Detectability of peripheral lung cancer on chest radiographs: effect of the size, location and extent of ground-glass opacity.

The purpose of this study was to evaluate the effect of the size and location of lung tumour and the extent of ground-glass opacity (GGO) on thin-section CT for the detection of peripheral lung cancer on chest radiographs. 100 posteroanterior chest radiographs of peripheral lung cancer 20 mm in diameter or smaller were reviewed retrospectively by two chest radiologists individually. Lung cancer was detectable on chest radiographs in 51 (51%) cases. However, in six cases, the tumour was recognized not as a nodular opacity but as a subpleural linear or localized hazy opacity. The median size of detectable lung cancer (17 mm) was larger than that of undetectable lung cancer (14 mm; p<0.001). The frequency of tumours with extent of GGO less than 70% was 94% in detectable cases and 59% in undetectable cases (p<0.001). The frequency of tumours located in unobscured lung was 94% in detectable cases and 59% in undetectable cases (p<0.001). The detectability of peripheral lung cancer on chest radiographs is influenced by tumour size, location and extent of GGO seen on thin-section CT. It should also be noted that some tumours may not be recognized as a nodular opacity even if they are detectable.

Comparison of ultrasonically activated scalpel versus conventional division for the pancreas in distal pancreatectomy.

PURPOSE: The goal of this study was to compare the benefits and complications of using an ultrasonically activated scalpel and conventional division of the pancreas in patients undergoing a distal pancreatectomy. METHODS: A retrospective review was performed of all patients who underwent distal pancreatectomy at the Department of Surgery, Koshigaya Municipal Hospital. In the ultrasonically activated scalpel (US) group (n = 11), the pancreas was divided using coagulation shears. The stump of the pancreas was left open without parenchymal suturing. In the conventional surgical division (CV) group (n = 20), the pancreas was cut with a knife and the stump was oversewn with interrupted mattress sutures. The main pancreatic duct was ligated in all patients in both groups. The postoperative courses in the two groups were then compared in terms of postoperative serum amylase levels and the incidence of pancreatic fistulas. RESULTS: The postoperative serum amylase levels were significantly lower in the US group than in the CV group (P < 0.01 on the day of operation). The incidence of pancreatic fistulas was also significantly lower in the US group (0%) than in the CV group (30%) (P = 0.04). CONCLUSIONS: The use of the ultrasonically activated scalpel was found to reduce the incidence of pancreatic fistula in distal pancreatectomy. Furthermore, the use of this device without any clamping or parenchymal suturing may reduce the damage to the remnant pancreas.

Double cancers in the common bile duct: molecular genetic findings with an analysis of LOH.

We report a 69-year-old man with double cancers in the common bile duct. One cancer was located between the superior and middle parts of the bile duct, while the other cancer was in the inferior part of the bile duct. Pylorus-preserving pancreatoduodenectomy was performed. There was no communication between the two cancers in either the mucosal layer or the subepithelial layer. On pathological examination, the upper cancer was diagnosed as poorly differentiated adenocarcinoma, while the lower one was found to be moderately differentiated adenocarcinoma. We analyzed loss of heterozygosity (LOH), using microsatellite markers on five chromosomal arms, in both the upper and the lower cancers. Both cancers showed common regions of LOH at 5q, 6q, 9p, 17p, and 18q, whereas the upper cancer showed one additional region of LOH at 8p, thus suggesting progression, due to the acquisition of the additional LOH, in the upper cancer. No LOH was observed in the region between the two cancers. The presence of one additional LOH in the upper cancer suggests that the upper cancer was a metastasis of the lower one.

Clinical investigation of endothelin-1 and nitric oxide in patients with portal hypertension focusing on plasma levels and immunohistological staining of liver tissues.

