Perioperative serum syndecan-1 concentrations in patients who underwent cardiovascular surgery with cardiopulmonary bypass and its association with the occurrence of postoperative acute kidney injury: a retrospective observational study

BACKGROUND

Various factors can cause vascular endothelial damage during cardiovascular surgery (CVS) with cardiopulmonary bypass (CPB), which has been suggested to be associated with postoperative complications. However, few studies have specifically investigated the relationship between the degree of vascular endothelial damage and postoperative acute kidney injury (pAKI). The objectives of this study were to measure perioperative serum syndecan-1 concentrations in patients who underwent CVS with CPB, evaluate their trends, and determine their association with pAKI.

METHODS

This was a descriptive and case‒control study conducted at the National University Hospital. Adult patients who underwent CVS with CPB at a national university hospital between March 15, 2016, and August 31, 2020, were included. Patients who were undergoing preoperative dialysis, had preoperative serum creatinine concentrations greater than 2.0 mg dl-1, who were undergoing surgery involving the descending aorta were excluded. The perioperative serum syndecan-1 concentration was measured, and its association with pAKI was investigated.

RESULTS

Fifty-two patients were included. pAKI occurred in 18 (34.6%) of those patients. The serum syndecan-1 concentration increased after CPB initiation and exhibited bimodal peak values. The serum syndecan-1 concentration at all time points was significantly elevated compared to that after the induction of anesthesia. The serum syndecan-1 concentration at 30 min after weaning from CPB and on postoperative day 1 was associated with the occurrence of pAKI (OR = 1.10 [1.01 to 1.21], P = 0.03]; OR = 1.16 [1.01 to 1.34], P = 0.04]; and the cutoff values of the serum syndecan-1 concentration that resulted in pAKI were 101.0 ng ml-1 (sensitivity = 0.71, specificity = 0.62, area under the curve (AUC) = 0.67 (0.51 to 0.83)) and 57.1 ng ml-1 (sensitivity = 0.82, specificity = 0.56, AUC = 0.71 (0.57 to 0.86)). Multivariate logistic regression analysis revealed that the serum syndecan-1 concentration on postoperative day 1 was associated with the occurrence of pAKI (OR = 1.02 [1.00 to 1.03]; P = 0.03).

CONCLUSION

The serum syndecan-1 concentration at all time points was significantly greater than that after the induction of anesthesia. The serum syndecan-1 concentration on postoperative day 1 was significantly associated with the occurrence of pAKI.

TRIAL REGISTRATION

This study is not a clinical trial and is not registered with the registry.

Effectiveness of remimazolam in preventing postoperative delirium in elderly patients with proximal femoral fractures

PURPOSE

Elderly patients with proximal femoral fractures are known to be a high-risk group for postoperative delirium (POD). The aim of this study was to determine the association of the benzodiazepine drug remimazolam with POD in elderly patients with proximal femoral fractures.

METHODS

In this single-center retrospective observational study, we included patients aged 65 years or older who underwent general anesthesia for proximal femoral fractures. We collected data for the incidence of POD within 3 days after surgery. We also obtained data for complications, preoperative blood examinations, maintenance anesthetic and intraoperative vital data. The occurrence of POD in patients who received remimazolam for general anesthesia (remimazolam group) was compared to that in patients who received general anesthesia with other anesthetic agents (other group). We finally conducted a multivariate analysis to assess the independent association of remimazolam with the risk of POD.

RESULTS

A total of 230 patients, including 54 patients who received remimazolam for maintenance anesthesia, were included in this study. The incidence of POD in the patients was 26.1%. The incidence of delirium within 3 days after surgery was significantly lower in the remimazolam group than in the other group (14.8% vs. 29.5%, p  =  0.03). The multivariate analysis showed that the use of remimazolam independently reduced the occurrence of POD (adjusted odds ratio  =  0.42, p  =  0.04).

CONCLUSION

This retrospective observational study showed that the use of remimazolam is independently associated with a reduced incidence of POD. Remimazolam may be considered as an option to reduce POD in elderly patients with proximal femoral fractures.

Improvement of sleep and pain with lemborexant administration in patients with chronic pain: a retrospective observational study

OBJECTIVE

Patients with chronic pain often have sleep disturbances, and many patients receive sleep medications in addition to analgesics. Although there have been scattered reports of negative pain-sleep interactions, only a few reports have investigated the efficacy of sleep medication interventions in patients with chronic pain for improving sleep disturbances and reducing pain. We retrospectively examined whether lemborexant, an orexin receptor antagonist, is effective in improving sleep disturbances and reducing pain in patients with chronic pain. This study was approved by the Ethics Committee of our hospital.

METHODS

The subjects were 26 patients with chronic pain undergoing treatment at our pain clinic between July 2021 and March 2022, who had been diagnosed with insomnia, with an Athens Insomnia Scale (AIS) score of ≥6 and had been started on lemborexant. The AIS score and pain score (Numeric Rating Scale [NRS]) before and after 2 and 4 weeks of starting lemborexant were investigated.

RESULTS

Patients who were already taking other sleep medications, such as benzodiazepines were switched to 5 mg of lemborexant after all the other sleep medications were discontinued. Those who had not yet used sleeping pills were started on 5 mg of lemborexant. During the study course, the dose of lemborexant was adjusted at the discretion of the attending physician, based on improvement of insomnia symptoms and secondary symptoms, such as daytime sleepiness and lightheadedness. The study finally included 21 patients, excluding 5 who could not continue taking lemborexant due to side effects, such as lightheadedness. The AIS scores significantly improved, decreasing from baseline (mean ± standard deviation: 12.5 ± 4.9) to 2 weeks (7.8 ± 3.1) and 4 weeks (5.3 ± 2.9) after the start of lemborexant. No significant difference was observed in the degree of improvement in sleep disturbance between patients with or without previous sleep medications, and there was also no statistically significant improvement in the NRS score before (6.1 ± 2.7) and after 2 weeks (5.5 ± 2.3) and 4 weeks (5.9 ± 2.2) from treatment initiation.

Anesthetic management of Stanford type B acute aortic dissection that occurred during transcatheter aortic valve implantation under monitored anesthesia care: A case report

We report a case involving anesthetic management of Stanford type B acute aortic dissection occurred during transcatheter aortic valve implantation (TAVI) under monitored anesthesia care (MAC) in a patient with aortic stenosis (AS). An 87-year-old woman was undergoing TAVI under MAC for severe AS. During the surgery, the patient suddenly moved possibly because of pain. This was followed by hemodynamic collapse. She was then transitioned to general anesthesia, and extracorporeal membrane oxygenation (ECMO) was initiated. Transesophageal echocardiography revealed a Stanford type B acute aortic dissection, which was safely managed perioperatively with appropriate interventions.

