[Adjuvant chemotherapy for resectable non-small cell lung cancer (NSCLC)].

A randomized clinical trial of adjuvant chemotherapy has been evaluated for non-small cell lung cancer (NSCLC) patients, because the prognosis of early NSCLC does not enough after surgery (stage I: 70-80%, stage II: 50% in overall 5-years survival). Japanese guide line for lung cancer treatment (2005 edition) recommends adjuvant chemotherapy after complete resection for pathological stage IB, II and IIIA. Previous studies have suggested that uracil-tegafur has benefit for stage IB NSCLC patients, and platinum-based adjuvant chemotherapy has benefit for stage IB, II and IIIA NSCLC patients. In 2007 ASCO Annual Meeting, Harpole D talked about molecular prognostic profiles in early resected NSCLC. The goal of this study design is to validate a molecular-based tumor model that identifies those patients at low risk for cancer recurrence who will not benefit from adjuvant chemotherapy. The remaining patients will be randomly assigned to observation (the present standard of care) or adjuvant chemotherapy to determine the efficacy of adjuvant in this population. Biomarker for response of chemotherapy will be available to know who has benefit from adjuvant chemotherapy. When each patient has appropriate adjuvant chemotherapy, the prognosis is improved by that.

[Mid-term outcome of aortic arch operation for true aneurysms; using an axillary artery perfusion].

To prevent cerebral infarction during perioperative period, we have used an axillary artery for systemic perfusion and selective cerebral perfusion for aortic arch operation. Since 1996, 34 aortic arch operations were performed in our institution. Simultaneous 5 CABGs, 4 AVRs, 2 aortic root replacements and 1 MVR were performed. There were 2 hospital deaths (5.9%, sepsis and acute heart failure) and only 1 (2.9%) cerebral infarction. There were no deaths in patients over 75 years of age and in patients with extensive aneurysm which were replaced by 2-staged operation. Overall 3 years survival was 94.1% with no further death. We conclude that aortic arch operation through an axillary artery perfusion and with hypothermic selective cerebral perfusion can be performed with very low mortality and morbidity.

Native-like beta-hairpin retained in the cold-denatured state of bovine beta-lactoglobulin.

Bovine beta-lactoglobulin is denatured by increased temperature (heat denaturation) and by decreased temperature (cold-denaturation) in the presence of 4 M urea at pH 2.5. We characterized the structure of the cold-denatured state of beta-lactoglobulin using circular dichroism (CD), small-angle X-ray scattering (SAXS) and heteronuclear nuclear magnetic resonance (NMR). CD and SAXS indicated that the cold-denatured state, in comparison with the highly denatured state induced by urea, is rather compact, retaining some secondary structure, but no tertiary structure. The location of the residual structures in the cold-denatured state and their stability were characterized by 1H/2H exchange combined with heteronuclear NMR. The results indicated that the residues adjacent to the disulfide bond (C106-C119) connecting beta-strands G and H had markedly high protection factors, suggesting the presence of a native-like beta-hairpin stabilized by the disulfide bond. Since this beta-hairpin is conserved between different conformational states, including the kinetic refolding intermediate, it should be of paramount importance for the folding and stability of beta-lactoglobulin. On the other hand, the non-native alpha-helix suggested for the folding intermediate was not detected in the cold-denatured state. The 1H/2H exchange experiments showed that the protection factors of a mixture of the native and cold-denatured states is strongly biased by that of the labile cold-denatured state, consistent with a two-process model of the exchange.

[Prognosis of subacutely progressive interstitial pneumonia depends on the presence of focal usual interstitial pneumonia].

A retrospective follow-up study was conducted on patients with subacutely progressive interstitial pneumonia who underwent surgical biopsy. Pathologically, they were subclassified into subacute interstitial pneumonia (SIP) and SIP + F, which consisted of an SIP lesion and a focal usual interstitial pneumonia. The SIP group consisted of 35 cases and the SIP + F group, of 15 cases. The majority of patients in both groups were female and complained of dyspnea. Both groups showed increased neutrophil counts (8.8%, 6.3%), eosinophils (6%, 5.6%), and lymphocytes (43.1%, 42.3%) in bronchoalveolar lavage. Chest radiography generally demonstrated predominant lower lobe involvement together with shrinkage in both groups, and differentiation of the two was difficult before biopsy. All but one improved temporarily with steroid therapy, or spontaneously, in both groups. On further observation after temporary improvement, 27 cases (82%), did not show any worsening and 6 cases (18%) showed worsening (including death) in the SIP group, while 6 cases (43%) showed no worsening, though 8 cases (57%) worsened in the SIP + F group. Deaths in either group that were not related to the original diseases were excluded from the statistical analysis. We concluded that the presence of focal usual interstitial pneumonia in SIP lesions affects prognosis in patients with subacutely progressive interstitial pneumonia.