Plasma concentrations of endothelin-1 (ET-1) and nitrite/nitrate of patients with portal hypertension were measured. Sixteen patients with liver cirrhosis (the LC group) and 14 patients with idiopathic portal hypertension (the IPH group) and 12 healthy subjects (normal controls) were included in this study. The peripheral venous plasma concentration of ET-1 was significantly higher in the LC group (6.69+/-2.44 pg/ml) than in the IPH group (3.07+/-0.84 pg/ml) and normal controls (1.79+/-0.36 pg/ml), while the value in the IPH group was also significantly higher than that in normal controls. The peripheral venous plasma concentration of nitrite/nitrate was significantly higher in the LC group (67.7+/-38.9 &mgr;Mol/l) than in the IPH group (32.3+/-24.4 &mgr;Mol/l) and normal controls (26.1+/-9.8 &mgr;Mol/l). Hepatic venous plasma concentrations of ET-1 and nitrite/nitrate were measured in 8 patients from the LC group and 10 patients from the IPH group. The plasma concentration of ET-1 in the hepatic vein was significantly higher than that in the peripheral vein in both the LC and the IPH groups. The plasma concentration of nitrite/nitrate in the hepatic vein was significantly higher than that in the peripheral vein in the LC group. We also investigated the localization of ET-1, endothelin receptor (ET receptor) and nitric oxide synthase (NOS) in the liver tissue of LC patients (n=10), IPH patients (n=10) and normal controls (n=10). The expressions of ET-1, ET A receptors, ET B receptors, and inducive NOS (iNOS) were detected in patients with LC, and the labeling index (LI) was significantly higher than that in patients with IPH and normal controls. The expressions of ET-1, ET A receptors, and ET B receptors were found in patients with IPH, and the LI was significantly higher than that in normal controls. The expression of endothelial NOS (eNOS) was scarce in both LC and IPH patients. From these results, overproduction of ET-1 in the liver was regarded as one of the causes of the high plasma concentration of ET-1 in patients with LC and IPH. One of the causes of the high plasma concentration of nitrite/nitrate in LC was considered to be overproduction of nitric oxide (NO) in the liver. And we suggested that ET-1 is at a relatively higher density than NO in the hepatic sinusoid in LC and IPH.

Results of surgical and nonsurgical treatment for small-sized hepatocellular carcinomas: a retrospective and nationwide survey in Japan. The Liver Cancer Study Group of Japan.

Hepatic resection (HX), percutaneous ethanol injection (PEI), and transcatheter arterial embolization (TCAE) have all been used in the treatment of patients with small-sized hepatocellular carcinomas (HCCs). However, the indications for these therapeutic modalities remain unclear. Therefore, the first step to minimize the debate on these indications is to review the standard results from each treatment based on an extensive survey. The participants in this study were patients with HCCs less than 5 cm in diameter who were enrolled in The Liver Cancer Study Group of Japan. The survival rates in the HX (n = 8,010), PEI (n = 4,037), and TCAE (n = 841) groups were calculated in relation to the number of tumors and the clinical stage. In the clinical stage I cases with a solitary tumor less than 2 cm in diameter and in all clinical stages with a solitary tumor greater than 2 cm and in the clinical stage II cases with 2 tumors greater than 2 cm, the HX group showed higher survival rates than the nonsurgical groups. The HX group had a higher male/female ratio and a younger mean age than the PEI or TCAE group. The ratio of HBs antigen-positive cases/hepatitis C virus antibody-positive cases in the PEI group was lower than that in the corresponding HX group. In contrast, the PIVKA-II values in the HX group tended to be higher than in the PEI group. In conclusion, these findings will provide useful information for selection of a therapeutic modality for small-sized HCCs.

Hepatic resection using the harmonic scalpel.