Percutaneous retrocrural versus ultrasound-guided coeliac plexus neurolysis for refractory pancreatic cancer pain

We report a successful case of fluoroscopic percutaneous retrocrural coeliac plexus neurolysis (PRCPN) for pancreatic cancer pain refractory to endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN). A 55-year-old man with upper abdominal pain due to end-stage pancreatic cancer underwent EUS-CPN. Although CT revealed distribution of the contrast medium with neurolytic agent around the left and cephalic sides of the coeliac artery, the pain did not improve and became even more severe. PRCPN was performed, resulting in the drastic improvement of pain immediately. PRCPN should be considered when EUS-CPN is not effective.

Rocuronium action can be affected by hyperventilation: a case report and computational simulation

The neuromuscular blocking potency of rocuronium varies with respiratory pH changes, increasing at lower pH and decreasing at higher pH; thus, hyperventilation-induced respiratory alkalosis is expected to decrease the potency of rocuronium. We report a case of anesthetic management of modified electroconvulsive therapy (m-ECT) for a patient monitored with electromyography-based neuromuscular monitoring during two patterns of ventilation to elucidate their relationship and propose the possible mechanisms underlying the effects by computational simulations. Case presentation: The patient was a 25-year-old man with schizophrenia. In m-ECT, hyperventilation may be used to produce longer seizures. We compared the neuromuscular monitoring data recorded during hyperventilation and during normal ventilation while receiving the same dose of rocuronium. Despite receiving the same dose of rocuronium, the time required for the first twitch to decrease to 80% of the control value was delayed in hyperventilation compared to normal ventilation. Conclusions: This case report and computational simulation suggest that respiratory alkalosis might delay the action of rocuronium. It is necessary to consider the delayed action of rocuronium when hyperventilation is performed.

Effect of cerebrospinal fluid drainage pressure in descending and thoracoabdominal aortic repair: a prospective multicenter observational study

PURPOSE

Cerebrospinal fluid drainage (CSFD) is recommended during open or endovascular thoracic aortic repair. However, the incidence of CSFD complications is still high. Recently, CSF pressure has been kept high to avoid complications, but the efficacy of CSFD at higher pressures has not been confirmed. We hypothesize that CSFD at higher pressures is effective for preventing motor deficits.

METHODS

This prospective observational study included 14 hospitals that are members of the Japanese Society of Cardiovascular Anesthesiologists. Patients who underwent thoracic and thoracoabdominal aortic repair were divided into four groups: Group 1, CSF pressure around 10 mmHg; Group 2, CSF pressure around 15 mmHg; Group 3, CSFD initiated when motor evoked potential amplitudes decreased; and Group 4, no CSFD. We assessed the association between the CSFD group and motor deficits using mixed-effects logistic regression with a random intercept for the institution.

RESULTS

Of 1072 patients in the study, 84 patients (open surgery, 51; thoracic endovascular aortic repair, 33) had motor deficits at discharge. Groups 1 and 2 were not associated with motor deficits (Group 1, odds ratio (OR): 1.53, 95% confidence interval (95% CI): 0.71-3.29, p = 0.276; Group 2, OR: 1.73, 95% CI: 0.62-4.82) when compared with Group 4. Group 3 was significantly more prone to motor deficits than Group 4 (OR: 2.56, 95% CI: 1.27-5.17, p = 0.009).

CONCLUSION

CSFD is not associated with motor deficits in thoracic and thoracoabdominal aortic repair with CSF pressure around 10 or 15 mmHg.

Timing, Threshold, and Duration of Intraoperative Hypotension in Cardiac Surgery: Their Associations With Postoperative Delirium

OBJECTIVES

To study the timing, threshold, and duration of intraoperative hypotension (IOH) associated with the risk of postoperative delirium (POD).

DESIGN

A single-center retrospective observational study.

SETTING

University teaching hospital.

PARTICIPANTS

A total of 503 adult patients who underwent cardiac valvular surgery that required cardiopulmonary bypass (CPB).

MEASUREMENTS AND MAIN RESULTS

The authors predefined the following 4 periods: (1) during surgery, (2) pre-CPB, (3) during CPB, and (4) post-CPB, and 8 thresholds of mean arterial pressure for IOH according to every 5 mmHg between 50 mmHg and 85 mmHg. The authors calculated the cumulative duration below the 8 thresholds in each period. The primary outcome was delirium defined as a score of ≥4 for at least one Intensive Care Delirium Screening Checklist assessment during 48 h after the surgery. Among 503 patients, POD occurred in 95 patients (18.9%). There was no significant association of POD with all of the thresholds of IOH in the periods of pre-CPB, during CPB, and during surgery. However, in the post-CPB period, the patients with POD had a significantly longer cumulative duration of IOH according to all of the thresholds of mean arterial pressure. In multivariate analyses, 4 IOH thresholds in the post-CPB period were associated independently with POD: <60 mmHg (odds ratio [OR] =1.84 [95% CI 1.10-3.10]), <65 mmHg (OR = 1.72 [1.01-2.92]), <70 mmHg (OR = 1.83 [1.03-3.26]), and <75 mmHg (OR = 1.94 [1.02-3.69]).

CONCLUSIONS

A longer cumulative duration of IOH with the threshold between <60 and <75 mmHg that occurred after CPB was independently associated with the risk of POD.

Pain induces stable, active microcircuits in the somatosensory cortex that provide a therapeutic target

Sustained neuropathic pain from injury or inflammation remains a major burden for society. Rodent pain models have informed some cellular mechanisms increasing neuronal excitability within the spinal cord and primary somatosensory cortex (S1), but how activity patterns within these circuits change during pain remains unclear. We have applied multiphoton in vivo imaging and holographic stimulation to examine single S1 neuron activity patterns and connectivity during sustained pain. Following pain induction, there is an increase in synchronized neuronal activity and connectivity within S1, indicating the formation of pain circuits. Artificially increasing neuronal activity and synchrony using DREADDs reduced pain thresholds. The expression of N-type voltage-dependent Ca²⁺ channel subunits in S1 was increased after pain induction, and locally blocking these channels reduced both the synchrony and allodynia associated with inflammatory pain. Targeting these S1 pain circuits, via inhibiting N-type Ca²⁺ channels or other approaches, may provide ways to reduce inflammatory pain.

