Epithelioid sarcoma with an 18q aberration

Epithelioid sarcoma is a peculiar soft-tissue neoplasm of uncertain origin, which is characterized by an epithelioid morphology of tumor cells coexpressing epithelial (keratin) and nonepithelial (vimentin) antigens. We herein report a new cytogenetic abnormality with der(22)t(18;22)(q11;p11.2) in a case of epithelioid sarcoma that occurred in the elbow of a 75-year-old man. Histologically, the tumor demonstrated a multinodular proliferation of epithelioid cells, with positive immunostaining for keratin, epithelial membrane antigen (EMA), and vimentin. Cultured tumor cells obtained from fresh surgical materials were frozen in plastic ampules and stocked in a liquid nitrogen freezer. Six years after surgery, the cells were recovered from the freezer and utilized for both morphologic and cytogenetic analyses. These cultured cells both before and after the freezing exhibited essentially the same epithelioid morphology and immunophenotypes as those of the original tumor. A chromosome analysis, together with fluorescence in situ hybridization (FISH), demonstrated a 61-67 modal population, and a characteristic clonal abnormality with der(22)t(18;22)(q11;p11.2). Other clonal abnormalities included numerical (-3, -4, +7, -13, -14, -16, -18, +20, -22) and structural (8p+, 9p+, 12p+, i(21q)) aberrations. Some variant clones also demonstrated i(18q). Since the breakpoint at 18q11 is similar to that reported in synovial sarcoma, this finding may support the presence of a histogenetic relationship between epithelioid sarcoma and synovial sarcoma. Our study thus indicates that the storage of frozen cells is useful for both morphologic and cytogenetic analyses of soft tissue tumors.

[Criteria for the evaluating treatment on primary bone sarcoma]

The criteria for the evaluation of the treatment on primary bone sarcoma proposed by the Musculoskeletal Tumor Committee of the Japanese Orthopaedic Association (JOA) were accepted in 1993 by the Joint Committee for Cancer Therapy of the Japan Society for Cancer Therapy. The responses to treatment are classified as a complete response (CR), a partial response (PR), no change (NC), or as progressive disease (PD). It is a requirement that the condition of CR, PR, or NC continues for at least 4 weeks. The radiographical criteria are as follows: CR, the disappearance of the intramedullary lesions and the bone trabeculae recovering a normal appearance; PR, the circumscription of the extraosseous tumor and an appearance of sclerotic foci within the intramedullary lesion; NC, no changes noted in the extraosseous and intramedullary lesions; PD, an increase in the extraosseous or intramedullary lesion and/or the appearance of new lesions. Histopathological criteria are as follows: CR, no tumor cells appearing viable in any of the histologic sections; PR, greater than 90% tumor necrosis attributable to treatment; NC, 50 to 90% tumor necrosis and other secondary changes attributable to treatment; PD, less than 50% tumor necrosis. Responses in the clinical signs and symptoms including tumor size (or circumference of the extremities at the site of the tumor), pain and local heat are also graded as follows: PR, subsiding symptoms and/or decrease in the tumor size; NC, neither exacerbation nor decrease in the symptoms and no change in size; PD, the exacerbation of symptoms or an increase in size. Additionally, the serum alkaline phosphatase level can be used for evaluating the effect of the treatment on the osteosarcoma. The extent of the response to preoperative chemotherapy is a powerful predictor of patient survival.

[Intra-arterial combination chemotherapy using both regimen selected by chemosensitivity test and caffeine to increase effect for osteosarcoma in extremity]

We treated three patients with osteosarcoma in extremity with intra-arterial combination chemotherapy using a regimen selected by succinate dehydrogenase inhibition chemosensitivity test, and used caffeine to enhance its effect. In two patients with osteosarcoma in distal diametaphysis of the radius and extraskeletal osteosarcoma in sole of the foot, the effect of intra-arterial combination chemotherapy was increased and followed by the functional limb salvage procedure. But in one patient with osteosarcoma in the proximal tibia, the effect of pre-operative intra-arterial combination chemotherapy could not be increased, so amputation was required. He was changed to a post-operative intra-venous combination chemotherapy regimen selected by chemosensitivity test of the surgical material. All patients have been continuously disease-free at five to twelve months after surgery.

Sympathetic denervation of the epicardial border zone in the genesis of dispersion of refractoriness and arrhythmogenesis in a 7-day-old canine myocardial infarction model

BACKGROUND

The purpose of this study was to clarify whether sympathetic denervation occurs in the infarcted heart and contributes to the dispersion of the effective refractory period (ERP) and arrhythmogenesis.

