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Macrocystic serous cystadenoma (MSC) of the pancreas is a rare benign neoplasm with varied imaging appearances. We describe an intriguing case of a surgically resected and histologically proven giant MSC, developed in the pararenal space. Ultrasonography (US) revealed a large, oligocystic mass around the lower pole of right kidney. Like US, computed tomography, and magnetic resonance imaging were unable to detect the origin of the lesion, which was only verified at surgical exploration. A bizarre finding was the unusual location of the pancreatic tumor growing seemingly apart from the pancreas itself, with no obvious connection to it.

Immunonutrition is thought to reduce the incidence of complications in surgical patients and is useful in preoperative nutritional management. However, choosing the appropriate immunonutrient for a patient can be difficult because of the many enteral nutrients available. This study searched an index for appropriate preoperative nutrient choices and selected four (ANOM®, IMPACT®, MEIN®, RACOL®-NF) for comparison of their effects. The antiradical activity of each nutrient was measured in 10 healthy volunteers per group, and the effects of each nutrient on changes of free radicals in the blood were observed. Additionally, the effects of MEIN® on changes of free radicals and biochemical examination of blood in digestive system cancer patients were observed. Free radical scavenging ability was specific to each nutrient, and the obtained values showed antioxidant properties. The ascorbic acidcontent of each enteral nutrient could affect antiradical activity. Free radicals in the blood decreased after administration of the nutrients in healthy volunteers, and the free radical scavenging effects were maintained for 120 minutes with ANOM® or IMPACT® administration. In cancer patients, 7-day administration of MEIN® decreased free radicals in the blood. In conclusion, the antiradical activities and properties of free radicals in the blood are useful indices when choosing an appropriate nutrient.

後腹膜原発血管周皮腫術後19年目に両側肺に再発し切除した症例，58歳の女性，1988年7月に後腹膜原発血管周皮腫摘出術，同年9月に右転移性肺腫瘍摘出術，同年10月に左転移性肺腫瘍摘出術を施行した．病理診断は，後腹膜原発悪性血管周皮腫の両側肺転移であった．2006年夏頃より左胸部圧迫感が出現し，同年12月17日に当院外来を受診した．胸部CTにて両側多発肺転移の診断，腹部CTでは腹腔内には再発病巣は認めなかった．既往歴より悪性血管周皮細胞腫の再発と診断した．2007年2月22日左開胸にて最大径7.5cm大の7個の腫瘤を摘出した．同年10月25日右開胸にて14個の腫瘤を摘出した．悪性血管周皮腫の両側肺転移であった．再発までの期間が19年と長くQOLを重視した肺部分切除を2期的に行った．後腹膜原発血管周皮腫術後には，15年以降に再発する症例もあり長期の経過観察が必要である．

A great deal of clinical experience has firmly established the concept of the sentinel lymph node (SN) in breast cancer. SN biopsy allows treatment without axillary lymphadenectomy and has made it possible to perform a surgical intervention via just a small skin incision. In partial resection of the breast (quadrantectomy), we use a double retractor to form a workspace under the skin via a small axillary incision. Resection does not require a large incision even in cases in which the cancer lesion is located in the upper inner or lower inner quadrant of the breast, as the endoscope allows the surgeon to see the workspace formed by the double retractors.

Neck endoscopic surgery is likely to prove less invasive and more cosmetically advantageous than conventional methods. The surgical procedure used for 42 consecutive patients undergoing video-assisted thyroidectomy by the anterior chest wall approach is described herein. A 3-4 cm incision was made at the anterior chest wall 2 cm below the clavicle on the tumor side. Two Kirshner wires connected to a winching device were horizontally inserted beneath the skin in order to lift the neck skin. Specially made retractors were passed through the chest wall wound to the lateral neck bilaterally. Strap muscle on the tumor side was retracted laterally and the thyroid tumor was retracted medially. A suitable working space was thus created using this modified neck lifting method without gas insufflation. All patients underwent video-assisted thyroidectomy utilizing an anterior chest wall approach without conversion to open thyroidectomy. Mean operative time from incision to removal of the tumor was 145 min. Mean tumor size was 4.1 cm (range: 2.0-7.5 cm). The advantage of our approach is that the scar below the clavicle is invisible under normal clothing. In addition, conventional instruments for open thyroidectomy can be used. In our method, the thyroid tumor and trachea are palpable and some parts of the operation can be conducted under direct visualization if the assistant retracts the anterior chest wall wound upward. Video-assisted thyroidectomy utilizing an anterior chest wall approach is cosmetically less invasive, particularly for women who are frequently nervous about operative scars on the neck.

