Preoperative and intraoperative ultrasonographic examination as an aid in lung cancer operations.

To assess the extent of tumor invasion in lung cancer, my colleagues and I routinely use preoperative transesophageal ultrasonic endoscopy and intraoperative ultrasonography in addition to preoperative roentgenography, computed tomographic scanning, and other standard procedures. Both transesophageal ultrasonic endoscopy and intraoperative ultrasonography allow for a real-time assessment of the extent to which the lung cancer has invaded adjacent organs and are useful in determining the operability and safety margin of the involved organ or organs. We found intraoperative ultrasonography to be more accurate than transesophageal ultrasonic endoscopy, because intraoperative ultrasonography can be done at any time during the operation, as needed, and the probe can be directly applied to the desired location from a variety of angles. In contrast, when transesophageal ultrasonic endoscopy is used, the presence of air in the lung tissue can interfere with an accurate evaluation of some aspects of the tumor. Our results indicate that the sensitivity of transesophageal ultrasonic endoscopy and intraoperative ultrasonography is 68.4% and 100%, respectively, and the specificity is 81.3% for transesophageal ultrasonic endoscopy and 95.5% for intraoperative ultrasonography.

[A case of mediastinal cystic lymphangioma: with special reference to ultrasonographic findings].

We reported a rare case of mediastinal cystic lymphangioma, which happened to be discovered on chest X-ray. CT density level of the mediastinal tumor was 20 HU and the tumor was homogeneous cystic lesion. Multilocularity of the cyst and the relationship to the adjacent inferior vena cava were clarified by pre-operative transesophageal and intraoperative ultrasonographic examination, and the tumor was successfully excised without mishap.

A new surgical approach to apical segment lung diseases, including carcinomas and inflammatory diseases.

A new surgical approach to lung cancer and inflammatory pulmonary diseases has been developed. This approach focuses on diseases located in the apical segments of the lung and showing invasion or severe adhesion to the apical thoracic wall or to vital organs near the thoracic dome (including superior sulcus tumors). The conventional posterolateral approach leaves the surgeon "blind" because it forces the surgeon to perform the operation looking up through a tube from the bottom. This limited view makes accurate assessment of the surrounding vital organs involved in these diseases almost impossible and also increases the risk of injury to adjacent vital organs. The incision in this new approach allows extensive retraction of the scapula to provide easier access to the posterior chest wall. Because the incision curves upward anteriorly, rather than downward as usual, it gives excellent exposure of the apical anterior thoracic region. In the few cases in which we have used this approach, we have found that the surgical field is in plain view and that the operation is consequently safer and easier. So far we have not encountered any complications, and we can recommend this approach with confidence.

Further study of nebulisation chemotherapy, a new chemotherapeutic method in the treatment of lung carcinomas: fundamental and clinical.

Nebulisation chemotherapy, a chemotherapeutic method for the treatment of lung cancer that involves the administration of anticancer agents through the inhalation of nebulised aerosols, has been found to be highly effective (Tatsumura et al., 1983a,b). We confirmed that 5-FU administered by this method accumulates in the trachea, bronchi and regional lymph nodes of patients treated before surgery, along with 5-FU metabolites, FUR and FUdR, indicating that 5-FU is directly incorporated and metabolised in the respiratory tract. Parallel result were obtained using mongrel dogs. The 5-FU levels in other organs, such as the heart and liver, were found to be extremely low. Only a trace of 5-FU was found in the serum of both the patients and the dogs. We further investigated the anti-tumour effect of this therapy in ten selected patients and observed a satisfactory anti-tumour response of 60.0%. These results, along with our previous finding that the retention time of isotope tracers inhaled as aerosol is considerably longer in tumour tissues than in normal parts (Tatsumura et al., 1983a) explain the high antitumour action of this therapy and the absence of adverse effects of administered 5-FU.

[Problems in combined resection of adjacent organ in lung cancer: significance of preoperative and intraoperative ultrasonic examination].

Aggressive combined resections were carried out, on 24 lung cancer cases which showed invasion into surrounding organs. Those cases with wide infiltration of the ribs, and into surrounding intercostal tissues, and for those with invasion to diaphragm, the outcome of the operations was rather poor but, for those with invasion in pericardium and left atrium, fairly favorable results were obtained. These present results indicated that aggressive resections of adjacent organs is to be recommended for cases without N 2 infiltration. Experiences from these operations have taught us the importance and useful of diagnosis of the status of invasion of the tumor, during the operation by ultrasonogram (IUS), with direct contact of the probe to the thoracic wall or mediastinal organs, to discriminate the areas of chest wall and mediastinal organs that require resections. This method, in combination with esophagus ultrasonic endoscopy (EUS), enabled defining the infiltrated areas with accuracy far exceeding that obtained by tactile examination. Techniques of, and observations obtained by these examination methods are presented.