METHODS

ERP was measured at 47 epicardial sites in 13 dogs with 7-day-old infarctions after proximal ligation of the left anterior descending artery. To delineate the sympathetic innervation, the effects of ansae subclaviae stimulation (ASS), norepinephrine infusion, and prazosin infusion on ERP were tested.

RESULTS

The per cent change in ERP (delta ERP) induced by ASS was significantly lower at test sites where the surviving epicardial myocardial thickness (Th) was 2 mm or less than at those with a Th of more than 2 mm and the normal zone. Eleven out of 179 sites (6.1%) overlying the infarct showed no ERP change after ASS. ASS paradoxically prolonged ERP at 29 sites (16.2%). In contrast, norepinephrine infusion produced a greater delta ERP in the infarct zone than in the normal zone. Prazosin shortened ERP at sites where ASS prolonged it, but had no effect at sites where ASS shortened ERP. ASS increased both the degree of ERP dispersion and inducibility of ventricular tachycardias or ventricular fibrillation (VT/VF), whereas norepinephrine increased VT/VF inducibility despite a reduction in ERP dispersion.

CONCLUSIONS

We conclude that heterogeneous sympathetic denervation contributed to a prolongation and dispersion of ERP in the surviving epicardium overlying the infarct. Furthermore, a supersensitive response to norepinephrine with resultant ERP shortening and a paradoxical ERP prolongation during ASS caused by alpha-receptor mechanisms that may be related to increased electrical instability were observed.

[Post-operative intra-arterial chemotherapy for high grade malignant musculoskeletal sarcoma]

Twenty-nine patients with high grade malignant musculoskeletal sarcoma were treated with chemotherapy. Intra-arterial chemotherapy was performed post-operatively for patients with local recurrence, patients with poor response to pre-operative chemotherapy or patients with intra-lesional or marginal surgical margin. The local recurrence rate in patients with intra-arterial chemotherapy (8.8%) was lower than in those with intravenous chemotherapy (37.5%). Patients with post-operative intra-arterial chemotherapy showed no local recurrence. Of the 29 patients except stage 3 with intra-arterial chemotherapy, the metastatic rate in patients with intra-arterial chemotherapy (41.4%) was lower than in chemotherapy patients with intravenous chemotherapy (83.3%). The rate in the post-operative group (28.6%) was lower than in the pre-operative group (42.9%) or pre- and post-operative group (50.0%). The ten-year survival curve of patients given intra-arterial chemotherapy (51.0%) was higher than in patients on intravenous chemotherapy (17.9%). Among the 34 patients who underwent intra-arterial chemotherapy, the survival rate in the other pre- and post-operative groups and the post-operative group (55.6%) was higher than in the pre-operative group and pre- and post-operative group (49.8%).

Immature teratoma of the uterine fundus

An exceedingly rare case of extragonadal immature teratoma, which occurred primarily in the uterus, is described. The tumor developed into the pelvic cavity from the uterine fundus and consisted of ectodermal, mesodermal and endodermal derivatives. There were also significant amounts of immature elements; immature neuroepithelium with brisk mitotic activity, immature mesenchymal tissue, immature cartilage, immature striated muscle and immature hepatic tissue. Histologically, it was classified as a grade 3 immature teratoma. Treatment consisted of total simple hysterectomy followed by 2 courses of combination chemotherapy with vincristine, actinomycin D and cyclophosphamide (VAC). The patient was well and without evidence of recurrence at 5 years post-operatively.

Malignant Fibrous Histiocytoma Proliferative Compartment and Heterogeneity of “Histiocytic” Cells

