[Telomerase activity in benign proliferative breast disease and breast cancer]

The application of telomerase activity is expected to serve as a reliable indicator of biological malignancy in breast tumors. We performed a study to quantify telomerase activity, the results of which revealed that this activity tends to be unexpectedly low in scirrhous carcinoma having low histological differentiation. It is therefore felt that additional studies at the tissue level using in situ hybridization will be required in the future. Although we think that atypical cystic duct is a true pre-cancerous lesion in the sense of having a high possibility of progressing into breast cancer, it will be interesting to determine whether or not the tissue is composed of cells having telomerase activity.

[A case of complete response of breast cancer with pulmonary metastases to combination therapy of 5'-DFUR and MPA]

This paper presents a case with lung metastases from breast cancer. Complete response was obtained by combined chemoendocrine therapy with 5'-DFUR and MPA. The patient was a 62-year-old female. She underwent a standard radical mastectomy in April, 1988. The primary legion was ER (-) and PgR (-). Postoperative treatments using CMF and CAF were eventually discontinued owing to profound damage to the bone marrow. An adjuvant chemotherapy with UFT has been employed since. Two years and 7 months later, hemosputum and coughing appeared, and metastases to the lung were revealed. Combined chemoendocrine therapy with 5'-DFUR and MPA was undertaken. A significant decrease in tumor size was observed 3 months after the chemoendocrine therapy was begun, and complete response was obtained at the 8th month. The state has been maintained for one year and 9 months. The use of combined chemoendocrine therapy with 5'-DFUR and MPA in patients for whom intensive chemotherapy is not possible due to damage to bone marrow function is considered effective for its antitumor effects or maintaining patients' quality of life.

Surgical management of left main coronary artery aneurysm

To date only 7 patients with left main coronary artery aneurysm associated with atherosclerosis have undergone surgical treatment. This report reviews a case of atherosclerotic aneurysm of the left main coronary artery with concurrent stenotic coronary artery disease that was successfully treated by direct approach to the left main coronary artery aneurysm and establishment of coronary artery bypass grafts.

[A case of postpartum silent thyroiditis misapprehended as malignant lymphoma of the thyroid]

A case of postpartum silent thyroiditis misapprehended as malignant lymphoma of the thyroid is reported. The patient was a 30-year-old female who had received irradiation therapy to the neck for malignant lymphoma 9 years ago. She was referred to our department owing to a struma accompanying rapid aggravation of chronic thyroiditis after delivery. The mechanism of this case was possible to be explained by immune rebound theory. It was difficult to make differential diagnosis of this case from malignant lymphoma of the thyroid clinically and cytologically when immune rebound phenomena with invasion of lymphocyte and appearance of lymph follicle were the strongest. Immune state of the patients with chronic thyroiditis accompanied by morphological change should be taken into consideration in the process of making diagnosis of malignant lymphoma of the thyroid.

Primary squamous cell carcinoma of the breast in a pregnant woman: report of a case

Although reports on primary squamous cell carcinoma of the breast have been increasing in number, the morbidity rate of the disease is comparatively low. Its onset in pregnant women, especially, is quite rare. We herein report a case of primary squamous cell carcinoma of the breast in a pregnant woman. A 33-year-old woman was admitted with a lump in the right breast and an abnormal bloody nipple discharge. The breast mass was 5.6 x 5.4 cm in size, and both ultrasonogram and CT scanning showed that it consisted of a cystic tumor for the most part. A large amount of bloody cystic fluid was aspirated by fine-needle aspiration; squamous cell carcinoma of the breast was suspected by a cytological study on the fluid. Twelve days after an induced abortion was performed, a modified radical mastectomy was carried out. Histological findings of the resected specimen demonstrated that the tumor was squamous cell carcinoma which had been well differentiated with partial keratinization and cancer pearls. Noninvasive ductal carcinoma was also observed in a very small region of the specimen, which indicated that the tumor was probably originally adenocarcinoma which later transformed into squamous cell carcinoma.

