Effect of transcatheter arterial chemoembolization on kidney hemodynamics and function in patients with cirrhosis and hepatocellular carcinoma.

BACKGROUND/AIMS: Transcatheter arterial chemoembolization (TACE) may have deleterious effect on the kidney in patients with cirrhosis and hepatocellular carcinoma. The aim of the study was to test this hypothesis. METHODS: Twenty-four patients with cirrhosis and hepatocellular carcinomas were included. They consisted of 16 patients undergoing a single TACE and eight patients undergoing diagnostic angiography. Doppler ultrasonography was used to measure hepatic artery pulsatility index (HA-PI) and renal artery pulsatility index (RA-PI) before and 1 day and 10 days after the procedure. Similarly, kidney function was assessed by measuring creatinine clearance. In addition, plasma renin activity, noradrenaline, and endothelin-1 were also measured. RESULTS: In patients receiving diagnostic angiography, no significant changes in HA-PI were observed after the procedure. In contrast, HA-PI increased significantly 1 day after the procedure (19%, p<0.01) in patients undergoing TACE, although it returned to baseline value 10 days after the procedure. In patients undergoing diagnostic angiography, no significant changes in RA-PI were observed after the procedure. Similarly, no detectable changes in RA-PI were noted in patients undergoing TACE. A transient small reduction in creatinine clearance was noted after the procedure in patients undergoing diagnostic angiography (-12%, p<0.05) and in those undergoing TACE (-11%, p<0.05). However, the effect was similar in the two groups (two-way ANOVA, p=0.72). No significant changes in plasma renin activity, noradrenaline, and endothelin-1 were observed after either diagnostic angiography or TACE. CONCLUSIONS: These results suggest that TACE per se has no deleterious effect on the kidney hemodynamics and function in patients with cirrhosis and hepatocellular carcinoma.

[Diagnosis and treatment of bleeding esophago-gastric varices].

Endoscopic injection sclerotherapy and/or endoscopic variceal ligation are well accepted and established in the treatment of bleeding esophageal varices. Endoscopic treatment for bleeding gastric varices is behind in hemostatic rate by 5% ethanolamine oleate as sclerosant. However, since cyanoacrylate is employed as endoscopic injection sclerosant, hemostatic rate was greatly improved especially for the bleeding large gastric varices. In addition angiographic sclerotherapy (balloon occluded retrograde transvenous obliteration) is highly effective for large gastric fundal varices and no rebleeding is expected when successfully done. Endoscopic and angiographic sclerotherapy made great improvement in the treatment of esophagogastric varices.

Effect of large fundal varices on changes in gastric mucosal hemodynamics after endoscopic variceal ligation.

UNLABELLED: BACKGROUNDS AND STUDY AIMS: Effect of endoscopic variceal ligation (EVL) on gastric mucosal hemodynamics would differ in patients with and without large fundal varices. The aim of this study was to test this hypothesis. PATIENTS AND METHODS: Twenty-seven patients with cirrhosis and large sized esophageal varices were prospectively studied. There were eight patients with large fundal varices and 19 patients without large fundal varices. Before EVL, gastric mucosal hemodynamics were endoscopically assessed by laser-Doppler velocimetry and reflectance spectrophotometry in the antrum and the corpus. In the reflectance spectrophotometric measurements, gastric mucosal hemoglobin content (IHb) and gastric mucosal oxygen saturation (ISO2) were determined. The severity of portal-hypertensive gastropathy (PHG) was also recorded at the antrum and the corpus. For data analysis, PHG was scored (absent, 0; mild, 1; severe, 2; bleeding, 3). These measurements were repeated after initial (three days after initial session) and repeated (seven days after last session) EVL. RESULTS: At the antrum, neither PHG score nor gastric mucosal hemodynamic parameters were modified after initial and repeated EVL in patients with and without large fundal varices. In addition, no significant differences of the integrated changes in PHG score and gastric mucosal hemodynamic parameters were observed in the two groups. At the corpus, PHG score significantly increased after initial and repeated EVL in patients without large fundal varices. In these patients, laser-Doppler signal and ISO2 significantly decreased and IHb significantly increased after initial and repeated EVL. In contrast, PHG score, laser-Doppler signal, and ISO2 did not change significantly in patients with large fundal varices, although IHb transiently increased after initial EVL. Furthermore, the integrated changes in PHG score and gastric mucosal hemodynamic parameters were significantly lower in patients with large fundal varices than in those without. CONCLUSION: The aggravation of PHG after EVL is due to congestion of the gastric mucosal circulation. The presence of large fundal varices plays a protective role in the development of EVL-induced gastric mucosal hemodynamic derangement.

