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Tissue distribution of the subunits of human chorionic gonadotropin (hCG), hCGα and hCGβ, in eight cases of trophoblastic tumors, including four cases of choriocarcinoma, two cases of invasive mole and two cases of hydatidiform mole, was studied by the immunoperoxidase method. In villous trophoblasts of hydatidiform mole, though distribution patterns in the cytoplasm differed, both hCGα and hCGβ were revealed to be located chiefly in the syncytiotrophoblast and to a lesser extent in the cytotrophoblast suggesting that hCG is not only localized but also synthesized mainly in the syncytiotrophoblast while the immature cytotrophoblast does not produce hCG. In invasive mole, villi were markedly degenerative, composed mostly of the syncytiotrophoblast with scarce intraplasmic hCGα. This condition of the villi is considered to be the result of intensive chemotherapy prior to operation, and may be explained by the so-called cellular effect of transient increase of hCG in the serum during chemotherapy. In choriocarcinoma, strongly immunoreactive products of hCGα and hCGβ were observed in the syncytiotrophoblast-like cells with several nuclei scattered like islands in the invading front. These findings are considered to be related to the local immunosuppressive effect of hCG on invasion and survival of choriocarcinoma cells analogous to the syncytiotrophoblast in the trophoblastic shell and column of normal pregnancy.

II est essentiel que s'etablisse une bonne collaboration entre les medecins et les infirmieres afin que le controle de la douleur soit adequat particulierement lorsqu'il s'agit de soins a domicile. Dans cette etude on decrit la facon dont les medecins et les infirmieres collaborent au Japon pour controler la douleur chez les patients en phase terminale soignes a la maison et on evalue l'usage que l'on fait de la prescription renouvelable dans ces situations. On a expedie des questionnaires autogeres a l'ensemble des 565 institutions inscrites dans le registre national des dispensateurs de soins a domicile pour les malades en phase terminale : 177 de ces institutions ont retourne les questionnaires lesquels ont ete par la suite analyses. En general, les institutions qui s'occupaient d'un nombre peu eleve de patients par annee ne faisaient aucun effort specifique pour collaborer avec les infirmieres tout comme ils ne faisaient que tres peu usage de la prescription renouvelable. Etant donne que nombre de ces institutions dispensent des soins que sur une petite echelle, on devrait s'attarder a developper un protocole de soins standard et l'appliquer dans toutes ces institutions afin de s'assurer de la qualite et de la disponibilite des soins palliatifs a la maison a travers tout le pays.

In the practice of home hospice care, death education for both patient and family is extremely important, although little information on its usefulness is available. In this study, the effects of death education under home hospice care were analyzed for 16 patients who died at home. Death education for the patient and his/her family was given at least once in each phase of care, and at least four times in total. The acceptance of death by the patients was judged according to the way they spent their remaining time, to their attitudes, and to their hope for a life after death. Fourteen of 15 patients appeared to accept their own death. An autopsy was performed in five of the 16 cases. In one case, the doctor recommended an autopsy to the family; in the other cases, it was performed in accordance with the patient's or family's wish. As the goal of death education in home hospice care is the acceptance of death by both patient and family, our methods of death education appear to be effective.

There are various types of families of terminally-ill cancer patients, and care for the family should therefore be individualized. In cases where the primary caregivers have schizophrenia, caring for the patients at home might cause a serious burden to a family. From this aspect, two patients who were cared for by family with schizophrenia were reviewed. Four important factors were obtained. First, assessment of psychiatric conditions of the family collaborating with the psychiatrist or public health nurse; second, confirmation of the patients'/family's wills concerning living through death at home; third, death education given to a family; and fourth, efficient collaboration with social services by an other organization. It was considered that these factors would constitute a model for providing home hospice care to a family with schizophrenia.

In order to clarify the clinical characteristics along with the practical care of home hospice care for gynecological cancer patients, we analyzed 37 terminally-ill gynecological cancer patients who died at home from July 1, 2003 through June 30, 2010, and these patients were compared with 762 non-gynecology cancer patients. The range of patients' ages with gynecological malignancies was statistically younger(p0. 05)than that of the control patients, whereas the duration of home care and home death ratio did not show significant differences. As for medical treatment, the frequency of the management of nephrostomy was significantly higher in cases with gynecological malignancies. However, the frequencies of the usage of strong opioids, home oxygen therapy, home parenteral hyperalimentation, management of central venous port and indwelling bladder catheter showed no significant differences. There were patients, who needed special treatments by a gynecologist, with vesicovaginorectal fistula in one case, subcutaneous abscess probably caused by rectocutaneous fistula in one case, vaginal bleeding in one case and acute urinary retention treated by an emergent bladder puncture. By analyzing the focus problem lists of the total suffering at each clinical phase, in patients living longer than 15 days at home,(Kawagoe's classification in 1991)this did not show significant difference against the control group. In conclusion, gynecologic cancer patients were significantly younger than those with non-gynecologic malignancies, though not statistically significant, showing the tendency of short duration. Thus, in cases of gynecologic malignancies, it is important to take these characteristics into consideration.