To elucidate the precise origin and characteristics of the proliferating cells in malignant fibrous histiocytoma (MFH), the authors analyzed 33 MFH tumors, using immunohistochemical techniques with a panel of 12 antibodies. All three types of MFH cells (spindle cells, polygonal cells, and bizarre giant cells) stained positively for mesenchymal antigens (FU3 and vimentin) but did not stain for macrophage/histiocyte markers (HAM 56 and CD68). Therefore, the MFH cells may not represent true histiocytes, although they may be mesenchymal-derived cells behaving as "facultative histiocytes" with superficial resemblance to actual histiocytes. Normal histiocytes in the stroma tested positive for macrophage/histiocyte antigens; the most common cells were HAM 56-positive cells constituting 30-80% of nonneoplastic stromal cells, followed by those positive for CD68 (10-50%), Mac 387 (less than 2%), and S-100 protein (less than 1%). Our results indicate the presence of heterogeneity of "histiocytic" cells in MFH. Proliferating-cell nuclear antigen (PCNA) was expressed not only in the spindle and polygonal MFH cells but also in the bizarre giant cells. These findings suggest that all three types of MFH cells participate in the proliferative compartment of MFH. Uneven PCNA staining of the irregular nuclear segments of the bizarre giant cells may result in abnormal DNA synthesis, possibly contributing to the marked diversity of nuclear morphology in MFH. Touton-type and osteoclast-like giant cells did not stain for PCNA but stained positively for histiocytic markers. Therefore, these giant cells may lack proliferative activity and probably result from normal histiocytes fusing together.

Malignant fibrous histiocytoma. A tumor of facultative histiocytes showing mesenchymal differentiation in cultured cell lines

The histogenesis of malignant fibrous histiocytoma (MFH) is controversial. To elucidate the cellular origin and characteristics of this neoplasm, the authors analyzed cell lines grown from 17 patients (15 soft tissue MFH and 2 bone MFH) by using light and electron microscopy, immunocytochemistry, enzyme cytochemistry, and functional tests for receptors for the Fc portion of immunoglobulin (Fc receptors) and immunophagocytosis. Each culture exhibited a storiform/pleomorphic pattern with mixed cellular populations consisting of spindle cells, polygonal cells, and bizarre giant cells; these morphologic features corresponded to the histologic characteristics of the primary tumors. The cells in each MFH line displayed histiocytic functional markers such as lysosomal enzymes, Fc receptors and immunophagocytosis. However, these cells differed from monocyte-derived macrophages (histiocytes) in immunoreactivity; the MFH cells expressed a mesenchymal antigen (FU3) distributed among perivascular cells and fibroblasts but demonstrated no positive reactions with Leu-M1 (CD15) and Leu-M3 (CD14), which recognize the cells of the monocyte-macrophage lineage. In conclusion, these findings suggest that MFH is not a tumor of true histiocytes but of facultative histiocytes showing mesenchymal differentiation in vitro. Chromosomal analysis performed in one MFH line demonstrated abnormal karyotypes; the modal chromosome number was 58, with 5 marker chromosomes.

Malignant fibrous histiocytoma. A tumor of facultative histiocytes showing mesenchymal differentiation in cultured cell lines

The histogenesis of malignant fibrous histiocytoma (MFH) is controversial. To elucidate the cellular origin and characteristics of this neoplasm, the authors analyzed cell lines grown from 17 patients (15 soft tissue MFH and 2 bone MFH) by using light and electron microscopy, immunocytochemistry, enzyme cytochemistry, and functional tests for receptors for the Fc portion of immunoglobulin (Fc receptors) and immunophagocytosis. Each culture exhibited a storiform/pleomorphic pattern with mixed cellular populations consisting of spindle cells, polygonal cells, and bizarre giant cells; these morphologic features corresponded to the histologic characteristics of the primary tumors. The cells in each MFH line displayed histiocytic functional markers such as lysosomal enzymes, Fc receptors and immunophagocytosis. However, these cells differed from monocyte-derived macrophages (histiocytes) in immunoreactivity; the MFH cells expressed a mesenchymal antigen (FU3) distributed among perivascular cells and fibroblasts but demonstrated no positive reactions with Leu-M1 (CD15) and Leu-M3 (CD14), which recognize the cells of the monocyte-macrophage lineage. In conclusion, these findings suggest that MFH is not a tumor of true histiocytes but of facultative histiocytes showing mesenchymal differentiation in vitro. Chromosomal analysis performed in one MFH line demonstrated abnormal karyotypes; the modal chromosome number was 58, with 5 marker chromosomes.

Quantitative indices of dispersion of refractoriness for identification of propensity to re-entrant ventricular tachycardia in a canine model of myocardial infarction

STUDY OBJECTIVE

To identify propensity to re-entry in a canine model of 7 day old myocardial infarction, the sensitivity and specificity of five indices of dispersion of refractoriness (ERP) were investigated.

DESIGN

With an epicardial patch electrode containing 47 electrodes, ERP was measured by S1-S2 method at each site overlying the infarct. ERP range, maximum adjacent dispersion, difference between mean ERPS of the infarct and normal zones, standard deviation (sigma) of the mean ERP, and sigma/mean ERP X 100 were calculated.

