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We compared the effectiveness of promoting bone healing between two teriparatide preparations for atypical femoral fracture (AFF). A total of 45 AFFs were included in this study, and we compared the duration of bone union. Teriparatide administered by daily injection enhanced bone union more than weekly administration in complete AFFs. The efficacy of teriparatide for atypical femoral fracture (AFF) has been recently reported. Although two different teriparatide preparations can be used to treat osteoporosis in Japan, daily or weekly injection, all previous reports on the effectiveness of teriparatide for AFF only examined daily injection formulations. Therefore, we compared the promotion of bone healing between the two teriparatide preparations for AFF. A total of 45 consecutive AFFs in 43 Japanese patients were included in this study. They received either a daily 20-μg teriparatide injection (daily group; n = 32) or a once-a-week 56.5-μg teriparatide injection (weekly group; n = 13). We compared the clinical background and duration of bone union between these two groups. When all patents were included, the fracture healing time was not significantly different between the two groups. Only patients with complete AFFs had significantly fewer daily bisphosphonate or denosumab injections than the weekly group (P

The current study aimed to compare cytology using SurePathBetween January 2014 and December 2016, 57 patients underwent endoscopic retrograde cholangiopancreatography for the diagnosis of biliary disease. Biliary cytological samples were processed using SP-LBC and subsequently BTH was performed. A final diagnosis was confirmed by surgery (23 malignant cases) and clinical follow-up (34 benign and malignant cases): 18 extrahepatic cholangiocarcinoma; 17 intrahepatic/hilar cholangiocarcinoma (intra/H-CC); eight other malignant disease; and 14 benign biliary disease. The diagnoses made using SP-LBC and BTH were classified into four categories: (1) benign; (2) indeterminate; (3) suspicious for malignancy/malignant; and (4) inadequate. In addition, diagnostic accuracy was compared between SP-LBC and BTH.Although 23% (13/57) of BTH samples were classified as inadequate, all SP-LBC cases were classified as adequate. Among 43 malignant cases, 11 normal, four indeterminate and 28 suspicious for malignancy/malignant were found using SP-LBC (26%, 9% and 65%, respectively), in contrast to 10 inadequate, nine normal, 10 indeterminate and 14 suspicious for malignancy/malignant observed using BTH (23%, 21%, 23%, and 33%, respectively). The identification of malignant cells was strikingly different between SP-LBC and BTH. Furthermore, limited to intra/H-CC, accuracy was significantly higher using SP-LBC than using BTH (P .001).SP-LBC of the biliary tract is a useful and reliable method for diagnosing biliary malignant disease and has an advantage over BTH for detecting malignant cells and accurately diagnosing intra/H-CC.

The purpose of the present study was to evaluate the reproducibility of the cytological diagnosis of endometrial lesions by the Osaki Study Group (OSG) method of new cytological diagnostic criteria using BD SurePathThis cytological classification using the OSG method consists of six categories: (i) normal endometrium (NE), (ii) endometrial glandular and stromal breakdown (EGBD), (iii) atypical endometrial cells, cannot exclude atypical endometrial hyperplasia or more (ATEC-A), (iv) adenocarcinoma including atypical endometrial hyperplasia or malignant tumour (Malignancy), (v) endometrial hyperplasia without atypia (EH) and (vi) atypical endometrial cells of undetermined significance (ATEC-US). For this study, a total 244 endometrial samplings were classified by two academic cytopathologists as follows: 147 NE cases , 36 EGBD cases , 47 Malignant cases, eight ATEC-A cases, two EH cases and four ATEC-US cases. To confirm the reproducibility of the diagnosis and to study the inter- and intra-observer agreement further, a second review round followed at 3-month intervals, which included three additional cytopathologists.The inter-observer agreement of NE classes improved progressively from 'good to fair' to 'excellent', with values increasing from 0.70 to 0.81. Both EGBD and Malignancy classes improved progressively from 'good to fair' to 'excellent', with values increasing from 0.62-0.63 to 0.84-0.95, respectively. The overall intra-observer agreement between the first and the second rounds was 'good to fair' to 'excellent', with values changing from 0.79 to 0.85. All kappa improvements were significant (P0.0001).In this study, it seemed that the use of the OSG method as the new diagnostic criteria for SP-LBC preparation, may be a valid method to improve the precision (reproducibility) of endometrial cytology.

Syringo-subarachnoid shunt (S-S shunt) is one of the established surgical procedures for syringomyelia. However, this procedure requires a laminectomy which may lead to spinal column complications. We present a modified form of S-S shunt using a partial hemilaminectomy; a S-S shunt is placed via the dorsal root entry zone into the anterior subarachnoid space which is considered to be an ideal site for the drainage of the syrinx fluid. This technique will decrease the incidence of neuronal and spinal complications after surgery and avoid subarachnoid adhesions around the shunt tube. Between 1992 and 1997, a total of 24 patients with syringomyelia have been treated with this surgical procedure without any complications. Collapse of the syrinx was achieved in all cases. The authors believe that the procedure is an effective surgical treatment for syringomyelia and can be applied safely to adolescent and child cases.

objective To assess the effectiveness of an urinary trypsin inhibitor (UTI) on a surgical stress, particularly the influences on cytokines and diuretic hormones. subjects and methods Sixteen patients with carcinoma of the digestive system and predicted to suffer from circulatory insufficiency were enrolled. Selection of group was divided alternatively. UTI was administered for 5 consecutive days, at a dose of 300,000 units per day. Urine and blood specimens were collected before, immediately after, and 1, 3, and 5 days after surgery. Interleukin 8 (IL-8), polymorphonuclear leukocyte elastase (PMNE), vasopressin (ADH), atrial natriuretic peptide (ANP), angiotensin II (AT-II), and endothelin 1 (ET-1) in the blood, and N-acetyl-D-glucosaminidase (NAG) in the urine, were determined. results A UTI group was 9 patients, and a control group was 7 patients. The operation time was significantly longer in the UTI group than in the control group. In the UTI group, the elevation of IL-8, PMNE/WBC, ADH, urinary NAG, and BUN were significantly inhibited. AT-II and ET-1, in the UTI group, tended to be suppressed, and ANP showed the similar changes in the two groups. conclusion UTI is considered effective in the prevention of excessive reaction against major surgery.

