Ascending parabrachio-thalamo-striatal pathways: potential circuits for integration of gustatory and oral motor functions.

The medial parabrachial nucleus (MPB) and external part of the medial parabrachial nucleus (MPBE) relay gustatory, oral mechanosensory and other visceral information in the rat brain and reportedly project not only to the parvicellular part of the posteromedial ventral thalamic nucleus (VPMpc) but also to the ventrocaudal part of the intralaminar thalamic nuclei. Generally, the intralaminar thalamic nuclei project topographically to the caudate putamen (CPu); however, it is unclear where the ventrocaudal part of the intralaminar thalamic nuclei projects within the CPu. Thus, we visualized neural pathways from the MPB and MPBE to the CPu via the ventrocaudal part of the intralaminar thalamic nuclei using an anterograde tracer, biotinylated dextran amine, and a retrograde tracer, cholera toxin B subunit. We found that the MPB and MPBE sent a relatively stronger input to the ventrocaudal part of the intralaminar thalamic nuclei such as the oval paracentral thalamic nucleus (OPC), central medial thalamic nucleus (CM) and parafascicular thalamic nucleus (PF) and retroreuniens area (RRe) as compared to the VPMpc. In turn, these thalamic nuclei projected to the ventral part of the CPu with the topographical arrangement as follows: the OPC to the ventrocentral part of the CPu; ventrolateral part of the PF to the ventrolateral part of the CPu; and the caudal part of the CM, ventromedial part of the PF and RRe to the ventromedial part of the CPu. Further, we found that the VPMpc rather projected to the interstitial nucleus of the posterior limb of the anterior commissure than the CPu. The ventral part of the CPu is reported to be involved in jaw movement as well as food and water intake functions. Therefore, these parabrachio-thalamo-striatal pathways that we demonstrated here suggest that gustatory and oral mechanosensory information affects feeding behavior within the ventral part of the CPu.

Erdheim-Chester disease associated with intramedullary spinal cord lesion.

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis. We present a case of a 56-year-old male with ECD. As time progressed, involvement of the orbital fossa, cranial convexity, spinal cord, brain stem, thyroid, lung, retroperitoneum, lower extremity bones and skin were found. Previously reported cases reveal the frequency of ECD with spinal cord involvement is rare. Although this was a presumed diagnosis based on other lesions, our case is the first in which both intramedullary and epidural masses are present.

Usefulness of mini-tracheostomy and torque controlled insertion of applicator in fractionated endobronchial brachytherapy.

Endobronchial brachytherapy was developed as effective treatment of endobronchial cancer and fractionated schedule is applied to decrease late toxicity. However, repeated bronchofiberscopy is onerous to the patient and restricts the treatment schedule itself. We applied mini-tracheostomy for a ready access route, and a torque controlled technique for easy insertion of the endobronchial applicator. Eight patients with tracheobronchial cancer invasion were treated with endobronchial brachytherapy of 18-30 Gy/3-5 fractions/1.5-2.5 weeks (median 24 Gy/4 fractions/2 weeks) at reference points of 5 mm from the bronchial surface. The averaged individual irradiation and single session times were 4 min and 24 min, respectively. There were no procedure-related complications. These technical improvements may facilitate flexible fractionated dose prescriptions.

Brachytherapy technique for abdominal wall metastases of colorectal cancer: ultrasound-guided insertion of applicator needle and a skin preservation method.

PURPOSE: To report a technique of interstitial brachytherapy for the treatment of subcutaneous metastatic abdominal wall tumors. MATERIAL AND METHODS: We developed a brachytherapy technique consisting of ultrasound-guided insertion of applicator needles to avoid the organs at risk, such as intestines, and saline injection into the subcutaneous tissue between the tumor and the skin to decrease the skin dose. We encountered three patients with painful metastases from rectal carcinoma in the abdominal wall refractory to external radiotherapy. They were subjected to this brachytherapy with a single dose of 20 Gy. RESULTS: The procedure was safely achieved in all three patients. Long-lasting pain reduction and tumor shrinkage was obtained without early or late complications. CONCLUSION: This interstitial brachytherapy technique seems to be feasible in the treatment of metastatic abdominal wall tumors.

Selective conformal radiotherapy for arteriovenous malformation involving the spinal cord.

Radiotherapy has seldom been used in the treatment of arteriovenous malformations (AVM) involving the spinal cord because of the cord's limited radiation tolerance. A 57-year-old woman with progressive myelopathy due to AVM was treated with a selective conformal radiation therapy (55.6 Gy/20 days) on the nidus region preserving the spinal cord, drainer veins and involved bones. The drainers and symptoms were minimized at the end of treatment and disappeared over 2 years. This case illustrates the usefulness of selective conformal radiation therapy.