Myasthenia gravis with thymoma associated with occult thyroid carcinoma

We report herein a case of myasthenia gravis associated with thymoma and occult thyroid carcinoma with metastasis to a cervical lymph node, which was treated in two stages by a total thymectomy and radical dissection of the bilateral neck after a total thyroidectomy. A 48 year old woman was admitted with right blepharoptosis and hypodynamia of the proximal muscles. After various examinations, a diagnosis of myasthenia gravis was made. The association of thymoma was clarified upon CT scanning and a total thymectomy performed. However, after surgery, swelling of the cervical lymph nodes became apparent and a biopsy revealed metastasis of thyroid carcinoma in the lymph nodes. A diagnosis of occult thyroid carcinoma with metastasis to a cervical lymph node was subsequently made and a total thyroidectomy and radical dissection of the bilateral neck performed 37 days after the total thymectomy. The patient's postoperative course was uneventful and for the time being, no recurrence is expected. It is considered better to perform two-stage operations for easier and safer postoperative management when myasthenia gravis associated with occult thyroid carcinoma is treated, although it depends on the development of thyroid carcinoma being occult.

[A clinical study of the significance of the gradient between feeding arterial tissue polypeptide antigen (TPA) and draining venous TPA in assessing the risk for recurrent breast cancers]

The incidence of postoperative recurrence of primary breast cancers in 73 patients was correlated with the blood levels of tissue polypeptide antigen (TPA) in peripheral veins (V-TPA), feeding arteries (A-TPA), draining veins (V-TPA) and the gradient between the TAP levels in draining veins and feeding arteries (V-A TPA). With progression in the stage of the cancers, all parameters were increased. In stages II and III, the mean level of V-TPA was significantly higher than the mean level of A-TPA (p less than 0.05). In each stage, each parameter was increased in the patients with recurrences when compared with the levels in the patients with no recurrences. In patients with V-A TPA gradients greater than 30 U/L, the rate of recurrence was significantly higher when compared with patients with gradients less than 30 U/L (p less than 0.05). The clinical significance of this finding is that patients with V-A TPA gradient greater than 30 U/L should be closely followed because of the increased risk of recurrences.

[Two cases of cardiac injuries due to nonpenetrating trauma of the chest]

Successful repair of nonpenetrating traumatic cardiac injury is uncommon. Two cases of nonpenetrating traumatic cardiac injuries from accident are reported. Case 1. Seventy eight year old man with shock was admitted to Iida City Hospital four hours after getting a bruise by a wood block on the anterior chest wall. Soon after his arrival ultrasonic cardiography was performed because of a doubt of cardiac trauma. And it revealed cardiac tamponade. Then the emergency operation was performed. After pericardial effusion was drained, rupture on the out-flow tract of the right ventricle was found and was successfully repaired without the aid of cardiopulmonary bypass. Case 2. Sixty five year old man with left heart failure was admitted to Iida City Hospital four months after getting a bruise on left chest and back from falling. Chest and back pain was reduced three weeks after the accident, however, shortness of breath was getting worse. Ultrasonic cardiography and aortography showed aortic regurgitation. Under cardiopulmonary bypass aortic valve replacement was performed. His aortic regurgitation was caused by perforation of non-coronary cuspid due to accident. Ultrasonic cardiography is useful to make a diagnosis of nonpenetrating traumatic cardiac injury. It is necessary to operate as soon as possible in cardiac rupture, and to select valve replacement for aortic regurgitation.

[A case of quadruple cancer composed of the breast, kidney, liver and uterus carcinomas]

A case of quadruple cancer is reported. A 74-year-old female was admitted because of surgery for left breast cancer. Abdominal echography showed a mosaic patterned mass of the liver and a solid tumor with central necrosis at the left kidney. Echographic diagnosis was hepatoma and Grawitz's tumor. All the tumors were justified as being operable. Progressive cystorrhagia which was due to radiation cystitis after radiotherapy for uterine carcinoma could not be controlled. Autopsy diagnosis was a quadruple carcinoma composed of solid tubular carcinoma of left breast, left renal carcinoma, hepatocellular carcinoma and squamous cell carcinoma of the uterus.