To better understand the mechanisms responsible for the increase in numbers of fibroblasts and increased collagen synthesis in fibrotic intestitial lung diseases, platelet-derived growth factor (PDGF)-A and PDGF-B, PDGF receptor-alpha and -beta, insulin-like growth factor I (IGF-I), and IGF-I receptor were evaluated immunohistochemically. Additionally, the messenger ribonucleic acids (mRNAs) for PDGF-A and PDGF-B, PDGF receptor-alpha and -beta, and IGF-I were investigated by in situ hybridization in alveolar macrophages and lung tissues from patients with interstitial lung disease. In specimens of bronchoalveolar lavage fluid (BALF), PDGF-A, PDGF-B, and IGF-I were local in alveolar macrophages in patients with idiopathic pulmonary fibrosis (IPF), patients with sarcoidosis (Sar), and normal individuals. Although there were no differences between IPF and Sar in terms of the staining intensity or number of positive cells, the number of such cells was smaller in the normal controls. In lung tissues with early-stage IPF, PDGF and IGF-I proteins were localized exclusively in alveolar macrophages, mononuclear phagocytes, fibroblasts, alveolar Type II cells, vascular endothelial cells, and vascular smooth-muscle cells. In lung tissues with late-stage IPF and those from normal controls, only alveolar macrophages contained PDGF and IGF-I proteins. Interestingly, the cellular localizations of PDGF receptor-alpha and -beta, and of IGF-I receptor were the same as those of the PDGF and IGF-I proteins in early-stage IPF, whereas these cells were not positive for any of these substances in late-stage IPF or normal controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Obesity and insulin resistance have been reported as negative predictors for sustained virological response (SVR) in hepatitis C virus (HCV) genotype 1 infected patients treated with pegylated interferon-α plus ribavirin. They are also known to affect serum levels of several cytokines including adipocytokines. But the association between these cytokines and treatment outcome has not been fully elucidated. We examined pretreatment serum levels of 14 cytokines among 190 patients who were treated with pegylated interferon-α-2b plus ribavirin for chronic HCV-1b infection with high viral load (≥ 5 log IU/mL) and analyzed their contribution to treatment response. Plasminogen activator inhibitor-1 (PAI-1), vascular endothelial growth factor, and 11 clinical factors showed significant association with SVR in univariate logistic regression analysis. Four significant factors in multivariate analysis; serum PAI-1 (odds ratio [OR] = 15.42), body mass index (OR = 4.56), rs8099917 (OR = 4.95) and fibrosis stage (OR = 5.18) were identified as independent predictors. We constructed a simple and minimally invasive prediction score for SVR based on the presence of these factors except for fibrosis stage. The accuracy of this score was 73%, and was confirmed using an independent validation cohort consisting of 31 patients (68%). The strongest correlation was between PAI-1 level and platelet count (r = 0.38, P = 1.8 × 10(-7)), and PAI-1 level was inversely correlated with fibrosis stage. Serum PAI-1 is a novel predictor for the response to combination therapy against chronic HCV-1b infection and may be associated with liver fibrosis.

Excessive daytime sleepiness (EDS) is a common sleep disorder in patients with Parkinson disease (PD). Non-ergot dopamine agonists increase the risk of unanticipated sleep episodes. We aimed to assess the influence of renal function on EDS in patients with PD.Sixty-two patients treated with ropinirole or pramipexole were recruited for this study. We evaluated the historical and clinical characteristics including the motor symptom rating scales, Epworth Sleepiness Scale (ESS), and estimated glomerular filtration rate (eGFR). An ESS score of 10 or greater was defined as EDS. Participants with eGFR60 ml/min/1.73 m(2) were determined to have chronic kidney disease (CKD). Multiple logistic regression analysis was performed to determine the predictive factors of EDS.Chronic kidney disease was found to be a significant predictive factor for EDS in all patients (P = 0.014). We observed a negative correlation between the severity of daytime sleepiness and renal function in patients treated with pramipexole alone (r(s) = -0.637, P0.001).Chronic kidney disease may be a risk factor for EDS, especially in patients treated with pramipexole, which is directly excreted in the urine.

99mTc-methylene diphosphonate (99mTc-MDP) bone scans in 80 patients, 30-80 years old (average, 62 years old) with uterine cancer who received high doses of radiation (10-60 Gy; average, 46 Gy) were reviewed retrospectively to evaluate the frequency of pelvic insufficiency fractures caused by radiotherapy and to study the appearance of the fractures on bone scans. Bone scans in 29 of 80 patients showed abnormalities in the pelvis: insufficiency fractures were identified in 27 patients (34%) and osseous metastases were found in two patients (3%). The fractures and metastases were diagnosed by CT and were confirmed by observing the patients' clinical courses. Fractures were identified in 27 (39%) of 69 postmenopausal women and in none of 11 premenopausal patients (p greater than .05). Fractures were found in 21 (84%) of 25 patients who had pelvic pain and in six (11%) of 55 patients who were asymptomatic (p greater than .001). Scintigrams in patients with fractures showed more than one fracture in most patients (85%), and fractures were often symmetric (67%). Scintigrams in two patients with osseous metastases showed increased activity in an iliac wing that was outside the radiation field. Our results suggest that a marked increase in insufficiency fractures occurs after radiation therapy, especially in postmenopausal patients. A symmetric area of increased uptake of radionuclide is a characteristic scintigraphic appearance of an insufficiency fracture.

A 63-year-old man visited our hospital because of intermittent claudication due to an embolic episode in the left femoral artery. He had a long history of arterial fibrillation but had received no anticoagulant therapy. Echocardiography showed a large floating ball-shaped shadow in the right atrium, without any sign of tricuspid stenosis. Pulmonary perfusion scintigram was normal. At the operation, the thrombus which attached to the superior atrial septum with a thin string was removed. The thrombus was 54 x 40 x 25 mm in size and 23.8 g in weight, whose cut surface was in layers. There was neither atrial septal defect nor foramen ovale to suggest possibility of paradoxical embolism. The postoperative course was uneventful and he was discharged on the 9th postoperative day. Although the mechanism of the thrombus formations is unknown, it is considered to be important to continue anticoagulant therapy to avoid reccurence of intracardiac thrombus.