EXPERIMENTAL MATERIAL

42 dogs were divided into three groups; 20 dogs with epicardial functional block on induction of sustained ventricular tachycardia or fibrillation, 10 dogs with inducible ventricular tachycardia or fibrillation but without epicardial functional block, and 12 control dogs without ventricular tachycardia, fibrillation or block.

MEASUREMENTS AND MAIN RESULTS

All five indices were significantly greater in the 20 dogs with ventricular tachycardia or fibrillation than in control dogs. A receiver operating characteristic curve analysis of the five indices showed that sigma was the most sensitive and specific index for discriminating these 20 dogs. The sensitivity and specificity of a sigma value greater than 14 ms (the mean value plus two SD of the control dogs) were 70% and 100%, respectively.

Electrophysiologic effects of E-4031, a class III antiarrhythmic agent, on re-entrant ventricular arrhythmias in a canine 7-day-old myocardial infarction model

Effects of E-4031, a class III antiarrhythmic agent, on re-entrant ventricular arrhythmias were studied in eight dogs with a 7-day-old myocardial infarction. Epicardial mapping and local refractory periods were obtained using 47-channel bipolar electrodes attached to the epicardium. The induction of sustained ventricular tachycardia by programmed electrical stimulation was not suppressed by i.v. infusion of E-4031 at 1 microgram/kg/min, but was suppressed markedly by infusion at 10 micrograms/kg/min in six of seven dogs. During the infusion of E-4031 at 10 micrograms/kg/min, epicardial conduction velocity in the normal ventricle did not change (0.7 +/- 0.12 to 0.71 +/- 0.13 m/sec, n = 6), whereas slowed conduction in the infarct zone improved (0.58 +/- 0.10 to 0.77 +/- 0.13 m/sec, n = 6). E-4031 at 10 micrograms/kg/min prolonged effective refractory periods (ERP) in the normal zone (139 +/- 8 to 164 +/- 18 msec, P less than .01, n = 8), nontransmural infarct zone (145 +/- 7 to 177 +/- 15 msec, P less than .01, n = 8) and transmural infarct zone (156 +/- 14 to 191 +/- 22 msec, P less than .01, n = 8). The degrees of ERP prolongation were almost equal in all zones. On epicardial mapping, the areas of longer ERP and delayed conduction were observed to become inexcitable after the administration of E-4031. These results demonstrated that E-4031 effectively prevented the induction of re-entrant ventricular tachycardia in canine myocardial infarction model, and suggested that E-4031 rendered re-entrant circuits inexcitable by marked ERP prolongation in both normal and infarct zones.

Neuroectodermal tumor of bone. Evidence for neural differentiation in a cultured cell line

A new cell line was established from a "neuroectodermal tumor of bone" affecting the right scapula of an 18-year-old man. The original neoplasm had dense proliferation of small round cells with abundant glycogen content and numerous Homer-Wright rosettes. The culture showed proliferation of small spindle cells with uniform oval nuclei and slender cytoplasmic processes. When the culture reached maximum density, rosette-like structures similar to those in the original tumor were formed. Under the influence of N6,O2'-dibutyryl adenosine 3',5'-cyclic monophosphoric acid (dibutyryl cAMP), the cultured cells expressed these rosette-like structures even in the lower cell concentration. Electron microscopy revealed that the cultured cells treated with dibutyryl cAMP contained high-density granules, well-developed microtubules, and abundant 10-nm filaments. By immunocytochemistry, neuron-specific enolase (NSE), and N-myc oncogene product were detected in the cultured cells as well as the original tumor. These results indicated the neuroectodermal origin of some of the small round cell tumors of bone.

Electrophysiological and anatomical substrates for late potential recorded by signal averaging in seven-day-old myocardial infarction in dogs

