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This study aimed to determine the outcomes and prognostic factors associated with octogenarians who underwent pulmonary resection for lung cancer. From 2009 to 2018, 76 octogenarians underwent pulmonary surgery for lung cancer at the Kanazawa Medical University, Japan. They were divided into two groups (early and late octogenarians), and their clinicopathological characteristics and outcomes were investigated. Overall survival rates and recurrence-free survival rates were determined using Kaplan–Meier curves. Univariate and multivariate analyses were performed to identify prognostic factors. Limited surgery was performed more often in the late octogenarian group; however, most perioperative factors were not significantly different between the two groups. The 3-year overall survival and recurrence-free survival rates were 61.2% and 52.8%, respectively. The median observation period was 37.5 (8.9–112.3) months postoperatively. Kaplan–Meier curves showed that age ≥ 85 years (late octogenarian), smoking history, and squamous cell carcinoma on histology were associated with worse survival rates. Multivariate analysis identified age ≥ 85 years (late octogenarian) (p = 0.011) and cigarette smoking (p = 0.025) as unfavorable prognostic factors for overall survival and recurrence-free survival, respectively. Most octogenarians with an indication for surgery can tolerate pulmonary surgery. However, owing to the limitations of this retrospective, single-center study, future studies involving multiple-institutions are required to confirm our findings.

This study was aimed to investigate etiology and clinical profiles of recurrent acute pancreatitis (RAP), particularly from the morphology of the pancreaticobiliary duct system.Pancreaticobiliary morphology was examined in 230 of 381 patients with acute pancreatitis (AP) using endoscopic retrograde cholangiopancreatography. We analyzed factors associated with RAP including the pancreaticobiliary duct system.RAP was diagnosed in 74 patients (19%). Major etiologies of RAP were alcoholic (38%), idiopathic (26%) and pancreaticobiliary malformation (22%). Patients with alcoholic RAP were significantly younger (47.2±11.6 years) than those with gallstone RAP (67.3±16.8; p0.05). RAP with pancreaticobiliary malformation (male-to-female ratio: 1:4.3; p0.01) and gallstone RAP (1:1.7; p0.05) occurred predominantly in females in comparison with alcoholic RAP (1:0.2). Recurrence rate was 80% for AP with pancreaticobiliary malformation, significantly higher than for the others (p0.01). Pancreas divisum was suspected as the etiology of mild RAP in 7 patients. Four RAP patients with pancreas divisum underwent endoscopic minor papilla sphincterotomy and improved. Pancreaticobiliary maljunction with biliary dilatation (choledochal cyst) was suspected as the etiology of mild RAP in 3 patients. The 3 RAP patients with choledochal cyst underwent prophylactic flow diversion surgery with complete resection of the dilated common bile duct, and achieved improvement. High confluence of pancreaticobiliary ducts was suspected as the etiology of mild RAP in 6 patients.Pancreaticobiliary malformation is one of the major causes of RAP. As some of them benefit from endoscopic or surgical treatment, morphology of the pancreaticobiliary duct system should be examined where possible in RAP patients.

Early dynamic and late 123 I-MIBG SPET studies were performed to investigate several parameters used to distinguish the characteristics of various cardiac disorders. Forty-six individuals (34 non-diabetic, 12 diabetic) with or without heart disease were included in the study. Early dynamic and late static SPET images were acquired using a triple-headed gamma camera. After selecting mid-sections from vertical (VLA) and horizontal (HLA) long-axis images, regions of interest were created over the apex, whole heart and anterior, inferior, septal and lateral walls of the heart. Various uptake ratios at 3, 11 and 19 min and 4 h after injection (HU3, HU11, HU19, DUP) and clearances (K se : between HU3 and HU11; K e : between HU11 and HU19; K d : between HU19 and DUP) were calculated. There were significant differences among various cardiac pathologies on the delayed images. Cardiomyopathy patients showed the lowest uptake on the delayed images. When all segments in normal patients and all involved segments in myocardial infarcted patients were compared, there was significantly lower uptake of MIBG in infarcted segments at all time points. K d showed the lowest value compared with K se and K e . In cardiomyopathy patients, K se , K e and K d were significantly different from each other. Both K se and K e were significantly higher in cardiomyopathy patients than in normal patients. In conclusion, the results of this study are in line with published data and precise measurement of uptake and clearance was possible when excluding background and blood pool activity.

The aim of this study was to establish and confirm the safety of administering 1110MBq of 131I to outpatients.Total radiation exposure from patients to household members was hypothesized from the measured dose rate at 1 m when the patient is released. Actually we also measured the effective dose to household members who assisted outpatients during the first 7 days after the administration of 131I by personal dosimeter. A list of radiation safety precautions is given to the patient and household members. Behavioral reports about the distances and times of close contact throughout the 7 days are requested of each household member.The effective dose measured using the personal dosimeter to all household members employing several safety precautions was confirmed to be lower than the hypothesized dose calculated using our formula. And the mean whole-body effective dose rate over the 7 days in household members was 0.05±0.08 (range, 0.05 to 0.43) mSv, which specify that radiation exposure to household members of the outpatients who have just received ablative radiation therapy must be below 5.0 mSv/event.Remnant thyroid ablation with 1110MBq for outpatients showed that the radiation doses to household members were within the recommended constraint dose according to several safety precautions. The method of returning home after remnant thyroid ablation is thought to be the most important factor that determines the effective dose to household members of outpatients.

The time dependency of the antitumour activity of (-)-(R)-2-aminomethylpyrrolidine(1,1-cyclobutanedicarboxylato++ +)platinum(II) monohydrate (DWA2114R) was examined in mice inoculated i.p. with 10(5) mouse L1210 leukaemia cells. The increase in life span was greater in mice treated with 72 mg kg-1 DWA2114R on the 6th day following tumour inoculation than in mice treated at earlier times. Such superior effects against advanced L1210 were also seen with cis-diammine (1,1-cyclobutanedicarboxylato)platinum(II) (CBDCA) but not seen with the parent compound, cis-diamminedichloroplatinum(II) (CDDP) or other antitumour agents devoid of platinum. After the injection of DWA2114R on day 6, most of the ascites tumour cells accumulated in the S and G2/M phases of the cell cycle and the total cell number markedly decreased from 10(8) to less than 10(6). On the other hand, only a temporary G1 arrest and a less than 50% reduction of the cell number were induced after a similar treatment on day 3. Interestingly, the superiority of DWA2114R for advanced L1210 was lost in athymic nude mice and mice depleted of T cells by anti-thymocyte antisera. In addition, mice cured of advanced L1210 specifically rejected re-inoculated L1210 cells. These results indicate that the superior antitumour activity against advanced L1210 is unique to DWA2114R among the agents tested (except for CBDCA) and is caused by both an increased drug susceptibility of tumour cells and a drug-induced antitumour effect mediated by T cells of the host mice.