Ligation plus low-volume sclerotherapy for high-risk esophageal varices: comparisons with ligation therapy or sclerotherapy alone.

Endoscopic variceal ligation therapy (EVL) seems to be a more effective and safer method than endoscopic injection variceal sclerotherapy (EVS) for treating bleeding esophageal varices. However, EVL may entail a higher recurrence rate than EVS. The aim of this study was to examine whether EVL combined with low-dose EVS reduced the recurrence rate compared to treatment with EVL alone and reduced the complication rate compared to treatment with EVS alone. In this prospective study, 59 patients with cirrhosis and high-risk (F2 or F3, red color sign ++ or ) esophageal varices were enrolled. They were randomly assigned to an EVS group (n = 18), an EVL group (n = 20), and a combination EVL plus low-dose EVS group (n = 21). After the eradication of varices, follow-up endoscopic examinations were carried out for 24 months to determine the recurrence of varices. Complications, e.g., severe dysphagia, fever, renal dysfunction and pleuritis were also evaluated. The recurrence-free rate was significantly lower in the EVL group (60% at 24 months) than in either the EVS group (90%, P < 0.05) or the combination group (88%, P < 0.05). However, no significant difference was found between the EVS group and the combination group. The complication rate was significantly higher in the EVS group (50%) than in either the EVL group (5%, P < 0.01) or the combination group (10%, P < 0.01). The combination therapy seems to be useful to improve the benefits achieved with EVL alone and to reduce the harmful effects induced by EVS alone. EVL plus low-volume EVS is advisable in the treatment of high-risk esophageal varices.

Prognostic factors in cirrhotic patients receiving long-term sclerotherapy for the first bleeding from oesophageal varices.

OBJECTIVE AND DESIGN: The aim of this study was to identify prognostic factors in cirrhotic patients receiving long-term sclerotherapy for their first bleeding from oesophageal varices. METHODS: Ninety-eight patients with acute bleeding from oesophageal varices receiving long-term endoscopic injection sclerotherapy were retrospectively investigated. Thirteen variables (five qualitative and eight quantitative) related to clinical, biological, and radiographic features were collected at admission. The qualitative variables were: gender, hepatocellular carcinoma, cause of cirrhosis, ascites and degree of encephalopathy. The quantitative variables were age, bilirubin, albumin, prothrombin index, number of sessions of sclerotherapy, volume of ethanolamine oleate, time taken to reach the hospital and shock index. These variables were examined with a multivariate analysis using stepwise logistic regression procedures and a prognostic index was calculated from the Cox equation. The predictive power of the final Cox model was prospectively tested in 43 patients with cirrhosis receiving long-term sclerotherapy for their first variceal bleeding. RESULTS: Of the 13 variables studied in a multivariate analysis using a logistic regression model, four had an independent prognostic value: the presence of hepatocellular carcinoma, bilirubin, albumin and time taken to reach the hospital. When the Cox model was examined in an independent set of 43 patients, there were no statistically significant differences between the observed and expected survival. CONCLUSION: Prognosis of patients with bleeding from oesophageal varices is related to residual liver function and time taken to reach the hospital. Furthermore, the presence of hepatocellular carcinoma is an additional risk factor.

Splanchnic hemodynamic pattern and liver function in patients with cirrhosis and esophageal or gastric varices.