A 56-year-old man with thoracoabdominal aortic aneurysm combined with inferior mesenteric artery aneurysm and occlusion of celiac and superior mesenteric arteries is presented. Contrast-enhanced computed tomography (CT) and aortography revealed thoracoabdominal aortic aneurysm of 6 cm in diameter, accompanied by inferior mesenteric aneurysm of 3 cm in diameter. Severe calcification of the abdominal aorta and occlusion of the celiac and the superior mesenteric arteries were also noted, whose territories were perfused by collateral circulation of the inferior mesenteric artery. At the operation, orifice of the left renal artery was stenosed by severe calcification, which was resected. Because of severe adhesion around the origins of celiac and superior mesenteric arteries, they were left unrevascularized. The thoracoabdominal aortic aneurysm was replaced with an Dacron tube graft, whose side branch was anastomosed to the inferior mesenteric artery after resection of its aneurysm. The postoperative course was uneventful, and no symptoms of intestinal ischemia were noted. As blood supply to the abdominal viscera mostly depends on the inferior mesenteric artery, careful follow-up is necessary.

The authors report on female homozygous twins with idiopathic intracranial hypertension. At the age of 12 years, both twins simultaneously developed visual disturbances with photophobia. At the age of 19 years, an ophthalmological examination disclosed papilloedema in both their eyes. At the age of 22 years, a lumbar puncture showed raised CSF pressure over (200 mm H2O) in both twins. Their neurological and radiological examinations were extremely similar; both of them had severely impaired visual acuity and impaired visual field, bilateral optic nerve atrophy, intracranial hypertension, an enlarged and partial empty sella turcica, digital markings of the calvalium, and an enlarged frontal subarachnoid space. This is the first case report describing idiopathic intracranial hypertension occurring in homozygous twins.

Our group, Ujike et al., recently reported that the A1 allele of TaqI A polymorphism of the dopamine receptor D2 (DRD2) gene, associated with transient psychosis, significantly differs from that of patients with prolonged psychosis in methamphetamine psychosis. Therefore, we examined the association between the TaqI A polymorphism of the DRD2 gene and the brain MRI view for patients with methamphetamine psychosis. The subjects underwent brain MRI scans using the FLAIR method. Genotyping was performed by PCR-RFLP methods using genomic DNA extracted from peripheral blood by the phenol method. Ten subjects had the A1/A2 genotype, eleven subjects had the A2/A2 genotype, and no subject had the A1/A1 genotype. The domain size, including the thalamus and basal ganglia that were inside each side of the putamens, did not differ between the three groups (the A1/A2-group, the A2/A2-group, and the young healthy person group). In the comparison based on this domain, the temporal lobe tended to narrow in the A2/A2-group compared to the A1/A2-group (P = .06). The other domain (cerebrum, corpus callosum, etc.) showed no difference between the A1/A2-group and the A2/A2-group. It is suggested that in methamphetamine psychosis the TaqI A polymorphism not only regulates prolongation of psychosis symptoms but also influences the form of the temporal lobe.

We describe the application of the biomolecular interaction (BIA) technique to detection of the interaction between protein (e.g., c-Jun) and DNA (e.g., two AP-1 motifs from bcl-2 promoter), compared with immunohistochemistry (IHC) of c-Jun. The specific binding assay for the interaction of c-Jun and activating protein-1 (AP-1) motifs was performed using a Biacore 2000 system. Intense immunoreactivity of c-Jun in glandular cells of the human uterine endometrium was observed in the proliferative phase, while c-Jun in stromal cells was expressed throughout the menstrual cycle. In contrast to the IHC of c-Jun, the specific binding of c-Jun to two separate AP-1 motifs in the bcl-2 promoter region was detected only in nuclear extracts of glandular cells, but not in stromal cells, during the proliferative phase. These results indicate that, while transmitting various signals, c-Jun enhances the transcription level of bcl-2, which in turn keeps glandular cells alive and proliferating in normal human endometrium during the proliferative phase. Moreover, the method involving real-time biomolecular interactions such as DNA-protein binding is novel for the study of transcription factors when combined with IHC.

The resistance of Helicobacter pylori to clarithromycin has become one of the primary reasons for eradication failure.To compare the eradication rates of triple therapy using amoxicillin (A), clarithromycin (C) and rabeprazole (R) or lansoprazole (L) against clarithromycin-sensitive and clarithromycin-resistant strains.Two hundred and ninety-five patients were randomly divided into four groups and treated for 1 week: 147 cases were treated with RAC, i.e. 49 cases with R20C400 (10 mg R + 750 mg A + 200 mg C, twice daily), 48 cases with R40C400 (20 mg R + 750 mg A + 200 mg C, twice daily) and 50 cases with R40C800 (20 mg R + 750 mg A + 400 mg C, twice daily); 148 cases with treated with LAC (30 mg L + 750 mg A + 200 mg C, twice daily).According to intention-to-treat and per protocol analyses, the eradication rates were 88% and 91% with RAC and 78% and 81% with LAC; the eradication rates with R20C400, R40C400 and R40C800 were 94%, 81% and 86%, respectively, in the intention-to-treat analysis. In addition, the eradication rates for clarithromycin-sensitive strains with RAC and LAC were 98% and 89%, respectively, and for clarithromycin-resistant strains with RAC and LAC were 8.1% and 0%, respectively.The eradication rate was significantly higher with RAC than LAC. The eradication rate for clarithromycin-resistant strains was low in both groups, and an improved eradication rate could not be achieved by changing the dose of clarithromycin or proton pump inhibitor.

To determine whether the K-ras oncogene is associated with parathyroid hormone-related protein (PTHrP) production in renal cell carcinoma (RCC) and whether the serum value of PTHrP is related to the patients' survival.The serum levels of PTHrP and corrected serum calcium levels were analysed in 51 consecutive patients (29 men and 22 women, mean age 63.7 years, range 33-82) with newly diagnosed RCC. Matched pairs were analysed of the mRNA levels of K-ras and PTHrP in tumour and in corresponding non-tumour tissue originating from the same patient, using the polymerase chain reaction after reverse transcription.Seven patients had elevated serum PTHrP values at the diagnosis of RCC. The mRNA expression of K-ras and PTHrP were detected in both tumour and non-tumour tissues, with K-ras mRNA levels being higher in the former than the latter (P0.05), and correlated with tumour stage (P0.05). There were no differences in PTHrP mRNA levels between the tissues. Furthermore, the mRNA levels of K-ras and PTHrP in seven tumours from patients with high serum values of PTHrP were higher than in tumours from those with normal values (both P0.01). The expression of mRNAs of K-ras and PTHrP was positively correlated (r = 0.771, P0.001). In seven patients with high serum PTHrP values the mRNA levels of PTHrP correlated with serum values of PTHrP and calcium (r = 0.875, P0.01 and r = 0.762, P0.05, respectively). Kaplan-Meier plots of survival rate in patients with elevated or normal serum PTHrP showed that high serum PTHrP was associated with a shorter overall survival (P0.05). The Cox proportional hazards model showed that serum PTHrP was an independent predictor of overall survival (P0.05).These findings suggest that K-ras may be associated with PTHrP-induced hypercalcaemia and that PTHrP levels may reflect the aggressiveness of tumour cells through the K-ras oncogene in RCC.

