A case of recurrent follicular cholangitis leading to decompensated cirrhosis after left-sided hepatectomy

Follicular cholangitis (FC) is a rare non-neoplastic biliary tract disease first reported in 2003. A 74-year-old woman underwent extended left hepatectomy with a diagnosis of intrahepatic cholangiocarcinoma. Histopathological examination of the surgical specimen demonstrated no malignant findings, and lymphocytic infiltration with lymphoid follicles was observed within the bile duct wall. Along with immunohistochemical findings, the patient was diagnosed with FC. More than 3 years after surgery, the patient exhibited elevated hepatobiliary enzymes and total bilirubin. Endoscopic retrograde cholangiography revealed stricture and dilation from the extrahepatic bile duct to the right intrahepatic bile duct. Histopathological findings uncovered lymphocytic infiltration without malignant results. It was concluded that bile duct stricture due to FC had newly developed in her remnant liver. Subsequently, the patient developed hypoalbuminemia, and abdominal computed tomography revealed atrophy of the remnant liver and ascites accumulation. Esophagogastroduodenoscopy exposed the development of esophageal varices, which were not observed preoperatively. The patient was diagnosed with decompensated liver cirrhosis accompanied by portal hypertension. This case strongly suggests that long-term follow-up after surgery may be required for patients with FC for screening of potential new bile duct stricture and progression to liver cirrhosis due to cholestasis.

Primary Hepatic Other Iatrogenic Immunodeficiency-Associated Lymphoproliferative Disorders After Methotrexate Therapy

Prior reports described cases of lymphoproliferative diseases occurring after methotrexate (MTX) administration, which are called methotrexate-associated lymphoproliferative disorders (MTX-LPDs). It has become clear that these lymphoproliferative diseases also occur following treatment with other immunosuppressive drugs, and they have been termed as other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPDs). In most of these cases, the duration of immunosuppressive drugs is very long, on the order of years. In the present study, we evaluated the development of lymphoproliferative disease despite the short duration of immunosuppressive treatment and determined the tumor doubling time. A 71-year-old woman was diagnosed with adult-onset Still's disease. The patient was administered prednisone 30 mg per day starting on February 25, 2022 and MTX 6 mg per week starting 2 weeks later. Because she was a hepatitis B virus (HBV) carrier, nucleic acid analog therapy was also started to prevent HBV activation. Eight weeks later, biweekly tocilizumab was started. After 5 months of MTX administration, a solitary liver tumor measuring 37 × 32 mm2 was detected. Three months later, repeat computed tomography revealed that the liver tumor had grown rapidly to 7 cm in diameter. We considered the possibility of OIIA-LPDs and stopped MTX therapy. Biopsy specimens of the liver tumor exhibited lymphocyte proliferation, which was consistent with OIIA-LPDs. The doubling time for tumor growth was 33 days. Despite withdrawing MTX for 6 weeks, the tumor continued to grow, and thus, the patient was referred to the hematology unit. In previously reported cases of MTX-LPDs of hepatic origin, the average duration of MTX administration was 7.3 (2 - 13) years. This report describes a primary hepatic OIIA-LPDs-associated tumor that rapidly increased in size after an extremely short period of MTX administration.

Not Only Hypoxia- but Radiation-Induced Epithelial-Mesenchymal Transition Is Modulated by Hypoxia-Inducible Factor 1 in A549 Lung Cancer Cells

Hypoxia leads to post-treatment metastasis and recurrences of cancer via the epithelial-mesenchymal transition (EMT). Radiotherapy itself may also contribute to the acquisition of EMT phenotypes. Despite extensive studies on the EMT driven by either hypoxia or radiation stimuli, the molecular mechanisms characterizing these EMT events remain unclear. Thus, we aimed to evaluate the differences in the molecular pathways between hypoxia-induced EMT (Hypo-EMT) and radiation-induced EMT (R-EMT). Further, we investigated the therapeutic effects of HIF-1α inhibitor (LW6) on Hypo-EMT and R-EMT cells. A549 cells, lung adenocarcinoma cell line, acquired enhanced wound-healing activity under both hypoxia and irradiation. Localization of E-cadherin was altered from the cell membrane to the cytoplasm in both hypoxia and irradiated conditions. Of note, the expression levels of vimentin, one of the major EMT markers, was enhanced in irradiated cells, while it decreased under hypoxia condition. Importantly, LW6 significantly blocked EMT-related malignant phenotypes in both Hypo-EMT cells and R-EMT cells with concomitant re-location of E-cadherin onto the cell membrane. Moreover, LW6 deflected stress responsive signalling, JNK, activated sustainably under hypoxic condition, and the blockage of JNK impaired EMT phenotypes. Together, this work demonstrated the molecular events underlying Hypo-EMT and R-EMT, and highlighted HIF-1α as a therapeutic target not only in Hypo- EMT, but also in R-EMT.