OBJECTIVES: This study was designed to characterize the splanchnic hemodynamic pattern and liver function in patients with cirrhosis and esophageal or gastric varices. METHODS: Forty control subjects and 112 patients with cirrhosis were studied. Portal inflow (the sum of superior mesenteric arterial and splenic arterial flows), portal venous flow, and collateral flow (the difference between portal inflow and portal venous flow) were measured using duplex ultrasonography. Endoscopic examination showed that 45 patients had no varices or small esophageal or gastric varices, 49 had large esophageal varices, and 18 had large gastric varices. Liver function was assessed by Pugh-Child score. RESULTS: Portal inflow was significantly greater in patients with large esophageal varices or large gastric varices than in control subjects and patients with no varices or small esophageal or gastric varices. Portal venous flow was significantly lower in patients with large gastric varices than in the other three groups. Collateral flow was significantly greater in patients with large gastric varices than in patients with large esophageal varices. The Pugh-Child score was significantly higher in patients with large gastric varices than in patients with large esophageal varices. The Pugh-Child score was also inversely correlated with portal venous flow (r = -0.35, p < 0.01) and directly correlated with collateral flow (r = 0.59, p < 0.01). CONCLUSIONS: Both patients with esophageal varices and those with gastric varices have increased portal inflow. However, patients with gastric varices, in contrast to patients with esophageal varices, have a reduced portal venous flow associated with an increased collateral flow. Such a portal outflow pattern may contribute to the worse liver function seen in patients with gastric varices.

Value of Doppler ultrasound parameters of portal vein and hepatic artery in the diagnosis of cirrhosis and portal hypertension.

OBJECTIVES: This prospective study was designed to assess the sensitivity and specificity of Doppler ultrasound parameters in the diagnosis of cirrhosis and portal hypertension. METHODS: Portal and hepatic arterial Doppler ultrasound was performed on 76 patients with cirrhosis and esophageal varices and on 73 age- and sex-matched controls. The parameters evaluated were portal venous velocity and hepatic arterial pulsatility index. The liver vascular index was calculated as the ratio of portal venous velocity to hepatic arterial pulsatility index. RESULTS: Portal venous velocity was significantly lower (11.0 +/- 2.4 vs 15.9 +/- 2.8 cm/s, p < 0.001) and hepatic arterial pulsatility index was significantly higher (1.28 +/- 0.18 vs 0.95 +/- 0.17,p < 0.001) in patients than in controls. Thus, the liver vascular index was significantly lower in patients than in controls (8.7 +/- 2.1 vs 17.2 +/- 4.3 cm/s, p < 0.001). The sensitivity and specificity of these parameters in the detection of cirrhosis and portal hypertension was then analyzed with the receiver operating characteristic curve. The best cut-off values were considered to be 13 cm/se of portal venous velocity and 1.1 of hepatic arterial pulsatility index, showing a sensitivity and specificity of 83, 85, 84, and 81%, respectively. The best cut-off value of the liver vascular index was 12 cm/s with a sensitivity and specificity of 97 and 93%, respectively. CONCLUSIONS: The liver vascular index is a high sensitive and specific Doppler ultrasound parameter in the diagnosis of cirrhosis and portal hypertension.

Portal-hypertensive gastropathy develops less in patients with cirrhosis and fundal varices.