Contribution of the Fas system to apoptosis of renal cell carcinoma (RCC) was investigated in vivo.Tissues from 30 RCC cases were immunostained for Fas and Fas ligand (FasL) to assess associations between Fas labeling status of RCC, indices of FasL-positive tumor-infiltrating mononuclear cells (FasL-TIM) and apoptotic indices (AI) of RCC.In all cases, tumor cells co-expressed Fas and FasL; strongly and diffusely in 13 cases (43%) and weakly in 17 (57%). Despite the constitutive co-expression of Fas and FasL, AI was low in most cases (median, 7 per 1,000 tumor cells; range, 1 to 257). The Fas labeling status did not significantly associate with AI while FasL-TIM index positively correlated with AI.These results suggest that the Fas system is not the principal mechanism of apoptosis of RCC while activated tumor-infiltrating mononuclear cells induce apoptosis via mechanisms other than the Fas system.

Skeletal involvement is a common clinical feature in acromegalic patients. Although several recent reports are available concerning bone mineral density (BMD) in acromegaly, the controversy still exists as to whether BMD of acromegalic patients is increased or not. The present study was performed to examine biochemical bone metabolic indices and BMD as well as body composition in 26 Japanese patients with active acromegaly and 26 control subjects matched for age, sex, race and height in a cross-sectional study.BMD of the lumbar spine and femoral neck, as well as body composition, was measured by dual-energy X-ray absorptiometry. Mid-radial BMD was measured by single-photon absorptiometry. We also determined serum levels of IGF-I, IGFBP-3 and osteocalcin (OC) as well as urinary levels of deoxy-pyridinoline (D-Pyr) and CrossLaps.Percent lean body mass was increased and percent fat mass was decreased in the acromegalic patients compared to control subjects. Serum levels of OC, as well as urinary levels of D-Pyr and CrossLaps, were significantly higher in acromegalic patients compared to control subjects (9.8 +/- 1.2 vs. 5.7 +/- 0.77 for OC; 11.8 +/- 1.66 vs. 5.0 +/- 0.49 for D-Pyr; 437.6 +/- 68.4 vs. 156.5 +/- 39.6 for CrossLaps). Z scores of BMD at mid-radius as well as lumbar spine and femoral neck were significantly higher in acromegalic patients compared to control subjects (1.086 +/- 0.311 vs. -0.060 +/- 0.274 for mid-radius; 1.022 +/- 0.280 vs. 0.319 +/- 0.165 for lumbar spine; 1.292 +/- 0.347 vs. 0.232 +/- 0.264 for femoral neck).The present study revealed that a decrease in percent fat mass and an increase in percent lean body mass were observed in Japanese patients with active acromegaly. Bone mineral density at all sites and bone metabolic markers were also increased in acromegaly. The present findings provide additional evidence that the GH/IGF-I axis might play an important role in the maintenance of bone mass as well as the regulation of body composition in Japanese adults.

The authors describe four cases with concomitant coronary and carotid severe stenosis operated by combined procedure. As the cerebral revascularization, carotid endarterectomy (CEA) was performed for three patients, while carotid artery bypass grafting was performed for the other one. In one patient with bilateral carotid stenosis, percutaneous transluminal stenting of the right internal carotid artery was performed one day before combined left CEA and coronary artery bypass grafting (CABG). Both perioperative myocardial infarction and neurological complication could be avoided in each case. When a CABG candidate also has significant extracranial carotid stenosis with clinical symptoms, combined cerebral revascularization and CABG is desirable.

A 49-year-old male had experienced diplopia for half a year. The intracranial pressure was markedly elevated (450 mmH2O). Neuroimaging revealed a tumor incompletely occluding the torcular herophili and the bilateral transverse sinuses without cerebral or cerebellar compression by the tumor. Both cortical veins and cervical veins were enlarged, and the Sylvian vein and Rabbe's vein and the tentorial sinus were collateral vessels. Biopsy was performed and histologic examination proved hemangiopericytoma. The patient underwent Gamma-knife treatment and the tumor decreased in size 3 months after the treatment.

The authors applied PET activation study to two patients with arteriovenous malformation (AVM) to localize primary motor cortex before surgery or embolization. The change in regional cerebral blood flow (rCBF) was measured during foot movements in Case 1 who had a 2-cm AVM located in the post-central gyrus. Superimposed PET/MRI images revealed that the rCBF increase was located in the pre-central gyrus. Its validity was confirmed by intraoperative cortical mapping using electrical median nerve stimulation. The patient safely underwent total removal of AVM. The change in regional cerebral metabolic rate for glucose (rCMRglc) was measured during hand movements in Case 2 who had a huge AVM over the central sulcus. Superimposed PET/MRI images revealed that hand movements significantly increased rCMRglc in the frontal cortex, which was separated from the original primary motor area. The patient safely underwent partial embolization, although he suffered transient weakness of the face after embolization. The preliminary results strongly suggest that PET activation study is useful to localize precisely cortical functions of the patients with AVM, thus reducing morbidity after treatment. The results also suggest that cortical functions may undergo translocation when huge AVM involves the eloquent area.

The objective of our retrospective study was to clarify factors relating to place of death of Japanese people from a small town in a rural area who had been bedridden for at least one week before dying. The caregivers of subjects aged 40 and above who died during a three-year period were surveyed by trained interviewers. Of 352 subjects who died, 312 caregivers responded and agreed to a face-to-face interview. A total of 213 subjects were considered as an eligible sample. The main outcome measures were odds ratios for death at home in relation to age, pain, cause of death, and home visit service. One hundred and two people died at home, while 112 people died in a hospital. Multivariate logistic regression analysis showed that the probability of home death increased with age of the bedridden, lack of pain during the bedridden period, not having cancer as a cause of death, having senility as a cause of death, and receiving regular home visits by a Public Health Nurse. In conclusion, expansion of the home visit programs by Public Health Nurses may enable people to die at home as they so desire. Further prospective research is needed to explore the association between the attitude toward terminal care and the place of death.