Long-term preoperative glycemic control restored the perioperative neutrophilic phagocytosis activity in diabetic mice

BACKGROUND

The risk of surgical site infection has been reported to be higher in patients with poorly controlled diabetes. Since chronic hyperglycemia impairs neutrophil functions, preoperative glycemic control may restore neutrophil function. However, long-term insulin therapy may lead to a delay in surgery, which may be a problem, especially in cancer surgery. It is therefore unfortunate that there have been few studies in which the optimal duration of perioperative glycemic control for diabetes with chronic hyperglycemia was investigated. Therefore, we investigated the effects of preoperative long-term insulin therapy and short-term insulin therapy on perioperative neutrophil functions in diabetic mice with chronic hyperglycemia.

METHODS

Five-week-old male C57BL/6 J mice were divided into four groups (No insulin (Diabetes Mellitus: DM), Short-term insulin (DM), Long-term insulin (DM), and Non-diabetic groups). Diabetes was established by administrating repeated low-dose streptozotocin. The Short-term insulin (DM) group received insulin therapy for 6 h before the operation and the Long-term insulin (DM) group received insulin therapy for 5 days before the operation. The No insulin (DM) group and the Non-diabetic group did not receive insulin therapy. At 14 weeks of age, abdominal surgery with intestinal manipulation was performed in all four groups. We carried out a phagocytosis assay with fluorescent microspheres and a reactive oxygen species (ROS) production assay with DCFH-DA (2',7'-dichlorodihydrofluorescein diacetate) before and 24 h after the operation using FACSVerse™ with BD FACSuite™ software.

RESULTS

Blood glucose was lowered by insulin therapy in the Short-term insulin (DM) and Long-term insulin (DM) groups before the operation. Neutrophilic phagocytosis activities before and after the operation were significantly restored in the Long-term insulin (DM) group compared with those in the No insulin (DM) group (before: p = 0.0008, after: p = 0.0005). However, they were not significantly restored in the Short-term insulin (DM) group. Neutrophilic ROS production activities before and after the operation were not restored in either the Short-term insulin (DM) group or Long-term insulin (DM) group.

CONCLUSIONS

Preoperative and postoperative phagocytosis activities are restored by insulin therapy for 5 days before the operation but not by insulin therapy for 6 h before the operation.

Mean amplitude of glycemic excursions in septic patients and its association with outcomes: A prospective observational study using continuous glucose monitoring

PURPOSE

To apply continuous glucose monitoring (CGM) and determine the mean amplitude of glycemic excursions (MAGE) in septic patients and to assess the associations of MAGE with outcomes and oxidative stress.

MATERIALS AND METHODS

This study was conducted in adult septic patients expected to require intensive care for >48 h. We continuously measured blood glucose level for the first 48 h in the ICU using FreeStyle Libre®. MAGE was calculated using glycemic information obtained by CGM during the study period of 48 h. The primary outcome was 90-day all-cause mortality. The secondary outcomes were 90-day ICU-free days and the concentration of urinary 8-isoprostaglandinF2α measured 48 h after commencement of the study as a surrogate of oxidative stress.

RESULTS

Forty patients were included in this study. Median of MAGE was higher in non-survivors than in survivors: 68.8 (IQR;39.7-97.2) vs. 39.3 (IQR;19.9-53.3), p = 0.02. In multivariate analysis, MAGE was independently associated with 90-day all-cause mortality rate (p = 0.02), urinary 8-isoprostaglandinF2α level (p = 0.03) and 90-day ICU-free survival days (p = 0.03).

CONCLUSIONS

In the current study, MAGE for the first 48 h of treatment that was obtained by using CGM was associated with 90-day all-cause mortality, 90-day ICU-free days and urinary 8-isoprostaglandinF2α level in septic patients.

Suppression of behavioral activity and hippocampal noradrenaline caused by surgical stress in type 2 diabetes model mice

Background

There has been much discussion recently about the occurrence of neuropsychological complications during the perioperative period. Diabetes is known to be one of the metabolic risk factors. Although the number of patients with diabetes mellitus (DM) has been increasing, the pathophysiology of postoperative neuropsychological dysfunction in DM patients is still unclear. Recently, a deficiency of neurotransmitters, such as monoamines, was reported to be associated with mental disorders. Therefore, we investigated the effects of surgical stress on behavioral activity and hippocampal noradrenaline (NA) level in type 2 diabetes mellitus model (T2DM) mice.

Methods

Eighty-four 6-week-old male C57BL/6J mice were divided into four groups (non-diabetes, non-diabetes with surgery, T2DM, and T2DM with surgery groups). T2DM mice were established by feeding a high-fat diet (HFD) for 8 weeks. At 14 weeks of age, fifteen mice in each group underwent a series of behavioral tests including an open field (OF) test, a novel object recognition (NOR) test and a light–dark (LD) test. In the surgery groups, open abdominal surgery with manipulation of the intestine was performed 24 h before the behavioral tests as a surgical stress. Hippocampal noradrenaline (NA) concentration was examined in six mice in each group by high-performance liquid chromatography. The data were analyzed by the Mann–Whitney U test, and p values less than 0.05 were considered significant.

Results

The T2DM group showed significantly increased explorative activity in the NOR test (P = 0.0016) and significantly increased frequency of transition in the LD test (P = 0.043) compared with those in the non-diabetic group before surgery. In T2DM mice, surgical stress resulted in decreased total distance in the OF test, decreased explorative activity in the NOR test, and decreased frequency of transition in the LD test (OF: P = 0.015, NOR: P = 0.009, LD: P = 0.007) and decreased hippocampal NA (P = 0.015), but such differences were not observed in the non-diabetic mice.

Conclusions

Mice with T2DM induced by feeding an HFD showed increased behavioral activities, and surgical stress in T2DM mice caused postoperative hypoactivity and reduction of the hippocampal NA level.

Anesthetic management of modified electroconvulsive therapy for a patient with coronary aneurysms: a case report

Background

Modified electroconvulsive therapy (m-ECT) is utilized worldwide as an effective treatment for drug-resistant psychiatric disorders. However, during m-ECT, treatment of hypotension and hypertension in response to rapid hemodynamic changes is required. We used noninvasive continuous blood pressure monitoring system for continuous hemodynamic measurement during m-ECT.

