Extracranial metastasis of glioblastoma to the lung and heart with a histological resemblance to small cell carcinoma of the lung: an autopsy case]

An autopsy case of small cell glioblastoma, showing multiple extracranial metastases, is reported with special reference to histopathological differentiation from metastatic small cell carcinoma. Widely spread lesions in the bilateral lungs were developed after an operation and chemo-radiotherapy for glioblastoma, and the lung lesions led to fatal respiratory failure. Postmortem examination revealed multiple tumors in the lung, lymph nodes, and the heart, as well as local invasion of the primary tumor to the dura, skull, and the scalp. The mechanism of extracranial metastasis of brain tumor is discussed.     

Relationship between ventricular arrhythmias and myocardial fatty acid metabolism in patients with coronary heart disease: evaluation using iodine-123 beta-methyl-p-iodophenyl-pentadecanoic acid]

The effect of metabolic abnormalities of myocardial fatty acids on ventricular arrhythmias was evaluated by myocardial imaging with iodine-123 beta-methyl-p-iodophenyl-pentadecanoic acid (BMIPP) in 27 patients with coronary heart disease. The disturbance of myocardial blood flow was also evaluated using thallium-201 (Tl). The patients were divided into 2 groups based on the character of the premature ventricular contractions: Group A: number of contractions > or = 120 per day and/or consecutive contractions (n = 9, mean age 63.7 yr), and Group B, number of contractions < 120 per day and no consecutive contractions (n = 18, mean age 64.2 yr). Left ventricular ejection fraction was measured by left ventriculography, and significant coronary artery stenosis was defined as stenosis of 75% or greater. Cardiac scintigraphy was performed using single photon emission computed tomography with BMIPP at rest in 27 patients and in the early phase (early Tl) and delayed phase of Tl (delayed Tl) in 20 patients. BMIPP and Tl uptakes were scored as 0: absent, 1: moderately reduced, 2: mildly reduced and 3: normal in 7 segments of the left ventricular wall and then the total scores were calculated in each patient. Ejection fraction significantly correlated with the scores of BMIPP, and early and delayed Tl(p < 0.001, respectively), although the ejection fraction in Group A was significantly less than in Group B (51.2 +/- 16.7% vs 68.2 +/- 14.4%, p < 0.02). The BMIPP scores in Group A were significantly less than those in Group B (14.2 +/- 4.3 vs 17.2 +/- 3.1, p < 0.05), but the early and delayed Tl scores in Group A were not significantly different compared with those in Group B. The BMIPP scores showed no significant differences between the patients with and without significant coronary artery stenosis, but the early and delayed Tl scores in the patients with stenosis were significantly less than those in patients without stenosis (early Tl: 19.8 +/- 2.6 vs 16.8 +/- 2.8, p < 0.01; delayed Tl: 19.6 +/- 2.5 vs 16.8 +/- 3.1, p < 0.05). More patients had values of Tl minus BMIPP scores of at least 3 in Group A than in Group B (early Tl-BMIPP > or = 3: 66.7% vs 7.7%, p < 0.01; delayed Tl-BMIPP > or = 3: 50.0% vs 7.7%, p < 0.05). In patients with coronary heart disease, decreased ejection fraction is thought to be a major cause of ventricular arrhythmias, and also associated with abnormal myocardial metabolism and abnormal myocardial blood flow. Furthermore, ventricular arrhythmias were more closely correlated with abnormal metabolism of fatty acids than with disturbance of blood flow in the myocardium, and large mismatching between the 2 images may be related to risky ventricular arrhythmias in coronary heart disease.     

Surgery for multiple primary lung cancers]

Thirty-eight patients (3.4%) of multiple primary lung cancers were treated among 1,106 patients of lung cancer at Nagoya City University Hospital. Twenty-eight patients had multiple lung lesions at the same time. Ten had the second primary lung cancer from 5 to 12 years after the first operation. Thirty-six patients had the second operation, and two had adjuvant therapy for lung cancer. Their 5 year survival rate was 36%. Especially of the patients with stage I lung cancer, 5 year survival rate was 65%. Radical but less invasive operation like VATS should be chosen for their treatment.     

A case of antithrombin III abnormality presenting as bronchial asthmatic symptom due to pulmonary thromboembolism

A 32-year-old housewife with AT III abnormality visited our out-patient clinic because of dyspnea on April 14, 1988, and was diagnosed as bronchial asthma of non-atopic type. In spite of treatment, her asthmatic symptom did not improve. Therefore, she was admitted to our department on August 12 for a detailed examination and more effective therapy. Xanthine derivatives and beta 2 stimulant were ineffective, and only steroid hormone was effective to some degree. Pulmonary perfusion scan revealed that her pulmonary thromboembolism had become worse. Then she was treated with AT III concentrate and urokinase and her asthmatic symptom was significantly improved and steroid hormone could be easily reduced. Her asthmatic symptom was suggested to be due to progression of pulmonary thromboembolism. We were not able to find any other report of a case with AT III abnormality presenting as bronchial asthma due to pulmonary thromboembolism.     