Clinical Results of Accelerated Hypofractionated Radiotherapy for Central-Type Small Lung Tumours

Purpose: We evaluated the efficacy and toxicity of accelerated hypofractionated radiotherapy (AHYPOF-RT) for central-type small lung tumours. Methods: Between November 2006 and January 2015, 40 patients with central-type small lung tumours underwent AHYPOF-RT delivered using 10 MV X-rays and a coplanar 3-field technique. The number of fractions ranged from 24 to 28, with a fraction size of 2.5–3 Gy. A total dose of 69–75 Gy to the isocentre of the planning target volume was administered to each patient. Cumulative survival and local control rates were calculated using the Kaplan–Meier method. Results: The 27 men and 13 women enrolled in the study had a median age of 79 years (range: 60−87 years). The tumour stage was T1a in 9 patients, T1b in 17 patients, and T2a in 14 patients, with a median size of 26.5 cm (range: 11–49 cm). The median follow-up period was 23 months. A complete response was achieved in 3 patients (7.5%), and a partial response, in 17 patients (42.5%). The overall 2-year and 3-year local control rates were 87.3% and 81.8% respectively; the 2-year and 3-year overall survival rates were 78.9% and 66.7% respectively. Grade 3 pneumonitis occurred in 3 patients; no other severe adverse events (≥grade 3) were observed in any patient. Conclusions: Accelerated hypofractionated radiotherapy using a fraction size of 2.5–3 Gy was highly safe and can be a more effective treatment option than conventional radiotherapy for patients with central-type small lung tumours.

Preliminary results of proton-beam therapy for stage III non-small-cell lung cancer

BACKGROUND

We conducted a preliminary retrospective evaluation of the efficacy and toxicity of proton-beam therapy (pbt) for stage iii non-small-cell lung cancer.

METHODS

Between January 2009 and August 2013, 27 patients (26 men, 1 woman) with stage iii non-small-cell lung cancer underwent pbt. The relative biologic effectiveness value of the proton beam was defined as 1.1. The beam energy and spread-out Bragg peak were fine-tuned such that the 90% isodose volume of the prescribed dose encompassed the planning target volume. Of the 27 patients, 11 underwent neoadjuvant chemotherapy. Cumulative survival curves were calculated using the Kaplan-Meier method. Treatment toxicities were evaluated using version 4 of the Common Terminology Criteria for Adverse Events.

RESULTS

Median age of the patients was 72 years (range: 57-91 years), and median follow-up was 15.4 months (range: 7.8-36.9 months). Clinical stage was iiia in 14 patients (52%) and iiib in 13 (48%). The median dose of pbt was 77 GyE (range: 66-86.4 GyE). The overall survival rate in the cohort was 92.3% at 1 year and 51.1% at 2 years. Locoregional failure occurred in 7 patients, and distant metastasis, in 10. In 2 patients, initial failure was both locoregional and distant. The 1-year and 2-year rates of local control were 68.1% and 36.4% respectively. The 1-year and 2-year rates of progression-free survival were 39.9% and 21.4% respectively. Two patients experienced grade 3 pneumonitis.

CONCLUSIONS

For patients with stage iii non-small-cell lung cancer, pbt can be an effective and safe treatment option.

In vivo pharmacological characterization of AC-3933, a benzodiazepine receptor partial inverse agonist for the treatment of Alzheimer's disease

GABAergic neurons are known to inhibit neural transduction and therefore negatively affect excitatory neural circuits in the brain. We have previously reported that 5-(3-methoxyphenyl)-3-(5-methyl-1,2,4-oxadiazol-3-yl)-1,6-naphthyridin-2(1H)-one (AC-3933), a partial inverse agonist for the benzodiazepine receptor (BzR), reverses GABAergic inhibitory effect on cholinergic neurons, and thus enhances acetylcholine release from these neurons in rat hippocampal slices. In this study, we evaluated AC-3933 potential for the treatment of Alzheimer's disease, a disorder characterized by progressive decline mainly in cholinergic function. Oral administration of AC-3933 (0.01-0.03mg/kg) resulted in the amelioration of scopolamine-induced amnesia, as well as a shift in electroencephalogram (EEG) relative power characteristic of pro-cognitive cholinergic activators, such as donepezil. In addition, treatment with AC-3933 even at the high dose of 100mg/kg p.o. produced no seizure or anxiety, two major adverse effects of BzR inverse agonists developed in the past. These findings indicate that AC-3933 with its low risk for side effects may be useful in the treatment of Alzheimer's disease.