Case presentation

The patient was a 77-year-old man with depression complicated by coronary artery aneurysms (CAAs). We managed general anesthesia during m-ECT by using the ClearSight™ system (Edwards Lifesciences Corp, Irvine, CA, USA) for hemodynamic measurement. As a result, we performed a total of 10 m-ECTs. No rupture of CAAs or myocardial ischemia occurred and depressive symptoms improved.

Conclusion

We successfully managed the anesthesia in m-ECT for a depressed patient with CAAs without complications by using the ClearSight™ system, which was used for the effective management of circulatory fluctuations.

Anesthetic management and associated complications of peroral endoscopic myotomy: A case series

AIM

To investigate the anesthetic management of peroral endoscopic myotomy (POEM) and its associated complications.

METHODS

This study was a single-center, retrospective, observational study comprising a case series of all patients who underwent POEM in our hospital from April 2015 to November 2016. We collected data regarding patient characteristics, anesthetic methods, surgical factors, and complications using an electronic chart.

RESULTS

There were 86 patients who underwent POEM in our hospital during the study period. Preoperatively, patients were maintained on a low residue diet for 48 h prior to the procedure. They were fasted of solids for 24 h before surgery. There was one case of aspiration (1.2%). During POEM, patients were positioned supine with the upper abdomen covered by a clear drape so that pneumoperitoneum could be timeously identified. In three cases, the peak airway pressure exceeded 35 cmH2O during volume controlled ventilation with tidal volumes of 6-8 mL/kg and subsequent impairment of ventilation. These cases had been diagnosed with spastic esophageal disorders (SEDs) and the length of the muscular incision on the esophageal side was longer than normal.

CONCLUSION

In the anesthetic management of POEM, it is important to prevent aspiration during induction of anesthesia and to identify and treat complications associated with CO2 insufflation.

Critical exacerbation of idiopathic pulmonary fibrosis after transcatheter aortic valve implantation: Need for multidisciplinary care beyond "heart team"

An 82-year-old man with severe aortic stenosis and idiopathic pulmonary fibrosis (IPF) underwent transcatheter aortic valve implantation (TAVI) under general anesthesia. However, following a successful TAVI procedure, he developed progressive respiratory failure because of the exacerbation of IPF. Despite the use of immunosuppressants, the patient could not be saved and he died of respiratory failure. Although TAVI is a less invasive procedure compared to conventional surgical aortic valve replacement, it is currently selected for management of severely ill, frail, and elderly patients. This case highlights the potential risk of IPF exacerbation following a TAVI procedure performed under general anesthesia. <Learning objective: Transcatheter aortic valve implantation (TAVI) procedures have been increasingly performed for high-risk patients, including those with high frailty and pulmonary dysfunction. Although TAVI is less invasive compared to open surgery, it may cause critical exacerbation of idiopathic pulmonary fibrosis when performed under general anesthesia. Multidisciplinary care beyond "heart team" would be necessary for prevention, as well as for detecting the early signs of exacerbation of idiopathic pulmonary fibrosis.>.

[Vital Sign Changes and the Requirement of Analgesics after Discontinuation of Dexmedetomidine in Patients after Esophageal Cancer Surgery.]

BACKGROUND

There is few study to examine the vital sign changes and the requirement of analgesics after discontinuation of dexmedetomidine in postopera- tive patients.

METHODS

This is a retrospective observational study conducted in 74 patients after esophageal cancer sur- gery. We recorded vital signs including blood pressure, heart rate and respiratory rate one hour before discon- tinuation of dexmedetomidine, and at 1, 2, 4, 6 hours after its discontinuation. We also recorded the use of opioid and analgesic within 6 hours after discontinua- tion.

RESULTS

Mean blood pressure, pulse rate, and respi- ratory rate significantly increased after DEX discon- tinuation. Compared with the data before discontinua- tion, the mean blood pressure increased by 13.3 mmHg, heart rate increased by 7.5 beats - min- and respira- tory rate increased by 3.0 times - min-' in average at 6 hours after discontinuation. There were 28 patients (38%) who required the additional analgesics within 6 hours after discontinuation.

CONCLUSIONS

After discontinuation of dexmedetomi- dine, significant changes of vital signs, especially in mean blood pressure, were observed in post-esopha- gectomy patients. About 38% of them required addi- tional analgesics within 6 hours after dexmedetomidine discontinuation.

Up-regulation of brain-derived neurotrophic factor in the dorsal root ganglion of the rat bone cancer pain model

Metastatic bone cancer causes severe pain, but current treatments often provide insufficient pain relief. One of the reasons is that mechanisms underlying bone cancer pain are not solved completely. Our previous studies have shown that brain-derived neurotrophic factor (BDNF), known as a member of the neurotrophic family, is an important molecule in the pathological pain state in some pain models. We hypothesized that expression changes of BDNF may be one of the factors related to bone cancer pain; in this study, we investigated changes of BDNF expression in dorsal root ganglia in a rat bone cancer pain model. As we expected, BDNF mRNA (messenger ribonucleic acid) and protein were significantly increased in L3 dorsal root ganglia after intra-tibial inoculation of MRMT-1 rat breast cancer cells. Among the eleven splice-variants of BDNF mRNA, exon 1–9 variant increased predominantly. Interestingly, the up-regulation of BDNF is localized in small neurons (mostly nociceptive neurons) but not in medium or large neurons (non-nociceptive neurons). Further, expression of nerve growth factor (NGF), which is known as a specific promoter of BDNF exon 1–9 variant, was significantly increased in tibial bone marrow. Our findings suggest that BDNF is a key molecule in bone cancer pain, and NGF-BDNF cascade possibly develops bone cancer pain.

Spinal nerve injury causes upregulation of ErbB2 and ErbB3 receptors in rat dorsal root ganglia

It is generally known that peripheral nerve injury causes changes in expression of some growth factors in the dorsal root ganglion. Altered expression of ErbB receptors, a well-known growth factor in somatic cells, reportedly follows peripheral nerve injury in the spinal dorsal horn; however, it remains unknown whether the expression of these receptors is altered in the dorsal root ganglion after nerve injury. Therefore, this study examined the gene expression profiles of ErbB receptors in bilateral lumbar (L)4/L5 dorsal root ganglia, using L5-selective spinal nerve ligation in model rats as a peripheral nerve injury model. The expression of ErbB2 and ErbB3 was observed in the dorsal root ganglia of the mature rat, despite ErbB1 and ErbB4 showing only subtle expression. We also demonstrated that peripheral nerve injury induced significant increases in ErbB2 and ErbB3 in the ipsilateral dorsal root ganglion as compared with uninjured nerve. Expression changes in ErbB receptors appear to play important roles in nerve injury and subsequent nerve regeneration.