The use of fat emulsion in total parenteral nutrition (TPN) is closely related to changes in respiratory function. The aim of this study was to evaluate the influence of exogenous fat emulsion on pulmonary gas exchange in the early period after major surgery. Total parenteral nutrition was administered to 18 patients for 6 days after esophagectomy for carcinoma. Half of the patients received glucose (glucose group), and the other half received glucose and fat (fat group). The fat emulsion was continuously infused for 24 hours over 6 days. Glucose utilization was significantly higher in the glucose group than in the fat group. Fat utilization was significantly higher in the fat group than in the glucose group. Carbon dioxide (CO2) production and respiratory quotient were significantly decreased in the fat group compared to the glucose group. There were no differences in the pulmonary vascular resistance index or alveolar-arterial difference in oxygen tension between the two groups. Although exogenous fat emulsion utilized as energy substrate decreases CO2 production after major surgery, it does not clinically influence the pulmonary hemodynamics or diffusion capacity.

It is known that fat oxidation is increased in patients who have sustained surgical stress, but it is not clear whether fat emulsion should be administered during the early postoperative period. The aim of this study was to evaluate the utilization of exogenous fat emulsion after major surgery. Total parenteral nutrition composed of glucose/amino acids or glucose/amino acids/fat was administered for 6 days to 18 patients who had undergone esophagectomy. The caloric intake was significantly less than the resting energy expenditure (REE), and there was no difference in substrate utilization in either group up to postoperative day (POD) 2. After POD 4, fat utilization was significantly increased in the fat group. The total ketone body concentration was higher in the fat group than in the glucose group on POD 1 and 2. The arterial ketone body ratio (AKBR), which reflects the rate of turnover of the Krebs cycle, was positively correlated with the caloric intake/REE ratio. It was negatively correlated with the oxygen delivery index, oxygen consumption, and lactate concentration between POD 0 and POD 2. The lactate concentration was decreased and the AKBR was increased by POD 4. Fat emulsion was effectively utilized as energy substrate after POD 4, after the relative tissue hypoxia had improved and the AKBR had increased. The utilization of exogenous fat emulsion was closely related to deficient caloric intake and oxygen metabolism.

Background. Recently, eicosapentaenoic acid (EPA) was found to have an anti-inflammatory effect attributable to diminished synthesis of arachidonic acid metabolites that initiate acute lung injury. We evaluated the ability of dietary EPA supplementation to prevent endotoxin-induced acute lung injury in rats. Materials and methods. Rats fed a standard diet were divided randomly into two groups: for 2 weeks one group additionally was fed 1000 mg/kg/day of EPA ethyl ester emulsion (EPA rats), while in the other group the diet was supplemented with vehicle alone (control rats). Fatty acid components of alveolar macrophages (AM) were measured, as well as leukotriene (LT) B 4 and LTB 5 production by AM exposed in vitro to calcium ionophore A23187. Plasma concentrations of thromboxane (Tx) B 2 , a stable metabolite of TxA 2 , were examined 1 h after inducing lung injury with endotoxin (2 mg/kg iv). At 6 h, wet/dry (W/D) weight ratios were calculated for the lungs to assess pulmonary edema, and neutrophils were counted in pulmonary parenchyma and peripheral blood. Results. Arachidonic acid content and LTB 4 generation in AM were significantly lower in EPA rats than in controls; conversely, EPA content and LTB 5 generation in AM were significantly higher in the EPA group. Neutrophil counts in lung parenchyma and peripheral blood did not differ between groups, but W/D and plasma TxB 2 concentrations were significantly lower in EPA rats. Conclusions. EPA supplementation depressed arachidonic acid content and LTB 4 generation in AM and plasma TxB 2 in our model, leading to decreased pulmonary edema.