BACKGROUND/AIMS: The aim of this prospective study was to examine the association of portal-hypertensive gastropathy and fundal varices in patients with cirrhosis. METHODS: We carried out an endoscopic observation in 476 patients with cirrhosis (study 1), including 62 patients undergoing endoscopic obliteration of esophageal varices (study 2). In study 1, patients were classified into five subgroups: no esophagofundal varices (n=119), small esophagofundal varices (n=127), dominant esophageal varices (n=177), dominant fundal varices (n=27), and large esophagofundal varices (n=26). The severity of liver dysfunction was assessed by Pugh-Child classification: class A (n=222), class B (n=200), and class C (n=54). In study 2, two groups, poorly developed fundal varices (n=50) and well developed fundal (n=12), were distinguished and the follow-up endoscopic examinations were performed on the basis of 3-month intervals for 2 years. In each study, the severity of portal-hypertensive gastropathy was scored: 0 (absent), 1 (mild), 2 (severe), and 3 (bleeding). RESULTS: Study 1: One-way ANOVA showed that both variceal pattern and Pugh-Child class significantly influenced portal-hypertensive gastropathy score. However, two-way ANOVA indicated that variceal pattern was the only significant variable. Portal-hypertensive gastropathy score was significantly higher in patients with dominant esophageal varices than in either patients with no esophagofundal varices or patients with small esophagofundal varices. In contrast, portal-hypertensive gastropathy score in patients with dominant fundal varices was similar to that in patients with no esophagofundal varices and was significantly lower compared with that in patients with dominant esophageal varices. Furthermore, portal-hypertensive gastropathy score was significantly lower in patients with large esophagofundal varices than in patients with dominant esophageal varices. Study 2: After the obliteration of esophageal varices, portal-hypertensive gastropathy score in patients with poorly developed fundal varices became significantly higher at 3-, 6-, 9-months while it was not modified in patients with well developed fundal varices during the follow-up period. Furthermore, the integrated incremental change in portal-hypertensive gastropathy score during the first 1-year follow-up period was significantly lower in patients with well developed fundal varices than in patients with poorly developed fundal varices. CONCLUSIONS: These results indicate that both spontaneous and obliteration-induced portal-hypertensive gastropathy lesions develop less in patients with cirrhosis and fundal varices.

Gastric mucus generation in cirrhotic patients with portal hypertension. Effects of tetraprenylacetone.

We have evaluated gastric mucus generation (study 1) and the effects of tetraprenylacetone on gastric mucus generation (study 2) in cirrhotic patients with portal hypertension. Study 1: Included were 50 noncirrhotics (group A), 25 cirrhotics without portal hypertension (group B), and 25 cirrhotics with portal hypertension (group C). The antrum, corpus, and fundus mucus generation was assessed by hexosamine concentration using biopsy specimens. In groups A and B, the antrum hexosamine concentration was significantly higher compared with the corpus (P < 0.01, P < 0.01) and the fundus (P < 0.01). In contrast, the hexosamine concentration at each location was similar in group C. Furthermore, the antrum hexosamine concentration of group C was significantly lower compared with that of group A (P < 0.05). In study 2, a double-blind design, 300 mg of tetraprenylacetone was administered for four weeks in 10 cirrhotics with portal hypertension and placebo in 10. The regional hexosamine concentrations were measured before and after drug administration. Placebo administration did not change hexosamine concentration at each location. In contrast, tetraprenylacetone increased the antrum and corpus hexosamine concentration (P < 0.01, P < 0.05), although the fundus concentration did not change. These data suggest that cirrhotics with portal hypertension have reduced gastric antral mucus generation and tetraprenylacetone normalizes this.

[Pulmonary blastoma--long-term survival of a patient with metastases].

We report a rare case of pulmonary blastoma. This 59-year-old woman has been apparently well with recurrent and metastatic tumors in her left lung for 9 years after the initial operation. On May 28, 1984, she underwent a thoracotomy of left upper lobectomy and lymph nodes dissection. The histologic diagnosis of resected specimen was pulmonary blastoma. In August 1986 (27 months after the initial surgery), chest X-ray revealed some nodules in the lungs. Then, the patient had two thoracotomies for the excision of 4 tumors and one chest wall resection of the tumor. In addition, she received systemic chemotherapy 28 times, directly intrapulmonary drug injection 3 times and radiation therapy once for recurrent and metastatic disease. Following some cycles of our combination chemotherapy consisting of cis-platinum and vindesine, some lesions had decreased in size and others previously seen on chest X-ray were no longer evident. She achieved an objective response with receiving two-drug chemotherapy. Our observation suggest that this intensive combination chemotherapy is effective in recurrent and metastatic disease of pulmonary blastoma as a surgical adjuvant.

