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A 59-year-old man was admitted to the hospital because of recurrent severe hypoglycemia, who had undergone a total gastrectomy for a cancer of the cardiac part of stomach about one year before. During hypoglycemia the plasma level of immunoreactive insulin was under 2.5μU/ml. Adrenal and liver functions were normal. The serum level of IGF-I was 34ng/ml (normal range, 88_??_240), and IGF-II was 550ng/ml (374_??_804). So the ratio of IGF-II to IGF-I was higher than normal. Western immunoblot assay showed high-molecular-weight IGF-II in the serum. Abdominal CT visualized multiple heterogeneous tumors in both lobes of the liver. Percutaneous needle biopsy disclosed metastasis of adenocarcinoma, and immunohistochemical staining for IGF-II was positive in tumor cells in both the liver and stomach. We conclude that the most likely cause of this patients hypoglycemia was IGF-II produced by the metastatic liver tumor from the gastric cancer.

To elucidate the metallic factors contributing to the signal intensities of hepatocellular carcinoma (HCC) on T1-weighted magnetic resonance (MR) images and to determine whether or not changes in signal intensity contribute to the diagnosis of histological grading of HCC.In 35 patients immediately after surgery, the quantities of water, lipid, copper (Cu), iron (Fe), and manganese (Mn) were determined in HCCs and the surrounding hepatic parenchyma. The correlations among these findings, the histopathological findings, and the signal intensities of T1-weighted MR images were evaluated.Among the 35 HCCs, 12 (34%) were of high intensity, 14 (40%) were isointense, and 9 (26%) were of low intensity on T1-weighted images versus the surrounding hepatic parenchyma. The paramagnetic ions, which contributed to the signal intensity patterns, were assumed to be Cu in HCCs (30.5 +/- 52.9 microg/g ww), and Fe in the livers (106.2 +/- 86.8 microg/g ww) and HCCs (87.7 +/- 49.1 microg/g ww). In 12 HCCs with high intensity, one was grade I, eight were grade II, and three were grade III according to Edmondson-Steiner's histopathological classification.Signal intensity and signal intensity patterns alone cannot be signs of low-grade malignancy because of the Fe in livers and in HCCs.

A 75-year-old man was admitted to the hospital because of a suspected lung cancer at routine chest X-ray examination. Tracheobronchoscopy and transbronchial lung biopsy demonstrated squamous cell carcinoma of the right upper lobe. His peripheral blood count showed pancytopenia and he was diagnosed as myelodysplastic syndrome (MDS), refractory anemia, based on dysplastic findings of the bone marrow. He received perioperative transfusion of packed red blood cells and platelets, and recombinant human granulocyte colony-stimulating factor (rhG-CSF) was added. Right upper lobectomy and mediastinal-hilar lymph node dissection were carried out. After the operation he was successfully treated with antibiotics and rhG-CSF for postoperative pneumoniae. He is now doing well with no evidence of recurrence, as of 18 months after the surgery. An operating case of lung cancer with MDS is described with a review of the literatutre. It is considered that perioperative management with transfusion and rhG-CSF is reasonable for MDS patients.

In order to clarify the factors contributing to the signal intensities (SIs) of HCC on T1-weighted images, the amount of water, lipid, copper (Cu), iron (Fe), and manganese (Mn) was determined in HCC and surrounding hepatic parenchyma of 13 patients. The relationships among these findings, the histopathologic findings, and the SIs of T1-weighted images were evaluated.Among the 13 HCC, 3 had a high SI, 5 were isointense, and 5 had a low SI on T1-weighted images compared to the surrounding hepatic parenchyma. The paramagnetic ions which contributed to the SI patterns were assumed to be Cu in HCC (38.0±62.4 μg/g ww), and Fe in the liver (61.1±42.4 μg/g ww) and HCC (40.0±34.3 μg/g ww). In 8 HCC with high- or isointensity, 2 were grades I, 5 were grade II, and one was grade III according to the Edmondson-Steiner's histopathologic classification. It is concluded that the SI patterns alone can not be a sign of low grade malignancy because of the existence of Fe in livers and HCC.