Antinociceptive effects of intrathecal landiolol injection in a rat formalin pain model

Perioperative beta-blocker administration has recently been recommended for patients undergoing cardiac or other surgery due to the beneficial cardiovascular effects of these agents. In addition, some studies have reported that perioperatively administered beta-blockers also have analgesic effects. In this study, to investigate the antinociceptive effects and the analgesic profile of landiolol, we examined the effects of intrathecal landiolol administration on nociceptive pain behavior and c-fos mRNA expression (a neural marker of pain) in the spinal cord using a rat formalin model. We found that pain-related behavior was inhibited by intrathecal landiolol administration. Moreover, the increase in c-fos mRNA expression on the formalin-injected side was less pronounced in rats administered landiolol than in saline administered controls. Thus, intrathecal administration of landiolol exhibited antinociceptive effects. Further investigation of the antinociceptive mechanism of landiolol is required.

Prognostic factors of patients with yolk sac tumors of the ovary

OBJECTIVE

Our purpose was to evaluate the prognostic factors in yolk sac tumors of the ovary.

STUDY DESIGN

We performed a retrospective review of 47 patients with yolk sac tumors of the ovary from 1979 to 1997.

RESULTS

Twenty-two patients had pure yolk sac tumors and 25 had germ cell tumors with yolk sac tissue as a component of the disease. The 5-year survival rate in stages I, II, III, and IV was 95%, 75%, 30%, and 25%, respectively. Patients with stage I disease had a more favorable prognosis than those with stage III and IV disease (P <.001). All patients who did not respond to chemotherapy died of this disease within 36 months of the first treatment. Chemotherapy regimens that included cisplatin gave better results than those without cisplatin (P <.05). The difference in prognosis was significant in cases in which the size of residual tumor was <2 cm in diameter (P <.01) and in cases in which ascites was either absent or <100 mL in volume (P <.05). Coexistence of other components of ovarian germ cell tumors in histologic specimens, preoperative serum alpha-fetoprotein level, fertility-sparing surgery, dissection of intrapelvic nodes, and p53 status had no significant correlation with the prognosis in this study.

CONCLUSIONS

Staging and tumor-reductive surgery strongly affected the prognosis of this disease. Tumor-reductive surgery is advisable when ascites is minimal. Cisplatin-based chemotherapy after surgery was superior to chemotherapy without cisplatin; however, p53 status seemed to have no impact on chemosensitivity in yolk sac tumors of the ovary.

Color-coding reveals tandem repeats in the Escherichia coli genome

Genomic DNA contains a wide variety of repetitive sequences. In Escherichia coli, there have been several classes of repetitive sequences reported, some of which cluster as tandem repeats. We propose a novel method for analyzing symbolic sequences by two-dimensional pattern formation with color-coding. We applied this method for searching tandem repeats in the E. coli genome and found approximately 50 repeats with periods longer than 30 bases. The longest repeat has a period of 1267 bases.

A follow-up study of patients with cervical cancer after resection, with special emphasis on the incidence of second primary cancers

The causes of death in long-term survivors after resection of cervical cancer were investigated in a follow-up study of 375 women, focusing especially on the postoperative development of second primary cancers. The 5- and 10-year overall survival rates were 75.0 and 66.0%, respectively, in cases that showed frank invasion, 94.7 and 92.8%, respectively, in those showing microinvasion, and 96.2 and 96.2% respectively, in those showing carcinoma in situ. Multivariate analysis identified patient age and cancer stage at the time of diagnosis as separate factors prognostic for overall survival. During the observation period, 10 patients developed a second primary cancer, but no significantly elevated risk of developing a second primary cancer was demonstrated. However, during the same period, 20 patients also died of noncancerous disease, 9 of this number succumbing to acute myocardial infarction and/or heart failure. These results suggest that patients with cervical cancer may not have an increased risk of developing second primary cancer. It is felt that continued follow-up of long-term cervical cancer survivors should be pursued in order to prevent or arrest the development of noncancerous disease and/or second primary cancer, so that increased prolongation of survival can be achieved.

[Immunohistochemical study on the MHC class I antigen expression on squamous cell carcinoma of the uterine cervix]

Immunohistological analysis was performed to detect MHC Class I antigen expression on uterine cervical squamous cell carcinomas of 23 patients using a monoclonal antibody (W6/32) to recognize a monomorphic determinant of HLA-ABC and an antibody (MA2.2) to react only with cells typed as HLA-A2. The results were as follows. 1. In 2 of 23 cases examined, cancer cells lacked reactivity with W6/32, although normal epithelial cells and connective stromal cells surrounding cancer nests were clearly positive for the antibody in all cases. 2. Of the remaining 21 cases, fourteen cases were judged to be HLA-A2 positive, based on the obvious staining of the stromal cells with MA2.2. Of these 14 only 5 carcinomas were positive for HLA-A2, and the cancer cells in the other 9 cases failed to bind MA2.2. These data suggest that in most clinically diagnosed patients, cancer cells do not have their own MHC Class I products on their cell surfaces phenotypically, and this unique property may be related to the biological characteristic that permits cancer cells to survive and proliferate unrestrictedly in vivo, mainly escaping from the immune-surveillance system under cytotoxic T lymphocytes (CTLs), which need to recognize not only cancer-specific (associated) antigen(s) but also the self-MHC Class I products to kill the cancer cells efficiently.

Species difference of 5-lipoxygenase derived from polymorphonuclear leukocytes on sensitivity to drugs

Effects of 12 compounds including 5-lipoxygenase (5-LO) inhibitors and antiallergic drugs on the activity of 5-LO from the polymorphonuclear leukocytes (PMN) of guinea pigs, rats, rabbits, monkeys and humans were examined. The 5-LO activity was inhibited by the drugs according to the following orders of efficacy: Guinea pig 5-LO, 5-HDHDMF greater than TZI-2721 greater than NDGA greater than AA861 greater than FPL55712 greater than isoproterenol; rat 5-LO, 5-HDHDMF greater than AA861 greater than TZI-2721 greater than NDGA greater than FPL55712 greater than KP-136 greater than MCI-826 greater than benoxaprofen; and rabbit 5-LO, 5-HDHDMF greater than TZI-2721 greater than NDGA greater than AA861 greater than FPL55712 greater than KP-136 greater than MCI-826. The 5-LO activity from the rhesus monkey was dose-dependently inhibited by only 3 compounds, 5-HDHDMF greater than NDGA greater than TZI-2721, in this order, but the other compounds, except for AA861, did not show any effect on this activity. In humans, 5-LO activity was inhibited in the following order: TZI-2721 greater than 5-HDHDMF greater than NDGA greater than AA861 greater than FPL55712. From these results, it was strongly suggested that there is a species difference of this enzyme in its sensitivity to drugs.