The aim of this study was to evaluate the effect of fat emulsion administration on neutrophil arachidonic acid and leukotriene B4 (LTB4) generation in surgically stressed patients. Total parenteral nutrition was administered to 17 patients for 2 wk after esophagectomy for carcinoma. Eight patients received fat with glucose (fat group, 30% of total calories) and 9 patients received glucose (glucose group) as a non-protein calorie source from the day of the operation to the seventh postoperative day (POD), and they gradually were converted to enteral nutrition during the second postoperative week. The arachidonic acid in the fat group decreased in the serum from POD 4 to 14. and in neutrophils from 12 h after the beginning of surgery to POD 14, compared to preoperative levels. LTB4 production by A23187-stimulated neutrophils was highest 6 h after the beginning of surgery, when neutrophil arachidonic acid concentration was decreasing, and then fell below the preoperative value from POD 4 to 14 in both groups. LTB4 production on POD 14 was lower in the fat group than in the glucose group. Biosynthesis of arachidonic acid from linoleic acid is inhibited in surgically stressed patients receiving fat emulsion, resulting in the diminished synthesis of LTB4 by neutrophils. The decrease in LTB4 may diminish chemotactic and chemokinetic signals to other leukocytes.

This study was designed to clarify the clinical and pathologic features of diffusely infiltrative squamous cell carcinoma of the esophagus. Diffusely infiltrative squamous cell carcinomas were classified grossly into two types, namely, scirrhous carcinoma and nonscirrhous carcinoma. There were seven patients with the former type and three with the latter type. Scirrhous-type carcinoma was associated with a prominently thickened esophageal wall with strictures, whereas nonscirrhous-type carcinoma demonstrated thickening of the esophageal wall without strictures. Microscopically, all patients had lymph node metastases and lymphatic invasion. Blood vessel invasion was found in seven patients and extranodal invasion was found in seven. The prognosis of patients with both types of carcinoma was extremely poor. Only two patients who underwent curative surgery as well as chemoradiotherapy survived for more than 1 year. Therefore, further morphological studies on the early stages of diffusely infiltrating esophageal carcinoma should be performed. New treatment strategies such as intensive preoperative chemoradiotherapy based on sensitivity tests in individual patients will be required for treating the advanced stages of this disease.

A clinicopathologic study was carried out on 30 patients with mucosal esophageal cancer (MEC). The depth of cancer invasion was subdivided histologically into three categories: m1 = carcinoma in situ (intraepithelial carcinoma) or carcinoma with questionable invasion beyond the basal membrane; m2 = cancer invasion confined to the lamina propria, and m3 = cancer reaching to or infiltrating into the muscularis mucosae. Lymph node metastases and lymphatic invasion were found only in the tumors reaching or infiltrating the muscularis mucosae (m3). The maximum histologic vertical extent of the tumors was more than 1 mm in 4 of 5 patients with lymph node metastasis or lymphatic invasion. None of the patients died of recurrent esophageal disease, and 3 of the 6 patients who had a second primary tumor died of this other malignancy. It is critical to distinguish between m1, m2 and m3 tumors to plan a treatment strategy, including an endoscopic mucosal resection.

輸液にて腹部膨満感を訴えた太陽病と少陽病の併病を経験した。62歳の女性で主訴は, 輸液後の腹部膨満感, 全身倦怠感, 頭重感と耳鳴りである。悪寒, 発熱, 頭痛の太陽病の症状と眩量や口苦咽乾および心下痞鞭の少陽病の症状を伴うことより太陽病と少陽病の併病と診断した。輸液を中止し柴苓湯を投与した結果, 全身倦怠感の消失, 食欲の回復, 心下痞鞭の改善および体重減少が認められた。嘔気や上腹部圧迫感は柴胡桂枝湯が奏功し, 笑顔と活力がみられ旅行に行くまで回復した。足腰の冷えと痛みは, 当帰四逆加呉茱萸生姜湯が奏功した。栄養補給や脱水の治療として輸液がなされるが, かぜ症候群の輸液療法の適応には注意が必要である。

Background This study was designed to assess the impact of oxygen transport variables on outcome in 115 patients undergoing elective surgery for oesophageal carcinoma. Methods Haemodynamic parameters were determined using a Swan-Ganz catheter in all patients on the day before operation, 6 h after operation, and daily for the first 4 days after operation. Results Oxygen delivery and consumption at 6 h were significantly higher in survivors than in non-survivors. However, oxygen delivery and consumption in both groups did not differ significantly after postoperative day 1. Of 17 patients with oxygen delivery levels lower than 445 ml min -1 m -2 at 6 h, eight died in hospital. Oxygen delivery in patients who developed either an anastomotic leak or severe pneumonia was significantly lower 6 h after surgery. Lower levels of oxygen delivery preceded postoperative complications. Conclusion Oxygen delivery 6 h after oesophagectomy correlates with postoperative complications and may be a determinant of hospital mortality.