硬化性あるいは硬化性被包性腹膜炎 (SEP) は, CAPDの最も重篤な合併症である. 我々は, 1980-93年までに5例の本症を経験した.症例の年齢は30-64歳, 平均48歳で, 男性3例, 女性2例である. 血液浄化法は, いずれも血液透析およびCAPDの両者を用いており, CAPDの実施期間は平均5年であった. うち1例は, CAPD開始後2年で生体腎移植を受け, 4年後慢性拒絶反応にて血液透析に再導入された症例であり, その半年後にSEPを合併した. また, 全例がCAPD期間中に1-8回, 平均4回の腹膜炎を経験している. SEPのため手術を行った例は4例で, 症例1-3には, 開腹による癒着剥離, 腸瘻造設を, また症例5には, 腹腔鏡下に癒着剥離, 腹膜生検を行った. 症例4, 5は在宅IVHおよび胃管自己挿入による腸内容の排除で経過を観察した.症例1-3は手術後早期に, また症例5は手術後1年で, いずれも敗血症で死亡した. 一方, 症例4は1年後の現在, 全身状態は良好である.SEPでは, 被包内に圧縮された腸管の循環障害, 壊死などにより敗血症を呈し死に至ると考えられる. しかし, 現時点で進行した症例に対する有効な治療法はなく, 早期診断進展の予防が重要と思われる. 開腹術後の予後は特に不良であり, 完全中心静脈栄養による保存的療法が望ましい. また, 根治的治療として今後, 全小腸摘除および同種移植なども検討する必要がある.

In order to clarify the factors contributing to the signal intensities (SIs) of HCC on T1-weighted images, the amount of water, lipid, copper (Cu), iron (Fe), and manganese (Mn) was determined in HCC and surrounding hepatic parenchyma of 13 patients. The relationships among these findings, the histopathologic findings, and the SIs of T1-weighted images were evaluated. Among the 13 HCC, 3 had a high SI, 5 were isointense, and 5 had a low SI on T1-weighted images compared to the surrounding hepatic parenchyma. The paramagnetic ions which contributed to the SI patterns were assumed to be Cu in HCC (38.0±62.4 μg/g ww), and Fe in the liver (61.1±42.4 μg/g ww) and HCC (40.0±34.3 μg/g ww). In 8 HCC with high- or isointensity, 2 were grades I, 5 were grade II, and one was grade III according to the Edmondson-Steiner's histopathologic classification. It is concluded that the SI patterns alone can not be a sign of low grade malignancy because of the existence of Fe in livers and HCC.

Vascular access devices that are completely implanted have been used for treatment of cancer patients. Vascular access devices are useful for transarterial infusion of anticancer drugs, intravenous hyperalimentation, and drainage of bile juice in obstructive jaundice. These systems have several advantages in the care of patients: they are sealed, they have no external tubes, and they may be useful for blood or biliary sample and intravenous hyperalimentation or chemotherapy. There are only minimal discomforts related to the implantation procedure and no need for routine external catheter care. Most importantly, the quality of the patient's life is dramatically improved without external tubes. For these reasons, we believe that vascular access devices should be indicated for patients with malignant tumors as much as placement of these devices is technically feasible.

血液透析を行っている腎不全患者の食道粘膜癌に対し, 内視鏡的粘膜切除術を行い, 術中術後ともに合併症もなく順調に経過した1例を経験したので報告する.症例は, 66歳男性, 透析歴2年で, 定期検診で施行された上部消化管内視鏡にて下部食道に, ヨード不染性のIIb様病変を発見された. 生検の結果食道癌と診断し, 精査の上, 粘膜切除術の適応と考え内視鏡的粘膜切除を施行した. 術中術後, 出血などの合併症もなく順調に経過し, 術後のQOLにほとんど影響を与えず, 術後7日目に退院した.血液維持透析の患者に対する内視鏡的粘膜切除術は本邦で初めてと思われるので, その手技と術後管理について若干の文献的考察を加え報告する.

A case of Brunner's gland hyperplasia in the duodenum presenting as a duodenal submucosal tumor was experienced. A 36-year-old male patient with no symptoms was found abnormality in the duodenum by mass screening examination. X-ray and endoscopic examinations of upper gastrointestial tract revealed a submucosal tumor in the duodeal bulb. The specimen of biopsy could not reveal histology of the tumor. Therefore, endoscopic ultrasonography (EUS), computed tomography, and magnetic resonance imaging were carried out. EUS visualized a homogenous and slight high echoic tumor originating from the submucosal layer, and Brunner's gland hyperplasia was strongly suspected. A possibility of malignant tumor, however, could not be excluded, and distal partial gastrectomy was performed. The excised tumor was 30×20×20 mm in size. Histrogical examination revealed nodular hyperplasia of the Brunner's gland and it was diagnosed as Brunner's gland hyperplasia in the duodenum.EUS was useful for the diagnosis of the Brunner's gland hyperplasia, in which biopsy failed to make a definite diagnosis.