To the authors' knowledge, multiple carcinoid tumors of the duodenum have not been reported previously. However, multiple carcinoids in the stomach, ileum, and rectum, which were accompanied by the proliferation of endocrine cells, have been reported in the published literature.A patient with multiple carcinoids including argyrophilic cell hyperplasia of the duodenum and hypergastrinemia underwent surgery. The resected stomach and duodenum were analyzed histopathologically.There were 11 carcinoid lesions, each of which was accompanied by peripheral endocrine cell micronests (ECMs). Increasing gastrin positive cells in the antral region and chronic duodenitis in the duodenal bulb also were observed. The peripheral ECMs usually were adjacent to proliferating argyrophilic cells in the Brunner gland ducts or the crypts of Lieberkühn, which showed focal pyloric gland metaplasia.In the case presented in the current study, the development of the multiple carcinoid lesions may be strongly related to the presence of multifocal pyloric gland metaplasia, as well as to the trophic action of gastrin, which is present at high levels in the setting of chronic duodenitis.

Near infrared spectroscopy (NIRS) have been accepted as a useful modality for non-invasive monitoring of brain oxygenation state. Using a newly developed NIRS apparatus, HEO-200, the authors continuously monitored the changes in the oxygenation state of brain hemoglobin during carotid endarterectomy (CEA) or carotid balloon occlusion tests (BOT) in 21 patients. Somatosensory evoked potentials (SEP), regional cerebral blood flow (rCBF) or transcranial Doppler sonography (TCD) were also employed to compare with the NIRS-responses. In 7 of 21 patients, the carotid artery occlusion caused a continuous deoxygenation of brain hemoglobin as well as a decrease in total hemoglobin. These findings correlated well with temporary neurological deficits and a marked reduction of rCBF in the ipsilateral hemisphere in patients who underwent carotid BOT under local anesthesia. The patients also showed a marked decrease in the N20 amplitude of SEP during CEA under general anesthesia. Restoration of blood flow immediately resolved these findings. The other 14 patients demonstrated no or only transient changes on NIRS as well as on SEP and rCBF study. HEO-200 could non-invasively monitor the relative changes of cerebral oxygenation state with good time resolution, and detect critical ischemia during CEA and carotid BOT.

A 60-year-old female and a 40-year-old male underwent surgical revascularization for moyamoya disease and suffered small infarction in the ipsilateral frontal lobe 3 or 4 days postoperatively. Neuroimaging suggested that the bypass flow had caused rapid progression of occlusive changes in the carotid forks, a diminishing of moyamoya vessels, and flow reduction in the anterior cerebral artery ipsilateral to surgery, leading to critical ischemia in the frontal lobe. Surgical revascularization improves the outcome of patients with moyamoya disease, but postoperative management such as hydration is important to avoid ischemic complications due to frontal lobe infarction.

To investigate the relationship between the components of the first-order multifocal electroretinogram (M-ERG) and glaucomatous visual field loss.Twenty-six eyes of 14 patients with primary open-angle glaucoma (POAG) were evaluated with the M-ERG techniques. Twenty-six eyes of 26 normal subjects also were tested as control subjects. To record the M-ERG, a stimulus matrix of 103 scaled hexagonal elements was displayed on a monitor driven at a 75-Hz frame rate according to a binary m-sequence. The M-ERG responses were averaged in each quadrant of the stimulus field and the peak-to-trough amplitudes and peak implicit times of the first trough (N1), the first peak (P1), and the second trough (N2) of the M-ERG were compared with the mean sensitivity values (dB) of the corresponding quadrant of the Humphrey static perimetric field.The changes in the peak latencies of P1 and N2 in the POAG group were small but significant compared with those in the normal group (P0.01). However, no significant differences in the amplitudes of (P1-N1) and (P1-N2) between the two groups were found. Significant negative correlations between the peak implicit times of N1, P1, and N2 and the mean sensitivity values (dB) of static perimetry were observed. The correlation coefficients were -0.20 (P0.05) for the N1, -0.41 (P0.001) for the P1, and -0.59 (P0.001) for the N2. No significant correlations were observed between the amplitudes (P1-N1 and P1-N2) and the mean sensitivity values.The present study findings suggest that the peak implicit times, but not the amplitudes, of the M-ERG increase as the glaucomatous visual field deteriorates. The amplitudes of the M-ERG did not decrease as the glaucomatous optic nerve dysfunction progressed.

A 43-year-old man was admitted to a hospital because of acute dyspnea and nocturnal orthopnea. Echocardiogram and chest CT showed the dilation of thoracic aorta from the root to ascending portion. On the third hospital day, he died suddenly. At autopsy, the cause of death was indicated to be a tear of an aortic valve due to a rupture of the aneurysm of Valsalva's sinus, followed by acute aortic regurgitation and acute cardiac insufficiency. Histopathological findings of thoracic aorta revealed mesoaortitis, characterized by patchy destruction of the media with a moth-eaten appearance of the medial elastic laminae and a microgranuloma formation, a perivascular mononuclear cell infiltration of the vasa vasorum, and a fibrous thickening of the intima and adventitia. However, there were no abnormalities in main branches of aorta and abdominal aorta, and no systemic vasculitis. This case is a rare one in the clinical course, and may be important to be differentiated from other cases with aortitis, especially Takayasu arteritis and syphilitic aortitis.

To evaluate the function of the reticuloendothelial system and macrophage-monocyte system, blood samples from Thorotrast patients and age-matched healthy controls were used to determine the titer of plasma antibodies to lipid A and the numbers of several lymphocyte subclasses in peripheral blood and for an autoradiographic study of peripheral blood monocytes. The titer of plasma IgM class antibodies to lipid A was significantly elevated in the Thorotrast patients. Counts of CD 11-positive lymphocytes and CD 57-positive lymphocytes, which correspond to monocytes and natural killer cells, respectively, were significantly increased in the Thorotrast patients. Autoradiography showed that alpha-particle tracks were emitted from the monocytes isolated from the peripheral blood of Thorotrast patients. Thus the depressed function of the reticuloendothelial system resulted in the activation of the macrophage-monocyte system in the Thorotrast patients.