[New trends in trophoblastic disease]

In Japan, population-based trophoblastic disease registries were set up in the 1974s by the Registration Committee for Trophoblastic Disease (Japan Society of Obstet. & Gynecol.). The results indicate the following. 1. The incidence rates for trophoblastic disease show that the incidence of hydatidiform mole has been decreasing year by year from 10.2 to 5.9 throughout the observation period 1979-1986. But the incidence for hydatidiform mole per 1,000 pregnancies was from 1.83 to 1.91, and that per 1,000 deliveries was also from 2.84 to 2.93 throughout the observation period. The incidence of choriocarcinoma has also been decreasing year by year from 0.31 to 0.13 throughout the observation period. The frequency of choriocarcinoma after hydatidiform mole with complete remission was 0.32% (4/1, 171), but that after hydatidiform mole with no remission was 3.08% (4/130). The high risk groups for choriocarcinoma were hydatidiform mole over 40 years old, metastatic mole, and invasive mole. Five-year survival rate of choriocarcinoma with no metastatic foci was 100%, and that of metastatic choriocarcinoma was 59.2%. For cases treated with surgery combined with chemotherapy, 80.0 per cent of the cases survived 5 years compared with 71.4 per cent of the cases treated with chemotherapy alone and 67.7 per cent of the cases treated with surgery alone. The mortality for choriocarcinoma per 100,000 female population has been decreasing year by year from 0.123 to 0.065 throughout the observation period.

[Experimental study of the treatment of uterine leiomyosarcoma in the mouse with progestogen]

Because of its rare occurrence in the human, the endocrinologic and receptor-related aspects of an uterine leiomyosarcoma (LMS) are poorly understood when compared to what is known of, say, human endometrial cancer. Thus, to increase our understanding, we have succeeded, by the string method, in inducing an uterine LMS in the mouse and have studied the possibility of hormonal therapy as a method of treatment. The findings of our study are enumerated as follows: 1. The induced uterine LMS had an estrogen receptor, which was confirmed by a biochemical assay and, morphologically, by a PAP (the peroxidase anti-peroxidase technique); 2. The growth of this tumor was significantly inhibited by MPA (medroxyprogesterone acetate) therapy (100 mg/kg); 3. After MPA therapy, the estrogen receptor levels were increased, especially in the nucleus; and, 4. The growth of a secondary tumor, transplanted after the initial hormone therapy, was not inhibited by the readministration of MPA. Our results suggest that this experimentally-induced uterine LMS in the mouse provides a useful means to study therapeutic treatment, and may assist in furthering our understanding of human uterine LMS and lead to finding an effective therapy.

[Squamous cell carcinoma with a sarcomatoid variant of the vagina]

A case of squamous cell carcinoma with a sarcomatoid variant, usually called a spindle cell carcinoma, located in the vagina of a postmenopausal woman is reported. Although a cytologic examination of a smear of the scraped tumor showed the coexistence of sarcomatous spindle and keratinizing carcinomatous cells, the first bioptic specimen consisted only of sarcomatous tissue. Further histologic, immunohistochemical and ultrastructural examinations succeeded in making a definite diagnosis of a squamous cell carcinoma with a sarcomatoid variant. We would like to emphasize that combined cytologic and histologic examinations led us to make a correct diagnosis after discussing the differential diagnosis.

[Clinico-pathological study of the partial hydatidiform mole]

We studied 302 spontaneous abortuses with no molar swelling of villi (S.Ab.) and 156 partial moles (P.M.), clinico-pathologically. The results were as follow: The estimated "in utero retention time" of the conceptus of S.Ab. and P.M. was 24.8 +/- 13.1 days (n = 63) and 45.9 +/- 10.7 days (n = 37), respectively (p less than 0.01). Among the cases with "in utero retention time" of 4 or more weeks, 9 of 35 S.Ab. and 32 of 37 P.M. showed no degenerative change of trophoblasts. IgG was localized on the cell membrane of the syncytiotrophoblasts in 19 of 63 S.Ab. and 27 of 37 P.M. (p less than 0.01). IgM was also localized on the cell membrane of syncytiotrophoblasts in 29 of 63 S.Ab and 6 of 37 P.M. (p less than 0.01). Six patients (3.85%, 6/156) with P.M. received operative procedure and/or chemotherapy after evacuation of the mole. Four had invasive mole, on had metastatic lesion in the lung and one had persistent trophoblastic disease. Four of these six patients with subsequent disease were 40 years of age or older. All patients with partial mole needed hCG assay monitoring because of the risk of abnormal sequelae.

[Regional registration study of uterine neoplasia in Niigata Prefecture]

In this study, we examined the incidence of the uterine neoplasia in Niigata prefecture on the basis of the data collected by the Niigata Gynecologic Cancer Registry between 1982 and 1984. The results are as follows: The registered cases with dysplasia (Dysp.), cervical carcinoma in situ (CIS), cervical invasive carcinoma (Inv. Ca.) and endometrial carcinoma (End. Ca) were 358, 147, 530 and 141, respectively. One hundred and ninety-six cases with Dysp., 81 cases with CIS, 99 cases with Inv. Ca. and 10 cases with End. Ca. were detected by mass cancer screening. The crude incidence rate for Dysp., CIS, Inv. Ca. and End. Ca. was 9.44, 3.88, 13.98 and 3.72, respectively. The age standardized incidence rate (all age, world population) for Dysp., CIS, Inv. Ca. and End. Ca. was 7.48, 3.08, 9.45 and 2.63, respectively. The age standardized incidence rate (over 30 years, world population) for Dysp., CIS, Inv. Ca, and End. Ca. was 16.48, 6.77, 21.00 and 5.90, respectively. The lifetime incidence rate for uterine carcinoma in women aged 0 approximately 75 years was 1.65%.