[Clinical evaluation of severe toxicity in two patients with acute lymphoblastic leukemia receiving outpatient methotrexate therapy]

Methotrexate (MTX) is now widely used for the treatment of acute leukemia and non-Hodgkin lymphoma in the pediatric oncology field and is thought to be one of the key drugs for this treatment. A regimen utilizing high dose MTX (HD-MTX) with leucovorin rescue is being investigated as effective chemotherapy in the patients with these kinds of cancer. Relatively large amounts of MTX (225 mg/m2) are given to such outpatients by intravenous push as a course of maintenance therapy. It is said that those amounts will infuse safely. However, we experienced two serious cases-patients T.H. and M.Y.--which developed into severe side effects after this treatment. Both patients showed acute renal failure, severe myelosuppression, erosion around the oral and anal region, and continuous diarrhea. Judging from the serum concentration of MTX, patient T. H. was exposed to more than the maximum allowance serum MTX level for 9.6 days, patient M. Y. for 6.5 days. This suggests physicians must pay attention to the clinical symptoms even after treatment using MTX without HD-MTX.

[Cytogenetic studies on 53 childhood acute nonlymphocytic leukemia]

Cytogenetic study in 53 children (aged less than 15 years) with acute non-lymphocytic leukemia (ANLL) were studied. The cytogenetic findings were compared with those of ANLL patients (136 aged less than 19 years and 747 aged over 20 years) in the Fourth International Workshop on Chromosomes in Leukemia (IV IWCL) and also with those of childhood acute lymphoblastic leukemia (ALL) cases (previously reported as our 124 ALL case). Of the ANLL patients, 77.4% had acquired chromosomal clonal abnormalities. As abnormalities, t(15;17), all cases which were seen in M3 or M3V cases, t(8;21), which was seen in M1 or M2, and rearrangements of 11q23, which were seen in M5, were more frequently seen than was reported at the IV IWCL (20.8%, 17.0% and 7.5% vs 6.3%, 6.3% and 3.2% respectively). 5q-, monosomy 7, t(6;9) and t(9;22), which have been noted previously in this disease, were not seen. Besides structural abnormalities, some cytogenetic differences in numerical abnormality between ALL and ANLL were observed as follows: 1) Hyperdiploidy of greater than 51 chromosomes noted in ALL was not found in ANLL. 2) Isolated trisomy 8 was frequently found in ANLL, but not in ALL. 3) Loss of a sex chromosome was frequently found in ANLL, but not in ALL. Our study revealed a different frequency of non-random chromosome abnormality in children with ANLL as compared with that of adults, and clarified the differences in numerical abnormalities, as well as structural abnormalities, between ALL and ANLL.

[Significance of the 14q32 translocations in childhood acute lymphoblastic leukemia]

To assess the frequency and significance of 14q32 translocation abnormalities in childhood acute lymphoblastic leukemia (ALL) and the differences between the clinical and cytogenetic features of patients with the 8; 14 translocation and those of patients with other 14q32 translocations, we analyzed our experience with 124 consecutive cases with completely banded karyotype. Eight cases (6.5%) with 14q32 translocation were identified :5 with the 8; 14 translocation and 3 with other 14q32 translocations. As compared with ALL children lacking 14q32 translocations, these 8 cases had a higher serum lactic dehydrogenase (LDH) level, more L3 (FAB classification), and a poorer outcome. On the other hand, in comparison with ALL patients with other 14q32 translocations, patients with the 8:14 translocation were likely to be younger (median age 4.5 years vs 10.4 years), to have a higher serum LDH level (median 5832 IU/l vs 504 IU/l), to have more L3 (3/5 vs 0/3), to have a higher induction failure rate (4/5 vs 1/3), and to have more partial duplication of the long arm of chromosome 1 (4/5 vs 0/3). These results helped clarify the characteristic features of ALL children with 14q32 translocations and showed that ALL children with the 8 ; 14 translocation have different clinical and cytogenetic findings from those of ALL children with other 14q32 translocations.

