The clinical significance of PIVKA-II in the diagnosis of hepatocelluar carcinoma was evaluated in comparison with that of other diseases. The positive rate of PIVKA-II in hepatocellular carcinoma was 56.1% which was low compared to 73.7% of AFP. However, the positive rate in other diseases was very low and 91% of the patients with positive PIVKA-II had hepatocellular carcinoma. PIVKA-II was not correlated with AFP, and a combination assay of AFP and PIVKA-II improved the rate of diagnosis of hepatocellular carcinoma. PIVKA-II was positive in 26.7% of patients with non-AFP producing hepatocellular carcinoma. It is concluded that PIVKA-II is a tumor marker that is highly specific to hepatocellular carcinoma and is useful in the screening test for the diagnosis of hepatocellular carcinoma, but PIVKA-II is not reliable as a tumor marker in patients with early stage carcinoma. PIVKA-II levels decrease gradually with treatment of hepatocellular carcinoma, so it is considered to be useful as an indicator of therapeutic effects, and for monitoring of the clinical course, particularly in non-AFP producing hepatocellular carcinoma. Attention should be paid to evaluating the clinical significance in patients with vitamin K administration which decreases blood PIVKA-II levels.

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In the present study, detailed statements for claim payment of medical care expenditure for aged in the downtown Tokyo area were examined for one month, July, 1988, and causes of the increase, particularly of the expenses for aged inpatients, were examined. For the analyses the area of medical organization was divided into two parts : in the administrative region, and out of the area. Differences in the amount of medical care expenditure in and out of the area were examined. The results, clarified the following causes of difference between in- and out-side of an area, in more expensive cases : (1) The difference was found in the three age groups, the 70 to 74 year-old, 75 to 79 year-old, and 80 to 84 year-old populations. (2) Illness was classified according to the ICD in III. Endocrine, nutritional and metabolic diseases, and immunity disorderd; VI. Diseases of the nervous system and sense organs; VII. Diseases of the circulatory system; IX. Diseases of the digestive system; and XVI. Symptoms, signs & ill-defined conditions. (3) Injections, treatments, laboratory analyses, drugs, image analyses and diagnoses were the main causes of medical activities that caused differences in medical care expenditures for the aged. The results may be valuable for administrative consideration of medical care expenditures. Comparative studies in the present report clarify differences in medical expenses in- and oue-side of a particular area. The comparative data in the present report suggest establishing a structural analytical method for medical care expenditure for the aged in local administrations.

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Myofibrous organization of human psoas major muscle was investigated and the results were compared with those of orang-utan and Japanese macaque psoas major muscles. Psoas major muscles were obtained from 2 adult human males, 2 orang-utan (one male and one female) and 2 Japanese macaque (one male and one female) . Muscle fibers were classified into three fiber types (white, intermediate and red) by Sudan Black B stain, and the distribution pattern and fiber sizes in three fiber types were measured. The following results were obtained : In human psoas major muscles, the ratio of red fiber type was about 50% and the fiber size was largest in red fibers, followed by intermediate and white fibers. These results were different from those of the other human muscles. In orang-utan and Japanese macaque, the distribution pattern and fiber size were similar to other muscles. These results suggest that the human psoas major muscles have more differentiated functions.

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The effects of oral administration of teprenone (TPA) on two different types of experimental acute pancreatitis were studied in rats. In the first experiment, the preventive and therapeutic effects of TPA were investigated in acute edematous pancreatitis induced by intraperitoneal injection of caerulein. Pancreatic wet weight, pathological alternation of the pancreas, and serum amylase concentration were examined and, for preventive study, plasma secretin concentration was measured in the group. In the second experiment, the effects of TPA on the survival rate of necrotizing hemorrhagic pancreatitis induced in the rat by retrograde injection of a mixed solution of sodium taurocholate and trypsin into the bile-pancreatic duct were estimated. Plasma secretin levels were elevated by TPA. Prevention of the development of edematous pancreatitis was determined from pancreatic wet weight and edema, but no therapeutic effect was found. Serum amylase activity was increased by TPA. The results suggested that oral administration of TPA released endogenous secretin and could be used for the prevention of edematous pancreatitis, but had no influence on severe pancreatitis.

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We studied: (i) the technical difficulty of puncture and (ii) the characteristics of cytodiagnosis of breast cancer cells that influence the positive ratio in cytodiagnosis and aspiration biopsy. From September 1981 to December 1988, 127 cases diagnosed from tissue specimens as cancer were subjected to this study. (i) The technical difficulty in determining the size of the tumor, degree of obesity (obese group and non-obese group by Broca's modified model) and palpation findings (localized type, intermediate type, infiltrating type) were studied. The positive ratio was 74.0% of the total, 69% (20/29) of the obese group, and 75.5% (74/98) of the non-obese group. With regard to positive ratio by size, positive ratio was (68.4%) unsatisfied for tumors less than 2cm, and 83.8% for tumors exceeding 3cm. Slight decrease in the positive ratio for tumors less than 3cm was noted in the obese group compared to that in the non-obese group. The positive ratio was more than 80% for tumors exceeding 3cm despite obesity. The positive ratio from palpation was favorable (82%) in the localized type, but only about 50% in the intermediate and infiltrating types. (ii) The positive ratio by tissue type was 70.3% in scirrhous carcinoma, 72.7% in papilotubular carcinoma and 82.4% in solid tubula carcinoma. Tumors with histologically favorable fixed specimens, many collectable cells, comparatively large uncleus diameter and exceptional nuclear atypia and sporadic state were diagnosed as Class V. These tended to be difficult to diagnose as Class V even if one factor was absent. Moreover, falte negativity with a small collectable number of cells and comparatively small nuclear diameters tended to be noted in scirrhous carcinoma. The results indicate early surgical biopsy because aspiration biopsy is inadequate with palpation findings of comparatively small tumors, obese body type with intermediate and infiltrative tumors.