The purpose of this investigation was to determine whether the concepts of critical velocity (CV) and anaerobic swimming capacity (ASC) could be used by coaches as a reliable index in order to monitor 1500-m Surface (SF) performances in Finswimming. Thirteen Finswimmers (6 males and 7 females, 24+/-6 years), members of the Japanese national team, were instructed to swim three different swimming distances (400-, 800-, and 1500-m) at maximal effort in a 50m long course swimming pool. CV and the ASC were calculated using 400-m and 800-m swim times. Mean height and body mass were 170.2 cm and 69.7 kg in male and 160.5 and 61.0 kg in female. A highly positive correlation was found between the CV and the mean velocity of 1500-m SF (V1500) (r=0.91, P

New platinum complexes, (-)-(R)-2-aminomethylpyrrolidine(1,1- cyclobutanedicarboxylato)platinum(II) monohydrate (DWA2114R) and its enantiomeric isomer, (+)-(S)-2-aminomethylpyrrolidine(1,1- cyclobutanedicarboxylato)platinum(II) monohydrate (DWA2114S), were compared in their antitumour effects and nephrotoxicity-inducing activities. Both compounds were effective against the murine tumours L1210 and Colon 26 by i.p. injection of 20-100 mg kg-1. While DWA2114S showed marked increases in blood urea nitrogen (BUN) and urinary protein and sugar in BDF1 mice treated i.p. at the maximum tolerated dose, DWA2114R showed no increases in these parameters. To clarify the difference of nephrotoxicity between the isomers, tissue distribution was examined. Renal Pt concentration in DWA2114S-treated mice was more than 5-fold higher compared with that in DWA2114R-treated mice 2h after i.p. injection of 80 mg kg-1. However, there were no such marked differences in the lung, liver, heart, spleen and plasma. The low content of Pt in the kidneys of DWA2114R-treated mice could explain its lower nephrotoxicity. The in vitro experiments for uptake of the drugs into the cultured normal rat kidney cells and fresh splenocytes revealed that the Pt amount in the cells treated with DWA2114S, especially in the kidney cells, was much higher than DWA2114R.

Surgical strategy for patients for lung cancer with coronary disease remains controversial. We performed concomitant off-pump coronary artery bypass grafting (off-pump CABG: OPCAB) and left lower lobectomy with ND 2a lymph nodes dissection for lung cancer with pneumoconiosis. After CABG, due to fixed adhesion of peribronchial lymph node, left lower lobectomy was hard to carry out. Postoperative management was done with much difficulty for massive sputum and pneumonia caused by chronic inflammatory lung disease. As a result, postoperative course has been uneventful for 2 years after operation. In the concomitant OPCAB and lung resection with chronic inflammatory lung disease, whether the synchronous or 2 periods operation was appropriate was still unknown. We think that careful pre- and intraoperative assessment for this disease is important.

Of 185 patients with single ventricle physiology, 59 patients who underwent Fontan type operations between April 1970 and May 2002 served as subjects. Subjects displayed a median age of 5.2 years and a median body weight of 11.4 kg. In the first 22 years (group 1), 34 patients underwent concomitant right atrium-pulmonary artery (RA-PA) anastomosis, Björk procedure and total cavopulmonary connection (TCPC), while in the last 8 years (group 2), 25 patients underwent staged TCPC, where bidirectional cavopulmonary shunt (BCPS) and obliteration of additional pulmonary blood flow was performed previously. Four cases of early death (group 1:4 patients, group 2:0 patient) and 12 cases of late death (group 1:11 patients, group 2:1 patient) were encountered. Early mortality was 6.8% (group 1:12%, group 2:0%, p = 0.10) and late mortality was 21%. The 5-year survival rate was 85.2 +/- 4.9% (group 1:80.0 +/- 6.8%, group 2:93.8 +/- 6.1%, p = NS), and the 10-year survival rate was 79.6 +/- 6.0%. Staged TCPC, precedent BCPS with obliteration of additional pulmonary blood flow, seems to be beneficial for accurate patient selection for Fontan candidate.

Gastrointestinal involvement is often seen in patients with systemic lupus erythematosus (SLE). All parts of the gastrointestinal tract may be affected. However, rectal involvement at onset is rare. We describe here a case of SLE in which rectal ulcers due to vasculitis occurred as the initial manifestation of the disease without involvement of any other organ. The ulcers worsened, along with the appearance of lupus nephritis 5 years later When steroid therapy was initiated, there was rapid clinical and radiographic improvement. Our case suggests that rectal ulcer is a rare but important complication of SLE and can represent the initial and sole clinical manifestation of the disease.

A 50-year-old man was admitted to our hospital because of an abnormal shadow, detected during an upper gastrointestinal examination. A chest radiograph showed an infiltrating shadow in the right middle lung field. A chest CT showed a fistula communicating between a bronchus (rt. B6) and the middle of the esophagus. Resection of the fistula was performed by video-assisted thoracoscopic surgery (VATS). Isolation of the fistula was straightforward, and there was no evidence of inflammation or adherent lymph nodes around it. Histologic examination of the resected specimen revealed that the fistula lumen was covered with squamous epithelium and muscularis mucosa. These findings suggested that this case could be categorized as Braimbridge type II. In this case, the chest CT showed the esophagobronchial fistula clearly, and was useful for the diagnosis.