A filtered QRS (fQRS) was recorded by signal averaging in 7-day-old myocardial infarction (MI) in dogs to detect late potential (LP). The criteria for the LP included a duration of fQRS (D) greater than or equal to 60 msec and a voltage in the last 15 msec (V15) less than or equal to 10 microV. These parameters were determined from the control data from 15 dogs without infarction (D: 45 to 60 msec and V15: 12.0 to 83.6 microV). On the seventh day of infarction, the D had increased from 53.5 +/- 4.7 to 62.2 +/- 9.6 msec (P less than 0.05) and the V15 decreased from 38.6 +/- 19.5 to 18.4 +/- 16.0 microV (P less than 0.01). Of 23 dogs, 14 met the LP criteria (group A) and 9 did not (group B). Sustained ventricular tachycardia (SVT) was induced in 12 group A dogs and in none of the group B dogs. The delayed epicardial activation (DEA) was recorded after the end of QRS at 5.1 +/- 4.7 sites in group A dogs and 1.3 +/- 1.8 sites in group B dogs (P less than 0.05). The maximum value of epicardial activation time was more prolonged in group A than in group B (70.0 +/- 28.3 vs 44.4 +/- 9.8 msec, P less than 0.01). The area of MI was more extensive in dogs with DEA than those without (24.9 +/- 5.8% vs 10.3 +/- 9.0% of the total left ventricular weight, P less than 0.01). In 72 of 90 sites with DEA, the thickness of the surviving epicardial muscle was less than or equal to 1 mm. The sensitivity and specificity of the criteria for LP in detecting DEA were 71.4% and 55.6%, and 100% and 81.8% for predicting inducibility of SVT. It was thus concluded that LP, reflected the DEA, was identified from infarct areas of slow conduction within a reentry circuit of SVT.

[Post-operative intra-arterial chemotherapy in patients with malignant bone and soft tissue tumors]

Fourteen patients with bone and soft tissue sarcoma were treated with post-operative intra-arterial chemotherapy. Three drugs (Adriamycin, vincristine, carboquone or THP-adriamycin, cisplatin, vindesine) or two drugs (cisplatin, vindesine) were used post-operatively for patients with local recurrence, patients with poor response of pre-operative intra-arterial chemotherapy or patients with intra-lesional or marginal surgical margin. Of the 14 patients treated with post-operative intra-arterial chemotherapy, 8 (57.1%) were continuously disease-free (7.1%) were disease-free after treatment of lung metastasis, 2 (14.3%) had a local recurrence and/or multiple distant metastasis, and 3 (21.4%) died with multiple distant metastases. The rate of local recurrence was 14.3%. The Kaplar-Meier disease free survival curves showed 59.6%). Evaluation of limb function were excellent or good in 9 (69.2%) of 13 patients treated with limb-saving procedures.

Malignant fibrous histiocytoma in the thoracic region--a clinico-pathologic investigation

Seven cases of malignant fibrous histiocytoma (MFH); 3 originating in the thoracic region, one which was considered to arise from the lung parenchyma, and 4 which were metastatic to the lungs, are presented herein. Six of these patients underwent surgical excision and analysis under light and electron microscopy revealed the lesions of MFH to be composed of two cell types; a fibroblast-like cell and a histiocyte-like cell. The latter showed histologically characteristic growth in a so-called storiform pattern. In all patients adjuvant chemotherapy was performed, although in only one patient did it prove temporarily effective. Despite the fact that the prognosis of MFH in the thoracic region is poor, the suggested therapy for longer survival is resection with postoperative combination chemotherapy including the use of sensitive anticancerous agents.

Anterior rib strut grafting for the treatment of malignant lesions in the thoracic spine

Anterior stabilization during thoracotomy, using the patient's own ribs, was carried out seven times in six subjects with malignant lesions of the thoracic vertebrae. The primary malignancy was lung carcinoma in four cases, thyroid carcinoma in one case, and alveolar soft tissue sarcoma in one. Resection of the lung tumor and spinal surgery were carried out simultaneously. Four of the six patients had complete paraplegia and two had partial paraplegia prior to the operation. After the decompression and anterior stabilization, three subjects responded well and three responded poorly because of respiratory insufficiency.

[Intra-arterial high-dose adriamycin in patients with malignant bone or soft tissue tumors. The factors in poor prognosis]

Twenty-eight patients with malignant bone or soft tissue tumors were treated with preoperative and/or postoperative intra-arterial high-dose adriamycin. The antitumor effects of intra-arterial adriamycin were noted in not only primary tumor but also skip and distant metastasis (2 patients with lung metastasis). Clinical or histopathological responses were noted in 14/26 (54%) and 8/20 (40%) patients, respectively. Four patients were inoperable, but 24 patients were operable. Limb-saving procedures or amputation became subsequently feasible in 19/24 (79%) and 5/24 (21%) patients, respectively. Median follow-up of all the 28 patients was 23 months (minimum 3 months, maximum 127 months). Of the 20 patients with operable sarcomas, 11 (55%) were continuously disease-free, 3 (15%) were disease-free after treatment of a local recurrence or distant metastasis, and 5 (25%) died with multiple distant metastases. The Kaplan-Meier survival curves at 10 years showed 70% in 20 patients with operable sarcomas (66% in 8 with bone sarcomas, and 75% in 12 with soft tissue sarcomas). The initial large tumor size (greater than or equal to 10 cm diameters), poor response to intra-arterial adriamycin (less than NC* Clinically, less than II-B histopathologically), low total dose of adriamycin (less than 300 mg/m2), short total chemotherapy time (less than 6 months), and inadequate position of the tip of the catheter were the factors in poor prognosis.