教室では, 原則として深達度m2までの早期食道癌は内視鏡的粘膜切除 (endoscopic mucosal resec tion, EMR) の対象としている. 1992年5月から96年8月までにEMRによって切除された30症例, 38病巣について, その適応の妥当性, 治療成績について検討した. その結果, 1) 内視鏡所見は28病集 (73.7%) が, 0-IIbまたは0-IIcであった. 2) 大きさは30病巣 (78.9%) が20mm以下であった. 3) 予測深達度と組織学的深達度の一致率はdysplasiaであった4例を除いて70.6% (24/34病巣) であった. 4) 合併症として, 動脈性出血が5例 (16.7%) に, 穿孔, 皮下気腫がそれぞれ1例 (3.3%) にみられた. 5) 再発が3例, 異時性食道癌が1例にみられ, いずれも再EMRを施行した. 6) 他病死1例, 深達度sm3で手術を施行した1例が癌死した. その他は最長4年5か月を含め, 全例生存中である. 深達度m2までの, 全周性でない癌はEMRの適応であり, その治療成績も満足できるものであった.

食道癌術後早期の酸素運搬量と術後合併症の関連を右開胸切除食道癌133例を用いて検討した.前期94例の検討では, 縫合不全, 呼吸不全および入院死亡例の術後6時間の酸素運搬量は合併症がない症例に比べて有意に低下していたが1病日以降では差を認めず, 術後6時間の酸素運搬量の低下と以後の合併症発生の関連が示唆された.後期39例では術後12時間以内の酸素運搬量を600ml/min/m2以上に維持するように循環管理を行った.その結果, 縫合不全は前期28.7%から後期10.3%に, 呼吸不全は19.1%から5.1%に減少し, 入院死亡は前期8.5%に対して後期では認められなかった.食道癌切除術における術後早期の酸素運搬量の値は術後の縫合不全, 呼吸不全さらに入院死亡発生と密接な関連をもつと同時に, 術後12時間以内の酸素運搬量の増加は重症合併症予防の有用な手段となると考えられた.

胸部食道に対する頸部郭清の適応について, 鎖骨上と反回神経沿いリンパ節の術前超音波診断ならびに手術成績の面から検討した. 対象は1986年から93年にcl以上の切除を行った胸部食道癌136例 (3領域郭清105例, 2領域郭清31例) とした. 3領域郭清例において, 術前に鎖骨上リンパ節転移陰性とした84例中7例 (8.3%) に組織学的に転移が認められた. False negative 7例中5例は反回神経沿いに術前超音波診断および術中に転移を認めた. したがって, 術前超音波診断による鎖骨上リンパ節の転移の有無のみで頸部郭清を省略するのは危険であるが, 反回神経沿いリンパ節の術前・術中診断を加味すると97.6% (82/84例) の症例で頸部郭清の適応を術前診断にて判断可能であった. また術前に鎖骨上・反回神経沿いに転移陰性としたmp以上の症例における5生率は頸部郭清の有無に関係なく37%であった. 術前診断による鎖骨上または反回神経沿い転移陽性症例が頸部郭清の適応である.

真武湯が有効であった食道静脈瘤術後の横隔膜下膿瘍を経験した。43歳の女性で術前肝機能は Child B で汎血球減少症を伴っていた。Hassab 手術の第10病日に38℃の発熱が出現し脾摘熱と診断してステロイド剤を投与した。一旦は解熱したが第35病日より再び発熱し, CT, 超音波検査にて左横隔膜下膿瘍と診断した。超音波下のドレナージ術と抗生物質を投与したが, ドレナージが不良で発熱が持続した。第70病日に真武湯を開始したところしだいに解熱し横隔膜下膿瘍は縮小した。西洋医学的にドレナージや抗生物質が無効な横隔膜下膿瘍に真武湯が著効した。