[Clinico-pathological study of choriocarcinoma localized in the lung with emphasis on hCG monitoring systems]

We studied 15 cases of lung choriocarcinoma clinico-pathologically with emphasis on hCG monitoring systems. The results are as follows: Vivid tumor cells (VTC) were found to persist in 83.3% (5/6) of cases with a continued "LH level" of urinary hCG over 4 weeks. VTC were found to persist in all 4 cases with cellular response and in 6 of 8 cases with no cellular response. The syncytial cell element was observed in 75% (3/4) of cases with cellular response, but in only 25% (2/8) of cases with no cellular response. VTC were recognized in 83.3% of cases (5/6) with serum beta-hCG higher than the sensitivity of the beta-hCG-RIA system (0.2 ng/ml or 1.5 miu/ml). Even though serum beta-hCG was lower than 0.2 ng/ml or 1.5 miu/ml, VTC were found to persist in 2 of 3 cases. All of 5 cases with beta-hCG-CTP higher than the sensitivity of beta-hCG-CTP-EIA (Enzyme-Immuno-Assay) system (0.2 miu/ml) showed VTC in operative specimens. These results indicate that beta-hCG-CTP-EIA is a most useful means to employ in the monitoring of serum hCG.

[Endocrinological and clinico-pathologic study of granulosa-theca cell tumors of the ovary]

Nine granulosa-theca cell tumors (four pure theca cell tumors, one granulosa cell tumors, two granulosa-theca tumors and two juvenile granulosa-theca tumors) were studied endocrinologically and clinico-pathologically. The cases of juvenile granulosa-theca tumors developed precocious pseudopuberty. Three of seven other cases were re-feminized and four cases showed no hormonal manifestation clinically. The peripheral vein serum values of estradiol, progesterone, testosterone and prolactin were elevated in six of eight cases, three of four cases, four of six cases, and two of three cases, respectively. The concentration ratios between tumor harboring ovarian vein samples and peripheral vein (or opposite normal ovarian vein) samples was 2.7 to 16.9 for estrone, 8.8 to 28.6 for estradiol, 3.6 to 4.7 for progesterone, 1.6 to 6.6 for testosterone and 0.6 to 1.0 for prolactin. Estradiol was localized in both granulosa cells and theca cells, and testosterone was localized in granulosa cells in half of the cases and in theca cells in 60% of the cases. Also, testosterone was localized in all three cases in which luteinized theca cells were present. There were no cases with positive prolactin localization. These results are compatible with the concept that in granulosa-theca cell tumor, both granulosa and theca cells can produce a wide range of steroid hormones.

[Pathological and endocrinological study of epithelial ovarian tumors in post-menopausal women]

We have studied 37 cases of ovarian epithelial tumors in post-menopausal women, histopathologically and endocrinologically. The normal values for androstenedione, estrone, estradiol and progesterone in healthy post-menopausal women were less than 83 ng/dl, 75 pg/ml, 30 pg/ml and 0.6 ng/ml, respectively. The numbers of cases, the serum values for which were higher than normal, were 9 of 16 (androstenedione), 9 of 16 (estrone), 22 of 29 (estradiol) and 14 of 20 (progesterone). The serum levels of these 4 sex hormones in cases with ovarian stromal condensation (stromal cell hyperplasia) were higher than normal in 8 of 11 (androstenedione), 8 of 11 (estrone), 17 of 19 (estradiol) and 9 of 12 (progesterone), whereas those in cases with no stromal condensation were elevated in 1 of 5, 1 of 5, 5 of 8 and 5 of 7, respectively. After complete removal of the tumors, these elevated sex hormone levels dropped to normal. After the dexamethasone suppression test, the suppression rates for cortisol, 17-OHCS and 17-KS were 4 times as great as those of DHEA-S (dehydroepiandrosterone-sulfate), estrone, estradiol and progesterone. 17 beta-estradiol was localized in hyperplastic ovarian stromal cells in all cases with stromal condensation. We concluded that many of the ovarian epithelial tumors produce these sex hormones and that hyperplastic stromal cells are the source an increased amount of serum estradiol.

[A clinicopathological study of 11 patients with Paget's disease of the vulva]

A clinicopathological analysis of 11 patients with Paget's disease of the vulva was reported. A close association of this disease with cancer was strongly suggested in the histological examination. Nine of 11 patients had wide primary lesion; 4 patients had coexisting undifferentiated carcinoma (one patient with in situ sweat gland carcinoma) and one patient had squamous cell carcinoma in other lesion of the vulva. Five patients had downward growth of the tumor from the epidermis proper. There were, thus, only two patients who had Paget's cells confined within the epidermis. Three patients died of generalized metastasis of carcinoma and two patients had vulvar recurrence. The results of staining for PAS, PAS diastase resistant reaction, alcian blue, mucicarmin and carcinoembryonic antigen (CEA) were all positive in specimens with similar stainings to coexisting undifferentiated carcinoma of the vulva and metastasized lesions. CEA staining was positive in cytoplasm of Paget's cells and basal cells widely in the epidermis. It could be considered that the Paget's cells of the vulva originated multifocally from primitive stratum germinativum, which gave rise to the surface epithelium as well as all of the dermal appendages.

[Effect, toxicity and tissue concentration in the clinical use of cis-diamminedichloroplatinum (II)]

The tissue cis-diamminedichloroplatinum (II) (CDDP) concentration was measured in autopsies treated with CDDP therapy for gynecological malignancies. These cases consisted of 10 of ovarian tumor and one of choriocarcinoma. Total CDDP doses administered were from 55mg to 560mg and among them three cases were treated with more than 500mg (525mg, 555mg in ovarian cancer and 560mg in choriocarcinoma). We found moderate renal impairment with this drug by serum functional test and histopathology, although these changes did not correspond with the total doses. In liver, kidney and residual tumor measured for CDDP, the tissue concentration was highest in liver. When total doses administered were compared with the tissue concentration in liver, kidney, residual tumor and the decrease in creatinine clearance value, there were statistically significant differences only in residual tumor at p less than 0.01.