[Transient abnormal myelopoiesis followed by acute leukemia in children with Down syndrome]

This report describes three cases with Down's syndrome. These cases initially had transient abnormal myelopoiesis (TAM), from which they recovered spontaneously. They finally developed into overt acute leukemia characterized by an increase of blasts, hepatosplenomegaly, and elevated lactic dehydrogenase. Of these three cases, one was thought to have ANLL, which broke out 5 months after spontaneous remission. The other two had ALL, each occurring 8 and 9 years later. Chromosomal abnormality, in addition to trisomy 21, was detected in blast cells from one of the patients with acute leukemia. All three patients with acute leukemia experienced complete remission. However, two of the three patients relapsed and died. It is noted in the literature that remission is permanent in most cases of TAM, and is rarely terminated by leukemic relapse. In view of our observations, the importance of following up on such patients who evidence apparent remission of their leukemia-like disorder is emphasized.

[Septicemia in children with malignant disease]

Severe infection is a major cause of morbidity and mortality in patients with malignancy. In this study, 34 episodes of septicemia occurred in 1,468 childhood patients with malignancy who admitted and were treated at National Sapporo Hospital between 1979 and 1988. The occurrence of septicemia and its mortality rate were higher in malignant hematologic disease than in malignant solid tumor. Most cases of septicemia occurred in relapse. The most frequent organism causing septicemia were Klebsiella pneumoniae (16.3%) and Staphylococcus epidermidis (16.3%). Septicemia due to Gram-negative organism was more frequent than that of Gram-positive organism or fungus. Polymicrobic septicemia occurred 3 times and multiple episodes 6 times. They had a high mortality rate. Neutropenia was strongly associated with episode of septicemia. In our series, absolute neutrophil count under 500 per microliter developed septicemia. Especially, children with less than 100 granulocytes per microliter had a major risk factor for the development of infection and death. No children with granulocyte count greater than 1000 per microliter died in connection with septicemia.

[Role of the serotonergic nervous system in hemodynamic and vasopressin responses to centrally administrated angiotensin-II in spontaneously hypertensive rats]

The purpose of the study is to investigate the role of the serotonergic nervous system in centrally administrated angiotensin II (A-II) mediated hemodynamic as well as vasopressin (AVP) responses. Eight-week-old male SHR and age-matched Wistar Kyoto rats (WKY) were used and the experiment was performed in the conscious state. In protocol 1, after resting observation of 30 minutes 10ng of A-II was given intracerebroventricularly (i.c.v.). This was followed by i.c.v. injection of 1 microgram of 5-HT2 receptor antagonist, xylamidine, 50 minutes later; then 10ng of i.c.v. A-II was repeated after 10 minutes (SHR: n = 7, WKY: n = 10). In protocol 2, plasma vasopressin (AVP) was measured in the following groups. In one group, 1.3ml of blood was sampled from the carotid cannula after resting observation, and the same amount of blood from an age-matched donor rat of the same strain was transfused immediately. Two hours later, 10ng of A-II was given i.c.v., and blood was sampled again after 1 minute (SHR: n = 7, WKY: n = 12). In another group, 1 microgram of xylamidine was given i.c.v. and was followed by 10ng of A-II 10 minutes later; then blood was collected after 1 minute (SHR: n = 8, WKY: n = 13). In protocol 1, resting MAP were 144 +/- 6mmHg in SHR and 99 +/- 2mmHg in WKY. I.c.v. A-II elicited a consistent pressor response in both SHR and WKY, but the response was significantly larger in SHR than that in WKY, +45 +/- 3 and +37 +/- 1mmHg, respectively. Xylamidine had no effect on MAP, and repeated A-II produced significant pressor responses. However, the responses were significantly smaller in both SHR (+36 +/- 3mmHg) and WKY (+25 +/- 1mmHg) as compared with those to initial A-II injection. In protocol 2, resting AVP were similar in SHR (1.5 +/- 0.2pg/ml) and in WKY (1.6 +/- 0.1pg/ml). However, after i.c.v. A-II injection, AVP became higher in SHR (131 +/- 14pg/ml) than in WKY (64 +/- 6pg/ml). AVP after A-II injection with xylamidine pretreatment were similar in SHR (48 +/- 6pg/ml) and in WKY (45 +/- 4pg/ml). Since the responses of both MAP and AVP to i.c.v. A-II were larger in SHR, and the responses were effectively suppressed by S2 receptor antagonists, the central serotonergic nervous system may play an important role in the hemodynamic as well as AVP responses to i.c.v. A-II administration.