We describe herein our technique of performing extensive resection of the liver by blunt dissection in combination with excision using a harmonic scalpel. A ball coagulator was inserted at 3-cm intervals along the proposed cutting line in the liver, and the liver parenchyma between these holes was then cut using coagulation shears. Regardless of the condition of the liver, good coagulation and cutting were achieved using the harmonic scalpel without vascular occlusion when dividing the shallow layer of the liver, and no complications in association with the harmonic scalpel, such as postoperative bleeding, bile leakage, or abscess formation at the cut margins, occurred. In the deep layer below the main trunk of the hepatic vein, blunt dissection was used, since it was difficult to achieve sufficient control of bleeding from large vessels using the harmonic scalpel alone. Therefore, when used in combination with other techniques, the harmonic scalpel appears to be an effective device for liver surgery that minimizes bleeding and decreases the vascular clamping time.

Effect of age on the relationship between gastric cancer and Helicobacter pylori. Tokyo Research Group of Prevention for Gastric Cancer.

Helicobacter pylori is thought to be involved in the pathogenesis of gastric cancer, but the time point at which it produces its effects (critical time) is unknown. We measured the serum level of H. pylori antibody in 787 gastric cancer patients and 1007 controls aged 20 to 69. Odds ratios for different gastric cancer types and stages were determined for each 10-year age class. The overall odds ratio for gastric cancer decreased with age, being 7.0 for those aged 20 - 29, 14.5 for those aged 30 - 39, 9.1 for those aged 40 - 49, 3.5 for those aged 50 - 59, and 1.5 for those aged 60 - 69 (trend in odds ratios: P < 0.01). However, there was no such age-dependent trend for early diffuse-type cancer; the odds ratios were 12.6, 4.0, 7.2, 6.5, and 18.5 respectively (P = 0.29). Early cancer tended to show higher seroprevalence than advanced cancer, especially in older subjects. No significant difference in seroprevalence was observed between diffuse and intestinal cancers within each age-class. Seroreversion must have occurred in the time interval between the critical time and the diagnosis of the cancer, especially in older patients. The age-dependent relationship between H. pylori and gastric cancer may be due to seroreversion, which itself may be independent of age. This age-independence indicates that prolonged exposure to H. pylori does not increase the magnitude of its influence on gastric carcinogenesis. Possible mechanisms through which H. pylori exerts pathogenic effects are continuous inflammation in adulthood and / or irreversible damage to gastric mucosa in childhood or the teenage years.

alpha-Glutathione-s-transferase as a new sensitive marker of hepatocellular damage in biliary atresia.

Early identification of patients likely to deteriorate post-hepatic portoenterostomy for biliary atresia (BA) would be beneficial. alpha-Glutathione-s-transferase (alpha-GST) is a serologic marker of reactive hepatocellular damage because of its low molecular weight, uniform hepatic distribution, high cytosol concentration, and short half-life. We evaluated whether serum alpha-GST in post-surgical BA patients correlates with liver function (LF) and investigated its potential as a medium- to long-term marker of prognosis. Postoperative BA patients (n = 30; mean age: 11.8 +/- 3.7 years) were divided into three groups based on average LF over the 3 months prior to this study. Group I (n = 8) were jaundice-free and had normal LF. Group II (n = 12) had moderate liver dysfunction, and group III (n = 10) had severe liver dysfunction. Serum alpha-GST was determined using a specific ELISA. Tissue alpha-GST was determined immunohistochemically, using liver needle-biopsy specimens. Bile lakes were found in 5 group II patients and 5 group III patients. Serum alpha-GST was significantly higher in group II (20.7 +/- 8.4 ng/ml) than in groups I (4.7 +/- 1.3 ng/ml) and III (8.0 +/- 1.2 ng/ml) (P < 0.0001) and was highest in group II subjects with bile lakes. In control liver specimens alpha-GST distribution was weak but uniform throughout normal liver lobule hepatocytes. In group II there was strong staining in centrilobular hepatocytes, and in group III alpha-GST was only found in regenerative nodules. We conclude that alpha-GST may be a more sensitive indicator of hepatocellular damage in BA because its distribution is correlated to the proportion of functioning liver tissue present. This is the first report of this relationship, which has great implications for group II subjects because a sudden shift in concentration of alpha-GST may be a better predictor of impending hepatic dysfunction than conventional LF tests.