Effects of limb loading on the lower-limb electromyographic activity during orthotic locomotion in a paraplegic patient.

The relationship between limb loading and lower-leg electromyographic (EMG) activity was examined during orthotic locomotion in a complete paraplegic patient. The level of limb loading was modified by a hanging system. Surface EMG in the lower-leg extensor and flexor muscles was unilaterally recorded together with the load signal on the ipsilateral sole. The motion of the knee and the ankle joints was minimized, which means that the change in length of the examined muscles was minimum. The muscles were activated synchronously with the locomotor movement and the magnitude of the extensor activity was changed relative to the peak load on the sole. It is conceivable that the spinal cord interpreted the load information and modified the EMG output in the anti-gravity muscles even in the absence of stretch reflexes.     

Calcium supplement necessary to correct hypocalcemia after total parathyroidectomy for renal osteodystrophy

BACKGROUND: Prediction of the extent of calcium supplement will facilitate safe and efficient management of hypocalcemia in the early postoperative stage of total parathyroidectomy with autotransplantation (PTXa) in patients with renal osteodystrophy. METHODS: The correlation between the extent of calcium deficiency, estimated by the amount of calcium supplement over 48 h after PTXa and using various parameters such as carboxy terminal parathyroid hormone (c-PTH), intact PTH (i-PTH), alkaline phosphatase (ALP), serum calcium, serum phosphorus, duration of hemodialysis, total weight of resected parathyroid glands and degree of subperiosteal resorption of the middle phalanx was examined in 49 patients who underwent PTX with subcutaneous autotransplantation. Bone mineral density (BMD) was also determined before, 3 months and 1 year after PTXa with dual energy X-ray absorptiometry (DEXA) in 13 patients. RESULTS: There was a positive correlation between pre-operative i-PTH level (r=0.56, P<0.0005) or ALP level (r=0.50, P<0.0005) and the amount of calcium supplement over 48 h after PTXa in these patients. Furthermore, the degree of subperiosteal resorption, determined by Jensen's classification, was significantly correlated with the amount of calcium supplement after PTX (P<0.05). Bone mineral density 3 months after (P<0.0005) and 1 year after PTXa (P<0.001) significantly increased compared with BMD before PTXa in all patients examined. CONCLUSION: These findings suggest that the pre-operative determination of i-PTH, ALP levels and degree of subperiosteal resorption allow the management of hypocalcemia safely and efficiently in renal osteodystrophy patients after PTXa.     

Retrospective studies of gastric cancer with hepatic metastases

From 1979 to 1988, a total of 1265 cases of gastric cancer were admitted to our Institute. Of these, 80 cases (6.3%) involved hepatic metastasis. Thirty-eight cases (47.3%) underwent gastrectomy (24 distal, 2 proximal, 11 total and one partial). Of these 38 cases, 7 underwent a combined resection of a simultaneous metastatic hepatic tumor. A total of 19 (67.9%) of the 28 cases in H1, 6 (37.5%) of the 16 cases in H2, and 13 (36.1%) of the 36 cases in H3 underwent gastrectomy. Hepatic metastasis occurred most frequently (18.2%) in Borrmann type 1, 5% in type 2, 14.9% in type 3 and 8.7% in type 4. Of all 593 resected advanced cases, there were 283 differentiated type, with a hepatic metastasis rate of 14.5%, and 310 undifferentiated type with 7.1% rate of hepatic metastasis. In H1 and H2, the prognosis after primary gastric cancer resection was better than for unresected cases. Moreover, there have been reports recently of long-term survival using continuous hepatic arterial infusion of anti-cancer drugs, and of combined resection of the metastatic hepatic tumor after curative gastrectomy. Therefore we should not give up these H1 and H2 patients.     

Neuronal intranuclear hyaline inclusion disease: report of a case and review of the literature.

A case of neuronal intranuclear hyaline inclusion disease (NIHID) is described. The patient was a 26-year-old man who died of a progressive neurologic disorder, the onset of which occurred at the age of 11 years. Clinically, the disease presented as juvenile parkinsonism, and pathologically it was characterized by multiple-system degeneration in conjunction with the ubiquitous presence of intranuclear hyaline inclusions in neurons of the central and peripheral nervous system including the autonomic ganglia. Smaller and less eosinophilic intranuclear inclusions were also present in a small number of glial cells. The neuronal inclusions emitted a strong yellow-green autofluorescence under ultraviolet light and were composed of filaments 10-15 nm in diameter. The glial inclusions also consisted of similar filaments but their autofluorescence could not be determined with certainty because of their small size and background autofluorescence. A review of the literature revealed 19 similar autopsy cases up to 1987. Since the clinical presentation and distribution of neuronal loss as well as the characteristics of the inclusions showed some differences among the cases, some authors speculated that NIHID represented more than one variant of a multiple-system degenerative disease. However, about half of the reported cases had favorable sites of neurodegeneration, such as the pallidum, substantia nigra, motor nuclei of the brain stem, anterior horn cells, Clarke's column and spinal ganglion as well as similarities among the inclusions. Thus, there seems to be a discrete group among cases of NIHID.