In order to clarify the clinical characteristics along with practical care of home hospice care for urological cancer patients, we analyzed 62 terminal ill urological cancer patients who died at home, and these patients were compared with 737 non-urological cancer patients in the period from July 2003 through June 2010. There was a tendency to have a longer homecare period for urological terminal cancer patients. However, no significant statistical differences in age, gender and a frequency of home death were observed among the urological and non-urological cancer patients. The frequency of medical treatments for urological cancer patients, such as home oxygen therapy, management of nephrostomy and a placement of indwelling bladder catheter, was much higher for the urological cancer patients. On the other hand, there was no big difference for consumption of strong opioid usage among the urological and non-urological cancer patients. In conclusion, although ordinary medical treatments for urological cancer patients showed no significant differences compared with non-urological cancer patients, professional special assistance such as a change of the nephrostomy catheter were required for urological cancer patients.

In order to clarify the clinical characteristics along with the practical care that we provided, 21 terminally ill blood cancer patients who died at home from July 1 in 2003 to May 31 in 2010 were analyzed and compared with 733 non-blood cancer patients. The patients'characteristics such as age, gender and the home death frequency did not show a significant difference. The home care period for blood cancer patients showed that it tended to be a short duration, but not a statistically-significant difference. For the cases of longer period of more than 15 days at home, focus lists at each phase based on total suffering classification did not show significant differences between the two groups. The frequency of strong opioid usage was significantly lower in the blood cancer patients, whereas a strong opioid was used for pain relief in multiple myeloma cases. As a preliminary report, firstly, although frequency of hematological malignancy in home hospice care is low, the care was not difficult by comparison with that of the non-hematological malignancies. Secondly, the main issue of symptom control was a pain relief, and fentanyl patch was the first-choice strong opioid without the need of opioid rotation because relief of dyspnea was few. Thirdly, in the multiple myeloma, the pain relief was the most important issue that was compared with in other blood cancer patients. And fourthly, although the hemorrhage was a big focus in case of leukemia, it didn't force to cease the home care.

Previous studies have found that inappropriate assessment of cancer pain can lead to inadequate pain management. To improve assessment, it may be helpful to collect real-time data in a natural environment using computerized ecological momentary assessment (cEMA). Therefore, the aim of the study was to develop a personal digital assistant (PDA) system to collect information on symptoms such as pain and mood states in patients with cancer using cEMA.Following a pilot study in inpatients with cancer, the second phase of the study involved patients with terminal cancer receiving home hospice care. These patients were asked to record their symptoms in a PDA (a palm-sized portable device) several times per day for a week when they took rescue medications and when an alarm sounded. At the end of the week, an interview on the usability of the device was conducted and overall response rates were calculated.Fifteen patients completed the second phase of the study. Their median age was 64 years and the median survival time after the study period was 22 days. The overall response rates were 90.3% to the sound of the alarm and 80.2% after taking rescue medications. The user-friendliness of the device was rated as 8.8 on a scale of 0 (worst) to 10 (best).The cEMA technique using a PDA might be applicable to patients with cancer in palliative care to evaluate symptoms in a natural setting. This system may also be useful for managing symptoms such as pain and mood states in patients with cancer.

It is essentially important for home hospice care, which provides hospice care at home to palliate the patient's sufferings, such as pain for example, and to provide cares in the form of the interdisciplinary team approach. Though the actual way of providing hospice care at home is principally based upon an institutional hospice care, there are some which are peculiar to home hospice care. The principles of symptom control in case of home hospice care are: (1) to take account of patient's daily life, (2) to make much of the natural course of the disease, (3) to palliate the patient's sufferings by focusing on the subjective complaints and (4) to provide relief on medical aspect at home. As for the interdisciplinary team approach, a special consideration of the members to visit the patient's home as few as possible in order to keep the patient's life quiet.

In Japan, a pain relief for terminally ill cancer patients has been improved greatly in the past twenty years owing to the appearance of several new opioids and manuals available, loosening the usage of opioids legally, and so on. Medical institutions including clinics which are involved in home palliative care have the knowledge and techniques in certain levels. Sixity-seven percent of such institutions have the ability to carry out the continuous subcutaneous morphine injection. Though very few, certain clinics can do the continuous subarachnoid morphine injection using subcutaneous indwelling port. Considering that home palliative care including pain control required a professional knowledge and techniques, it is necessary to establish a new system in the district which enables to provide the palliative care of high quality by a team in which palliative care clinic or PCC exists as the main medical center.