[Clinical evaluation of extended neck differentiated thyroid carcinoma]

In some patients with advanced differentiated thyroid carcinoma, an upper mediastinal dissection is recommended. Both 17 primary and 6 non-primary patients who had undergone an upper mediastinal dissection in Shinshu University Hospital, from 1984 to 1987, were surveyed. We also studied 198 patients who had been performed a modified radical neck dissection from 1984 to 1986. In the 17 primary cases, 6 (35%) had positive nodes in the upper mediastinum (M group), and 11 (65%) negative (NM group). And we analysed these two groups. In addition, 5 non-primary cases and 198 patients were analyzed in terms of the nodal metastatic status of the tumor-free side. From these results, we conclude the indication of mediastinal dissection for thyroid carcinoma as follows: (1) positive lymph node is suspected in the upper mediastinum by the study of CT or 201thallium scintigram. (2) nodal metastases are suspected in the deep cervical location of the tumor-free side. (3) a male patient whose age is younger than 50, and tumor is located in the left lobe and its size is larger than 3.0 cm.

[Intra-arterial infusion chemotherapy of locally advanced and recurrent breast cancer]

A total of 15 cases of advanced and recurrent breast cancer of more than 3-year duration were subjected to continuous intra-arterial infusion in our department, and its therapeutic effect and the judgement were examined. Using subclavian artery and internal thoracic artery for the primary cases and the latter artery for the recurrent cases for infusion, continuous administration of 5-FU and one-shot injection of ADM and MMC were performed twice a week. 99mTc-angiography was effective for the identification of arterio-controlled areas. Under the judgement criteria for therapeutic effects according to the breast cancer handling agreement, CR, PR, NC and PD were noted in 1, 8, 5 and 1 cases, respectively, with a 60% rate of effectiveness. Judgement of effects by 201Tl-chloride scintigraphy showed some correlation with the histological judgement, with its apparent effectiveness. Examination of the remote results revealed 3-year survival rate of 83.3% and 3-year healthy survival rate of 66.7% for the primary cases. Two of the 3 recurrent cases died at 2 and 11 post-infusional months, respectively, but 1 showing CR is still alive 4 years and 10 months, post infusionally.

Chest-wall reconstruction by contralateral latissimus dorsi musculocutaneous flap

Reconstruction of chest wall and axilla are performed in 11 patients using a contralateral latissimus dorsi musculocutaneous flap. The entire lattisimus dorsi muscle, including the fascial portion, safely carried an island of skin from the area of the lumbodorsal fascia to the contralateral axilla. The flap was transposed to the defect through a tunnel between the pectoralis major and minor muscles. Most patients who needed reconstruction of the chest wall and axilla had compromised ipsilateral vasculature that prohibited its use in a pedicled flap but had an intact contralateral chest wall, axilla, and thoracodorsal vessels. Therefore, this procedure was performed easily in comparison with a free flap or pedicled omental flap. This is a new, valuable application for the versatile latissimus dorsi musculocutaneous flap.

An evaluation of the intraoperative staining technique using methylene blue for the detection of hyperplastic parathyroid glands

Intraoperative staining with methylene blue was employed during parathyroid surgery on 50 glands from 13 patients, 5 with primary and 8 with secondary hyperparathyroidism. Forty-seven out of the 50 glands (94 per cent) were visualized by the staining and 2 out of the 13 patients were revealed to have supernumerary parathyroid glands. Since we started using this technique, there have been no cases of persistent hypercalcemia. The results of this study support the clinical usefulness of this staining procedure for detecting hyperplastic parathyroid glands in both primary and secondary hyperparathyroidism.