This study was aimed to compare changes in hemodynamics between unilateral (UL) or simultaneous bilateral (BL) lung volume reduction surgery (LVRS) for chronic obstructive lung disease. Sixteen patients underwent LVRS by stapler resection with neodymium: yttrium-alminum-garnet (Nd: YAG) laser ablation; five underwent BL-LVRS (four by median sternotomy and one by thoracoscopy) and 11 underwent UL-LVRS by thoracoscopy. Four patients had multiple bullae within pulmonary emphysema. At preoperation and 6, 12, 24, and 48 hours postoperatively, hemodynamics and right ventricular performance were evaluated. UL- and BL-LVRS reduced afterload of the right and left ventricle postoperatively. Although the pulmonary arterial resistance increased after surgery, the total pulmonary resistance decreased (p=0.001) in association with the reduced systemic vascular resistance (p=0.001). These reductions improved cardiopulmonary circulation, resulting in increased stroke volume and cardiac output (p=0.003). The right ventricular ejection fraction showed minimal change 48 hours postoperation. Two patients died of pneumonia caused by persistent air leakage. In conclusion, both the UL- and BL-LVRS showed similar effectiveness in terms of improvement in the systemic and cardiopulmonary circulation after LVRS, if there were no postoperative complications. We concluded that we had to reduce and repair the persistent air leakage after LVRS.

Amplification of the c-myc gene has been reported in non-small cell lung cancer (NSCLC). We investigated the c-myc gene amplification and the numerical aberration of chromosome 8 by dual color fluorescence in situ hybridization (FISH) to evaluate the relation between possible genetic abnormalities, pathological factors and prognosis.Tumor tissue samples were obtained from 31 patients with NSCLC who underwent lobectomy with mediastinal lymph node dissection. Samples were analyzed by FISH using 8 alpha satellite DNA probe and c-myc gene cosmid probe. The relation between genetic abnormalities, pathological factors (T factor, tumor size, and N factor), and prognostic factors was evaluated by univariate and multivariate analysis, and by the Kaplan-Meier method and log-rank analysis.Chromosome 8 aberrations were T1 (n=3), 44.0%; T2 (n=18), 35.7%; T3 (n=7), 40.0%; T4 (n=3), 39.7% (p=NS). The c-myc gene amplifications were T1, 54.3%; T2, 51.1%; T3, 51.0%; T4, 66.3% (p=NS). There was no difference between patients whose tumor was more than 5 cm (n=16), and 5 cm or less (n=15) in the rate of chromosome 8 aberration (39.3%: 36.3%), or the rate of the c-myc gene amplification (52.1%: 53.7%). N factors for chromosome 8 aberrations were N0 (n=18), 35.9%; and N2 (n=11), 44.9% (p=NS). In the c-myc gene amplification, there was a significant difference between N0 and N2 (48.6%, 61.3%, p=0.040). In univariate and multivariate analysis, chromosome 8 aberrations correlated with a poor prognosis (p=0.037 and p=0.041). The 5-year survival rate was 15.4% in patients whose rate of chromosome 8 aberrations was 40% or more (n=13), which was significantly less than that in patients with an aberration rate of less than 40% (n=19, 57.9%, p=0.014).The c-myc gene amplification correlates with lymph node metastasis. Although there was no significant link between the amplification of the c-myc gene and clinical outcome, the numerical chromosome 8 aberrations was considered to be a factor for survival.

The applicability of the right internal thoracic artery (RITA) for coronary artery bypass grafting is higher when used as a free graft than as a pedicled graft. However, the technical difficulty of directly connecting the proximal end of the free RITA to the much larger aorta leads to poor patency. To overcome this technical limitation, we have used a modification that places the proximal end of this artery onto the hood of an accompanying vein graft at the aortic anastomosis instead of directly onto the aorta. We performed isolated coronary artery bypass grafting on 43 patients using the free RITA as a second arterial graft following pedicled left internal thoracic artery grafting. The mean patient age was 60 years and 38 patients were male. There was no mortality and no incidence of morbidity related to free RITA use. Postoperative coronary angiography performed in all patients revealed that all proximal anastomoses were widely patent, making the patency rate of the free RITA 100%. With these encouraging results, the free RITA graft with the described modification is thought to be a more promising second arterial graft with greater versatility than the pedicled graft. The long-term evaluation of a large patient population will determine the significance of this modification.

In this study, we investigated perioperative and long-term prognosis and the risk of major complications after repair of ventricular septal defect in 48 patients with Down's syndrome who underwent ventricular septal defect repair between May 1980 to August 1999 were compared with those in 48 patients with normal chromosomes matched for age and time period. Pp/Ps were significantly lower after the operation in both groups; however perioperative and postoperative Pp/Ps of Down's syndrome group were significantly higher than that those of control group. The duration of intubation was significantly longer in the Down's syndrome group and the case-control study revealed that the risk of long intubation (or = 7 days) was significantly higher in the Down's syndrome group, but the incidence of PH crisis did not differ between the 2 groups. The main reasons of prolonged intubation period were respiratory complications such as pneumonia or atelectasis. In Down's syndrome group, a 5 months old boy died of heart failure on the 5th postoperative day. All other patients were survived through a mean follow-up period of 122.4 months (the follow-up rate was 95.8%). In conclusion, the perioperative and long-term prognosis after ventricular septal defect repair in patients with Down's syndrome were similar to those in patients with normal chromosome.

Hepatitis B virus (HBV) reactivation in patients with positive hepatitis B surface antibody (HBsAb) has been reported in some cases of allogenic bone marrow transplantation, acquired immunodeficiency syndrome (AIDS), and organ transplantation. However, to our knowledge, no reports have been made on the frequency and risk factors involved in HBV reactivation after autologous peripheral blood stem cell transplantation (APBSCT). Forty seven patients who underwent APBSCT were retrospectively analyzed. Three patients who were HBsAb positive before APBSCT contracted post-transplant HBV acute hepatitis. All 3 patients had multiple myeloma. HBV DNA could not be demonstrated in preserved samples of transfused blood. Therefore, we speculated that reactivation of latent HBV had occurred. The 3 patients with HBV hepatitis had relatively lower titers of pre-transplant HBsAb, and the total dose of steroids they received after APBSCT was significantly higher than for other patients who did not experience post-transplant HBV reactivation. There were no significant differences in pre-transplant hepatitis B core antibody (HBcAb) titer or total post-transplant blood transfusion volume. Our study suggested that immunocompromised states, especially those induced by high-dose steroid therapy, may allow the reactivation of HBV after APBSCT, even in patients who had HBsAb before APBSCT.

SPECT was performed in 11 patients with metastatic hepatic cancer by intraarterial infusion of 99mTc-MIBI before hepatic arterial chemotherapy was started, and the degree of accumulation and clinical efficacy were compared. Early and delayed SPECT images were obtained and various parameters were calculated, including early ratio (ER), delayed ratio (DR), washout rate (WR), and retention index (RI). Judgement of clinical efficacy was made by CT before and after hepatic arterial chemotherapy and was classified as effective, unchanged, and progressive groups. The mean values of ER and DR in the effective group were higher than those in the progressive group. No relationships were noted among the WR and RI values of the groups. The assessment of ER and DR using 99mTc-MIBI intraarterial SPECT is considered to be useful for prediction of the clinical efficacy of hepatic arterial chemotherapy for metastatic hepatic cancer.