Pancreatic pseudoaneurysm converted from pseudocyst: transcatheter embolization and serial CT assessment.

We present a case of pancreatic pseudoaneurysm converted from a pseudocyst. Contrast-enhanced CT disclosed a round enhancing lesion at the previously identified pseudocyst, and angiography confirmed the diagnosis of a pseudoaneurysm. The pseudoaneurysm was successfully treated by arterial embolization. We believe arterial embolization to be the treatment of choice for pseudoaneurysm as a complication of pancreatitis.

Serum alpha-glutathione S-transferase: a new marker of hepatocellular damage associated with hepatectomy.

Serum concentrations of alpha-glutathione S-transferase (alphaGST) were determined before and after hepatectomy to examine the clinical usefulness of alphaGST as a marker of hepatocellular damage compared with the conventional liver function tests. Prior to hepatectomy, serum alphaGST concentrations correlated significantly with serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT). In patients who had a good postoperative course, serum alphaGST concentrations rose significantly to a peak immediately after surgery, followed by a rapid fall to the normal range within 1 week, yielding a monophasic pattern. Serum alphaGST concentrations reached a peak earlier than other parameters of liver function, and peak serum alphaGST concentrations correlated with peak serum concentrations of AST and ALT. The mean decrease rate of serum alphaGST concentration from peak values was significantly more rapid than that of serum AST and ALT, indicating an early return of alphaGST concentrations to the normal range. These findings suggest that serum alphaGST may be a more sensitive marker of hepatocellular damage than transaminases and may therefore be useful for rapid monitoring of the extent and persistence of liver injury after hepatectomy.

Significant changes in the serum levels of IL-6, h-HGF, and type IV collagen 7S during the perioperative period of a hepatectomy: relevance to SIRS.

We analyzed the changes in the serum levels of both interleukin-6 (IL-6), human hepatocyte growth factor (h-HGF), and type IV collagen 7S (7S) during the perioperative period of a hepatectomy and evaluated their relationship with systemic inflammatory response syndrome (SIRS). The study subjects consisted of 40 patients who underwent a hepatectomy. In 14 out of 40 patients, postoperative SIRS(+) was observed. Between the SIRS(+) and SIRS(-) cases, there were significant differences in the preoperative values of prothrombin time, hepaplastin test, cholinesterase, and indocyanine green retention at 15 min (P < 0.01). Compared with the SIRS(-) cases, the IL-6, h-HGF, and 7S of the SIRS(+) cases fluctuated in a higher range and remained significantly higher after postoperative day 1 (P < 0.05). Eight out of 14 SIRS(+) patients had postoperative complications. In the 8 SIRS(+) patients with postoperative complications and in the 4 patients in which the SIRS(+) state lasted 3 days or longer, the 7S levels were significantly higher during the perioperative period (P < 0.05). In the SIRS(+) cases, the postoperative levels of IL-6 and h-HGF, as well as pre- and postoperative levels of 7S, were elevated. We therefore consider these levels to be risk factors for complications during the perioperative period of a hepatectomy.

Early diagnosis of postoperative infection: assessment of whole blood chemiluminescence.

Whole blood chemiluminescence (CL), which allows for the evaluation of both the oxygen radical release by phagocytes and the serum opsonin activity using very small amounts of blood, is considered to be a useful means of assessing the host defense against infection. We measured the whole blood chemiluminescence in 59 patients before and after open surgery (surgery by a laparotomy) for gastrointestinal disease. Early postoperative infection was detected in 12 (20.3%) of the 59 patients. These 12 patients all had significantly higher white blood cell counts compared with the noninfected patients on the third and subsequent days after surgery (P < 0.01). The peak CL in the early postoperative infected group was also significantly higher than that in the noninfected group on the day of surgery (P < 0.0001), 1 day after surgery (P < 0.0001), and 3 days after surgery (P < 0.01). Whole blood CL may therefore be a useful modality for the early detection of postoperative infection in the future.