Epidermoid cyst originating from an intrapancreatic accessory spleen.

Pancreatectomy in a 45-year-old woman showed, after pathologic analysis, an epidermoid cyst originating from an intrapancreatic accessory spleen. This mass consisted of parenchymal and cystic components. It is important to note the relation between the splenic parenchyma and the parenchymal component of the mass for the differential diagnosis of a cystic mass in the pancreatic tail.

Usefulness of CT virtual endoscopy in imaging a large esophagorespiratory fistula.

A 73-year-old woman with a large esophagorespiratory fistula underwent bronchoscopy and computed tomographic (CT) virtual endoscopy before stenting. Noninvasive CT virtual endoscopy showed the large fistula, and the CT findings agreed with the bronchoscopic findings.

T1 and T2 lip cancer: a superselective method of facial arterial infusion therapy--preliminary experience.

PURPOSE: To formulate and evaluate a facial arterial infusion chemotherapy for squamous cell lip carcinoma. MATERIALS AND METHODS: The study included six patients (age range, 46-84 years) with squamous cell carcinoma of the lower lip. There were two T1 tumors, three T2 tumors, and one T1-compatible postoperative recurrent tumor. A 4-F, double-lumen balloon catheter was inserted into the external carotid artery through the superficial temporal artery and placed for selective infusion into the tumor-feeding facial artery. Patients received a combination of mitomycin C (4.4 mg/m2 per body surface area) on day 1 and 3.2 mg/m2 of peplomycin sulfate on days 1-7 (22.4 mg/m2 per week), or, when peplomycin sulfate was contraindicated, 16 mg/m2 of cisplatin only on days 1-5 (80 mg/m2 per week). Two to three cycles of chemotherapy were given until tumor disappearance was histologically confirmed. RESULTS: Complete tumor disappearance was achieved in all cases. One patient had a self-limiting asthma attack during peplomycin sulfate treatment, and another had transient partial hair loss. No disfigurement, recurrence, or late complications were observed at a mean follow-up of 5.0 years (range, 2.3-11.2 years). CONCLUSION: The described facial arterial infusion chemotherapy appears to be a safe and curative treatment for T1 and T2 squamous cell lip carcinomas.

[Experimental study of percutaneous hot ethanol injection therapy (PHEIT) by continuous heating device for hepatocellular carcinoma].

Percutaneous ethanol injection therapy (PEIT) is widely used as a local treatment for hepatocellular carcinoma (HCC). However, because only a small amount of ethanol can be used in one PEIT session and because the antitumor effect is limited, this modality is indicated only when there are three or fewer tumors and when the tumor diameter is < or = 3 cm. To obtain a more potent and certain antitumor effect, we have devised a new treatment called percutaneous hot ethanol injection therapy (PHEIT), and developed a Continuous Heating Device with which ethanol can be heated and locally injected at a specified temperature. The continuous Heating Device is composed of three major components: a syringe heater, a needle thermocontroller, and a needle tip thermosensor. A disposable syringe filled with liquid is inserted into the syringe heater, which heats the liquid to a desired temperature by adjusting the voltage. The needle thermocontroller is a puncture guide needle to which a heating device has been attached. The needle-tip thermosensor constantly measures, displays and records the temperature of the liquid at the needle tip during injection. Also, because the Continuous Heating Device is a closed-circuit system, there is no risk of accidental a fire, which ensures procedural safety. It is also possible to use this device to safely heat and inject a variety of other liquids, such as physiological saline and anticancer agents and thus contribute to the widespread development of ultrasound-guided injection therapy.

Focal fatty infiltration in the quadrate lobe of the liver accompanied by aberrant right gastric vein.

Focal fatty liver in the posterior edge of the quadrate lobe was observed in a 59-year-old woman. This lesional portion was nourished by the aberrant right gastric vein, not by the main portal vein. This abnormality in portal blood flow was suspected to be one of the causes of the focal fatty liver.

Balloon-occluded retrograde transvenous obliteration for gastric varices: a feasibility study.

PURPOSE: To evaluate the clinical feasibility of balloon-occluded retrograde transvenous obliteration (BORTO) for gastric varices. METHODS: BORTO was performed in 14 patients with gastric varices due to liver cirrhosis. The gastric varices were confirmed by endoscopy, and their feeding and draining veins were identified by contrast-enhanced computed tomography (CT) and angiography. A 6 Fr Simmons-shaped balloon catheter was inserted into the gastrorenal shunt. The balloon was inflated, and 5% ethanolamine oleate iopamidol was infused slowly through the catheter. Patients were followed up with endoscopy and enhanced CT at 1 week, 1, 3, and 6 months after the procedure and every 6 months thereafter. RESULTS: The gastric varices completely disappeared in 12 of 14 patients and was partially resolved in the remaining 2 patients. Neither a recurrence nor an aggravation of gastric varices were found. No major complications were experienced. CONCLUSION: BORTO is a safe and effective treatment for gastric varices.