A series of 335 patients with squamous cell carcinoma of the thoracic esophagus undergoing resection and reconstruction via a right thoracotomy and laparotomy with cervical anastomosis between 1973 and 1990, were reviewed. Prior to 1982, the removal of lymph nodes was limited to the nodes in the mediastinum below the tracheal bifurcation and upper abdomen (142 patients). Nodal metastases were found in 89 of these patients at operation. The upper abdominal nodes were the most frequent sites of metastasis (47.2%). None of the 38 patients with positive nodes sampled from the neck and superior mediastinum survived for more than 45 months. In the 50 patients with recurrences, 30 were in the neck and/or superior mediastinum. During or after 1983, the superior mediastinal nodes, particularly the bilateral recurrent nerve nodal chains, were routinely removed (193 patients). Nodal metastasis was proven in 131 of the 193 patients, in whom 87 (45.1%) had metastasis in the neck and superior mediastinum. Eleven of these 87 patients survived for 45 months or more. In the 61 patients with recurrences, 20 were in the neck and/or superior mediastinum. These data suggest that recurrent nerve nodal chains should be removed to improve survival in patients with esophageal carcinoma.

食道表在癌71例の組織学的深達度について50μ ごとの亜連続切片を作製し再検討した. 深達度はep, mm1, mm2, mm3, sm1, sm2, sm3に細分類した. 粘膜癌で深達度が変更になった症例はepの6例中3例がmm1に, mm1の5例中1例がmm2へ, mm3の6例中1例がsm1となった. 粘膜下層癌では, sm2の18例中5例がsm3へ, sm3の14例中1例に固有筋層への浸潤を認めた.食道表在癌全体では71例中11例 (15.5%) に深達度の変更が認められた. これらの症例の肉眼型はepの症例ではO-IIb型が, mmではO-IIc型が, smでは隆起型であった. 切り出し時の隆起や陥凹部分のわずかなずれが深達度の誤差の要因と考えられた. いずれの症例でも再検した切片に新たなリンパ管侵襲や血管侵襲は発見されなかった. 今回の検討では治療上大きく問題となるほどの誤差は認められなかつた. 肉眼所見と組織学的深達度に差異がみられる症例に対しては深切りによる深達度の再検討が必要と考えられた.

胸部食道癌根治手術例で右開胸開腹, 頸部吻合, 胸骨後あるいは後縦隔経路再建の285例を対象とし, 再建術後の問題点と対策を検討した. 反回神経リンパ郭清を行わなかった1982以前の88例 (First Gr.) と, それ以降の197例 (Latter Gr.) の, 非再発死亡と再発例の生存率では, First Gr.で非再発死亡の生存率が再発例より有意に良好であった. しかし, Latter Gr.ではその有意差は消失し, 非再発死亡の66.7% (30/45例) は肺炎, 全身衰弱, 突然死であった. Latter Gr.の胸骨後再建80例と後縦隔再建117例では, 退院時の体重, 肺活量, 1秒量は後縦隔経路で有意にその落ち込みが少なく, 退院後3年の体重も良好に維持された. 術後3～5年経過例のアンケート結果でも後縦隔再建例で食物のつかえ感や誤飲, 腹痛, 息切れを訴える症例が少なかった. 消化器・呼吸器症状が少なく, 術後長期の栄養状態も良好な後縦隔経路は, 食道癌根治手術におけるfirst choiceの再建経路と考えられる.

教室では1983年以降, 胸部食道癌に対して積極的に3領域リンパ節郭清を施行してきた.最近, 高齢者の食道癌切除症例が増加しているが, 果たして高齢者に対しても3領域リンパ節郭清が有効であろうか? c1以上の切除症例251例を対象に, 70歳以上の高齢者群 (65例) と70歳未満の非高齢者群 (186例) に分け検討した.その結果, 1) 術前併存症は高齢者群に有意に多かった.2) 術後合併症は高齢者特有の合併症はなかったが, 不整脈やせん妄が多くみられた.3) 3領域郭清群に合併症が多く認められた.4) 人院死亡率は両群間に差を認めなかった.5) 2領域郭清例の相対5生率は両群間に差はないが, 3領域郭清例では高齢者の5生率は8.0%で, 非高齢者群の35.9%に比べて有意に低かった.高齢者胸部食道癌の外科治療に対しては, 画一的な術式の選択よりも, 臨床的に癌をとり残さないことを最低条件とした合理的なリンパ節郭清が必要である.