Measurement of 99mTc-MAG3 plasma clearance (CLmag) based on one-compartment model (MPC method) was applied to renal transplantation and evaluated for the factors which might affect the calculated results, especially concerning renal depth. Correlation coefficient of CLmag between MPC method using real renal depth and Russell or Bubeck single sampling method was good (r = 0.852 or 0.876, respectively). Regression equation between MPC method and Russell method was y = 1.044x - 3.0 and was more closer to y = x than that between MPC method and Bubeck method. CLmag of MPC method calculated by estimated renal depth from the abdominal thickness was also similar to that by real renal depth. Even if the fixed renal depth, 4 cm, was applied, the coefficient and regression equation between MPC method and Russell method were r = 0.884 and y = 1.004x - 10.2. In conclusion, MPC method is applicable to the evaluation of renal transplants. Though measuring renal depth is best, calculation with fixed renal depth of 4 cm might be practically acceptable.

A 19 year-old man with a history of dysphagia and chest pain was diagnosed as having a cyst of the esophagus by endoscopic ultrasonography and magnetic resonance imaging. The patient's bronchogenic cyst was treated by video-assisted thoracoscopic excision with mini-thoracotomy. This procedure is applicable for patients who require repair of the esophageal wall after excision of a lesion and reduces post-operative complications.

BACKGROUND AND AIMSLaser induced fluorescence (LIF) from colonic mucosa was measured in vivo with and without δ aminolevulinic acid (ALA) in an attempt to differentiate between neoplasia and non-neoplasia in real time during colonoscopy.METHODSSpectra from 32 adenomas, 68 normal sites, and 14 hyperplastic polyps in 41 patients were obtained with a point monitoring system. Twenty one of the patients had been given a low dose of ALA as a photosensitiser before the examination. Light of 337, 405, or 436 nm wavelength was used as excitation. Stepwise multivariate linear regression analysis was performed.RESULTSWith 337 nm excitation, 100% sensitivity and 96% specificity was obtained between normal mucosa and adenomas. Seventy seven per cent of the hyperplastic polyps were classified as non-neoplastic. When exciting with 405 and 436 nm, the possibility of distinguishing different types of tissue was considerably better in the ALA patients than in the non-ALA patients.CONCLUSIONSThe in vivo point measurements imply that a good discrimination between normal tissue and adenomatous polyps can be obtained using the LIF technique. Excitation at 337 nm and at 405 nm or 436 nm using ALA gives good results. LIF also shows potential for distinguishing adenomatous from hyperplastic polyps. The number of detection wavelengths could be reduced if chosen properly.

The aim of this study was to assess the usefulness of 99Tcm-tetrofosmin for detecting tumours of the lungs and adjacent structures and to compare the results with those for 201Tl. In the 18 patients studied, there were 30 lesions in total. Dual-isotope SPET acquisitions were performed 10 min and 3 h after the administration of 99Tcm-tetrofosmin and 201Tl. Image quality and semi-quantitative parameters were evaluated for both tracers. All lesions were detected by the two radiopharmaceuticals on both the early and delayed images. In seven patients, the image quality of 99Tcm-tetrofosmin was better than that of 201Tl. For the detection of metastatic lymph nodes, the delayed 201Tl and the early 99Tcm-tetrofosmin images were superior. No significant difference was observed between the uptake ratios of the two tracers. 99Tcm-tetrofosmin showed significantly (P0.001) higher washout than 201Tl from both the lesions and normal lungs, although washout of 201Tl from normal lungs was significantly higher than that from the lesions. In conclusion, 99Tcm-tetrofosmin may be helpful for detecting tumours of the lungs and adjacent structures, but has limited applicability in differentiating between malignant and benign tumours and may not be used instead of 201Tl to detect malignant tumours of the lungs.

The aim of this study was to characterize lung lesions by means of the uptake, retention and washout of 201Tl, and to quantify the sensitivity of 201Tl SPET (single photon emission tomography) in detecting mediastinal and hilar lymph nodes. A total of 68 patients with lung lesions (tumours and inflammation) underwent both helical computed tomography (CT) and 201Tl SPET examinations. Uptake, retention and washout parameters were calculated from early and delayed 201Tl SPET by drawing regions of interest over the primary lesion and the background of the lung. The findings on 201Tl SPET were compared with those on CT and surgical findings. A significant difference in the retention index (RI) was observed between primary malignant and benign lesions. In detecting lymph nodes, the sensitivity, specificity and negative predictive value were 83%, 60% and 90% respectively for early 201Tl SPET, and 50%, 80% and 80% respectively for delayed 201Tl SPET. 201Tl SPET with semi-quantitative analysis, especially RI, helps to differentiate between malignant and benign lung lesions. Lymph nodes larger than 1 cm on CT but not showing 201Tl uptake could be considered non-metastatic lesions.

A 35-year-old man with non-Hodgkin's lymphoma (NHL) (follicular small cleaved, B cell, stage IVB) received double myeloablative chemotherapy with syngeneic peripheral blood stem cell transplantation (PBSCT). Although platelet recovery was delayed until day 29 after the second transplantation, thereafter trilineage hematopoietic reconstitution was achieved. The evaluation after PBSCT did not detect any residual tumor. The patient was in good health until day 138, when his platelet count suddenly began falling; on day 150, it had fallen to 1.5 x 10(4)/microliter, and the patient was re-admitted for treatment. The bone marrow was normocellular with a normal count and megakaryocyte structure. Other examinations, including serological tests and computed tomography of the neck, chest, abdomen, and retroperitoneum, did not indicate a recurrence of NHL or reveal the cause of thrombocytopenia. The patient's platelet-associated IgG (PAIgG) level was at 70.9 ng/10(7) platelets (normal range: 9-25 ng/10(7) platelets); a diagnosis of thrombocytopenia due to an autoimmune mechanism such as idiopathic thrombocytopenic purpura (ITP) was made. Prednisolone therapy increased the platelet count and reduced the PAIgG level. Thrombocytopenia with an ITP-like mechanism rarely occurs more than 100 days after autologous or syngeneic stem cell transplantation, and should be taken into consideration as a late complication of PBSCT.

