbital branch is recognized at 93% on the right side and 97% on the left, and the other a1 between the internal ophthalmic artery and anastomosis a6 is formed in 7% on the right side and 3% on the left. Anastomosis a2 between the supraorbital and infraorbital branches is recognized in all the cases. Anastomosis a3 between the distal part of the external carotid artery and the proximal portion of the mandibular branch is found out in all. Anastomosis a4 between the distal portion of the internal carotid artery and the supraorbital branch or each of its distal branches in the orbita is recognized at 90% on both sides. Anastomosis a5 between the distal part of the internal carotid artery and the proximal part of the infraorbital branch or the middle meningeal artery is found at 97% on the right side and 87% on the left.(ABSTRACT TRUNCATED AT 400 WORDS)