To evaluate the value of performing extended regional lymph node dissection for gallbladder carcinoma, the mode of recurrence after curative resection was analyzed.Records of 45 patients who underwent surgical resection for gallbladder carcinoma from 1973 to August 1997 were reviewed.Thirty-three cases underwent a curative resection and 12 received a non-curative resection. Among the 32 patients who survived the curative resection, cancer recurred in 7 with lymph node metastasis, whereas recurrence was found in only 1 of the remaining 25 patients without lymph node metastasis (p0.0001). At the 1st diagnosis of recurrence in these 8 patients, lymph node recurrence was detected in 7, and the site of recurrence was limited to the lymph nodes, which were confined to the peripancreatic region and the interaortocaval nodes near the left renal vein in 4 cases.In view of the site of the metastatic lymph nodes and the lymphatic drainage system of the gallbladder, it was considered that lymph node dissection was inadequate in 5 of the 8 patients and that 2 might have been cured by extended regional lymph node dissection, including complete resection of the retroportal, posterior pancreatoduodenal, right celiac and interaortocaval nodes.

BACKGROUND AND PURPOSE: The appropriate choice of embolic materials with respect to the permanency of obliterated nidi after embolization and complications related to the procedure is essential for safe and effective embolization of cerebral arteriovenous malformations (AVMs). Our purpose was to ascertain the recanalization and complication rates after AVM treatment with polyvinyl alcohol (PVA) particles. METHODS: Between 1988 and 1994, 36 AVMs were embolized with PVA particles at our institution. Follow-up angiographic findings and occurrence of complications during the embolization procedures were analyzed retrospectively. RESULTS: Complete obliteration of the nidus immediately after embolization was achieved in five patients, and 80% to 99% obliteration was attained in 12 patients. Fifty-one follow-up angiographic examinations were performed 1 week to 60 months (mean, 7 months) after embolization in 31 patients. An increase in nidal size was seen on 15 follow-up angiograms (29%) and a decrease was seen in seven (14%). In 28 of the 51 angiograms obtained more than 1 month after follow up (mean, 13 months), 12 (43%) showed AVM enlargement. In four (80%) of five cases of complete obliteration, nidi reappeared on follow-up angiograms. Hemorrhagic complications occurred in three cases and ischemic ones in seven. One patient (3%) died and five (14%) suffered persistent neurologic deficits. CONCLUSION: Embolization with PVA particles can produce significant volume reduction in AVM nidal size, but recanalization is a distinct possibility.

Although the adrenal gland is one of the common sites for metastasis from hepatocellular carcinoma, the significance of adrenalectomy for treatment of metastatic hepatocellular carcinoma still remains unclear.Analysis of 4 patients with adrenal metastasis from among 390 patients with hepatocellular carcinoma admitted to our department between October 1994 and December 1997, and a review of 79 cases reported between 1984 and 1997, were performed.Four patients with adrenal metastasis, right in 2 and left in 2, underwent surgical treatment. Three of the patients developed tumor thrombi in the renal vein or inferior vena cava. Diagnosis of adrenal metastasis was made by ultrasonography or computed tomography scan, following an increase in serum tumor markers. Adrenalectomy with removal of the venous tumor thrombi was performed successfully. Three patients died of recurrence within 1 year, and one patient died due to other causes showing no recurrence at autopsy. The literature review revealed the left-sided metastases were significantly larger than the right-sided ones (p0.01). There was no significant difference in the survival periods between left and right metastasis, or between patients who underwent adrenalectomy and those treated by other means (p0.05).The rationality of surgical treatment for adrenal metastasis from hepatocellular carcinoma still remains controversial. However, we believe that adrenalectomy would be a safe procedure and increases the chance of survival for patients.

An optic neuritis treatment trial was conducted at 30 clinical centers in Japan using the same protocol. Patient participation was based on: age range of 14-55 years; acute symptoms indicative of unilateral optic neuritis of unknown or demyelinating origin; visual symptoms of 14-day duration or less; relative afferent pupillary defect in affected eye; and normal or swollen optic disc of affected eye.Initially, 102 patients qualified for participation; baseline data were obtained for analysis from 70 of these patients. Demographic characteristics of Japanese patients with optic neuritis were clarified and compared with those in a US study.The incidence of ocular or periocular pain and the presence of periventricular plaques were noted to be lower, and the incidence of disc swelling higher, in the Japanese patients, suggesting racial differences in the characteristics of the disease. Such differences may possibly be related to the lower incidence of multiple sclerosis in Japanese patients. The results of visual function tests were virtually the same in both studies. The nonaffected eyes of more than half the patients showed abnormal mean deviation in Humphrey field analysis, as also noted in the US study.The baseline clinical features of optic neuritis in the Japanese patients have been defined. Some racial differences in the characteristics of the disease may exist.

A randomized, controlled clinical trial was conducted in 1991 to compare an intravenous megadose of methylprednisolone with a control drug (mecobalamin) for treating acute idiopathic optic neuritis.Sixty-six cases from 22 clinical centers throughout Japan were examined to evaluate the treatment on visual function parameters, such as visual acuity, visual field, color vision, contrast sensitivity, and critical flicker frequency.The methylprednisolone pulse treatment group showed faster recovery of visual function, particularly the visual acuity at 1 week (P.05), Humphrey field analyzer mean deviation at 3 weeks (P.05), and color vision at 1 week (P.05). Recovery of contrast sensitivity at several different spatial frequencies was significant in the pulse treatment group at 1 (P.01), 2 (P.05), and 4 weeks (P.05) after the start of treatment. Visual function test results at 12 weeks and 1 year were essentially the same in the two treatment groups. Side effects appeared more frequently in the pulse treatment group than in the control (P.05).Pulse treatment does not appear effective for idiopathic optic neuritis even though visual function in the pulse treatment group of this trial recovered more quickly during the initial phase compared to the controls. More effective and specific treatment should be established for optic neuritis.

We compared CT and MRI obtained within the first 3 h of onset of a cerebral infarct. Echo-planar diffusion-weighted MRI delineated the infarcted areas most clearly, and subtle low-density areas on CT were consistent with those shown to be abnormal by diffusion-weighted MR. The signal changes of affected areas on fast spin-echo proton-density, T2-weighted and fast FLAIR images were subtler than the low density on CT.