消化器外科に入院した患者84例を対象として, 栄養状態と虚実証の関連について検討した。虚実証の判定は, 大竹の虚実判定スコアーを用いて行った。癌患者の%理想体重は, 非癌患者より有意に低値であった (p

右開胸による食道癌切除を行った69例について, 年代別に59歳以下 (24例), 60～69歳 (32例), 70歳以上 (13例) の3群に分けるとともに, 術中から術後2日目までの輸液量別に, 80ml/kg/day未満, 80～119ml/kg/day, 120ml/kg/day以上の3群に分けて術後早期の循環呼吸動態に対する加齢および輸液量の影響を検討した.年代別の循環動態では70歳以上で術後早期の心機能低下や肺循環の異常が明らかであった.術当日の循環動態は, 59歳以下ではnormal type 79%に対して60歳以上では34%と有意に低率であり, hypovolemia typeやcardiac failure typeが高率であった.59歳以下では, 輸液量の多い群において循環動態はhyper dynamicとなり呼吸係数も輸液の少ない群に比べて有意に低かった (p

We would like to draw attention to hepatic tumor-like lesions which frequently complicate the differential diagnosis of hepatocellular carcinoma (HCC), while considering their pathology and diagnosis by radiographic imaging. In particular, adenomatous hyperplasia is recognized as a precancerous lesion of HCC, and the relationship between adenomatous hyperplasia and the multicentric development of HCC is recognized. We observed a patient who demonstrated hyperplastic changes in both the liver cells and a well-differentiated HCC lesion adjacent to the adenomatous hyperplasia, suggesting a multicentric development of the HCC. The histopathological features of adenomatous hyperplasia are also described.

The incidence and circumstances of colonization by methicillin-resistant Staphylococcus aureus were prospectively investigated. Among 404 patients, 15 (3.7%) were carriers on admission, and 43 (10.6%) became colonized, mainly after surgical operation. A different mode of transmission was suggested in each ward.

Neck endoscopic surgery is likely to prove less invasive and more cosmetically advantageous than conventional methods. The surgical procedure used for 42 consecutive patients undergoing video-assisted thyroidectomy by the anterior chest wall approach is described herein. A 3-4 cm incision was made at the anterior chest wall 2 cm below the clavicle on the tumor side. Two Kirshner wires connected to a winching device were horizontally inserted beneath the skin in order to lift the neck skin. Specially made retractors were passed through the chest wall wound to the lateral neck bilaterally. Strap muscle on the tumor side was retracted laterally and the thyroid tumor was retracted medially. A suitable working space was thus created using this modified neck lifting method without gas insufflation. All patients underwent video-assisted thyroidectomy utilizing an anterior chest wall approach without conversion to open thyroidectomy. Mean operative time from incision to removal of the tumor was 145 min. Mean tumor size was 4.1 cm (range: 2.0-7.5 cm). The advantage of our approach is that the scar below the clavicle is invisible under normal clothing. In addition, conventional instruments for open thyroidectomy can be used. In our method, the thyroid tumor and trachea are palpable and some parts of the operation can be conducted under direct visualization if the assistant retracts the anterior chest wall wound upward. Video-assisted thyroidectomy utilizing an anterior chest wall approach is cosmetically less invasive, particularly for women who are frequently nervous about operative scars on the neck.

A solitary well-demarcated tumor was found in the left lung of a 53-year-old man. It was located in the posterior region of the lower lobe just adjacent to, but apart from, the pleura. It was resected by video-associated thoracic surgery. Macroscopically, the tumor was a whitish solid nodule without hemorrhage or necrosis, and it was 1.5 cm in diameter. Histologically, the tumor consisted of a proliferation of fibromuscular tissue in interlacing fascicles in which many tubular or cleft-like epithelial inclusions were involved. The epithelial inclusions showed cystic changes with goblet cell metaplasia in part, but no atypical changes. Other mesenchymal components such as cartilaginous, myxomatous or adipose tissues were not seen. The patient had no history of neoplasm, including smooth-muscle tumor. Thus, we diagnosed this tumor as a "true" fibroleiomyomatous hamartoma, as distinct from so-called fibroleiomyomatous hamartoma or benign metastasizing leiomyoma, which are usually found in the lungs of women who have had hysterectomies, as multiple fibromuscular nodules. We report here this rare case and we review and discuss published reports of fibromuscular tumors of the lung.