A dedicated Z-stent for acquired saber-sheath tracheobronchomalacia.

The tracheobronchial lumen has a continuous horseshoe arch morphology. We formed Z-stents accordingly to support the weakened cartilagenous portions. With this type of stent we treated a patient with acquired saber-sheath type tracheobronchomalacia (TBM), Rayl's type II, Johnson's grade III, whose condition was aggravated even under positive end expiratory pressure (PEEP) therapy. The patient improved gradually. No immediate complication was observed. Bronchofiberscopic examination revealed that the tracheobronchial arcade was closely strut-braced and showed no expiratory collapse. Six months later, when the patient was intubated due to asthmatic attacks, tissue ingrowth through the stent was found and removed. There was no recurrence of TBM. The patient died 2 years later of pneumoconiosis.

Brain MR imaging in patients with hepatic cirrhosis: relationship between high intensity signal in basal ganglia on T1-weighted images and elemental concentrations in brain.

In patients with hepatic cirrhosis, the globus pallidus and putamen show high intensity on T1-weighted MRI. While the causes of this high signal have been thought to include paramagnetic substances, especially manganese, no evidence for this has been presented. Autopsy in four cases of hepatic cirrhosis permitted measurement of metal concentrations in brain and histopathological examination. In three cases the globus pallidus showed high intensity on T1-weighted images. Mean manganese concentrations in globus pallidus, putamen and frontal white matter were 3.03 +/- 0.38, 2.12 +/- 0.37, and 1.38 +/- 0.24 (micrograms/g wet weight), respectively, being approximately four- to almost ten-fold the normal values. Copper concentrations in globus pallidus and putamen were also high, 50% more than normal. Calcium, iron, zinc and magnesium concentrations were all normal. The fourth case showed no abnormal intensity in the basal ganglia and brain metal concentrations were all normal. Histopathologically, cases with showing high signal remarkable atrophy, necrosis, and deciduation of nerve cells and proliferation of glial cells and microglia in globus pallidus.. These findings were similar to those in chronic manganese poisoning. On T1-weighted images, copper deposition shows no abnormal intensity. It is therefore inferred that deposition of highly concentrations of manganese may caused high signal on T1-weighted images and nerve cell death in the globus pallidus.

Scoop biopsy of intracaval tumor thrombi: a preliminary report of a minimally invasive technique to obtain large samples.

PURPOSE: The purpose of this study is to safely improve the yield of intracaval biopsy. MATERIALS AND METHOD: A co-axial system was composed of an inner catheter with a smoothly tapered tip with a shark jaw, and an outer sheath. The biopsy procedure consisted of four steps: (1) the tip was stuck into the target thrombi; (2) the inner sheath was advanced deeply into the target and the jaw was opened within the mass; (3) the outer sheath was advanced to envelope the inner cather; (4) then the system was withdrawn. After simulation experiments seven patients underwent this scoop biopsy. RESULTS: A simulation experiment proved that this technique brought much larger samples with minimal damage of the target surface. Seven patients who had been suspected of intracaval tumor thrombi underwent this procedure and confidential pathological examination without any complications. CONCLUSION: This scoop biopsy procedure was thought to be helpful in obtaining large samples safely.

[Evaluation of hepatic encephalopathy and portal hemodynamics by Doppler ultrasonography after a transjugular intrahepatic portosystemic shunt].

TIPS (transjugular intrahepatic portosystemic shunt) is an efficacious treatment for esophagogastric varices, ascites and hypertensive gastrointestinal vasculopathy associated with portal hypertension. The main complication after the procedure is hepatic encephalopathy. We tried to elucidate the correlation between hepatic encephalopathy and changes in portal hemodynamics after TIPS, based on observation by Doppler ultrasonography. We carried out Doppler ultrasonography in 28 cases of TIPS to assess hepatopetal and hepatofugal blood flow in the right and left portal branches. Hepatic encephalopathy occurred after TIPS in 9 cases out of 28 (32%), and new onset of disease was observed in 6 of 9. Doppler ultrasonography revealed hepatofugal blood flow in both right and left portal branches in 6 cases, 5 of which showed encephalopathy. Hepatopetal blood flow of the right and left portal branches was observed in 17 of 28 cases after TIPS. Hepatic encephalopathy occurred in only 2 of 17 cases. The changes in portal vein hemodynamics after TIPS were investigated by color Doppler ultrasonography, which were considered to be very useful for prediction of hepatic encephalopathy and indication of medical treatment to prevent the occurrence of this disease.