[Comparison of the clinical features of uterine cervical cancers detected by mass screening and voluntary visit]

In order to identify the characteristics of uterine cervical cancers detected by mass screenings (mass group), these cancers were compared to cancers diagnosed in patients voluntarily visiting medical institutions (voluntary group), and the following results were obtained. 1. The mass group tended to show a higher incidence of cervical cancer, and the voluntary group had a higher incidence of endometrial cancer. 2. In the mass group having cervical cancer, the age was younger than that in the voluntary group. Also the incidence of cancer among relatives within the third generation and the frequency of previous participating in a mass screening were both significantly greater (p less than 0.01), compared to the voluntary group. 3. As compared to the voluntary group, many patients in the mass group having cervical cancer were asymptomatic and were diagnosed at an early stage, and even if symptomatic, there still were more early cancers in the mass group than in the voluntary group (p less than 0.01). 4. The incidence of lymph node metastases in advanced cervical cancer, that is beyond stage I b, was lower in the mass group than in voluntary group (p less than 0.01). 5. Cervical cancers in the mass group were surgically treated in 94.2% of cases, and the rate was higher than that in the voluntary group. In the surgical treatment, 77.4% of cases in the mass group underwent a simple hysterectomy and a semi-radical hysterectomy, and the frequency of surgical treatment was higher than that in the voluntary group (p less than 0.01). There also was a tendency toward a shorter time of operative procedures, less bleeding during operation, and fewer postoperative complications. 6. In the mass group having cervical cancers, the prognosis was favorable (p less than 0.01). By the clinical stage, in early cancers including stage 0 and stage I a, there was no significant difference in the prognosis between the mass group and voluntary group, and in the advanced cancer, the prognosis was more favorable in the mass group compared to the voluntary group (p less than 0.01). Asymptomatic patients had a better prognosis than symptomatic patients, and there was no difference between the two groups, but among symptomatic patients the prognosis was more favorable in the mass group than in the voluntary group.

[Reduced operation for cervical carcinoma and its evaluation]

Cervical carcinoma is usually treated by extensive total hysterectomy such as Okabayashi's procedure. However, since the introduction of the criteria for classification of stage Ia lesions in 1978 by the Registration Committee for Cervical Carcinoma of the Japan Association of Obstetrics and Gynecology, surgical procedures have been categorized in greater detail, and reduced operations have begun to be performed. Generally, simple hysterectomy is performed for stage 0 cervical carcinoma, and semi-extensive hysterectomy is indicated for stage Ia lesions. In this study, reduced operations were evaluated in 254 patients with stage 0 and 288 with stage Ia cervical carcinoma selected from 1,412 patients with cervical carcinoma treated at our department between 1976 and 1985. The time required for the operation was 90.8 +/- 34.8 min for simple, 126.7 +/- 36.5 min for semi-extensive, and 173.5 +/- 42.5 min for extensive hysterectomy. The volume of bleeding was 274.5 +/- 257.7 ml for simple, 545.4 +/- 758.2 ml for semi-extensive, and 805.7 +/- 441.6 ml for extensive hysterectomy. The frequency of blood transfusion increased with the increase in the extent of surgery, being 9.0, 22.9, and 61.8% for the respective operations. The incidence of postoperative complications (cystoplegia, renal disorders, fistula of the urinary tract, ileus and hepatitis) also increased to 12.4% for semi-extensive and 44.8% for extensive hysterectomy. Simple hysterectomy was sufficient for stage 0 lesions, and side effects associated with this operation were infrequent and mild. Curative conization was performed for 14 patients who expressed a desire to have babies, and no recurrence has been observed to date. Semi-extensive hysterectomy was performed in 77% of stage Ia patients, and extensive and simple operations were performed in 8.0% and 10.4%, respectively. Close histological evaluation and postoperative care were carried out, particularly for patients who underwent simple hysterectomy. All these patients are currently alive without signs of recurrence. Two patients received only curative conization due to their strong desire to have babies and are currently being followed up. Both of these patients showed small degrees of interstitial invasion of less than 2mm.