We have previously reported a novel heterozygous donor splice site mutation in intron 9 of the GH receptor (GHR) gene in Japanese siblings who showed partial GH insensitivity and high serum GH-binding protein (GHBP) levels. This mutation caused the splicing abnormality and produced the truncated GHR consisting of 277 amino acids (GHR-277), which lacked most of the intracellular domain of GHR, including both boxes 1 and 2. In this study, we have characterized the function of GHR-277 expression in COS-7 and CHO cells in vitro. Scatchard analysis revealed that GHR-277 possessed approximately 1.5 times higher affinity to GH and twice the number of binding sites compared to wild-type full-length GHR (GHR-fl). The GHBP level in culture medium of GHR-277-expressing cells was approximately 3 times higher than that in GHR-fl-expressing cells. Interestingly, the ligand-induced internalization of GHR-277 was significantly reduced compared with that of GHR-fl. Moreover, in GH-induced tyrosine phosphorylation of signal transducer and activator of transcription-5 (STAT5), GHR-277 exerted a dominant negative effect when GHR-277 and GHR-fl were cotransfected. These in vitro data would well explain the clinical characteristics in our patients showing high serum GHBP levels and development of short stature despite a heterozygous mutation of the GHR gene.

To evaluate the characteristics of 10 glaucomatous cases with microcornea, we measured corneal diameter, curvature, axial length, and depth of anterior chamber, and examined the eyes with a specular microscope and an ultrasound biomicroscope. The ten cases examined in this study included 1 case of cornea plana, 2 cases of sclerocornea, 2 cases of nanophthalmos, and 5 cases of anterior microphthalmos. Three of the 10 cases were combined with open angle glaucoma, and the others with closed angle glaucoma. Open-angle glaucoma seemed like developmental glaucoma with angle maldevelopment. The closed angle type may appear at a younger age than in patients who have simple pupilary block. There are probably complex mechanisms related with closed angle glaucoma with microcornea. While differential diagnosis among these cases is relatively easy, we should evaluate how or why the intraocular pressure rises as far as possible before forming a treatment plan for each patient.

The effectiveness of extracranial-intracranial arterial bypass (EC-IC bypass) surgery for patients with hemodynamic compromise still remains controversial. In the present study, we evaluated the correlation between the pre- and post-surgical cerebral hemodynamics and long-term prognosis. 28 patients and a subsequent 21 patients (41 men, eight women: mean age 59.9 [S.D. 8.6] years) with reduced cerebrovascular reserve due to steno-occlusive disease of the cerebral major arteries formed the study groups 1 and 2, respectively. Measurement of the mean hemispheric cerebral blood flow (mCBF) and the cerebral vasoreactivity (%mCVR) with an intravenous acetazolamide injection were performed by a 133Xe inhalation method and SPECT. Patients were treated with EC-IC bypass surgery and measurement of mCBF and %mCVR were made again about one month after surgery. The patients were observed for a long period (mean 44.3 months). During the follow-up period, 6 patients experienced recurrent ischemic strokes. The annual incidence of recurrent ischemic stroke was 4.4%. The patients with significantly reduced pre- and post-surgical resting mCBF of the affected hemisphere were at significantly higher risk of recurrent ischemic stroke than the patients with normal mCBF (p0.01). The %mCVR of the affected hemisphere rose after surgery.

We used a specular microscope to evaluate the corneal endothelial cells in 119 eyes before and 2 to 3 weeks after trabeculectomy with topical mitomycin C. The endothelial cell density per square millimeter averaged 2,569 +/- 487 (mean +/- standard deviation) before surgery and 2,444 +/- 536 after surgery, showing a decrease of 4.98%. The hexagonality decreased by 1.7%, the coefficient of variation increased by 1.9, and the average cell area increased by 6.82%. There were no statistical differences as a whole in these values. Decrease in hexagonality was more frequent in eyes with prior intraocular or glaucoma surgery. Eyes treated by laser trabeculoplasty showed a decrease in endothelial cell density, an increase in coefficient of variation and an increase in hexagonality. Eyes with postoperative flat anterior chamber showed significant changes in each parameter. The findings show that trabeculectomy with topical mitomycin C does not significantly affect the corneal endothelial cells at 2 to 3 weeks after surgery.

We measured the thickness of retinal never fiber layer (RNFLT) in the peripapillary area in 120 eyes of 60 normal subjects. We used a scanning laser polarimeter, or Never Fiver Analyzer (NFA) by Laser Diagnostic Technologies, USA. Measurements were made along the peripapillary ring with the diameter of 1.75 disc diameter (DD) and another one 0.8 mm away from the disc margin. The RNFLT was not significantly correlated with age along The two rings. The RNFLT ratio of total/nasal area significantly decreased with increase in age. There was an increase in the difference of RNFLT between both eyes with increase in age in spite of considerable interindividual variations. The RNFLT values along both rings thus showed age-related changes in normal subjects.

We evaluated the relationship between the area under the concentration versus time curve (AUC) of cyclosporin A (CsA) and several other clinical factors, because the clinical utility of AUC monitoring has been ambiguous. Fifty-four clinical time courses from 14 Japanese renal transplant patients during hospitalization, in the period from April 1990 to March 1997, were examined. In a bivariate regression analysis there was no correlation between the AUC and the daily dose of CsA (mg/kg/day) when the individual data or total series data were analyzed. In a chi-square test, the donor type of kidney (chi(2) = 25.254, df = 1, p = 0.0000) and renal function-related episodes, i.e. acute tubular necrosis, hemodialysis, hypertension, nephrotoxicity, or rejection (chi(2) = 13.982, df = 1, p = 0.0002) directly affected posttransplant renal function assessed by creatinine clearance, while episodes of hepatic function as assessed by the glutamate-pyruvate transaminase (GPT) activity level had no correlation with the posttransplant renal function evaluated according to creatinine clearance. In contrast, the renal function-related episodes significantly affected the AUC after renal transplantation (chi(2) = 4.934, df = 1, p = 0.0263), while hepatic function assessed by GPT did not. In a multivariate analysis, the creatinine clearance and obesity had significant positive correlations with the AUC, whereas the hematocrit had a significant negative correlation with the AUC. From these observations, we concluded that the dosage adjustment of CsA cannot be performed using the linear relationship between the daily oral dose and the AUC, and that renal function, obesity, and the CsA blood distribution properties affect the CsA pharmacokinetics after renal transplantation. Posttransplant renal function as well as obesity and CsA blood distribution properties are important factors to be considered when therapeutic monitoring is performed.

A 51-year-old man underwent radical cystectomy with tubeless cutaneous ureterostomy. Methicillin-resistant Staphylococcus aureus (MRSA) enteritis developed postoperatively. MRSA caused critical infections such as pneumonia and sepsis, which subsequently progressed to adult respiratory distress syndrome, massive melena and multiple organ failure. The patient was rescued by intensive management including mask continuous positive airway pressure, systemic vancomycin administration and intraarterial embolization to stop jejunal bleeding.