[On the follow up period of postmolar patient (author's transl)]

We discussed how long should postmole patients be followed up by the analysis of 44 cases of postmolar invasive mole and 14 cases of postmolar choriocarcinoma treated in our hospital between 1971 and 1979. All of the invasive mole have been detected before their urinary hCG titer fell below normal pituitary LH level and by the 5 th month after the termination of molar pregnancy. While only 2 cases out of 14 cases of postmolar choriocarcinoma have been detected before their urinary hCG titer fell below LH level and by the 5 th postmole month. The other 12 cases of choriocarcinoma were diagnosed later than the 6 th postmole month. The longest interval between termination of mole and diagnosis of postmolar choriocarcinoma was 7 years and 2 months, the interval of which was also the longest among all of the postmolar choriocarcinoma registered to the Committee of Registration for Trophoblastic Disease in Japan Society of Obstetrics and Gynecology in 1974 through 1978. Therefore from the empirical point of view, the postmole patient should be followed up to 7 years and 2 months at the shortest. Besides almost all of the secondary sequelae after mole which were detected before urinary hCG titer fell below LH level were actually invasive mole (44 cases). Choriocarcinoma (2 cases) in this stage was exceptional (2 cases/46 cases = 4.4%). On the other hand, once the molar patient showed normal LH level in their urinary hCG determination, the secondary sequela was invariably choriocarcinoma. This way of discriminating invasive mole from choriocarcinoma is the key in the management of postmolar patient.

[Studies on the appropriate frequency of the cervical cancer screening (author's transl)]

A total of 73,897 cases of women above 30 years old were screened for their cervical cancer by Pap smear in Niigata prefecture in 1978 and 1979. From them 37 cases of invasive cancer (0.05%) including a case of endometrial adenocarcinoma, stage II, 30 cases of carcinoma in situ (0.04%), and 52 cases of dysplasia (0.07%) were detected. From the correlation between the check up frequency of these patients and the cervical malignancy detected, the following were pointed out: 1) No invasive cancer but carcinoma in situ were detected from those patients who were cytoscreened by successive annual visits. 2) Stage Ia but not more advanced cervical cancer were detected from those patients who were screened at 2 years interval. 3) Stage Ib or farther advanced cervical cancer were detected from those patients who visited at 3 years or more years interval just like from those patients who visited for the first time. To detect cervical cancer in its preinvasive stage, annual Pap smear of adult women over 30 years old should be continued.

Bacteriocin-like substance (melaninocin) from oral Bacteroides melaninogenicus

A bacteriocin-like substance, designated melaninocin, was extracted from a strain of Bacteroides melaninogenicus by ultrasonic treatment and purified. Melaninocin was heat labile and was destroyed by digestion by several proteolytic enzymes. Among the oral indigenous microorganisms, Bacteroides, Actinomyces, and streptococci were found to be sensitive to melaninocin.

Depression of heart function after angiotensin II infusion in patients on chronic hemodialysis

The response of heart function to angiotensin II (AT II) was studied in 18 patients on regular hemodialysis. The mean age was 33 years and they had been dialyzed for 55 months in the average. AT II was infused from a large vein and systolic blood pressure was raised by 40 mmHg. Before and after the change in blood pressure, M-mode echocardiogram of left ventricle was recorded. Left ventricular enddiastolic dimension, stroke index and cardiac index were found to be normal except for 9 patients who showed cardiac index above 4.0L/min/m2. No significant change was found in these parameters after the rise of blood pressure by AT II. Control ejection fraction (EF) was slightly but nonsignificantly lower in the patients than the healthy subjects; 0.73 +/- 0.13 vs. 0.80 +/- 0.05. Though significant falls in EF were found in the patient and in the healthy group, the former showed a profound depression of EF to 0.64 +/- 0.10. This value was significantly lower than the value of the latter group; 0.76 +/- 0.04 (p less than 0.01). Since none had overt heart failure, a depression of EF after AT II can be regarded as subclinical abnormality of heart function. AT II will be useful to detect this limited reserve of heart function in patients on regular hemodialysis who may show normal function at rest.

[Cellular localization of alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and carcinoembryonic antigen (CEA) in malignant germ cell tumors of the ovary using immunoperoxidase technique (author's transl)]

An immunohistologic study of germ cell tumors of the ovary was undertaken to investigate a correlation of the histology with the presence of alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and carcinoembryonic antigen (CEA) in the tissue specimens. A positive reaction for AFP was consisted of dark brownblack granular intracytoplasmic deposits and some of hyaline globules were also positive in some instances. There was tissue localization of AFP in 9 of 10 embryonal carcinomas (endodermal sinus tumor, Teilum) and in 4 of 5 solid teratomas. Two patients with embryonal carcinoma positive for AFP had normal serum level in AFP. A positive staining for HCG was found in 4 embryonal carcinomas and in 2 solid teratomas; it was consisted of dark brown cytoplasmic deposits localized exclusively to syncytiotrophoblast giant cells. The tumor cells positive for AFP but negative for HCG, and vice vasa indicated that these two carcinoembryonic proteins were produced by different cells. The localization of CEA was also studied in 3 embryonal carcinomas. None of embryonal carcinomas and 3 solid teratomas were reacted to CEA; it was consisted of a dark brown deposit localized in cell surface of stratified squamous cells and tall columnar cells forming glandular structure. All of the histologically immature neural components were negative for these carcinoembryonic proteins.

[A correlation between the histological parameters such as stromal reaction and cell-mediated immune-structure of the regional lymph nodes, and the delayed cutaneous hypersensitive reaction toward DNCB in cervical cancer (author's transl)]

We have studied a correlation between the histological parameters such as stromal reaction to cervical cancer and cell-mediated immune response of the regional lymph nodes designated as lymphocyte depletion, unstimulated, and lymphocyte predominance pattern which were thought to reflect the cell-mediated immune reaction to cervical cancer and the DNCB skin reaction in 84 patients. 1) Group with DNCB skin reaction negative (20 cases): Eight showed no or only the slightest trace, 7 moderate degree, and 5 marked degree of the stromal reaction. The immune response of the regional lymph nodes were 4 of lymphocyte depletion, 6 of unstimulated and 10 of lymphocyte predominance pattern. 2) Group with DNCB skin reaction positive (64 cases): This group showed 7 cases with no or only the slightest trace, 30 cases with moderate degree and 27 cases with marked degree of the stromal reaction. In this group, 6 had the regional lymph nodes of lymphocyte depletion, 10 unstimulated and 48 lymphocyte predominance pattern. 3) There was a significant correlation between the DNCB skin reaction and the degree of stromal reaction (p less than 0.05), but no correlation between the DNCB skin reaction and the regional lymph node morphology was found in this study (p greater than 0.05). 4) The discrepancy between the stromal reaction, the lymph node morphology and the DNCB skin reaction was discussed in relation to the significance of these parameters.