Histologic sections of endoscopically flat colorectal polyps removed in Tokyo and Stockholm were reviewed. A total of 178 flat colorectal neoplasias (88 from the Tokyo Medical College Hospital, Tokyo and 90 from the Karolinska Hospital, Stockholm) were classified following strict histologic criteria by two different pathologists (one Swedish and the other Japanese). The number of polyps with high grade dysplasia, with intramucosal carcinoma and with invasive carcinoma were significantly higher (p0.001) in Tokyo (61.4% or 54/88) than in Stockholm (15.0% or 14/90). The present results suggest that flat colorectal neoplasic polyps may be histologically more "severe" and more "aggressive" in Japanese than in Swedish patients. The possibility that more "advanced" lesions had been inadvertently removed in Tokyo was discounted as Japanese endoscopists were also instrumental in excising many of the flat colorectal polyps in Stockholm. Ethnic and/or environmental differences seem to play a crucial role in the evolution of flat colorectal neoplasic polyps from LGD and HGD, to intramucosal and to invasive carcinoma.

Preoperative CT and Ultrasonography (US) showed adrenal tumors in four patients with lung cancer. Although metastasis of the cancer to the adrenal gland was suspected, a definitive diagnosis could not be made by CT and US alone. MRI is as ineffective as CT and US. Needle biopsy is useful if tumor cells are detected, but not unless they are discovered. Surgery, therefore, is necessary to establish the final diagnosis. (Adrenalectomy was performed on all cases, one of which had metastasis). No particular complications occurred after adrenalectomy. Adrenalectomy was considered unavoidable to determine stage and treatment policies in patients suspected of metastasis in imaging diagnosis.

Measurement of 99mTc-MAG3 plasma clearance based on 1-compartment model (MPC method) were applied to 12 pediatric patients and evaluated for the factors which might affect the calculated results. Depth correction is a critical factor for the measurement of renal uptake. Three different equations for estimating renal depth were compared with the real depth measured by ultrasonography. The equation proposed by K. Itoh was suitable though the equations by T. Ito and Raynaud were insufficient. Estimation of distribution volume, which is regarded as circulating plasma volume (CPV), is also critical for the calculation of MAG3 clearance by MPC method. Precisely, hematocrit measured by venous sampling and circulating blood volume (CBV) calculated as 7.5% of body weight are used for estimation of CPV. However, assumed CPV as 5% of body weight was acceptable if the hematocrit was not severely deviated from the normal value. Simplified MPC method utilizing two factors mentioned above gave a positive correlation with Russell's one point sampling method. In conclusion, MPC method is applicable for pediatric patients.

We report a case of uretero-aortic fistula. A 69-year-old man with rectal cancer underwent a pelvic exenteration and a double--barreled cutaneous ureterostomy in the right lower abdomen. Stomal stenosis necessitated continuous indwelling of double J stents in the two ureters. Two years postoperatively, massive bleeding occurred during exchange of double J catheters. Occlusive ureterogram demonstrated a uretero-aortic fistula at the crosspoint between the left ureter and the aorta. The surgical repair consisted of closure of the aortic fistula, ligation of the left ureter proximal to the fistula and percutaneous left nephrostomy.

The phase III clinical trial of strontium-89 chloride agent (SMS.2P) was performed in 90 patients with painful bone metastases secondary to prostate (53), breast (18) and other types of cancer (19). Some patients experienced a transient increase in pain or nausea and vomiting. However both symptoms subsided and serious side effects were not observed in any of the patients. As reported, we confirmed some abnormal changes in peripheral blood picture. A decrease in the number of white blood cells and platelets was considered to be partly a result of bone marrow suppression due to 89Sr irradiation. Pain was substantially improved after 89Sr therapy in 58% of the patients and there was some alleviation in 12%. The release from pain was accompanied by an improved quality of life for these patients including sleep patterns and morbidity. Some patients were able to resume their former life styles. Most of the improved patients experienced pain relief from days to one week following 89Sr therapy and in half cases, this remained effective for 2 or 3 months. There were even cases in which the pain relief continued over an observation period of time of clinical study.

We investigated and compared findings on combined 99mTc pertechnetate-201Tl with those of [99mTc]pertechnetate-67Ga scintiscans to elucidate the advantages of 201Tl in detecting various salivary glands disorders.We studied 23 patients: 6 had sialadenitis, 12 had benign tumors and 5 had malignant tumors. All but four patients had undergone [99mTc]pertechnetate (before and after lemon stimulation), 201Tl (early and delayed) and 67Ga imaging.Five of six sialadenitis patients showed various degrees of diffuse uptake of 99mTc. All six except one showed early uptake without retention of 201Tl on delayed imaging. The 67Ga scan showed uptake in all patients except one. Nine of 12 benign tumors showed a cold defect on 99mTc scans. Patients with Warthin's tumors and plasmacytoma showed increased 99mTc uptake at the tumor with retention. The 201Tl scan showed early uptake without retention in benign tumors except in three patients, two of whom had Warthin's tumor. Five of the benign tumors, however, were positive on 67Ga scan. None of the malignant tumors showed any uptake of 99mTc. The 201Tl scan showed uptake with tumor retention on delayed images in three patients; three other patients also had positive 67Ga scans. Overall, sensitivity and specificity of 201Tl in detecting malignant tumors were 60% and 73%, respectively, with a negative predictive value of 85%. Sensitivity and specificity for 67Ga were 60% and 47%, respectively, with a negative predictive value of 80%.In view of sensitivity, specificity and convenience of 201Tl as well as future prospects for dual-isotope acquisition, 67Ga may be replaced by 201Tl in detecting salivary gland disorder.

Radioactive strontium chloride (89Sr) was administered for pain relief in 6 patients with bone metastases (4 prostate cancer and 2 breast cancer patients). Out of 6 patients, 2 showed apparent relief of bone pain and improvement of QOL, and 3 showed slight relief of the pain with or without improvement of QOL; that is, 83% was effective. Side effects were seen in 2 patients; transient deterioration of bone pain in one patient and bone marrow suppression in the other patient. The patient who showed bone marrow suppression had rather more lesions of bone metastasis (diffuse metastasis) and least urinary excretion of the radioactivity. Urinary excretion for 2 days varied 5 to 40% of the administered dose and was less in the patients with more metastatic lesions.