Reconstruction of the carotid artery using a temporary shunt during an operation for advanced thyroid carcinoma--a case report

A case of a patient who required reconstruction of the carotid artery during a radical operation for advanced thyroid cancer is reported herein. The patient, a 64-year-old female who had had three previous operations for thyroid cancer, underwent a two-stage operation. In the first stage, the left cervical lymphnodes were dissected, but as a large metastatic node invading the left carotid artery could not be completely removed, some carcinoma tissue was left attached to the wall of the artery. The second stage involved a temporary shunt being set up between the common carotid artery and the internal carotid artery following heparinization, after which the invaded portion was resected, and the defect patched with a saphenous vein graft. Monitoring with a Doppler flow-meter and EEG were conducted throughout the operation. At present, cancer has recurred in the left submandibular and supraclavicular regions.

[Relationship between biopsy and prognosis of breast cancer]

Clinical data from 131 patients who underwent primary radical operation for breast cancer at the Second Department of Surgery, Shinshu University Hospital during five-years from January 1976 to the end of December 1980 were analyzed to investigate for the relationship between biopsy and prognosis. The incisional biopsy group had a significant higher recurrence rate as compared with the no biopsy group, cytology group and the cancer negative group after excisional biopsy. Although the puncture aspiration cytology group did not show significant difference in recurrence rate, an any more than 3 weeks of interval between puncture aspiration cytology and radical surgery associated with a significant high recurrence rate. This suggests that the interval also exerts an unfavorable influence upon prognosis. Puncture aspiration cytology was recognized to be apt to result in distant metastasis than any other biopsy methods and also it is tended to have a higher recurrence rate in scirrhous and mucinous carcinoma of the breast.

The usefulness and significance of naso-pharyngo-laryngo-tracheal fiberscopy in thyroid surgery

The authors conducted naso-pharyngo-laryngo-tracheal fiberscopic examinations before and after thyroid surgery. Preoperative examination included an inspection of vocal cord movement, the compression and deformity of the trachea caused by goiters, changes in the color of the tunica mucosa tracheae, and the presence of tumorous invasion. Postoperatively, this method was employed primarily to determine the presence of recurrent laryngeal nerve paralysis, changes in the tracheal mucosa caused by manipulations in thyroid surgery and in cases in which surgery involved the tracheal wall, and to inspect the treated condition at the original tracheal site and detect the presence of possible recurrences. The manipulations can be easily carried out, causing little pain, and the procedure is economically feasible. Since it can provide more useful information than any other examination method, the active use of endoscopic examination by surgeons themselves at numerous facilities would appear desirable.

Parathyroid imaging: comparison of 201Tl-99mTc subtraction scintigraphy, computed tomography and ultrasonography

From 1982 to 1985, twenty-nine patients with suspected hyperparathyroidism were examined using 201Tl-99mTc subtraction scintigraphy (Tl-Tc), computed tomography (CT) and ultrasonography (US). For diagnosing neoplasm (adenoma or cancer), the sensitivities of the three procedures were 80 per cent or more, with no statistically significant differences. For diagnosing hyperplasia of the parathyroid glands, CT scan had the highest sensitivity (47 per cent). The most frequent source of error was minimally enlarged glands, weighing less than 500 mg. The second highest source of error was thyroid nodules, such as adenomatous goiter or cancer. Serum calcium and c-PTH levels were significantly higher in those with a parathyroid neoplasm than in those with hyperplasia (p less than 0.01, p less than 0.05, respectively). We concluded that hyperplasia is less easy to detect than neoplasm, and CT scan is superior to Tl-Tc or US scan for localizing hyperplasia.

[Advanced thyroid carcinoma--possible induction of the host's antitumor immunological response by 131I therapy]

The patient was a 76-year-old man. When he was 31, he had undergone right lobectomy for thyroid cancer. Following this, had repeated recurrences, and finally reached total-thyroidectomized status. Consequently, he was given thyroxin and PS-K thereafter. When he was 75, 131I therapy was undertaken for lung metastases. The changes of serum anti-microsomal antibody (AMA), immunosuppressive substance (ISS) and thyroglobulin (TG) were as follows: three months after the therapy, AMA was 40(2), although it had always been negative before. Nine months later, ISS and TG markedly decreased.