McCormack's endoscopic signs for diagnosing portal hypertension: comparison with gastroesophageal varices.

To assess the significance of McCormack's gastric mucosal signs for diagnosing portal hypertension, 100 controls and 100 patients with cirrhosis and portal hypertension underwent endoscopy. Each endoscopic recording was reviewed by multiple blinded observers to reduce bias. Individual signs more frequently observed in patients with cirrhosis and portal hypertension than in controls were fine pink speckling (20% versus 8%, p < 0.05), the snakeskin pattern (30% versus 5%, p < 0.01), and cherry-red spots (15% versus 3%, p < 0.01). In contrast, the prevalence of superficial reddening was similar in the two groups (7% versus 13%, NS). Overall, these gastric mucosal signs also appeared more commonly in patients with portal hypertension than in controls (54% versus 27%, p < 0.01); the sensitivity, specificity, and accuracy of McCormack's signs (overall assessment) for diagnosing portal hypertension were 54%, 73%, and 64%, respectively. Corresponding figures for modified McCormack's signs (exclusion of superficial reddening) were 50%, 85%, and 68%. However, these figures were still lower than those for gastroesophageal varices (72%, 100%, and 86%). We conclude that (1) superficial reddening is not a specific finding in patients with portal hypertension, and (2) gastric mucosal findings are of low sensitivity and specificity for diagnosing portal hypertension compared with gastroesophageal varices.

[A case report of giant esophageal leiomyoma associated with an epiphrenic esophageal diverticulum].

A well-nourished 33-year-old male, who was entirely asymptomatic and in apparently good health, was referred to our hospital because of abnormal findings on a routine chest X-ray film. A chest X-ray taken upon admission revealed an oval mass suggesting a mediastinal tumor in the posterior mediastinum. An esophagogram demonstrated severe distortion of the esophageal lumen and an epiphrenic diverticulum on the right side. Endoscopy disclosed a submucosal bulge covered by normal mucosa. The mass, which was located on the right diaphragm between the heart and right ribs, appeared to be of homogenous density on CT scan and MRI films. Infiltration of contiguous structures and enlargement of mediastinal lymph nodes appeared to be absent. The preoperative diagnosis was an esophageal leiomyoma. A right posterior thoracotomy was performed in the prone position under general anesthesia. The tumor (12 x 8 x 4.5 cm, 170 g) associated with an epiphrenic esophageal diverticulum was removed by a partial esophageal resection. The pathologic specimen showed a leiomyoma with normal esophageal mucosa and a true diverticulum containing all the layers of the esophageal wall. We suggest that the diverticulum resulted from retraction of the esophageal wall related to the extraluminal growth of the leiomyoma.

Portal vein hemodynamics in cirrhotic patients with portal hypertensive gastropathy: an echo-Doppler study.

Portal hypertensive gastropathy is a major complication of cirrhosis. The aims of this study were to characterize portal vein hemodynamics and sympathetic nervous activity in cirrhotic patients with gastropathy. Forty-seven cirrhotics (mild gastropathy in 7) and 25 controls were included in this study. Portal vein hemodynamics was assessed by echo-Doppler, and sympathetic nervous activity by plasma adrenaline and noradrenaline concentrations. Portal blood flow was similar in cirrhotics and controls. However, the congestion index of the portal vein (calculated as the ratio of cross-sectional area and blood velocity) was significantly higher in the former than in the latter. Furthermore, the congestion index of the portal vein paralleled the severity of the gastropathy (ANOVA, p < 0.05). Plasma adrenaline and noradrenaline concentrations were higher in cirrhotics than in controls. However, there was no linear relationship between plasma adrenaline (ANOVA, NS) and noradrenaline (ANOVA, NS) concentrations and the severity of gastropathy. These results suggest a relative contribution of "passive congestion" in the pathogenesis of gastropathy.

[Pulmonary resection for metastatic gallbladder carcinoma by thoracoscopic surgery--report of a case].