[Surgical treatment of adenocarcinoma in Barrett's esophagus and prognosis].

There is no consensus regarding the surgical approach to adenocarcinoma in Barrett's esophagus. From 1980 to 1988, 8 patients with adenocarcinoma in Barrett's esophagus were treated at the National Cancer Center Hospital. Seven patients underwent subtotal esophagectomy with extended lymph node dissection, and one transhiatal esophagogastrectomy with regional lymph node dissection. In 4 patients tumor invasion was limited within the submucosa and in 4 within the muscularis propria. Four of 8 patients had stage I disease. The 5-year survival rate for the 8 patients was 64.3%. Some reports have indicated that endoscopic survey for Barrett's esophagus is important for early diagnosis. We conclude that survival after esophagectomy for adenocarcinoma in Barrett's esophagus is dependent on the method of operation, and that patients with early lesions may expect significantly better survival after extended lymph node dissection.

[A successful case report on intralesional OK-432 therapy for cystic mediastinal lymphangiomas].

A 42-years-old female was referred to the university hospital because of cystic lesions of the right superior mediastinum. Drainage tube was found at right supraclavicular fossa with prolonged lymphatic discharge. We diagnosed this case as a benign cystic lymphangiomas with CT scan and CT scan with cystography and chemical analysis of the contents of the cyst. Intralesional OK-432 therapy for cystic mediastinal lymphangioma was performed. OK-432 was administered through intralesionally placed drainage tube. Excellent result was obtained. A few weeks later, residual lymphatic discharge through drainage tube became stopped. No expansion of the mediastinal cyst was found after drainage tube removal. Intralesional OK-432 therapy for cystic mediastinal lymphangioma was very effective and useful, it should be recommended for the management of the first choice of therapeutic method for cystic mediastinal lymphangioma because of no neurological deficit after this treatment.

Relationship between progression of gastric mucosal atrophy and Helicobacter pylori infection: retrospective long-term endoscopic follow-up study.

A retrospective long-term endoscopic follow-up study was designed to examine atrophic changes in the gastric mucosa over time in Helicobacter pylori-positive patients. Over a period of 8-17 years (mean, 13.4 years) 22 subjects (5 men, 17 women, mean age, 55 years) without localized gastroduodenal lesions underwent serial endoscopic examinations and serological and microbiological assessments of H. pylori infection. The extent of atrophic mucosa in the gastric body was expressed using the Kimura-Takemoto classification of atrophic pattern. Atrophic patterns were unchanged over time in 7 H. pylori-seronegative and culture-negative subjects with normal stomach, and in 1 seropositive and culture-negative subject with severe atrophy. Seven of 10 H. pylori culture-positive subjects not including three with the O-3 pattern, i.e., open type atrophic pattern, exhibited a cephalad shift of atrophic pattern. The cumulative progression rates of atrophy in the culture-positive subjects excluding O-3 subjects, were 10% after 2 years, 20% after 4 years, 50% after 6 years, and 70% after 8 years. The increases in the extent of the atrophic area were discontinuous, in terms of age, in the H. pylori-positive individuals and occasionally advanced rapidly within periods of several years with no relation to age.

Pneumatosis intestinalis and necrotizing enterocolitis associated with liver cirrhosis.

We report a 58-year-old woman with pneumatosis intestinalis and necrotizing enterocolitis associated with liver cirrhosis. She was receiving treatment for liver cirrhosis and hepatic failure when sudden severe right upper abdominal pain and fever developed. Abdominal radiograph disclosed pneumatosis intestinalis, involving the ascending colon, and small collections of free air along the right hemidiaphragm. The pneumatosis intestinalis appeared in both cystic and linear form. Autopsy revealed necrosis and multiple gas-filled mural cysts in the ascending colon. To our knowledge, this is the first case to be reported of pneumatosis intestinalis and necrotizing enterocolitis associated with liver cirrhosis.

[Early esophageal cancer--concept, diagnosis and treatment].

In spite of the conventional definition of early esophageal cancer which includes mucosal and submucosal cancers without lymph node metastasis, esophageal mucosal cancers are now considered as the early cancer in clinical field. The esophageal mucosal cancers are subclassified into m1 (intraepithelial cancer), m2(lamina propria mucosae) and m3(muscularis mucosae) in clinical view points. M1 and m2 esophageal cancers which had no lymph node metastasis could be treated completely by endoscopic mucosal resection. On the other hand, the patients with m3 cancer which showed lymph node metastasis in 10% of the cases should be treated by esophagectomy with lymph node dissection. For the diagnosis of the depth of carcinoma invasion, now, endoscopy with dye iodine stain and toluisine blue stain were most useful. Fundamentally, macroscopic appearance of lesions classified by Japanese Society for Esophageal Diseases are well related to the depth of invasion. Almost all mucosal cancers showed the superficial and flat type (0-IIc type). Subclassification of m1, m2 and m3 were easily differentiated by endoscopic observation of their characteristic appearances. In the evaluation of the methods of treatment for mucosal cancer, endoscopic mucosal resection and esopagostomy showed a complete resectability. While, the former was superior in the quality of life after treatment.