CONCLUSION

Under the administration of immunomodulating agents, 131I therapy might induce antitumor immunological responses by the effect of enhancement of cancer cell antigenicity.

[RI angiography with 99mTc and 201T1-chloride scintigraphy in determining the effectiveness of intra-arterial infusion in chemotherapy of locally advanced and recurrent breast cancer]

Eleven patients with local advanced and recurrent breast cancer were treated preoperatively with intraarterial infusion of chemotherapeutic agents. After the treatment, nine patients underwent radical mastectomy. RI angiography with 99mTc is a useful procedure for determining the correct position of the tips of an inserted cannula. The results of 201Tl-chloride scintigraphy have been found to be closely consistent with the results of the resected specimen histologically. Therefore, 201Tl-chloride scintigraphy is also a quite useful procedure for determining the effects of intraarterial infusion in cancer chemotherapy.

[Medical images; the clinical significance of the medical images of thyroid cancer]

Supplementary diagnosing methods for thyroid cancer were discussed, with particular reference to medical images. Although palpation is, of course, essential in the examination of nodules, we have also used soft X-rays and I-123 scintigraphy, as well as Tl-201 scintigraphy, ultrasonography and aspiration biopsy. In addition, various diagnosing methods have been employed to determine the degree of invasion in advanced cancer patients, such as CT scan for observing invasion of the surrounding tissues, naso-tracheoscopy for invasion of the trachea and a flow meter for vascular tracts. When the tumor size is under 2 cm, we use soft X-rays, ultrasonography and sometimes try additional aspiration biopsy. When the tumor is smaller, aspiration biopsy is employed with ultrasonography. For tumors larger than 2 cm, we use soft-X-rays, I-123 scintigraphy and ultrasonography. Tl-201 scintigraphy is employed to determine operative indication, following which aspiration biopsy and CT scan are performed. CT scan, tracheofiberscopy and doppler flow studies are carried out for advanced cancer cases to determine the degree of invasion of carcinomas.

[A case of bilateral metastatic breast carcinoma from gastric carcinoma]

The patient was a 48-year-old woman who had undergone radical surgery for gastric carcinoma in 1981. Seventeen months after the operation, recurrence of gastric carcinoma at the anastomotic stoma was found, and total gastrectomy was performed. Fourteen months after the second operation, she was revealed to have bilateral breast tumors and underwent exploratory excision. Histological examination suggested primary malignant tumor of the breast. Bilateral standard radical mastectomy was done seven days after the excision. Final histological examination revealed metastatic breast cancer originating from the stomach. She died from general metastasis seven months after the radical mastectomy in spite of adjuvant immunochemotherapy.

[Comparison of 201T1-chloride and 67Ga-citrate in thyroid tumor scintigraphy]

Twenty-five patients with thyroid tumors were examined by 201T1-chloride and 67Ga-citrate scintigraphy heterochronously in our department. All cases showed the cold nodule with 131I or 99mTc-pertechnetate thyroid scintigraphy and each one was given a histological diagnosis after surgery or excisional biopsy. In 15 cases of thyroid carcinoma, 12 (80%) were positive by 201T1-chloride; 4 (26.7%) were positive by 67Ga-citrate. In examining each histological type, 8 of 9 cases of papillary carcinoma (88.9%) were positive by 201T1-chloride. In 1 negative case the tumor was almost completely encysted; however, they were all negative by 67Ga-citrate. In 2 patients with follicular carcinoma, both of them revealed a positive figure by 201T1-chloride, and one of these with oxyphilic cell carcinoma showed a positive figure by 67Ga-citrate. In 1 case of medullary carcinoma there was slight accumulation with 201T1-chloride, but there was no accumulation with 67Ga-citrate. In 3 cases of undifferentiated carcinoma, 2 patients with small carcinoma showed a negative figure by 201T1-chloride. However, they all showed a positive figure using 67Ga-citrate and this medium also disclosed distant metastases of undifferentiated carcinoma. In 10 patients with thyroid adenoma, 3 (30%) showed a positive figure by 201T1-chloride. Histologically, these were all tubular adenoma, but in all cases of thyroid adenoma 67Ga-citrate revealed a negative figure. From the above mentioned results, the following conclusion were reached. Tumors showing a positive figure by 201T1-chloride that elicited negative results using 67Ga-citrate proved to be differentiated carcinoma or low differentiated types of adenoma. Surgery is indicated in these cases. All of the tumors revealing a positive figure by 67Ga-citrate were highly malignant types. If these tumors showed a negative figure when 201T1-chloride was used, undifferentiated carcinoma was suggested. In undifferentiated carcinoma, 67Ga-citrate scintigraphy is a useful procedure in locating distant metastases, in determining the area to be irradiated, and in judging the effect of therapy.