We have experienced three cases of intraperitoneal cysts caused by peritoneal dialysis (PD). These patients have been treated with PD for chronic renal failure. They complained of abdominal distension and a decrease in ultrafiltration. Ultrasonography and CT revealed cysts in all 3 cases, and cystectomy was performed in 2 on them. Histological findings showed that the cyst walls were composed of fibrin-organized fibrous tissues, no malignancy could be confirmed. As the 3 patients had experienced peritonitis, the cause of cyst formation was considered to be the deposition of fibrin by the inflammatory reaction due to peritonitis and chemical stimulation with dialysate.Intraperitoneal cyst is one of complication in PD. When a patient undergoing PD or having PD history complains of abdominal distension or a decrease in ultrafiltration, a possible formation of intraperitoneal cyst should be considered.

Seventy-nine inoperable patients with hepatic or intrapelvic cancer were treated by using vascular access device (VAD) and its patency and complications were investigated. There was no significant difference in the rate of patency between the abdominal and femoral method. When the patients were divided into two groups according to the implantation, namely the earlier (until December 1986) and later (from January 1987) periods, one year patency was 65% in the later while 30% in the ealier period. The improvement of patency rate was due to a progress in the implantation technique and improvement of instruments including catheter and guide wire.Occlusion of VAD occurred in the fifteen patients. The local complications were hematoma around VAD (7 cases), wound dehiscences (3), leaks of anticancer agent (6), and wound infection (4), but none of them were serious. VAD is considered a safe therapeutic tool in the treatment of inoperable cancer patients for a long time.

CAPDカテーテル挿入術後の合併症であるカテーテル周囲からの灌流液漏れを根絶する目的で, 山本のカテーテル挿入法 (第1カフを腹膜で包み込む) を行った. さらに本術式をより簡便にするためにCAPDカテーテル (トラベノール社製) の第1カフの長さを短縮し, カテーテルの長軸方向に対して斜めに装着した新しいカテーテルを作製して, これを使用した. 昭和63年11月から平成元年5月の7か月間に10名の患者に対して12回のカテーテル植え込み術を行い経過を観察した.10名の患者 (男:女=7:3, 平均年齢: 49.2歳) に計12回の挿入術を施行したが, 第1カフの腹膜による包み込みは容易に行え, 挿入後の貯液量もスムーズに増加しえた. 術後の観察期間は平均76.6日 (7-180日) であるがカテーテル周囲からの灌流液漏れは1例もなく, 全例が術翌日から安静解除可能であった. しかし10例中2例はカテ先の位置異常により注排液が不良となり再挿入術を要した.山本の提唱したCAPDカテーテル植え込み法を追試し, これに著者らの作成したカテーテルを使用することにより, 手術操作をより簡略化できた.

Background: Although helical computed tomography (HCT) has been widely employed for the evaluation of pancreatic tumors, its capability in the diagnosis of peripancreatic arterial invasion has not been established. Methods: HCT with a sequential cine-display was carried out in 34 patients with solid pancreatic tumors and 28 control subjects without angiographic abnormality. The HCT scans were compared with angiograms. Results: All major arteries (celiac, superior mesenteric, splenic, gastroduodenal) and superoanterior pancreaticoduodenal arteries were well demonstrated by HCT in control subjects. However, posterior pancreaticoduodenal arcades and other smaller arteries were poorly identified. Although 19 major arterial invasions were equally diagnosed by HCT and angiography in patients with pancreatic tumors, only 4 of 11 minor arterial invasions were correctly diagnosed by HCT. Conclusions: Although HCT has some limitations in the evaluation of minor peripancreatic arteries, it can provide enough information for making a decision about conducting pancreatic surgery.

Background: Because of its poor prognosis, the diagnosis of hepatocellular carcinoma with sarcomatous change (HCCSC) is clinically important. The purpose of this study is to elucidate the characteristic CT findings of HCCSC. Methods: Two-phased dynamic incremental CT images of six histologically proven HCCSC were retrospectively reviewed. Results: All tumors (100%) exhibited peripheral enhancement on delayed CT images. Lymphadenopathy was observed in 100% (six of six patients); intrahepatic metastases, in 83% (five of six). Both metastatic lesions showed findings similar to those of the primary hepatic tumors, such as peripheral enhancement. Histopathologically, delayed and/or prolonged peripherally enhanced areas consisted of viable cancer cells with sarcomatous changes. Conclusions: The appearance of HCCSC on CT is that of an irregularly demarcated intrahepatic mass with delayed or prolonged peripheral enhancement, frequently with intrahepatic metastases and lymphadenopathy.