From July 1 in 2003 through December 31 in 2008, 150 terminal lung cancer patients were provided home hospice care by us and died at home, whereas the following clinical characteristics along with the practical care we provided were examined by comparing with 432 non-lung cancer patients who died at home during that period. The frequency of home death (lung cancer/control group, 96.8/96.2%) and the duration of caring at home (48.7/54.6 days) did not show a significant difference. Significant differences were observed in suffering of breathing (62.7/31.5%), use of the opioids (96.0/ 87.5%), slow releasing oral morphine (32.7/18.1%), morphine suppository (73.3/56.5%), morphine injected subcutaneously (37.3/25.7%), slow releasing oral oxycodone (61.3/37.3%), and fentanyl (20.0/46.1%). These findings led us to conclude: (1) the main symptom, in case of the terminal lung cancer patients, was to control a difficulty in breathing, (2) the appropriate opioids were morphine and oxycodone in palliation of respiratory difficulties, (3) fentanyl was inappropriate for palliation of respiratory difficulties.

The following results regarding the frequencies of home visits by nurses were obtained by comparing a group consisting of those who died within a week after the initiation of home hospice care (Short cases) and of those who had lived more than two weeks after starting the home hospice care (Control cases). 1) The frequencies of both scheduled and emergency home visits in Short cases were statistically higher than in Control ones. 2) Among the nurse's visits, scheduled home visits were of great importance leading not only to lessening the frequency of emergency visits but also to the palliation of anxiety for the patient/family. If the scheduled home visits were done appropriately, the frequency of emergency visits for the Short cases was just as low as for the Control cases. Thus, we reached the conclusion that home hospice care should start as soon as possible and that prolongation of inpatient care should be avoided.

Summary With an avidin-biotin-peroxidase (or glucose oxidase) complex method using anti-epidermal growth factor receptor monoclonal antibody (528 IgG), the tissue and cellular distribution of the receptors for epidermal growth factor (EGF) in normal human placental villi, from 6 to 42 weeks of gestation, were studied. EGF receptors were mainly localized on the free surface of the syncytiotrophoblast that directly faced to intervillous space of the maternal circulation. The cell surface of cytotrophoblasts, except for the region that was adjacent to the basal lamina, was also positive for EGF receptors. The receptors were in close contact to the fetal vessels in the villous stroma. The EGF receptors on the syncytiotrophoblast were thought to be involved in the production and secretion of human chorionic gonadotropin and placental lactogen, probably under the control of maternal EGF. The receptors on cytotrophoblasts may play a role in trophoblastic proliferation, possibly mediated by EGF in the fertal circulatory system.

The negative surface charges on the immature, mature and neuraminidase from Vibrio cholerae (VCN)-treated mature placental villi were investigated by electron microscopy using cationized ferritin as an ultrastructural marker. The degree and distribution of negative charge was also studied in comparison with surface ultrastructure and surface glycoprotein identified by ruthenium red staining. The negative charge on the cell surface was distributed in two different configurations: a strongly negative part and a weakly negative one, which corresponded to the distribution of surface glycoprotein as revealed by ruthenium red staining. The number of ferritin particles per 1 micron long basal line was 8, 412±2, 211 in the immature placenta, 1, 318±610 in a mature one and 375±173 in a VCN-treated mature one. The total surface length per 1 micron long basal line was 21.5±4.5 micron in immature villi and 6.3±1.8 micron in mature ones. From these findings it is simply calculated that an immature placenta in contrast to the mature one bears about twice as strong a negative charge per unit length of surface, about 6 to 7 times as strong a negative charge per unit length of basal line and about 36 to 50 times as strong a negative charge per unit, thus suggesting a possible role of the strong electrochemical repulsion in the immature placenta leading to its escaping attacks from maternal lymphocyte.

Human chorionic gonadotropin (HCG) was proved to exist on the cell surface of a syncytiotrophoblast by the immuno-electron microscopic technique. The cell surface, including microvilli and micropinocytosis vesicles, was positive. Two types of HCG were observed; one loosely and the other tightly connected to the cell surface. The latter was closely related to the acid mucopolysaccharide of the cell surface coat, revealed by ruthenium red staining. These ultrastructural findings suggest that HCG acts as a local immunosuppressant on the syncytiotrophoblast cell surface, preventing partial maternal immunological reactions against the fetus.