Factors associated with survival exceeding 5 years after transcatheter arterial embolization for hepatocellular carcinoma.

During the period between April 1981 and March 1988, 232 consecutive patients underwent transcatheter arterial embolization (TAE) for hepatocellular carcinoma at the Department of Radiology, Wakayama Medical College. A > or = 5-year course calculated from the time of the initial TAE was able to be confirmed in 216 patients, who became the subjects of this study. Five-year survival rates were calculated by the direct method, while the clinical features existing at the time of the initial therapy and the clinical course of patients surviving > or = 5 years were studied. The 5-year survival rate was 6.0%. Comparison of the patients dying within 1 year and the patients surviving for > or = 5 years revealed differences in the severity of liver cirrhosis and the tumor type. The long-term survivors tended to have low serum alpha-fetoprotein values. The clinical picture of the patients surviving > or = 5 years after TAE was characterized by relatively mild liver cirrhosis (Child's class A or B), a serum alpha-fetoprotein value of < or = 1,500 ng/dL, relatively small nodular-type tumors with a maximum main tumor diameter of < or = 5.5 cm, a tumor-occupying rate of less than 20%, and absence of portal vein involvement by the tumor. There were patients in whom a relatively small number of TAE sessions was effective in controlling the tumor for a prolonged period, with the patients then dying of causes unrelated to the tumor, as well as patients in whom proliferation of the tumor was controlled by numerous applications of transcatheter therapy, resulting in > or = 5-year survival but with eventual death due to the tumor. Transcatheter arterial embolization makes a major contribution to achieving long-term survival of > or = 5 years in patients with hepatocellular carcinoma.

Radiotherapy for hypoglycaemia associated with large leiomyosarcomas.

A patient with recurrent severe hypoglycaemia attacks due to a large, irresectable retroperitoneal leiomyosarcoma was treated with radiotherapy (60 Gy). The blood glucose level gradually and steadily improved as the cumulative radiation dose was increased. Weaning of hyperalimentation was started when the cumulative dose reached 21.6 Gy. The patient became completely free from hypoglycaemic attacks despite no significant diminishment of local tumour size and untreated multiple lung metastases. The patient was discharged and the attacks did not recur until expiration as a result of tumour bleeding. This case report supports the clinical usefulness of radiation therapy in treating hypoglycaemia induced by non-islet cell tumour.

[Comparison of Gore-tex covered Ultraflex stent and bare Ultraflex stent: preliminary clinical results].

We clinically compared the covered Ultraflex stent and the bare Ultraflex stent for malignant esophageal strictures. Materials were 6 cases with esophageal carcinomas. We placed the Gore-tex covered stents (A group) in 4 cases including 2 cases of esophagorespiratory fistulae, and the bare stents (B group) in 2 cases. The stents were well-expanded in all cases. After stenting, dysphagia was improved in all cases. Fistulae were obstructed by the cover in 2 cases in A group. Mean survival term was 123 days in A group and 45 days in B group. Complications were fistulation of bare portion of the covered stent in one case in A group, and tumor bleeding in one case in B group. Considering of the risk of fistula or tumor bleeding, the cover is necessary to increase the safety and efficacy of the esophageal stent.

Dependency of tissue necrosis on gelatin sponge particle size after canine hepatic artery embolization.

PURPOSE: To determine the optimal size of gelatin sponge particles (GSPs) to produce maximum tumor necrosis with minimum side effects after canine hepatic artery embolization (HAE). METHODS: GSPs were separated into four size ranges: A, up to 200 microns (mean 152) as Gelfoam powder; B, 200-500 microns (mean 336) as Gelfoam powder; C, 500-1000 microns (mean 649) as Spongel; and D, 1000-2000 microns (mean 1382) as Spongel. Three mongrel dogs were assigned randomly to HAE with each particle size. On day 7 after HAE, the livers were removed and subjected to pathological examination. RESULTS: The mean volume of liver necrosis was 11% after embolization, with particle size A, 36.3% with B, 0% with C, and 1% with D. Coagulation necrosis was found in all livers with particles of sizes A and B, and in 1 of 6 with sizes C and D. Bile duct injury was found in five of six dogs with sizes A and B and in none with sizes C and D. Gallbladder necrosis was found in one dog with size B and pancreas necrosis in one with size A. CONCLUSION: GSPs of 500 microns are considered optimally effective for tissue necrosis according to this model.

Treatment of a malignant esophageal fistula with a Gore-Tex-covered flexible nitinol stent.

In order to treat fistulated esophageal cancer using a flexible stent, a covered flexible stent was constructed by wrapping a nitinol stent with a thin sheet of Gore-Tex, preserving the stents original advantages of flexibility and a low-profile introducer system. This stent was used to perform standard radiotherapy in a case of fistulated esophageal cancer.