Bronchopleural fistulas (BPF) developed in six (7.9%) of 76 patients who underwent a pneumonectomy for treatment of lung cancer. Five patients (18.2%) underwent a right pneumonectomy and one (3.7%) a left pneumonectomy. All patients were male, had squamous cell carcinoma, and were diagnosed as having BPF within one month after pneumonectomy. Their average age was 60.2 years. Univariate analyses related to development of BPF showed that significant risk factors were preoperative infection (Chi-square test; p0.001), right pneumonectomy (Chi-square test; p0.05), and metastasis to a subcarinal lymph node (Chi-square test; p0.05). However, sex, age, operating time, amount of blood loss during surgery, amount of blood transfused during surgery, history of smoking, degree of lymph node dissection, degree of curability, performance of combined resection, histologic type of tumor, tumor size, presence of residual tumor at the bronchial stump, and suturing method were not significant risk factors for development of BPF. Our stepwise regression analysis related to development of BPF showed that preoperative infection, metastasis to a subcarinal lymph node, right pneumonectomy, and combined resection were significant risk factors. Sometimes it is difficult to preserve the bronchial arteries upon the dissection of metastatic subcarinal lymph nodes which tightly adhere to the bronchial sheath. Moreover, after a conventional right pneumonectomy, the bronchial stump protrudes into the pleural cavity and is not covered by any tissue. Ligation of the bronchial arteries or protrusion of the bronchial stump into the right pleural cavity reduces the blood supply to the bronchial stump to a very low level and causes development of BPF. Therefore, we suggest that control of preoperative infection, wrapping of the bronchial stump, and preservation of the bronchial arteries during mediastinal lymph node dissection are important to prevent development of BPF.

We investigated the prevalence of coexisting diabetes mellitus among patients with active pulmonary tuberculosis by the time of admission, sex and age among 2659 active pulmonary tuberculosis patients admitted to National Chiba Higashi Hospital during the 8 years period from 1987 to 1994. Out of total patients, 352 patients were diagnosed as having coexisting diabetes mellitus and the rate was 13.2%. Prevalence of coexisting diabetes mellitus among active pulmonary tuberculosis during the period from 1991 to 1994 was significantly higher than that from 1987 to 1990. The prevalence in male was higher than that in female significantly. The prevalence was particularly higher in male of 40s (22.0%), and 50s (21.3%), than that in the other age groups.

A 22 year-old Thai male was admitted to our hospital because of chest pain and dyspnea. In 1989, he met with a traffic accident and was injured his head and the arm, and was given a blood transfusion in Thai. Laboratory examinations on admission revealed that serolopositivity for HIV, and CD4+T lymphocyte count was 17/microliter. Chest X-ray on admission showed bilateral diffuse nodular shadow, and he was diagnosed as miliary tuberculosis with AIDS. On the chest X-ray, in the right upper middle lung fields, the shadow was rough and partly influent. In the left lung, the nodular shadow were smaller and distributed evenly. As there was a difference in the distribution of nodular shadows between the left and right lung, the chest X-ray findings of this case was atypical of miliary tuberculosis.

Forty three patients detected by symptomatic visit and died of active pulmonary tuberculosis were investigated on their social background factors. As to age of 43 cases, 17 cases (40%) were fortieth of fiftieth; namely in young productive age. Sixteen were male and 13 cases lived alone and thirteen cases had no regular occupation when they were admitted. Three were too serious to talk about their case histories. Among other 13 cases, none visited a hospital within three months from the appearance of their symptoms and 8 cases visited a hospital after six months or long from the appearance of their symptoms. Thus, the patient's delay was obvious, and this was actually the cause of death in this cases.

A 77-year-old male consulted an orthopedist with complaints of lumbago and a lumbar swelling, and was treated with acupuncture. As the symptoms deteriorated, and smear of a specimen aspirated from the lumbar swelling was positive for acid fast bacilli which were later identified as Mycobacterium tuberculosis, he was hospitalized in the National Chiba Higashi Hospital. On admission to our hospital, CT-scan of lumbar vertebrae showed the destructive change of spinous process of the third lumbar vertebra accompanied by the abscess formation, and an occipital swelling with the destructive change of skull was also detected. Whole body examinations with CT-scan and bronchoscopy did not reveal any other abnormal findings suspective of tuberculous lesions. The above lesions were both gradually improved by antituberculous chemotherapy with INH, RFP, and EB. He was finally diagnosed as posterior tuberculous spondylitis of the lumbar vertebra with cold abscess, and also clinically diagnosed as skull tuberculosis caused presumably by the inoculation of tubercle bacilli from the lumbar lesion by acupuncture.

One hundred and forty patients underwent absolute curative resction for stage I non-small lung cancer from 1982 to 1993 at our department. For these, prognosis and changes in quality of life (QOL) were evaluated retrospectively with respect to the predicted postoperative lung function. The average age of the patients was 62 years (range 31 to 84 years), and 103 males and 37 females were included. Seventy-five of the patients had adenocarcinoma, 61 squamous cell carcinoma, and 4 large cell carcinoma. These 140 patients were classified into two groups, H and N, according to the predicted postoperative %FEV1.0 and %VC. Group H patients (n = 39) had a predicted %FEV1.0 and/or %VC of 55% or less for postoperative respiratory disease. Group N patients (n = 101) had a predicted %FEV1.0 and %VC of 56% or more for expected normal respiratory conditions postoperatively. Group N patients showed a 98% one-year survival rate, and 72% five-year survival rate and good QOL postoperatively. On the other hand, group H patients showed 86% and 45% one- and five-year survival rates respectively, the same as those predicted for patients with stage II non-small cell lung cancer. Furthermore, group H patients more than 70 years old showed 80% and 17% one- and five-year survival rates, the same as those predicted for patients with stage IIIA non-small cell lung cancer, and poor prognosis in comparison with that of the group N patients more than 70 years old. Then, QOL was investigated one year postoperatively. The group H patients showed deterioration of performance status in comparison with the group N patients. Since there was a high incidence of postoperative respiratory disease in the patients with a predicted %FEV1.0 and/or %VC of 55% or less, physicians should avoid extended lung resection, which might cause deterioration of the cardiopulmonary reserve volume, in patients in whom respiratory disease is predicted to occur, particularly for patients more than 70 years old. In conclusion, physicians should consider limiting surgical intervention to preserve lung volume and QOL of patients more than 70 years old with restricted cardiopulmonary function.