In order to characterize the negative surface charge of the abnormal human trophoblast and to cast light on its biological role, the negative charges on the trophoblastic surface of spontaneous abortion, partial mole and complete mole were investigated by electron microscopy using cationized ferritin as an ultrastructural marker. The degree and distribution of negative charge were also studied in comparison with surface ultrastructure and surface glycoprotein identified by ruthenium red staining.In a case of spontaneous abortion, the surface structure of the human trophoblast differed from site to site, correlating best with the degree of degeneration of the syncytiotrophoblast itself. For villi from a spontaneous abortion, which were otherwise normal in routine electron microscopy, the surface glycoprotein was observed to make prominent aggregates on the trophoblastic surface in concomitance with the reduced negative surface charge. In a severely degenerated system, the basic structure of the surface glycoprotein was lost in accordance with significant decrease of the negative surface charge. This finding seems to show the possible role of the negative surface charge of the trophoblast, that with the electrostatic repulsive forces, the membrane-bound glycoproteins can maintain their normal regular positions and, as a result, membrane specificity of the trophoblast can be expressed. When both complete hydatidiform mole and partial mole were observed by electron microscopy using ruthenium red staining and cationized ferritin, the complete mole differed essentially from the partial mole in that the former resembled normal villi while the latter resembled spontaneous abortion.

The occurrence of Ivemark syndrome with poly-splenia in sibs is presented in this paper. This is the fifth example of this case so far reported. Prenatal detection was made in the second child at nine months of pregnancy by means of abdominal fetal ECG and fetography. The two infants dealt with were recognized as poly-splenia with cardiovascular and abdominal visceral abnormalities at necropsy.

Twelve patients with advanced ovarian cancer with ascites were treated by intraperitoneal immunotherapy with OK-432 in combination with surgery and systemic immunochemotherapy. The median time for total resolution of ascites after the OK-432 injection was 7.1 days. In three of the four patients who died, it took more than the average number of days for the ascites to disappear. The ascites index, the ratio of the ascitic fluid volumes before and after intraperitoneal immunotherapy, was significantly higher in the patients who died than in those who survived. The side effects of intraperitoneal administration of OK-432 varied, but were not serious and relief was not needed in most cases. Intraperitoneal injection of OK-432 was considered effective in preventing the reappearance of ascites in these cases of advanced ovarian cancer, and the ascites index was believed to be related to the prognosis.

Sixteen patients with malignant ovarian tumors were treated conservatively; 1 had a serous cystadenoma of low potential malignancy; 6 had a mucinous cystadenoma of low potential malignancy; 2 had a pure dysgerminoma; 2 had a mature solid teratoma; 3 had a mucinous cystadenocarcinoma; and 2 had an endodermal sinus tumor. Postoperative chemotherapy was given in 12 cases and 1 patient with a pure dysgerminoma had radiotherapy. Eighteen pregnancies occurred in 13 patients. One full-term and one 8 month premature infant died in utero, and 2 infants had malformations; the other 14 infants are all well. The patient with moderately differentiated mucinous cystadenocarcinoma who delivered a premature infant and 2 patients with endodermal sinus tumors died of recurrence.

A case of mixed mesodermal tumor of the uterus with alpha-fetoprotein (AFP) production in a postmenopausal woman is reported, with special reference to its histogenesis. Judging from the serum AFP levels, the AFP content of the tumor and immunohistochemical localization of AFP in the tumor, AFP was produced by the tumor. The observation that in this patient AFP existed exclusively in carcinoma cells strongly supports the hypothesis that malignant transformation of Mullerian epithelial and stromal cells in mixed mesodermal tumors of the uterus occurs independently after the primitive mesenchymal cells have differentiated towards epithelial and stromal components.

Five cases of recurrent cervical carcinoma with sites of recurrence restricted to the pelvis were treated by intra-arterial infusion of oncostatics via the bilateral internal iliac arteries. One tip of the catheter was positioned in the internal iliac artery, proximal and close to the superior glutea artery, through the arteria glutea superior or inferior with ligations of both arteria glutea superior and inferior so as to give high concentration of drugs in the lesion. The other tip of the catheter was introduced subcutaneously up to the subclavian fossa of the anterior chest and was secured to the skin. Several chemotherapeutic agents (cisplatin, adriamycin, pepleomycin, mitomycin C and 5-fluorouracil) were infused repeatedly through the catheter, once or twice a week. The clinical efficacy according to Karnovsky's criteria was 0-C in one case, 1-A in one case and 1-B in three cases. The overall response rate of 1-B or higher was 60%. Two patients died, one from inflammation in the pelvic dead space and disseminated intravascular coagulopathy, the other from myocarditis and heart failure. The other three are alive and being treated by weekly intra-arterial infusion of chemotherapeutic agents at our outpatient clinic. No problems, such as spontaneous removal of the catheter, inflammation around the catheter or bleeding, have been encountered. The toxicity of the oncostatics in case of intra-arterial infusion was less pronounced than in the case of intra-venous administration of the same dose.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of androblastoma with not only signs of virilization but also manifestations of precocious puberty occurring in a five-year-old girl is presented. The postoperative diagnosis was one of undifferentiated Sertoli-Leydig cell tumor of the right ovary in stage I c (International Federation of Obstetrics and Gynecology). The histopathological findings are precisely described with special reference to occurrence in young females and unique hormonal manifestations.