A 58-year-old male was admitted to our hospital 11 months after undergoing a cholecystectomy and partial hepatectomy for carcinoma of the gallbladder with direct invasion of the liver at another hospital. Three round, abnormal shadows had been detected in the lungs by chest roentgenogram, but the patient had neither been diagnosed nor treated. On admission to our hospital, we confirmed three small lesions. Before operative procedure, the lung lesions were diagnosed as adenocarcinoma by transbronchial lung biopsies via fiberoptic bronchoscope and percutaneous needle biopsies. The ipsilateral lung was collapsed during one-lung anesthesia with a Unibent tube, and thoracoscopic surgery was performed using a flexible thoraco-fiberscope and reusable thoracic surgiports of our own design. A wedge resection of the pulmonary lesion was performed by intrathoracic ENDO-DIA. A well differentiated adenocarcinoma defined as a metastasis of gallbladder carcinoma was diagnosed by resected specimen. Thoracoscopic surgery appears to be a safe, effective and less morbid alternative procedure to thoracotomy for carefully selected patients with peripheral pulmonary lesions. Further evaluation and prospective studies are indicated.

Gastric mucosal blood flow after smoking in healthy human beings assessed by laser Doppler flowmetry.

We measured regional gastric mucosal blood flow by laser Doppler flowmetry before and after control (n = 8) or cigarette smoking (n = 8) in healthy human beings. The control group showed no change in both antrum (from 1.15 +/- 0.32 to 1.20 +/- 0.39 V, NS) and corpus gastric mucosal blood flow (from 1.15 +/- 0.32 to 1.12 +/- 0.28 V, NS). In contrast, cigarette smoking caused a significant reduction in gastric mucosal blood flow in the antrum (from 1.08 +/- 0.31 to 0.71 +/- 0.22 V, p < 0.01) and in the corpus (from 0.99 +/- 0.26 to 0.66 +/- 0.24 V, p < 0.01). The magnitude of reduction in gastric mucosal blood flow was similar between the antrum and the corpus (-34% +/- 11% versus -33% +/- 15%, NS). We conclude that cigarette smoking induces a significant reduction in gastric mucosal blood flow and that no heterogeneous response occurs in regional gastric mucosa. In addition, the laser Doppler flowmeter appears to be a sensitive method to assess rapid change in gastric mucosal blood flow in human beings.

[Endoscopic surgery of airway lesions by Nd-YAG laser treatment].

Between April 1980 and November 1990, we treated 212 cases of airway lesion using an Nd-YAG laser via the fiberoptic bronchoscope. The Nd-YAG laser power output was usually 40 W (20-60 W) delivered in 2 sec. shots. The cases consisted of 98 primary lung cancer, 12 primary tracheal cancer, 53 metastatic airway lesion, 7 benign tumor, and 42 cicatricial and granulomatous lesions. The therapeutic effects of Nd-YAG laser treatment were evaluated based on alleviation of dyspnea, widening of airway, and curative vaporization for therapeutic purposes. Effectiveness was observed in 180 of a total of 212 cases (84.9%). Out of 75 emergency cases in which a lifesaving procedure was performed to widen the airway, effective results were obtained in 70 (93.3%) with dramatic improvement in condition. It was also effective in 90 of 109 cases (82.6%) in which the procedure was performed for staged (palliative) widening of airway. In 55 cases of advanced lung cancer (Stage III or IV, mainly non-small cell cancer) in which palliative widening procedure was performed, one year survival was 44%. In 13 of 18 cases (72.2%) in which the procedure was performed for curative vaporization of invasive cancer, successful results were obtained. In 7 cases of benign tumor in which vaporization was performed as a radical curative procedure, no recurrence was observed in any cases. In 53 cases of metastatic airway lesion, effective results were obtained 48 (90.6%). The primary lesions of these cases consisted of 14 cases of esophageal cancer, 9 cases of lung cancer, 7 cases of colo-rectal cancer, 7 cases of thyroid cancer, and 16 others.(ABSTRACT TRUNCATED AT 250 WORDS)

The present status of bronchoscopic Nd:YAG laser.