[Thoracotomy as treatment for pneumothorax associated with pneumocystic carinii pneumonia in a patient with hemophilia A and the acquired immunodeficiency syndrome].

Pneumocystis carinii pneumonia is the most common respiratory infection in patients with the acquired immunodeficiency syndrome, and inhalation of pentamidine aerosol is currently used for secondary prophylaxis. A 16-year-old patient with hemophilia A and the acquired immunodeficiency syndrome had a spontaneous pneumothorax during inhalation of pentamidine aerosol for secondary prophylaxis of Pneumocystis carinii pneumonia. Tube thoracostomy and pleurodesis were done without success. Thoracotomy was done 27 days after admission. The patient tolerated the procedure well, and the postoperative course was uneventful. Grocott staining of tissue from the bronchopleural fistula revealed Pneumocystis carinii, which suggests that the pentamidine aerosol failed to control and active Pneumocystis infection in peripheral lung zones.

[A clinical study of associated bladder tumor in patients with renal pelvic and ureteral tumor].

We investigated the incidence of associated bladder tumor and prognosis in 101 cases with a pathological diagnosis of transitional cell carcinoma, selected from those with renal pelvic and ureteral tumor whom we had encountered over the 18 years between April 1976 and March 1993. Among these 101 cases, the incidence of associated bladder tumor was noted in 42 (41.6%), 23 (22.8%) with coexistence and 19 (18.8%) with subsequence. As for the primary site of renal pelvis and ureter, the coexistence was 15.4% and subsequence 20.5% in renal pelvis, and the coexistence was 24.6% and subsequence 19.3% in ureter, and the coexistence was 60.0% and subsequence 0.0% in both renal pelvis and ureter. The incidence of coexistent bladder tumor was high in both renal pelvis and ureter, but no significant difference was noted. As for the stage, the incidence of coexistence was high in T1, while subsequence was high in T2, but no significant difference was noted. As for the grade, the incidence of coexistence was high in G2, but no significant difference was noted. The 5 year survival rate was 58.2% in those without, 54.2% with coexistence, and 82.5% with subsequent bladder tumor, with a significant difference (p < 0.05) between the last two groups. The interval of subsequent bladder tumor ranged from 4 to 164 months (mean 27.7 months), with the incidence within 2 years being approximately 70.0%. It was found that the renal pelvic and ureteral tumors are frequently associated bladder tumor while associated bladder tumor dose not appear to have an ill effect on the prognosis. Therefore it is necessary that patients with renal pelvic and ureteral tumor be observed closely for 5 years, especially for the initial 2 years.

Phasic right coronary blood flow in a patient with right ventricular hypertension using transesophageal Doppler echocardiography.

Although phasic right coronary artery blood flow in right ventricular hypertension has been studied in animals, reports on human subjects are not available. We observed right coronary artery blood flow before and after operation in a patient with right ventricular hypertension secondary to atrial septal defect using transesophageal Doppler echocardiography. Prior to surgery, blood flow was predominantly diastolic in both right and left coronary arteries. Reversal of right ventricular hypertension after surgery resulted in a change in the pattern of right coronary flow, with doubling of flow during systole.

[Evaluation of the method of treating non-Hodgkin's lymphoma].

Forty-two patients with non-Hodgkin's lymphoma were treated between October 1983 and December 1992 in the department of Otolaryngology, Kagawa Medical School Hospital. The twenty-six of these patients whose tumor originated in Waldeyer's ring and who were diagnosed as Stage I or II have been reviewed. In principle, method of treatment was a combination of chemotherapy and radiotherapy. Between 1983 to 1987, COP was primarily used (9 cases) as combination chemotherapy, and after 1988 CHOP was used (17 cases). VAMA was used to treat the poor response and recurring cases. The five-year estimated overall survival rates calculated by the Kaplan-Meier method were 33.3% and 94.1% in the COP and CHOP groups, respectively. We investigated age, stage, cell type and grade, as factors related to recovery, but except for cell type, there were no significant differences in overall survival. The most serious side effect was decreased leucocyte count, but we prescribed G-CSF and were able to continue treatment.

[Resection of intra-atrial tumor thrombi from renal malignant tumors with the use of cardiopulmonary bypass and temporary exsanguination. An experience based on 4 cases].

