Additional Hepatocellular Carcinomas Undetectable before Surgery

The presence of small additional hepatocellular carcinomas (HCCs) undetectable before hepatic resection is a crucial topic for hepatic surgeons. We assessed the incidence of pathologically diagnosed multiple HCCs in 267 patients who underwent hepatic resection for HCC. Ninety-five additional HCC nodules were detected in 72 of the patients (27%). The survival rate of these 72 patients was significant worse than for the 195 with single nodular HCC (p= 0.0013). Twenty-one (22%) were detected before surgery, 29 (31%) during surgery, and 45 (47%) on pathologic examination after surgery. The mean nodule diameters for each group were 2.1, 1.0, and 0.9 cm, respectively (p < 0.0001). None of the 21 nodules detected before surgery was well differentiated, whereas 30 of the 74 nodules in the other two groups were well-differentiated. Although the mean nodule diameter of the well-differentiated HCC group was the smallest, there was no significant difference among the three groups assigned according to tumor differentiation (p= 0.2355). Altogether, 9 of 16 patients with additional nodules detected before surgery (56%) and 49 of 59 with additional nodules detected during or after surgery (88%) had cirrhosis of the liver. The odds ratio for detecting a new HCC nodule during or after surgery in the presence of cirrhosis was 5.444 (p= 0.0087). Improvement in the detection of small additional HCC nodules before and during surgery and meticulous follow-up after surgery are necessary for patients with cirrhosis. For patients without cirrhosis, surgical treatment may be performed according to the results of preoperative imaging studies.     

Subepicranial varix mimicking sinus pericranii: usefulness of three-dimensional computed tomography angiography and bone window computed tomography--case report

A 16-year-old female presented with a rare case of subepicranial varix in the left temporal area manifesting as a soft mass in the left temporal area when she laid down in the left lateral position. Bulging of the mass was observed when intracranial venous pressure was raised by the Valsalva maneuver, the left lateral position, or the prone position. Bone window computed tomography (CT) revealed a tiny hole, 1 mm in diameter, in the outer bone table. Three-dimensional CT (3D-CT) angiography clearly visualized a mass with a diameter of approximately 10 mm connected to the diploic vein. The mass was totally resected by operation. Venous bleeding was observed from the tiny hole. Histological examination revealed a venous lesion mimicking sinus pericranii and containing endothelial cells. No communication with the intracranial venous sinuses was identified, so the diagnosis was subepicranial varix. Radiological examination by direct injection of contrast medium is usually performed to identify subepicranial varix, but 3D-CT angiography is a non-invasive preoperative examination that can visualize this small venous lesion. Adjustment of the CT acquisition conditions may allow 3D-CT angiography to identify sinus pericranii in the future.     

Binaural advantage on usage of hearing aid together with cochlear implant--examination on speech perception (Japanese monosyllable word list 67-S and Japanese HINT)]

Six cochlear implant recipients with hearing aids in the opposite ear were studied to survey binaural advantage. They were examined in separate tests by using a hearing aid alone, cochlear implant alone, and by using both devices (bimodal condition). Test items used were the Japanese monosyllable word list 67--S and Japanese HINT. Statistically significantly results were obtained in the bimodal condition, three out of six subjects were successful in the monosyllable word test and all successful in the Japanese HINT. We conclude that all subjects enjoyed binaural advantage in speech perception in bimodal condition with no conflict at the recognition level; even when different sounds from cochlear implant and contralateral hearing aid were received. The plasticity of the brain is thought to be of importance in the bimodal condition.     

Primary central nervous system malignant lymphoma originating from the cerebellum and extending along the lower cranial nerves

We report a case of primary central nervous system (CNS) malignant lymphoma of the central nervous system originating from the cerebellum and growing along the lower cranial nerves. A 67-year-old woman presented with hoarseness, vertigo, nausea, and vomiting. Gd-DTPA enhanced MRI showed a homogeneous enhanced mass lesion extending from the cerebellum to the medulla oblongata around the jugular foramen on the right side. Although pre- and intra-operative diagnosis had been schwannoma, histopathological examination revealed a B-cell, diffuse malignant lymphoma. The growth pattern of malignant lymphoma in the present case, which extended extra-axially, is considered to be rare. We discuss here the growth patterns and difficulties of diagnosis of primary CNS malignant lymphoma in this area.     

Day surgery for treatment of varicose veins in the leg

We had surgically treated varicose veins in 554 legs of 386 patients as of June 30, 2000. Varicose veins of the stem or segment type without skin changes were treated with sclerotherapy combined with high ligation, while a part of secondary varicose veins and the reticular or web type were treated with sclerotherapy alone. This paper describes our methods for day surgery for this condition. The most important therapeutic consideration in the surgical procedure is achieving sufficient venous collapse to prevent the occurrence of intravenous thrombus. In our 386 patients, a massive intravenous thrombus that was resected occurred in one limb (0.1%). Postoperative bleeding also occurred in one limb (0.1%) of a patient with severe liver cirrhosis.     