[Evaluation of the role of surgery in 25 patients with metastatic neuroblastoma]

The role of surgery was evaluated using a recently proposed TNM staging system in metastatic neuroblastomas. Of twenty-five patients, twenty-four were over 1 year, 1 case was 3 months old, nine were boys, sixteen were girls, and all were stage IV using Evans-D'Angio staging system (excluding IV-s). They were retrospectively assigned a TNM clinical stage (CS) preoperatively and a pathologic stage (PS) postoperatively. All twenty-five patients were CS 4 using this TNM staging system. The role of surgery was evaluated by analyzing survival according to the postoperative PS. PS 1-2-3A were regarded as satisfactory resections, since all macroscopic tumor was removed, while PS 3B-3C-4-5 were regarded as unsatisfactory resections. With Kaplan-Meier analysis, there was a slight survival advantage when satisfactory resection of the primary tumor was achieved in the cases with any evidence of metastasis at the time of operation. However, in the cases with no evidence of metastasis at operation, there was a survival advantage when satisfactory resection of the primary tumor was done (p = 0.05). If metastatic disease is controlled prior to operation, total resection improves prognosis of metastatic neuroblastoma.

Karyotypic changes from initial diagnosis to relapse in childhood acute leukemia

Cytogenetic study was performed at both diagnosis and relapse in 31 children with acute leukemia who had initially abnormal karyotypes, 21 with acute lymphocytic leukemia (ALL) and 10 with acute nonlymphocytic leukemia (ANLL). Seventy percent of the patients showed karyotypic changes between diagnosis and relapse. The ALL patients showed karyotypic changes more often than the ANLL patients (76 vs. 40%)(chi-square test, p less than 0.05). All the initially abnormal patients with karyotypic changes exhibited structural changes, most frequently chromosome 1 abnormalities, especially in ANLL, and 6q-, 7p-, 9p- in ALL. Half of the patients, with structural karyotypic change had two or more clonally related cell lines at relapse. On the other hand, only 20% of the patients with karyotypic changes showed numerical changes. All but one of the initially abnormal patients showed karyotypic changes involving the original cytogenetically abnormal clone. Our study demonstrated that sequential cytogenetic studies may provide a better understanding of the nature of leukemia relapse.

[Clinical and cytogenetic features in childhood acute lymphoblastic leukemia with 1; 19 translocation]

We studied the clinical and cytogenetic features of 14 acute lymphoblastic leukemia (ALL) patients with 1; 19 translocation. Ten patients had poor prognostic factors such as age over 10 years, hyperleukocytosis over 5 X 10(4)/microliters or high serum lactic dehydrogenase levels over 5,000 IU/l. Two patients had relapsed within 12 months after the onset, but their 5-year survival rate was 84.6%. Cytogenetically, 6 of 14 patients had multiple subclones. Two had the clones with hyperdiploidy greater than 50 chromosomes, which was known to be one of the favorable prognostic factors in childhood ALL. These findings show ALL children with 1; 19 translocation have a more favorable outcome in spite of some high-risk features than hitherto been thought.

[Hyperdiploidy (greater than 50 chromosomes) has the most favorable prognosis among the major karyotypic subgroups of childhood acute lymphoblastic leukemia]

Thirty-four children, including nine relapsed cases with acute lymphoblastic leukemia (ALL) having hyperdiploidy (greater than 50 chromosomes) were studied on clinical and cytogenetic characteristics. The majority of children initially with hyperdiploidy (greater than 50 chromosomes), who showed favorable prognostic features such as lower leukocyte counts, lower serum lactic dehydrogenase levels, ages between 2 and 10 years, or the presence of common ALL antigen, had the most favorable outcome among childhood ALL (5-year survival rate was 100%). Even nine children, who showed poor prognostic features such as ages over 10 years, leukocyte counts over 2 X 10(4)/mm3 or lymphomatous signs, had also the same favorable outcome. There were no differences in clinical features between 6 patients with additional chromosomal structural abnormalities and 19 patients without them. Duplication of the long arm of chromosome 1 was frequently observed as additional chromosomal structural abnormalities. Patients with hyperdiploidy (greater than 50 chromosomes) observed at relapse, who had the same favorable clinical features as those at diagnosis, had a poorer prognosis. These findings show that initial hyperdiploidy (greater than 50 chromosomes) is an independent favorable prognostic sign in childhood ALL and additional chromosomal structural abnormalities may not indicate a poor prognosis among childhood ALL with hyperdiploidy (greater than 50 chromosomes). On the other hand, relapsed children with hyperdiploidy (greater than 50 chromosomes) have not a favorable outcome after the onset of relapse.