We report 4 patients, 1 female and 3 males aged 26-74 years, who underwent surgical treatment for renal malignant tumors with supradiaphragmatic extension into the vena cava. All of their tumor thrombi extended to the right atrium as confirmed by magnetic resonance imaging. The distinctive symptom was liver dysfunction caused by disturbance of the hepatic vein drainage in two patients. However, there was no common symptom in these 4 patients. Preoperative metastasis was found only in the female, whose metastasis was solitary in the lung and seemed to be able to be removed easily after radical nephrectomy. All of these 4 patients had radical nephrectomy and removal of the tumor thrombi with the use of cardiopulmonary bypass and temporary exsanguination. In 3 of these patients, the liver was mobilized to expose the retrohepatic vena cava by incision of the falciform, triangular and coronary ligaments. Two patients with vena caval wall invasion had vena cavectomy and an artificial vascular graft was then sutured to replace the caval wall in one of them. Preoperative liver dysfunction was gradually improved after operation and completely recovered about 1 week later. A postoperative complication, wound infection, occurred in only one patient. Pathological examination revealed renal cell carcinoma in 3 patients and nephroblastoma in the remaining one. In renal cell carcinoma, both patients without distant metastasis were alive about 15 months postoperatively. However, the one with lung metastasis died with newly appeared multiple metastases 9 months postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Morphological changes of Kock pouch investigated by autopsy two years nine months postoperatively].

A 62-year-old male patient consulted us because of gross hematuria and was diagnosed as having a bladder tumor. Total cystectomy was performed and a Koch pouch was utilized. Two years and nine months later, he died as a result of recurrence of bladder tumor and pathological autopsy was performed. A microscopic section of the reservoir mucosa showed a reduction in the number of crypts and an increase in the number of goblet cells. These morphological changes seemed to be caused by chronic exposure to urine, but have a favorable effect upon metabolic alterations following the utilization of the Kock pouch.

[Perioperative psychological status of patients undergoing radical mastectomy and total hysterectomy].

Using four different psychological tests, namely Spielberger's rating scale [The State-Trait Anxiety Inventory (STAI)], Self-Rating Depression Scale (SDS), Maudsley Personality Inventory (MPI) and Baum test, we investigated the perioperative psychological status of patients undergoing radical mastectomy for breast cancer and compared data with those of patients undergoing total hysterectomy for uterine myoma. Parameters reflecting the psychological status of hysterectomy patients disclosed lower postoperative anxiety, and slight nervousness and persistent depression perioperatively. In contrast, in patients with breast cancer, those with nervousness had persistent anxiety and depression, while those without nervousness showed the same persistent depression as in hysterectomy patients, as well as a high anxiety level postoperatively. Therefore, we speculate that the persistence of depressive mood during the perioperative period is a factor in the psychological disturbance of mastectomy patients with breast cancer, and moreover, they appear markedly apprehensive because of cancer. These results suggest that the persistence of anxiety and depressive mood associated with cancer is a prime factor in the etiology of postoperative psychological disturbance.

[Significance of the measurement of arterial ketone bodies during abdominal surgery].

Ketone body (3-hydroxy butyric acid) present in the blood was successively examined during surgical operations to ascertain the condition of energy metabolism and its clinical significance. In 10 patients (R group) to whom only the lactated Ringer's solution was infused during the operation, values of 3-hydroxy butyric acid increased remarkably in the 30 minutes after the operation began. In 7 patients (GI group), to whom the lactated Ringer's solution in 5% of glucose was administered, the values also increased in the 30 minutes after the operation was started. However, after the administration of glucose the values decreased, and returned to the normal value with administration of insulin. Furthermore, blood sugar readings which were examined at the same time increased significantly immediately after the beginning of the operation in both groups. Insulin readings showed considerably low values during the operation in R group. The readings of free fatty acid tended to show high values in R group, while they tended to decrease after the dose of glucose in GI group. With regard to epinephrine and norepinephrine readings, both groups showed significantly high values 30 minutes after the start of operation.

[A study on the psychological status of perioperative patients (II)].

In order to study the changes of the psychological status during perioperative period, we performed four different psychological tests, Spielberger's rating scale "The State-Trait Anxiety Inventory (STAI)", Self-rating Depression Scale (SDS), Maudsley Personality Inventory (MPI) and Baum test, in 63 patients who received simple total hysterectomy for myoma of uterus. The anxiety ratings showed a significant decrease postoperatively. On the contrary, the SDS index that expresses the level of depressive mood showed no significant change during perioperative period. Moreover the patients who had shown a tendency of nervousness in MPI kept the high level of the SDS index during perioperative period than the other patients who had not shown a tendency of nervousness in MPI. In Baum test, more than 75% of patients manifested psychologic fragility or lability. These results suggest that depressive mood affects strictly the psychological status in postoperative period more than anxiety. We presume that the depressive mood during perioperative period is responsible for the postoperative psychological disturbance.