In Japan, the first bronchoscopic Nd:YAG laser applied clinically was performed in our institute 10 years ago, and based on this decade of experience, the indications, effectiveness, and limitations were studied. Between 1980 and 1989, a total of 202 cases were treated by Nd:YAG laser in our institute. Among them, 94 (46.5%) cases were primary lung cancers, 10 (5.0%) cases were primary tracheal malignancies, 56 (27.7%) cases were metastatic tracheal tumors, 6 (3.0%) cases were benign tracheal tumors, and 36 (17.8%) cases were nontumorous tracheal lesions. The indications for Nd:YAG laser therapy were defined as emergency widening of airway, curative treatment, reduction of tumor size, nontumorous benign lesions, and hemostasis. The desired therapeutic effects were obtained in 55/58 (94.8%) for emergency airway widening, 22/27 (81.5%) for curative treatment, 69/88 (78.4%) for reduction of tumor size, and 48/68 (70.6%) for nontumorous benign lesions. While performing Nd:YAG laser treatment, some limitations, such as poor residual pulmonary function, tumor size, tumor depth, cartilage structure, granulation, and stricture length, were encountered. Since bronchoscopic Nd:YAG laser treatment has become a well-established therapeutic modality for tracheobroncheal lesions, areas to be addressed in the future are the training of bronchoscopic laser therapists and research on the extension of applications. To increase the range of clinical applications, it is hoped that makers of laser systems will provide tunable wavelength machines at reduced cost.

[Clinical studies on reconstruction procedure of total layer chest wall resection].

The results of clinical studies on 16 reconstruction procedure after total layer chest wall resection in 14 cases of malignant tumor of the chest wall were reported. The 14 cases consisted of two cases with recurrent primary chest wall tumor, two cases of primary breast cancer, seven cases of recurrent breast cancer, and others. The reconstruction procedure after total layer chest wall resection was conducted using only various myocutaneous flaps (eight cases using latissimus dorsi of the resected side, three cases using the abdominitis of the resected side, three cases using latissimus dorsi of the non-resected side, and two cases using a pectoralis major myocutaneous flap of the non-resected side). reconstruction only using a myocutaneous flap proved to be satisfactory for preventing early stage postoperative respiratory distress and maintaining the stability of the chest wall and respiratory function during prolonged observation. Namely, use of myocutaneous flap is the best approach of reconstruction the chest wall after total layer chest wall resection. We confirmed that reconstruction with latissimus dorsi myocutaneous free flap of the non-resected side with microvascular anastomosis of thoracodorsal vessels was useful for posterior chest wall tumors invading the latissimus dorsi muscle. Also, our results demonstrated the insertion of an omental flap under the myocutaneous flap was useful for cases with secondary chest wall infection or vascular damage caused by preoperative high dose irradiation.

[A case report of mediastinal malignant lymphoma with long survival following combination chemotherapy using adriamycin, vincristine and cyclophosphamide].

Mediastinal B-cell malignant lymphoma of a 22-year-old female was successfully treated by combination chemotherapy including Adriamycin, Vincristine and Cyclophosphamide. She suffered from dyspnea and axillary tumor in September 1984. Roentgenological examination revealed a large anterior mediastinal tumor. Biopsy of the axillary tumor yielded a diagnosis of metastatic undifferentiated carcinoma from thymus by hematoxylin and eosin. Radiotherapy and chemotherapy including CDDP and ACNU resulted in a symptom-free period of only 2 months. Superior vena cava syndrome and massive pleural effusion recurred. Salvage chemotherapy including Adriamycin, Vincristine and Cyclophosphamide resulted in rapid therapeutic effect. Six courses of chemotherapy were administered, and she is alive and well 4 years after the first salvage chemotherapy. A definitive diagnosis of B-cell lymphoma was made after review of biopsy specimens using immunohistochemical procedures. To select adequate treatment for mediastinal malignant lymphoma, reliable diagnostic procedures including immunohistochemistry are needed. Intensive chemotherapy with appropriate drugs may obtain good response even in advanced cases, such as this.