Galectin-3 is a member of the β-galactoside-binding protein family that plays an important role in cell-cell adhesion and in cell-matrix interaction. We have examined the expression of galectin-3 in normal, adenomatous, and malignant thyroid tissues and also in metastasic lesions. Galectin-3 was rarely expressed in normal thyroid tissue but was abundant in the cytoplasm of the neoplastic lesions. Among neoplastic lesions, galectin-3 was expressed to a greater extent in follicular carcinomas than in follicular adenomas and was present in greater amounts in papillary carcinomas than in follicular adenomas or carcinomas. Primary lesions of papillary carcinoma with metastasis contained significantly higher concentrations of galectin-3 than tumors of this type without metastases. However, the expression of galectin-3 was significantly decreased in metastasic lesions in the lymph nodes compared with their primary lesions. From these results, we assumed that galectin-3 works in different ways at different stages of thyroid neoplasm proliferation. Among primary tumors, galectin-3 expression is significantly different in 3 histological types. However, the continuity of progression among these tumors is not yet proven. In later stages, decreased expression of galectin-3 may aid the release of cancer cells from the primary lesions for invasion and metastasis.

The aim of this study was to clarify whether preoperative chemotherapy caused adverse effects on the perioperative course of patients undergoing esophagectomy. A total of 42 esophageal cancer patients were entered into a randomized trial and were analyzed. Twenty-one patients were assigned to immediate surgery (Surgery Group). The other 21 received two 5-day courses of chemotherapy comprising cisplatin (70 mg/m2) on day 1, and fluorouracil (700 mg/m2) and leucovorin (20 mg/m2) on each of days 1 to 5 (chemotherapy group). Hospital mortality comprised of one patient (2.3%) who had undergone an operation in the beginning of this series at 21 days after chemotherapy. Thereafter, the interval between the chemotherapy and operation was prolonged, with the average being 35 +/- 7 days. Preoperatively, both the lymphocyte counts and serum albumin levels were not increased in the chemotherapy group of patients even though their body weights increased. In the chemotherapy group, the operation time and the blood loss were increased and, on the 1st postoperative day, the development of systemic inflammatory response syndrome was high but the level of C-reactive protein was low. The incidence of positive microbial cultures of sputum and/or wound discharge within 8 postoperative days was higher in the chemotherapy group (42.9%) than in the surgery group (4.8%). The host defense damage caused by chemotherapy may be prolonged and may show adverse effects in patients undergoing esophagectomy in the early postoperative period. Minimally, a 4-week interval between the completion of chemotherapy and operation is recommended for preventing surgical mortality related to the preoperative chemotherapy.

BACKGROUND The aim of this study was to establish whether the site of lymph node metastasis influences the survival of patients with carcinoma of the thoracic esophagus. METHODS A series of 159 patients with lymph node metastasis who underwent right transthoracic R0 esophagectomy was analyzed retrospectively. Sites of the nodal metastasis were divided into two regions; the neck and/or upper mediastinum above (upward metastasis) and the abdomen and/or lower mediastinum below (downward metastasis) the tracheal carina. RESULTS Univariate analysis of prognostic factors revealed the tumor location, distant lymphatic metastasis, number of metastatic nodes and upward metastasis influenced survival, but downward metastasis did not. Multivariate analysis showed that the number of metastatic nodes and upward metastasis were also significant prognostic factors. Thirty-one (33.3%) of the 93 patients with, but only 6 (9.1%) without, upward metastasis had recurrences in the neck and/or upper mediastinum (P = 0.0002). Eighteen (60.0%) of the 30 patients with extranodal invasion in the neck and/or upper mediastinum had recurrence in these regions. CONCLUSIONS Nodal metastasis in the neck and/or upper mediastinum was a significant risk factor for prognosis, the same as the number of metastatic nodes.