[Clinical and laboratory studies in seven patients with pre-B cell leukemia in children]

We have experienced and treated seven patients of pre-B cell leukemia in childhood. Clinical, cytological and ultrastructural characteristics of them were studied. Most of them had higher counts of white blood cells, hepatosplenomegaly, high value of lactic dehydrogenase and various karyotype abnormalities at onset. The chromosomal translocation t (1; 19) that is supposed to be specific to pre-B cell ALL was found in four of seven of our cases. In the seven patients, survival was studied in comparison to that of 27 common ALL patients at our hospital that are common in childhood acute leukemia. Although no difference in remission duration and survival time between pre-B cell ALL patients and common ALL group, there have been seen the tendency that remission and survival were of shorter duration for patients with pre-B cell ALL.

[Cutaneous malignant lymphoma in childhood]

Two cases of malignant lymphoma in childhood were studied. The first case was a Japanese girl aged 8, in whom the primary site was skin of the right temple. The second case was a 4-year-old Japanese boy, who had metastases to the abdominal skin. Histochemical findings indicated B-cell lineage in both cases. Primary cutaneous lymphoma is extremely rare in childhood. Fourteen such cases that have been reported in Japan and our case added to them, were reviewed. The relationship between their morphologic, immunohistochemical and clinical findings were summarized and discussed. Although the prognosis of lymphoma confined to skin in childhood has been reported not to be bad as compared with other types of lymphoma, our first such case was fatal. This suggests that appropriate initial treatment is very important. Recent advances in science may clarify the clinical and biologic characteristics of this tumor in the near future.

[BH-AC.AMP protocol in the treatment of refractory childhood acute leukemia]

Sixteen children with refractory hematological malignancies were treated with a combination of BH.AC, aclacinomycin-A, 6-MP and predonisolone (BH-AC.AMP protocol). They were ALL(6), ANLL(8), CML(1) and NHL(1). The CR ratio was 17% in ALL, 50% in ANLL, and blast crisis of CML was treated successfully but NHL failed in the induction remission. Major complications were vomiting, nausea, gastrointestinal bleeding, hematuria and hemorrhagic cystitis. More than 10 days or 120 mg/m2 administration of aclacinomycin-A was thought to induce more severe side effects.

[Therapy of advanced neuroblastoma by the protocol of the Welfare Ministry used by the Sawaguchi Group]

Five patients with advanced neuroblastoma were treated with the protocol of the Welfare Ministry used by the Sawaguchi group. This protocol consists of cyclophosphamide (CPM), vincristine (VCR), 4'-O-tetrahydropyranyladriamycin (THP-ADM) and cisplatinum (CDDP). Two patients treated with this protocol as the first therapy obtained partial remission. Two patients who had obtained complete remission before the treatment with this protocol remained in complete remission after the treatment. One patient who had shown poor response to the therapy given before treatment with this protocol also showed poor response to the protocol. The most significant side effect with this protocol was myelosuppression, the severity of which was closely related to the dose of THP-ADM. Damage to the liver, kidney and heart was not very significant. We advocate that patients with advanced neuroblastoma can obtain complete remission with the aid of surgery and radiotherapy, etc., if they are treated with the present protocol as the first therapy.

Role of central serotonergic (5-HT2) receptor in blood pressure regulation in rats

To investigate the role of the serotonergic nervous system in blood pressure regulation, 5 micrograms of 5-hydroxytryptamine (5-HT) was given i.c.v. before and after 1 microgram of i.c.v. xylamidine or 200 micrograms of i.c.v. ketanserin or 200 micrograms of i.v. ketanserin in conscious Wistar Kyoto rats. Also i.v. (0.5, 1, 2 micrograms) or i.c.v. (1 microgram) phenylephrine (PHE) were given before and after 1 microgram of i.c.v. xylamidine. I.c.v. 5-HT elicited a consistent pressor response of approximately 27mmHg and slight decrease in heart rate. MAP and heart rate did not change after xylamidine or ketanserin. Whereas pressor response to i.c.v. 5-HT after i.c.v. ketanserin or i.c.v. xylamidine was suppressed, it did not change after i.v. ketanserin. Neither i.c.v. nor i.v. PHE-induced pressor response was influenced by i.c.v. xylamidine pretreatment. These data suggest that the central 5-HT2 receptor may subserve pressor function in rats.