Comparison of peripheral thyroid hormone metabolism in normal rats and in rats receiving prolonged glucagon infusion

An elevated plasma glucagon concentration and reduced T3 production from T4 have both been observed in several clinical disorders, including hepatic cirrhosis, uremia, diabetes mellitus, and starvation. The question of whether glucagon has a direct effect on T3 production was studied in normal rats infused iv with [125I]T4 of [125I]T3 and 3 micrograms T4/day, using implanted minipumps. The blood [125I]T4 and [125I]T3 levels maintained a plateau between the fifth and ninth days of infusion. Each animal also received a second minipump, implanted ip, that infused either a diluant solution or 30 micrograms glucagon/100 g BW . day. After 7 days of continuous infusion, the glucagon-treated animals showed a 20% increase in plasma glucose and a 4-fold increase in plasma glucagon from baseline. However, the levels of insulin, T4, and T3 remained unchanged. The MCRs and the disposal rates of T4 and T3, calculated by the constant infusion method, showed T4 and T3 MCRs to be 0.99 +/- 0.18 and 11.25 +/- 2.52 ml/h . 100 g, respectively, and T4 and T3 disposal rates to be 68 +/- 10 and 9 +/- 2 ng/h . 100 g; there was no difference between the control animals and the glucagon-infused animals. T3 production was also determined in vitro from T4 added to a liver homogenate. Compared to control animals, the liver homogenate prepared from glucagon-infused animals showed a modestly higher T3 production rate throughout the 60-min incubation period (P = 0.025--0.05). However, the concentration of nonprotein-bound sulfhydryls was similar in the liver, kidney, brain, muscle, and heart of the two animal groups. In conclusion, glucagon does not have an important regulating role on the peripheral metabolism of thyroid hormone and T3 production in rats.

Comparison of Tl-201 chloride and Ga-67 citrate scintigraphy in the diagnosis of thyroid tumor: concise communication

Twenty-five patients with thyroid tumors were scintigraphed with both Tl-201 chloride and Ga-67 citrate. All cases showed a focal area of decreased activity with I-131 or pertechnetate (Tc-99m), and each had a histological diagnosis after surgery or excisional biopsy. From the data we conclude the following: (1) Tumors giving a positive scan with Tl-201 chloride but negative results using Ga-67 citrate prove to be differentiated carcinoma or poorly differentiated adenoma. (2) All tumors that are positive with Ga-67 are highly malignant types, and if these tumors are negative by Tl-201, undifferentiated carcinoma is suggested. (3) Ga-67 citrate scintigraphy is a useful procedure in locating distant metastases, in determining the area to be irradiated, and in judging the effect of therapy on undifferentiated carcinoma.

Diagnostic usefulness of 201Tl-chloride scintigraphy for preoperative localization of parathyroid tumors

201Tl-chloride scintigraphy was performed in 10 patients with hyperparathyroidism to assess the localization of abnormal parathyroid glands. This approach proved to be useful in 8 of 10 patients. In particular, an intramediastinal ectopic gland was clearly demonstrated in one patient. Several disadvantages were noted, however, 201Tl-chloride scintigraphy could be the first choice for preoperative localization of abnormal parathyroid glands. If a negative image is obtained, further examinations such as arteriography or parathyroid hormone assay be selective venous blood sampling should be done.