Surgical treatment of bone and soft tissue tumors of the shoulder girdle

Data on ninety-seven patients with tumors of the shoulder girdle underwent surgical treatment at Fukuoka University Hospital from August 1972 to September 1987 were analyzed. Fifty-six of these 97 consecutive patients with bone tumors (60) or soft tissue tumors (37) were treated surgically. Six patients were given an intra-arterial high-dose of adriamycin preoperatively. The 36 treated with simple resection or curettage and bone graft for benign tumor showed no evidence of local recurrence, except for 3 patients with bone cyst, Among the 20 treated with wide resection (limb salvage operation) for locally aggressive benign or malignant tumors, 11 patients (55%) were disease-free after a median follow-up of 18 months (among the 7 with primary malignant tumor 3 patients were continuously disease-free, 2 were disease-free after treatment of a local recurrence and 2 died.) Functions of the shoulder were studied in 12 patients who had undergone limb salvage operation. We wish to stress the importance of reconstruction of shoulder stability to preserve functions of the elbow and hand, particularly when diseased bone has been removed. If intra-articular resection can be accomplished for tumors of the proximal humerus, constrained total shoulder arthroplasty is an effective method of reconstruction of the surgical defect, yet will lead to preservation of a stable shoulder in patients whose deltoid muscle and axillary nerve have been spared. Preoperative and postoperative chemotherapy will increase the disease-free survival time and the percentage of functional limb saving procedures.

[Tissue polypeptide antigen in gynecological cancer]

Serum tissue polypeptide antigen (TPA), CEA and IAP were measured simultaneously in cervical cancer, corpus cancer and ovarian cancer. TPA levels were increased (more than 110 U/1) in 39% (32/82) of the cervical cancer and in 46% (6/12) of the corpus cancer patients, respectively. In ovarian cancer, TPA levels were elevated (146 U/1 or higher) in 64% (13/22). The positive rate of CEA was somewhat lower than that of TPA and LAP levels were as high as TPA. Moreover, TPA levels were correlated in clinical course. In immunohistochemical examination, TPA was present in cancer cells and absent in normal tissue.

[The value of computed tomography in the diagnosis of the rotator cuff tears and bone and soft tissue tumors]

This report consists of 2 parts. Part I: The usefulness of computed tomography (CT) in the diagnosis of rotator cuff tear was assessed. The rotator cuff could not be visualized in detail by CT unless introduction of contrast material into the joint cavity was performed. CT arthrography was performed on 21 cases of rotator cuff tears. The most detailed information was obtained when a relatively low concentration of contrast material (3.25% Angiografin) was filled in the joint cavity, and when the shoulder joint was rotated to the maximum outwards at the side. CT arthrography proved to be the most reliable method for assessing the extent and portion of the rotator cuff tears, so that it demonstrated conclusive evidence of diagnosis and management in 89% of patients studied. Part II: The usefulness of CT in the diagnosis of bone and soft tissue tumors was assessed. CT examination provided unique preoperative information which could imagine a more precise histological characteristics and anatomical localization of the lesion. Contrast enhancement (CE), when used, proved to be helpful in predicting the nature of tumors. The CE by intra-arterial infusion, or intravenous bolus injection of contrast material during the scan was more useful than that by intravenous drip infusion of the material. The information regarding change of tumor size, CT number and CE were appropriate indicators which directly corresponded to responsiveness of the tumor to the chemotherapy and radiotherapy performed. Preoperative ABC classification of the tumor by information regarding its size, location, definition and anatomical relation of tumors to vital structures (neural, vascular, and visceral) was done by using CT. The classification clearly corresponded to the status of patients regarding the treatment required for the patients.

[Approach to the diagnostic colposcopy--a scoring method of colposcopic pattern]

In order to arrive at a final diagnosis of early cervical cancer by colposcopy alone, a colposcopic scoring system was applied to 172 patients with the disease. Each colposcopic pattern was scored from one point (for white epithelium) to 9 (for invasive cancer). The results obtained were as follows; 1) With these scoring criteria, stage 0 cancers were restricted to below 10 points and were characterized colposcopically by white epithelia with gland openings 2) In stage I-a lesion, atypical vessels, punctuation by irregular arrangement of the dots and concentration of abnormal gland openings were usually observed, and these findings were combined with each other to show a more complicated colposcopic pattern reflected in 11 to 18 points of the score 3) Frank invasions were indicated by 19 points or more, and punctuations or mosaics were seldom found in this stage, although the early "I-b" cancer was difficult to distinguish from I-a with this method 4) The diagnoses from this scoring system were identical with the final diagnoses confirmed by surgical methods in 66.7% of stage 0, 59.4% of I-a and 76.5% of I-b.