[The possibility of surgery for aged patients with gastric cancer]

The possibility of surgery for aged patients with gastric cancer has been studied. Of 484 cases who underwent a gastrectomy, patients 70 years of age or over amounted to 86 (20%). The postoperative mortality rate for these aged patients was 3% and the postoperative mortality rate with hospital deaths added from other causes than operative deaths was 7%. The postoperative mortality rate of aged patients who underwent total or proximal subtotal gastrectomy improved during the period between 1975-1983 compared with the period between 1967-1974. In the second period, there were no deaths among aged patients who underwent an R3-operation and/or a combine operation. This fact shows that operative procedures have become safer for aged patients.

[A study of multiple primary cancers of the stomach and other organs]

The incidence of associated synchronous or heterochronous malignant tumors in this series was 3.3% (21/633). These patients were found more in multiple cancer than single cancer of the stomach. A relatively high incidence of associated cancer of other organs was found with cancer of the large bowel and of the cervix in heterochronous cancer and cancer of the esophagus in synchronous tumors. The cumulative corrected 10-year survival rate of 15 cases of heterochronous tumors was 85.7%. On the other hand, six patients with synchronous tumor had more advanced cancer of other organs than gastric cancer, and four of them died due to cancer of other organs within two years. Both primaries should be found at the early stage and treated with curative surgery and/or radiotherapy.

[Clinico-pathological study and surgical treatment of cancer of the greater curvature of the stomach]

We retrospectively studied the clinicopathological features and surgical treatment of patients with cancer of the great curvature seen between 1967--1977. The incidence of cancer of the greater curvature in gastrectomized patients was 11% (31/281): this was the least frequent of four locations. Curatively resected patients, the five-year survival rate of those with cancer of the greater curvature was 50%, significantly lower than in patients with cancer of the anterior and posterior wall. Factors influencing the survival rate were age, size of the tumor, stage of the cancer, the presence of poorly differentiated adenocarcinoma, and relative curative resection. To improve the results of surgical treatment, early diagnosis and extended lymph node dissection are essential.

Effects of surgical treatment and adjuvant chemotherapy studied by the depth of penetration in gastric cancer patients undergoing curative gastrectomy

This report concerns 133 of 377 patients with gastric cancer who underwent curative gastric resection at the First Department of Surgery, Shinshu University Hospital, between January 1, 1967, and December 31, 1975. The effects of surgical treatment and adjuvant chemotherapy were investigated for every depth of penetration into the gastric walls. The 5-year survival rate was 41.7% among patients subjected to gastrectomy and 61.7% among those treated by curative gastrectomy. The 5-year survival rate decreased along with increased depth of invasion. Following surgical treatment, the 5-year survival rate was higher in the patients who underwent absolute curative resection than in those who were subjected to relatively curative resection. Extended radical gastrectomy is needed for patients with the depth of invasion through the muscularis propria. It is necessary to complement chemotherapy for patients with lymph node metastasis who are subjected to relative curative gastrectomy. In the patients with serosal invasion, papillary and tubular adenocarcinoma decreased and poorly differentiated adenocarcinoma increased substantially. The patients with poorly differentiated adenocarcinoma had a poorer prognosis than did those with tubular adenocarcinoma. Some ideas for the treatment of poorly differentiated adenocarcinoma are earnestly hoped for.

Surgical treatment of the radiation injured bowel

Over the last 10 years, 9 patients treated by surgical procedure for radiation injuries of the bowel were studied with the following conclusions: The damage to the small intestine caused by external irradiation leads to adhesion of the bowel, perforation and postoperative anastomotic dehiscence if the irradiated bowel is used in the anastomosis. Surgical treatment for the small intestine is resection of the damaged loop. In order to determine the extent of the resection it is important that during the operation fibrosis and obstruction of vessels in the submucosa and subserosa is examined by biopsy. On the other hand, rectal ulcer and/or rectovaginal fistula is chiefly caused by intracavitary application plus external irradiation. For these lesion Hartmann operation or colostomy is performed, and the postoperative course is uneventful.