Single photon emission computed tomography (SPECT) using I-123 metaiodobenzylguanidine (MIBG) was evaluated for the detection of doxorubicin (DXR) cardiomyopathy in seven patients with malignant lymphoma receiving DXR doses ranging from 70 to 530 mg (DXR group), and 20 normal subjects without hypertension, diabetes mellitus or electrocardiographic abnormalities (control group). The ratio of the heart to mediastinal counts (H/M) and the washout rate (WR) in MIBG SPECT images were compared between the two groups. Correlation of total doses of DXR with H/M and the relationship of H/M to WR were investigated. The H/M of the DXR group was lower than that of the control group (3.00 +/- 0.97 vs 4.90 +/- 1.08, p0.001). The WR of the DXR group was higher than that of the control group (30.9 +/- 10.5% vs 16.5 +/- 9.1%, p0.001). Total DXR doses were inversely correlated with H/M (r = -0.86), H/M correlated inversely with the WR (r = -0.83) only in the DXR group. Pathological findings of one patient, who died of DXR cardiomyopathy, showed atrophic and fibrotic nerve fibers in the apical inferior segment of the left ventricle where MIBG uptake was reduced markedly. DXR cardiomyopathy can be detected with MIBG SPECT as cardiac sympathetic nervous dysinnervation. The pathological findings correspond to the MIBG SPECT findings.

To define the frequency of decreased signal intensity (DSI) in cerebral cortex on T2-weighted images relative to aging and to the incidence of identifying white matter pathology, T2-weighted MR brain images of 906 patients consecutively examined between July 1989 and June 1991 were reviewed. MR images of cerebral cortex were divided into five areas: frontal lobe (F), pre- and postcentral gyri (C), parietal lobe (P), occipital lobe (O) and temporal lobe (T). Each area was separately and independently evaluated for the presence or absence of DSI. The frequency of DSI in each area was plotted against patients' ages. The severity of leukoaraiosis was evaluated in relation with DSI in each cortical area. Patients with DSI in area F numbered 61 (5.7%), in area C 236 (26.0%), in area P 174 (15.9%), in area O 428 (47.2%), and in area T 10 (1.1%). The number of patients with DSI in each area increased with age. The greater the severity of leukoaraiosis, the greater the chance of finding DSI of the cerebral cortex. The incidence of DSI in the cerebral cortex increased with the patient's age as well as with the severity of co-existent white matter pathology.

A 60-year-old male was admitted to our hospital complaining abdominal pain and fatigue. Complete blood count showed as follows; WBC 3,900/microliters (48% of monocytes), Hb 11.5 g/dl, Plt 0.9 x 10(4)/microliters. Marrow smears showed the presence of phagocytic histiocytes that consist 22.4% of total nuclear cells. Laboratory findings showed as follows; BUN 109.5 mg/dl, Creatinine 7.4 mg/dl, CPK 1,259 IU/l, Aldolase 195 IU/l, Myoglobin 4,200 mg/dl. Serological studies showed a 16-fold increase in herpes-simplex virus (HSV) antibody titers 4 weeks after admission. So we diagnosed his illness as virus-associated hemophagocytic syndrome (VAHS) and rhabdomyolysis that were associated with HSV. We performed three times of hemodialysis for acute renal failure and used prednisolone for VAHS. These treatments were successful, and he made a complete recovery from illness. VAHS complicated by rhabdomyolysis is very rare, and we think this case is full of suggestions.

A case of aneurysmal bone cyst of the left 5th rib is reported. A 57-year-old male complained of palpable lump and pain on his back. Chest X ray and CT showed expansive tumor arid pathological fracture of the left 5th rib. The tumor and the adjacent segments of the 4th and 5th ribs were resected en bloc. The pathological examination showed multiple blood filled spaces and fibrous trabeculae, confirming the diagnosis of aneurysmal bone cyst. He has been followed up for 3 years and 6 months with no signs of recurrence.

The most common neoplasms of the mediastinum are those of neurogenic origin, and the majority of these arise in the posterior compartment. We report a case of benign schwannoma originating in rare location, the anterior mediastinum, and its imaging findings.

Dynamic and static 123I-MIBG studies were used to investigate various parameters with regard to their usefulness in evaluating cardiac disorders.Four patient groups and one control group were included in this study. Dynamic study was acquired immediately after injection at 1 frame/sec for 2 min and at 1 frame/6 sec for the next 30 min using a 64 x 64 matrix format. Static study consisted of planar images at the anterior and left anterior oblique 45 degrees views in a 512 x 512 matrix format for 1 min. The early and delayed planar images were acquired soon after dynamic acquisition and approximately 4 hr after injection, respectively. Net injection dose was calculated as the difference in syringe counts before and after injection. From the dynamic and static studies, the heart uptake ratios at 3 min and 30 min, early uptake ratio and delayed uptake ratio were calculated at various intervals. Early and delayed clearance rates, Ke and Kd, respectively were also determined. These parameters were compared and correlated with each other.Three-minute heart uptake ratios were significantly higher than early or delayed uptake ratios or uptake ratios at 30 min in all groups. All uptake ratios in hemodialysis patients were significantly higher than those in other groups. The Kd values in dilated cardiomyopathy, doxorubicin therapy and vasospastic angina patients were significantly higher than those in hemodialysis patients and normal controls. At least bi-exponential clearance patterns of MIBG from the heart were observed in all groups.Three-minute and delayed heart uptake ratios calculated from dynamic and static studies are helpful in elucidating the uptake at nonvesicular sites, which reflect the severity of sympathetic nervous system abnormalities in the heart.

K-ras mutations are found in approximately half of all colorectal tumors examined. To explore the possibility of detecting mutated K-ras rapidly and efficiently in DNAs isolated from fecal material, we applied the mutant allele specific amplification (MASA)-PCR method to DNA from feces of patients with colorectal tumors. Among 55 colorectal adenocarcinomas or adenomas examined, 19 were found to carry K-ras mutations in codons 12 or 13. We were able to PCR-amplify DNAs isolated from feces of 15 of these 19 patients, but in only three of the fecal samples, we were able to detect the K-ras mutations corresponding to tumor DNA by MASA and ethidiumbromide staining of the gel. The carcinomas in these three cases were more than 40 mm x 40 mm in size and located in the sigmoid colon or rectum. However, we identified the K-ras mutations in fecal DNAs of additional seven patients by MASA when the gels were blotted and probed with a radio-labeled oligonucleotide; the tumors in those patients had arisen in the distal half of the colon and the smallest of these tumors was only 7 mm x 5 mm. No K-ras mutations were detectable in feces of the remaining five cases, whose tumors were relatively small and/or located in the proximal region. The results suggested that the MASA-PCR system has potential for development as a simple, rapid and noninvasive method for diagnosing the presence of colorectal tumors that carry mutant K-ras alleles, particularly tumors located in the distal colon.