The role of the sentinel lymph node in gastrointestinal cancer

Evaluation of the clinical significance of the sentinel node concept in GI cancer has just begun. The authors' preliminary data, using intraoperative radiation techniques and the gamma probe, suggest that it is worthwhile to continue the evaluation of this procedure to determine its role in an accurate staging and a minimally invasive approach to GI cancers.     

Expression level of valosin-containing protein (VCP) as a prognostic marker for gingival squamous cell carcinoma.

BACKGROUND: Valosin-containing protein (VCP) is associated with anti-apoptotic function and metastasis via activation of the nuclear factor-kappaB signaling pathway. In the present study, association of VCP expression with prognosis of gingival squamous cell carcinoma (GSCC) was examined. PATIENTS AND METHODS: VCP expression in 74 patients with GSCC (34 males and 40 females) with ages ranging from 42 to 85 (median 66) years was evaluated by immunohistochemistry, in which staining intensity in tumor cells was categorized as either weaker (level 1) or equal to/stronger (level 2) than that in the endothelial cells. RESULTS: Twenty-four (32.4%) cases showed level 1 and 50 (67.6%) level 2 VCP expression. Patients with level 1 GSCC showed a significantly better 5-year survival rate than those with level 2 GSCC (5-year overall survival: 100% versus 84.9%, P < 0.05). Multivariate analysis revealed VCP expression level, lymph node metastasis and pT(TNM) to be independent factors for overall survival. Patients with GSCC at stages I and II showed favorable prognosis regardless of VCP expression status, whereas at stages III and IV, patients with level 1 VCP expression showed better survival rates than those with level 2 expression. CONCLUSION: Prognostic significance of VCP expression level in GSCC was demonstrated.     

Saccular cerebral aneurysms in young adults

BACKGROUND: The formation and rupture of cerebral aneurysms has been controversial. In order to clarify their nature, this study investigates the size and location of ruptured and unruptured aneurysms in young adults and the results of surgery. METHODS: The subjects of this study are 35 patients with ruptured and two with unruptured aneurysms. They range in age from 20 to 39 years. The size and location of their aneurysms were determined by angiographic measure of their maximal inner diameters. Direct surgery was performed on 34 patients with ruptured aneurysms and on one with an unruptured aneurysm. RESULTS: Ruptured aneurysms in young adults increase in number and size as they grow older. In young adults showing no atherosclerosis or hypertension, ruptured aneurysms occurred in locations and with a frequency found in patients with hypertension. In young adults, aneurysms in the internal carotid artery larger than 3.5 mm (Fisher's exact test; p < 0.05) and the anterior communicating artery showed a tendency to rupture. The surgery produced excellent results in young adults with grade I to III by Hunt and Kosnik classification, but extremely poor results for those with grade IV resulting from vasospasm (Fisher's exact test; p < 0.05). CONCLUSION: It is possible that aneurysms found in young adults might in fact have been present from childhood and adolescence, increasing sufficiently in size to rupture in the forties and fifties. Accordingly, while aneurysm formation may be related to fragile arterial walls, aneurysm rupture may be the result of aging factors such as hypertension and atherosclerosis. Even in young adults, vasospasm had an impact on the outcome of surgery.     

Thrombin inhibitor ameliorates secondary damage in rat brain injury: suppression of inflammatory cells and vimentin-positive astrocytes

The effects of the thrombin inhibitor argatroban on the number of inflammatory cells and reactive astrocytes were investigated in a rat brain injury model. Gelatin sponge soaked with thrombin inhibitor (treatment group) or saline (control group) was placed in the brain defect to assess the infiltration of inflammatory cells by hematoxylin-eosin and immunohistochemical staining. Expression of polymorphonuclear leukocytes (PMNs) and monocyte/macrophage (Mo/Mo) cells, and vimentin (VIM)-positive astrocytes and glial fibrillary acidic protein (GFAP)-positive astrocytes were compared between groups. In the treatment group, infiltration of both PMNs and Mo/Mo cells, and the number of VIM-positive astrocytes were significantly reduced, but the number of GFAP-positive astrocytes was not different from the control group. Thrombin inhibitor suppresses the infiltration of inflammatory cells and excessive gliosis caused by VIM-positive astrocytes, but not expression of GFAP-positive astrocytes, suggesting minimization of secondary brain damage and promotion of the conditions required for neural regeneration.