The iron oxide/n-Si heterojunction electrode was studied as a photoanode for a regenerative photoelectrochemical (PEC) cell. The influence of modifying the top layer of the electrode with Pd or RuO2 was investigated. The photocurrent at the heterojunction electrode was produced by the holes which were photo-excited in both iron oxide andn-Si. The addition of Pd or RuO2 on the heterojunction electrode surface enhanced the optical-to-electrical conversion efficiency. The efficiencies for a stable working PEC cell were found to be 1.34% and 1.60% for a Pd-and a RuO2-modified electrode, respectively. This was measured in a 0.2 M KOH solution containing 0.2 M K4[Fe(CN)6] and 0.01 M K3[Fe(CN)6 at a xenon lamp intensity of 55 mW cm−2. The use of iron oxide made the photoanode highly stable, as compared to an electrode such as RuO2/n-Si. From a constant open-circuit voltage independent of the redox potential in 0.2 M KOH, it was concluded that Fermi level pinning occurs at the interface.

The injection of 25 mg/kg i.p. cyclosporin (CsA) for 3 wk caused marked functional and morphological deteriorations of pancreatic islet cells in Wistar rats that were prevented by the combined administration of p-aminobenzoic acid-N-D-mannoside sodium salt (K-MAP). In this article, the toxic effect of CsA on pancreatic islet cells and the preventive effect of K-MAP on CsA-associated islet cell toxicity were investigated. Prolonged hyperglycemia and depressed insulin secretion after the glucose challenge observed in CsA-treated rats could be prevented by the combined administration of 300 and 900 mg/kg K-MAP. Cytoplasmic vacuolizations and a decrease in the number of mitochondria, intact endoplasmic reticula, secretory granules, and insulin-positive cells, as revealed by peroxidase-antiperoxidase staining, could also be prevented by the administration of 900 mg/kg K-MAP. This preventive effect of K-MAP on CsA-associated islet cell toxicity may suggest the combined use of K-MAP with CsA in pancreas transplantation and treatment of insulin-dependent diabetes.

1977年より1986年に東京女子医大で心臓・大血管手術を施行した37例の透析患者のうち, 開心術あるいはaortocoronary bypass graft (ACB) を施行した12例について術中, 術後の管理上の問題点を血液浄化法を中心に検討した.症例は不安定狭心症5例 (全例3枝病変でうち1例は腹部大動脈瘤を合併), 急性心筋梗塞および中隔穿孔1例, 肺動脈狭窄, 心房・心室中隔欠損, 僧帽弁閉鎖不全1例, 亜急性心内膜炎, 大動脈炎, 大動脈弁・僧帽弁閉鎖不全1例, 僧帽弁狭窄2例, 僧帽弁閉鎖不全1例, 心房中隔欠損1例であり, 施行した手術はACB (2枝バイパス) 5例 (うち1例は腹部大動脈瘤切除・人工血管移植術も施行), 心室瘤切除, 中隔穿孔閉鎖1例, 肺動脈拡張, 心房・心室中隔欠損閉鎖1例, 心房中隔欠損閉鎖1例, 大動脈弁・僧帽弁置換1例, 僧帽弁置換1例, 交連切開術2例であった.直死例は2例 (16.7%) で, 1例は原疾患の心内膜炎が術後敗血症に進展したもので, 他の1例は術直後の低拍出量症候群によるものであった.6例の虚血性心疾患のうち5例にACB (全例2枝バイパス) を施行し, 1例が術後51日目に出血性脳梗塞で死亡した. 術後は10例に腹膜灌流 (PD) を行い, 循環動態の安定, 出血性合併症の予防の点で有効であった. その後7例は血液透析 (HD) に変更したが, うち2例は変更直後に出血性合併症で死亡した. 術前よりcontinuous ambulatory peritoneal dialysis (CAPD) に導入し, 術後もcontinuous PDで維持した4症例は全例術後経過は良好であった. また8例において術中人工心肺にHD, 血液濾過を併用したが, 術中術後の水分管理, 電解質・酸塩基平衡の補正, 高窒素血症の予防に有効であった.透析患者の心臓手術については早期に手術を行うこと, 適切な血液浄化法を施行することによりその成績の改善が期待される.

The iron oxide/n-Si heterojunction electrode was studied as a photoanode for a regenerative photoelectrochemical (PEC) cell. The influence of modifying the top layer of the electrode with Pd or RuO2 was investigated. The photocurrent at the heterojunction electrode was produced by the holes which were photo-excited in both iron oxide andn-Si. The addition of Pd or RuO2 on the heterojunction electrode surface enhanced the optical-to-electrical conversion efficiency. The efficiencies for a stable working PEC cell were found to be 1.34% and 1.60% for a Pd-and a RuO2-modified electrode, respectively. This was measured in a 0.2 M KOH solution containing 0.2 M K4[Fe(CN)6] and 0.01 M K3[Fe(CN)6 at a xenon lamp intensity of 55 mW cm−2. The use of iron oxide made the photoanode highly stable, as compared to an electrode such as RuO2/n-Si. From a constant open-circuit voltage independent of the redox potential in 0.2 M KOH, it was concluded that Fermi level pinning occurs at the interface.