Thallium-201 (201Tl) SPECT was performed 48 times in 26 patients to clarify its usefulness in the evaluation of malignancy and viability of brain tumors. The early counts ratio (ER) and delayed counts ratio (DR) of a lesion compared with normal brain were obtained 10-15 minutes and 3 hours, respectively, after intravenous administration of 185 MBq of 201Tl chloride. Untreated high grade malignant tumors and recurrent tumors did not always show high ER and DR, and they were widely distributed. High grade malignant tumors that showed low ER and DR were not well enhanced on CT or MRI. In low grade malignant tumors, such as pituitary adenoma which was well enhanced on CT, ER and DR were as high as in high grade malignant tumor. Whether a tumor recurred within three months after radiotherapy or not was retrospectively predicted at accuracy rates of 93.8% and 87.5% with cut-off points of 4.0 for ER and 3.5 for DR. Cerebral radiation necrosis showed ring-like increased uptake of 201Tl in proportion to the progress of necrosis and intensity of enhancement on MRI. In conclusion 201Tl SPECT is considered to be less useful for lesions that are well enhanced on CT, because they show high uptake of 201Tl regardless of their malignancy and viability. On the other hand, in tumors that are not well enhanced on CT. 201Tl shows good accumulation in viable and high grade malignant lesions. 201Tl SPECT should be performed in such cases.

The effect of single or daily oral administration of hot water extracts (HWE) from Byakushi or Ogon on rat hepatic drug-metabolizing enzymes were investigated in vivo. Enzymes were measured for 3 to 72 hr after single oral administration of HWE at the dose of 1.0 g/kg or 5.0 g/kg. Administration of 1.0 g/kg of Byakushi and 5.0 g/kg of Ogon inhibited aniline hydroxylase activity, while 5.0 g/kg of Byakushi inhibited it in the early phase, but increased it in the late phase. Byakushi inhibited aminopyrine N-demethylase activity, while 5.0 g/kg of Ogon increased it. Byakushi and Ogon decreased the amount of cytochrome P-450. Byakushi and Ogon increased the amount of cytochrome b5. Byakushi increased cytochrome c reductase activity 3 hr after administration and decreased it 6 and 12 hr after administration. In contrast, 1.0 g/kg of Ogon decreased cytochrome c reductase activity, and 5.0 g/kg increased it 6 hr after administration and decreased it 12 hr after administration. At 24 hr after the last administration to animals treated with a regimen of once a day administration of the HWE (0.1 or 1.0 g/kg) of Byakushi or Ogon for 14 days, the enzymes were measured. Byakushi decreased aminopyrine N-demethylase activity, the amount of cytochrome P-450, and cytochrome c reductase activity. Ogon decreased cytochrome c reductase activity. Byakushi altered the composition of cytochrome P-450 isozyme after daily administration.

We determined the appropriate incubation period to expand human peripheral blood (PB) CD34+ cells for clinical application and the role of recombinant human (rh) interleukin-3 (rhIL-3) in the expansion and differentiation of these cells. The cells were purified up to 40 +/- 16% and transitional changes in immunophenotypic subpopulations in suspension culture were examined following stimulation with three different combinations of rh colony-stimulating factors (rhCSFs): 1) rhIL-3 alone, 2) rhIL-6, rhSCF, rhG-CSF, plus rhGM-CSF, and 3) the four CSFs plus rhIL-3. With all three CSF combinations, the total cells increased continuously after day 5 until day 14, and a combination of the five CSFs always gave rise to the highest number of total cells. Immunophenotypic analysis of the expanded cells showed that with all three CSF combinations CD34+ cells reached a maximal rate on day 5 and then decreased in an inverse correlation between the logarithm of CD34 positive rate and the duration of suspension culture. The maximum expansion of CD34+ cells and PB progenitor cells (PBPC) with rhIL-3 alone, the four CSFs, or the five CSFs was observed on day 5, 10, or 7, respectively. The combination of the five CSFs was identified as the most potent stimulus for expansion of PBPC and CD34+ cells, as it increased non-erythroid PBPC 89 +/- 69-fold, with a range of 24 to 204-fold on day 7. However, differences in the expansion rate of these cells on days 5, 7, and 10 were not statistically significant. The majority of purified CD34+ cells coexpressed CD38 (91 +/- 3%) but were negative for CD33 (85 +/- 4%), and one-half coexpressed CD13. With all three combinations of CSFs, the mature CD34+ cells that coexpressed CD38, CD33, or CD13 expanded in parallel with the total CD34+ cells, while an increase in relatively immature CD34+ cells, which do not express CD38, CD33, or CD13, was only statistically significant with the five CSFs. Thus, rhIL-3 played a critical role when combined with the four CSFs by increasing both mature and immature CD34+ cells.

A 61-year-old male complained of acrocyanosis and dark urine when exposing to cold temperatures. This had continued for several years. His physical examinations showed neither lymphadenopathy nor hepatosplenomegaly. Laboratory findings were as follows; RBC 305 x 10(4)/microliters, Hb 10.3 g/dl, reticulocytes 4.32%, platelets 27.3 x 10(4)/microliters, WBC 7,400/microliters with 50% lymphocytes, and a high cold agglutinin titer (2,048-fold) with anti-I specificity. Bone marrow smear preparations showed erythroid hyperplasia and increase of lymphocytes (52%). Immunophenotypic analysis showed an increase of CD20+/B-lymphocytes in peripheral blood (32.6%) and in bone marrow, and 94% of these cells co-expressed CD5. Most B-lymphocytes expressed surface IgM-lambda, suggesting a monoclonal proliferation of B-lymphocytes. At this point we diagnosed cold agglutinin disease (CAD) because there was no evidence of lymphoma, and the absolute number of peripheral blood lymphocytes was lower than the criteria of chronic lymphocytic leukemia (CLL) proposed by the International Workshop (1989). However, there still remains the possibility of the transitional form between "idiopathic" CAD and B-CLL or lymphoma.