[Cytodiagnosis of ovarian cancer--usefulness of peritoneal washings in histological diagnosis]

To determine the clinical significance of intraperitoneal cancer cells, comparative cytologic studies on ovarian cancer cells in peritoneal washings and ascites were performed. The materials obtained from 6 patients with ovarian cancer were examined by light microscopy (LM), scanning electron microscopy (SEM) and transmission electron microscopy (TEM), and the results achieved were as follows: Ovarian cancer cells were recognized in both peritoneal washings and peritoneal effusion. It was easier to get a diagnosis from the cytologic features of the peritoneal washings than those of the effusion, because of the fewer contaminants such as fibrin, red blood cells and other degenerated tissues. Despite the presence of clustered cells in the washings, the nuclei and cytoplasmas were clearly seen. On SEM observation of the clustered cells from the effusion, red blood cells and fibrin were seen to adhere to the surface of cancer cells. Ultrastructural observation of cancer cells by TEM confirmed the fact that the activity of the cells was maintained even in ascites.

[Intraarterial high-dose adriamycin for patients with skeletal or soft tissue sarcoma]

In this paper, we summerized our experience with intraarterial high-dose adriamycin for thirteen patients with skeletal or soft tissue sarcoma. Eight patients had skeletal sarcoma and five had soft tissue sarcoma. Anticancer agents delivered intermittently an intra-arterial catheter (percutaneous placement by Sledinger technique) over 30 minutes. The compound of 1 mg of vincristine, 3 mg of Carboquone and 600 mg of dextran sulfate sodium was given weekly from the time of biopsy. Adriamycin was given at a dose of 0.8 mg/kg/day for 3 days after histological examination revealed sarcoma. Just prior to the adriamycin infusion, compound of 18,000 units of urokinase and 600 mg of dextran sulfate sodium was infused by bolous method. Course of therapy were repeated at every 3 to 4 weeks intervals. Surgical procedures were performed following completion of one to three courses of therapy. Total of 24 courses of therapy performed to 13 patients. Twelve patients had 20 courses preoperatively had three patients had 4 courses postoperatively. The overall objective clinical response rate (complete or partial response) by a combination of computed tomography and physical examination was 7/12 (58.3%). The overall histological response rate (greater than 75% tumor cell necrosis) was 4/9 (44.4%). During the period of follow up, with ranged from 2 to 60 months, none had local recurrence in the group performed radical operation (6 limb salvage procedures and 4 primary amputation). In this group one patient had lung metastases. The overall disease free survival rate was 8/10 (80.0%). In pharmacologic data from our series, adriamycin levels in venous blood adjacent to the arterially infused area were always higher than those from simultaneously sampled peripheral venous blood. Furthermore, peripheral blood levels of adriamycin following administration by the intraarterial route were not different from those obtained when the same dose is given intravenously. Our results of intraarterial high-dose adriamycin lend support and rationale to the use of regional intraarterial therapy even in patients with pulmonary metastasis. The latter will be exposed to a drug concentration expected from intravenous administration while the patient may also benefit from the augmented local effect.

Juvenile aponeurotic fibroma: an ultrastructural study

The light and electron microscopic findings in a case of juvenile aponeurotic fibroma are described. The tumor was composed of fibromatosislike areas and cartilagelike islands with characteristic calcification. The ultrastructural study verified the cartilaginous nature of this tumor. The cartilagelike islands were made up of chondrocytic cells embedded in an abundant intercellular matrix containing fine fibrils, spherical granules, and pleomorphic membrane-bound vesicles. The chondrocytic cells had many microvilli, a well-developed granular endoplasmic reticulum, and a prominent Golgi complex. In the periphery of each cartilagelike island was a perichondriumlike structure exhibiting transitional features from fibroblastic cells to chondrocytic cells. The fibromatosislike areas consisted of spindle-shaped fibroblastic cells and occasional myofibroblasts. The morphologic pattern of the tumor somewhat mimics embryonal chondrogenesis, and the fibromatosislike areas may represent an overgrowth of the fibrous layer of the perichondrium. It is possible to regard this tumor as an organoid tumor having a capacity for bidirectional differentiation into cartilage and fibrous tissue.