Extended right trisegmentectomy with total caudate lobectomy, extrahepatic bile duct resection and lymphadenectomy was performed for a 54-year-old man, who was diagnosed as type IV hilar bile duct carcinoma. After division of the right portal vein and all the portal venous branches to the caudate lobe and the left medial segment, the left hepatic artery and its branches to the segment II and III were dissected from the corresponding bile ducts to about 1 cm beyond the left margin of the umbilical portion of the left portal vein, where the lateral segmental bile ducts were divided after transection of the hepatic parenchyma. All bile duct margins were free from cancer microscopically. To our knowledge this is the first report of extended right trisegmentectomy for hilar bile duct carcinoma, in which the bile ducts of the left lateral segment are divided at the left side of the umbilical portion of the left portal vein. This technique facilitates making the intrahepatic bile duct stumps free from cancer. However, its impact on long-term survival remains to be determined.

We measured the area of parapapillary chorioretinal atrophy (PPA), i.e. zone alpha and zone beta in fluorescein angiography, and parapapillary avascular area (PPAVA) in indocyanine green angiography, using scanning laser ophthalmoscope in a total of 66 eyes of 39 patients. There were 26 eyes of 16 patients with normal tension glaucoma (NTG) and 40 eyes of 23 patients with primary open angle glaucoma (POAG). Although there was no significant correlation between the areas of PPAVA, PPA, zone alpha or zone beta, and mean deviation of Humphrey field analysis, there was significant correlation between all areas except for zone alpha and the spherical equivalent. The areas of PPAVA and zone beta in the NTG group were significantly larger than those in the POAG group (p = 0.04434, 0.02750, respectively). These results suggest that the pathogenesis of disease may be different in NTG and POAG.

A case is presented of the frontal brain abscess following resection of squamous cell carcinoma of the maxillary sinus who had undergone reconstruction of the anterior skull base using a free rectus abdominis muscle flap. Local flap, ex. galeal flap, can be used for separating the cranial space from the paranasal sinuses and the nasopharynx, but it cannot provide reliable separation and protection of the brain from bacterial flora of the upper airway and it is too weak to support the brain in cases where orbital exenteration has been performed. The distant flaps such as the pectoralis major musculocutaneous flap, on the other hand, can provide a good alternative for reconstruction of the anterior skull base in such difficult cases, but frequently requires a secondary division of the pedicle. The free flap can circumvent such problems. We used the free rectus abdominis muscle flap and the postoperative course was uneventful. A bone graft was not necessary to reconstruct the anterior skull base.

OBJECTIVE AND IMPORTANCE: Results of surgical repair of the injured abducens nerve are rarely reported in the literature. A full functional recovery of a completely resected abducens root may be exceptional. We describe a patient who obtained normal ocular alignment and binocular vision after surgical reconstruction of a transected abducens nerve. CLINICAL PRESENTATION: A 56-year-old woman with a petroclival meningioma was presented. She underwent total removal of the tumor through a combined supra/infratentorial transpetrosal approach. The abducens nerve was tightly attenuated by the tumor and thickened dura. During dissection, the nerve was completely transected just behind the entrance to Dorello's canal. INTERVENTION: The abducens nerve was the single root type and inevitably required surgical repair. To obtain a sufficient length of the distal stump for trimming, part of the petrosphenoidal ligament was cut and the superior border of the petrous bone was exposed. The proximal stump of the nerve was also trimmed to obtain healthy tissue, and reconstruction was performed with five 10-0 nylon sutures. Five months later, esodeviation began to improve. Nine months after the surgery, the patient did not complain of diplopia and an objective assessment reported normal ocular alignment and estimated binocular function as excellent according to Biglan's system. Overcorrection of abduction did not occur. CONCLUSION: The result in our patient confirms the possibility of full functional recovery after surgical repair of a totally transected abducens nerve.

This report describes a simple technique of cranioplasty for suboccipital craniectomy and the results of a clinical study to assess the effects of fibrin glue on regeneration of the skull. Cranioplasty using a mixture of autologous bone chips and human allogenic fibrin glue was performed in 31 patients who received lateral suboccipital craniectomy. Long-term observations with three-dimensional CT showed satisfactory reconstruction of the mastoid-occipital bone plate in 25 patients (81%); among them, a nearly complete reconstruction of the occipital bone (plate) was found in 14 patients. Regeneration of the bone began 6 months after surgery on the inner surface, adjacent to the dura mater. In conclusion, the present technique provides a new simple method to restore an autologous bone plate in a cranial defect made by piecemeal craniectomy.

Hemolytic anemia is a well-recognized complication of mechanical heart valve prosthesis but, as yet, has not been reported after mitral valve repair with chordal replacement. We report a case of severe hemolytic anemia after mitral valve repair with chordal replacement and Carpentier-Edwards annuloplasty ring insertion. Progressive prolapse of the anterior leaflet due to the artificial chordae being too long caused recurrent regurgitation which was responsible for the hemolysis. The patient also had idiopathic thrombocytopenic purpura, but successful second mitral valve repair was performed after high-dose gamma-globulin therapy.

A stereotactic irradiation (STI) system using a linear accelerator was developed and its effectiveness for brain metastasis was investigated. The system consisted of a conventional linear accelerator, invasive fixation head frame (RADFRAME, Mizuho Ika Kogyo), and a tungsten collimator. The RADFRAME was developed to be used with any linear accelerators and with any dose planning systems. The accuracy of the irradiation was assured to be within +/-1.5mm. Fifty-one patients with metastatic brain tumors were treated using the system. The overall median survival time was 10 months. No difference in survival was observed between patients with a single lesion and patients with two or three lesions. Complete, partial, and minimal responses were obtained in 16 (39%), 18 (41%), and 7 (16%) lesions. These were comparable to the reported results of gamma knife treatment. A maximum dose of 25 Gy was suggested to be more effective than lower doses. Local control rate was higher in tumors with a diameter of less than 2.0cm (87.5%) than in larger tumors (60%). No difference in tumor response was observed among various histopathologic types. In a patient with a 25mm cerebellar metastasis from an adenocarcinoma of the lung, autopsy at 5 months after STI showed fibrinoid degeneration and hyaline deposition without residual tumor at the Gd-enhanced region on MRI. The efficacy of linac stereotactic irradiation was equal to that of gamma knife radiotherapy for metastatic brain tumors.