A perforated non-specific ulcer of the cecum as seen in a 2-year-old female.

A 2-year-old female was hospitalized because of generalized peritonitis with pneumoperitoneum. A laparotomy disclosed a perforated ulcer of the cecum. A resection of the perforated portion of the cecum was then performed. Histopathologic examinations confirmed that the ulcer was non-specific in nature. No recurrence was observed four years since the limited operation. Pneumoperitoneum caused by perforation of non-specific cecal ulcer in a child has, to our limited knowledge, not yet been previously reported.

[A case of primary leiomyosarcoma of the lung].

We reported a case of 66-year-old female with leiomyosarcoma of the right lower lobe of the lung with the complaint of abnormal shadow of the chest roentgenogram. On December 2, 1987, partial resection was performed and the tumor was totally removed. Histological examination revealed primary leiomyosarcoma of the lung. By electron microscopic observation, pinocytotic vesicle was not observed, but myofilaments were observed in the cytoplasm.

4, 6-0-benzylidene-D-glucopyranose (BG) in the treatment of solid malignant tumours, an extended phase I study.

4, 6-0-Benzylidene-D-glucopyranose (BG), a derivative of benzaldehyde (BA), whose anti-tumour action has often been reported, showed responses in 10 out of 24 patients (41.7%). These patients consisted of 11 cases of primary lung cancer, 4 of metastatic lung cancer, 5 of gastric cancer, and one each of cancer of the sigmoid colon, liver, pancreas and prostate. There were two complete responses (one each of ipsilateral lung metastasis from breast cancer and metastatic liver lesions due to gastric cancer). The mean total dose of BG was 392.6 g, given by intravenous infusion of 1.2 g BG in 100 ml saline twice daily. The treatment was discontinued when no response was observed after two months. Careful monitoring showed no toxic action of BG at these large doses. Complete necrotic liquefaction of tumour, without any damage to surrounding tissue, was seen in 2 of 3 cases in which histological examination was feasible. It is apparent that BG, like BA, is not a cytotoxic agent in the ordinary sense, but its mechanism of action is still unknown.

A new technique for one-stage radical eradication of long-standing chronic thoracic empyema.

The surgical treatment of chronic long-standing thoracic empyema remains a challenging subject. A simple technique that consumes less operative time, accompanying less bleeding, and that enables eradication of the disease in one stage was devised by the senior author. The technique requires only three major steps: (1) decortication limited to the parietal sides of the peel's sac, (2) cleansing the empyemic cavity, and (3) drainage. To date, six patients have been treated by this method; complete cure was achieved in all. Neither death nor recurrence of the disease has been noted during the follow-up period averaging 24.5 months. The mean operative time was 3.06 hours, mean bleeding volume was 1262 ml, and the mean hospital stay period was 1.14 months. The methods and results of the technique are discussed.

[Pheochromocytoma combined with malignant lymphoma and prostatic cancer--a case report].

A rare case of pheochromocytoma associated with a malignant lymphoma and a prostatic cancer is reported. An 80-year-old male had had his terminal ileum resected one year earlier due to a malignant lymphoma. A year later, postoperative follow-up study by ultrasound revealed a solitary retroperitoneal tumor. The resected tumor was found to be a pheochromocytoma, which had provoked intraoperatively an intractable hypertension and ventricular arrhythmia. One year following this, a urinary disturbance was noted. On examination, a hard and irregular prostata was palpate and a subsequent biopsy revealed an adenocarcinoma. As far as we have been able to ascertain after a perusal of the Japanese literature, we believe that this case represents the first reported case of such a malignant lymphoma, combined with prostatic cancer and a pheochromocytoma.

Changes in glycosphingolipids accompanying the differentiation of human squamous SQCC/Y1 cells.