OBJECTIVE: To evaluate the efficacy of ultrasonography for the diagnosis of cervical lymph node metastasis in esophageal carcinoma. SUMMARY BACKGROUND DATA: Ultrasound (US) examination is useful for diagnosing lymph node metastasis. However, few reports have examined its role in the decision to perform cervical lymph node dissection in esophageal carcinoma. METHODS: Ultrasound examination was performed to evaluate cervical lymph node metastasis in 519 patients with esophageal carcinoma. The patients were divided into 5 groups according to treatment received: group 1, 153 patients who underwent curative resection of primary tumor by right thoracotomy and complete bilateral cervical lymphadenectomy; group 2, 112 patients who underwent curative resection of primary tumor by right thoracotomy but without cervical lymphadenectomy; group 3, 78 patients who underwent esophagectomy by left thoracotomy or blunt dissection with or without removal of cervical lymph nodes; group 4, 76 patients with palliative resection without cervical lymphadenectomy; and group 5, 100 patients without any surgical treatment. US diagnosis was compared with histologic findings or cervical lymph node recurrence. RESULTS: Lymph node metastasis was detected in 30.8% of patients (160/519). The sensitivity, specificity, and accuracy of US diagnosis in group 1 were 74.5%, 94.1%, and 87.6%, respectively. Cervical lymph node recurrence was seen in 7 patients (4.6%) in group 1, in 4 patients (3.6%) in group 2, and 3 patients (3.8%) in group 3. Although the incidence of cervical lymph node metastasis as determined by US examination was high in groups 4 and 5, almost none of the patients died of cervical lymph node metastasis. CONCLUSIONS: Ultrasound examination plays a useful role in the decision to perform cervical lymph node dissection in patients with esophageal carcinoma, particularly in those with potentially curative dissection.

Endoscopic mucosal resection (EMR) has recently been standardized for mucosal cancer of the esophagus. It may be hypothesized that EMR may be considered to be curative for superficial esophageal cancer (SEC), if the possibility of lymph node metastasis can be excluded beforehand. Ninety patients with p-T1 tumours who underwent esophagectomy were studied. Their primary lesions were stained with anti-Desmoglein 1 antigens using the ABC method. The p-T1 tumors were subdivided into three categories: carcinoma limited to the lamina propria mucosae (19 patients, SEC1), carcinoma invading the lamina muscularis mucosae or with invasion just into the submucosa (27 patients, SEC2), and carcinoma definitely invading the submucosa (44 patients, SEC3). Lymph node metastasis was not observed in the SEC1 patients but was observed in 19% of the SEC2 patients and 41% of the SEC3 patients. None of the SEC1 or SEC2 patients had lymph node metastasis when preserved Desmoglein 1 expression was obtained. The EMR appears to be appropriate therapy for SEC1. Our findings indicate that, for SEC2, preserved expression of Desmoglein 1 may be a helpful aid to exclude the possibility of lymph node metastases. Transthoracic esophagectomy with lymphadenectomy should be selected in the SEC3 patients.

We retrospectively analyzed the clinicopathologic findings, treatment and outcome of 22 patients with synchronous or metachronous carcinomas of the esophagus and head and neck. The patients with metachronous cancers in whom esophageal cancer occurred first had either an early-stage esophageal carcinoma or only one positive lymph node. Similarly, five of 10 patients with metachronous cancers in whom head and neck cancer was the first tumor had early-stage esophageal carcinomas. The esophageal lesion was mucosal carcinoma in four patients which was found by endoscopy with the iodine dye method. In the patients with synchronous cancers either one or both carcinomas were advanced, and the prognosis of these patients was poor compared with those of patients with metachronous carcinomas. Accordingly, endoscopic surveillance for early detection of metachronous lesions are encouraged.

We investigated extranodal connective tissue involvement (ECTI) in 39 patients with oesophageal carcinoma. Both the primary tumour and ECTI were immunohistochemically examined using the monoclonal antibody 32-2B for desmosomal glycoprotein 1 (DG1). Connective tissue carcinoma deposits were identified as cells within small lymph nodes, as lymphatic or venous vessel invasion or as widespread invasion beyond the capsule of metastatic lymph nodes. These histological findings were present in at least one area in 20 of 39 patients (51.3%). DG1 immunostaining intensity by tumour was graded as DG1 (++), DG1 (+) or DG1 (-). DG1 (+) or DG1 (-) primary tumours demonstrated lymph node metastases and ECTI more frequently than DG1(++) tumours (P