SqCC/Y1 cells grow as a monolayer in culture and differentiate when maintained in the plateau phase; in the absence of serum these cells differentiate more rapidly. The differentiation is characterized by the stratification of the culture to form a structure consisting of several cellular layers, synthesis of specific keratins, and the attainment of the capacity to form a cornified cell membrane. The stratification process is indicative of the importance of cell-cell interactions during maturation. To study the relationship between membrane glycosphingolipids (GSLs) and the state of differentiation of SqCC/Y1 cells, GSLs were measured in cultures grown in the presence or absence of fetal calf serum. Glycolipids were isolated by diethylaminoethyl-Sephadex and Iatrobeads column chromatographies, and their distributions were determined by high-performance thin-layer chromatography. GM3 was the major ganglioside present in these cells. Other ganglioside components were tentatively identified as GM2, GM1, and GD3. Differences in ganglioside patterns were observed in differentiated cultures; the major changes were accumulation of GD3 and depletion of GM1. The predominant neutral GSLs in SqCC/Y1 cells were identified as Glc beta 1-1Cer, Gal beta 1-4Glc beta 1-1Cer, Gal beta 1-4Gal alpha 1-4Glc beta 1-1Cer, Gal NAc beta 1-3Gal alpha 1-4Gal beta 1-4Glc beta 1-1Cer, and three unknown complex GSLs. Differentiated cultures, however, showed variations in banding patterns, which include an increase in Glc beta 1-1Cer and Gal beta 1-4Glc beta 1-1Cer and a decrease in Gal alpha 1-4Gal beta 1-4Glc beta 1-1Cer and Gal NAc beta 1-3Gal alpha 1-4Gal beta 1-4Glc beta-1Cer. These changes, however, were not observed when the cells were grown in the presence of epidermal growth factor or retinoic acid, factors which inhibit the differentiation process. The findings demonstrate significant changes in glycolipid composition of differentiated SqCC/Y1 cells grown in the absence of serum, suggesting that these lipids may be important to the differentiated state.

[Clinical study on papillary adenocarcinoma of the thyroid].

Disagreement still exists in relation to the extent of thyroid resection and lymph node dissection for papillary adenocarcinoma. Twenty eight cases comprise the present study. Seventy four percent of all cases studied revealed metastatic regional nodes, even in t1-cases, 73% of the treated cases showed metastatic nodes. The present results suggest that a modified neck dissection of the ipsilateral nodes would seem necessary in treating this carcinoma. Lobectomy with modified neck dissection is feasible, if the tumor is localized, but if it is not, then a total or subtotal thyroidectomy, combined with modified neck dissection, is necessary.

[The efficacy of temporary retention chemotherapy of the treatment of polyps in the remnant rectum of familial polyposis after total colectomy and ileorectostomy--a case report].

A case of familial polyposis is reported. The patient was a 24-year-old woman on whom total colectomy followed by ileorectostomy had been performed. However, there were multiple polyps remaining in the remnant rectum. For the treatment of these residual polyps, a new chemotherapeutic method known as Temporary Retention Chemotherapy (TRC), originally devised by us for the treatment of advanced gastric cancer, was applied. A balloon catheter was inserted and fixed into the rectum via the anus for the treatment of the rectal tumors. Through the catheter, high-dose 5-fluorouracil (5-FU) solution was injected into the rectum and retained there for one hour before being discarded. During the therapy, the patient was asked to change her position of recumbency at certain intervals, so that the 5-FU solution could act evenly on the lesions in question. This therapy was repeated twice a week, and followed by routine endoscopic studies. A total dose of 5,700 mg of 5-FU was necessary for obtaining a complete response of the remnant lesions. 6 months later, 4 polyps were found, and TRC was again applied, resulting in disappearance of the polyps again after the therapy. So far, no side-effect have been noted as a result of this therapy. She is currently still alive without any residual polyps, carcinoma or metastasis 6 years after the operation.

Intraabdominal bleeding attributed to ruptured periumbilical varices. A case report and a review of the literature.

A 50 year old man, who had had liver cirrhosis of 10 years, without previous variceal bleeding, presented with sudden abdominal pain, distension and hypotension and was admitted. The diagnosis of ruptured periumbilical varices was established at laparotomy. Despite surgical intervention to halt the bleeding varices the patient died of hepatic failure fourteen days postoperatively. The differential diagnosis and management of hemoperitoneum in this cirrhotic patient are discussed, and sixteen previously reported cases of intraabdominal variceal bleeding are reviewed.

[Residual gastric carcinoid complicated with multiple endocrine neoplasia and Cushing's syndrome--a case report].

A 51-year-old man had had his stomach resected 10 years earlier due to gastric ulcer. Ten months before the present illness, he complained of a puffy face and edema of the both lower extremities. Hyperparathyroidism with a high level of parathyroid hormone (0.75 ng/ml) was diagnosed. A submucosal tumor was noted at the residual stomach, and histologically, carcinoid was preoperatively confirmed by endoscopic study. Total gastrectomy with radical lymphadenectomy was performed, and concomitantly a small tumor noted at the body of the pancreas was also extirpated. In addition, three and a half of all four parathyroid glands were resected. Histologically, the pancreatic tumor was adenoma, with the parathyroid glands showing only hyperplastic changes. Subsequently, during the postoperative course, Cushing's syndrome was further diagnosed, and the patient is now under follow-up study.