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With the advancement of degeneration, tendons decrease markedly in elasticity and become fragile. This is attributed mainly to degeneration of the collagen fiber, but I hypothesize that microscopic calcification of the tendon fiber might be part of the cause of the process by which tendons become fragile. I examined supraspinatus tendons in various age groups under an atomic absorption-flame emission spectrophotometer to determine tissue calcium content. The subjects were 30 cases of supraspinatus tendon, obtained from fresh cadavers and operation, ranging in age from 17 to 90 years. The tissut collected was dried at 105°C for 48 hours, decomposed with nitric acid and perchloric acid and then subjected to atomic absorption analysis to determine its calcium content. A comparative study, using a transmission electron microscope, was also carried out on 6 cases including all age groups. The results are summarized as follows : 1) Aging was proportional to the calcium content in the supraspinatus tendon, with a coefficient of correlation of 0.676. 2) The calcium content of the tendon in patients over 60 years old with rupture of the supraspinatus tendon was significantly higher than that in patients of about the same age with other diseases (p<0.05) . 3) Under the electron microscope, the collagen fiber had a well-defined margin contour in the young. In middle age, the contour of the margin of collagen fiber was as sharp as that in the young, but division of the bundle of fibers was apparent. In the elderly, the contour of the collagen fiber was obscure. Many deposits, considered to be calcium deposits, were seen in various places, and some of the deposits appeared to be massive.

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The purpose of this study was to elucidate factors that influence portal blood flow as compared to splenic venous flow at the splenic hilus (SVH) measured by color Doppler echography, the size of the spleen or liver, and liver function tests, such as prothrombin time or ICG R15, in 34 patients with chronic liver diseases, including 14 cases of chronic active hepatitis (CH), 14 cases of viral liver cirrhosis (V-LC), and 6 cases of alcoholic liver cirrhosis (AL-LC) . The right portal blood flow (R-PBF) in CH was near normal, it was increased in AL-LC, and was markedly reduced in V-LC. The R-PBF was correlated with no other factor except the size of the caudate lobe in AL-LC. The left portal blood flow (L-PBF) was slightly increased in CH, but was significantly increased in cirrhotic patients. The L-PBF in V-LC correlated well with the increase of SVH in V-LC, and with the increase of L-PBF in SVH, suggesting that the increase of L-PBF reflected portal hypertension in cirrhosis. These results indicate that AL-LC might be quite different from V-LC in its developmental process and pathophysiological state.

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The use of laser therapy on benign stoma! constriction is reported. A 50-year-old male was admitted to our hospital because of dysphagia developing one month after partial gastrectomy and esophago-antrostomy for Borrmann-3 type gastric cancer. Barium meal test and endoscopy on admission revealed remarkable stomal constriction and histological examination of biopsied specimens showed no recurrence of gastric cancer. As the patient's consent for re-operation was not obtained, therapy with a Nd-YAG laser was employed and uneventfully performed with the total dose of 4500 Joule over 3 weeks. After laser therapy, stomal constriction was lightened and dysphagia disappeared. No recurrence of stenosis has been observed for 4 years. Because laser therapy is less invasive than surgery, we recommend application of this therapy to benign stomal constriction as well as to gastric cancer and ulcer.

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We encountered a case in which a pedunculated mushroom-shaped multiloc ular localized pleural mesothelioma originated from the visceral pleura was adhered to the parietal pleura. This paper is a report of our findings. The case was a 50-year old woman. In 1985, X-ray of the chest revealed abnormal density in the right upper lung field. In 1988, a tendency was noted for the density of a tumor mass to increase. The patient was diagnosed as having fibrous mesothelioma by percutaneous needle biopsy under CT guidance. Since no malignant findings were obtained, however, the patient was subjected to observations on the clinical course. In June 1989, the density increased further, so, the tumor centering around the site of adhesion in the parietal pleura was detached from the chest wall, and partial resection of the lung together with removal of the tumor was performed. At present, 2 years later, no recurrence or tendency to malignancy is recognized. Eary detection by further improvement in the diagnostic approach is expected to improve the results and prognosis of surgical resection.

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Synthetic hydroxyapatite is a bioactive ceramic developed in Japan. Of all artificial bones, it has the highest affinity for natural bone. We used synthetic hydroxyapatite as bone spacer in 19 cases. There were no problems or side effects, and progress was uneventful. We believe that hydroxyapatite is the safest and most useful synthetic bone spacer available.

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An 81-year-old femal e was hospitalized for anemia and constipation. Her anemia was severe (Hb 6.2g/dl), and tumor marker CEA increased (18.2ng/ml) . A Ba enema roentogenograph showed long-drawn stenosis like an apple-core sign from the sigmoid colon to the descending colon. Colonoendoscopy showed stenosis in the sigmoid colon. The result of biopsy was Group V poorly differentiated adenocarcinoma, so we diagnosed linitis plastica colon carcinoma. Left segmental colon resection and Hartmann method resection were performed. The resected colonic section showed Borrmann 3 type colon carcinoma on the anal side and stricture type obstructive colitts on the oral side. Obstructive colitis lesion, severe stenosis, and multiple longitudinal ulcer were also evident. This was a rare case that some reference suggested occurs in 3 to 5% of all colon carcinoma. When we encounter similar cases, we should pay careful attention to the diagnosis.

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We experienced an interesting case of type II c gastric carcinoma that suggested the multicentric, or field carcinogenesis. The patient was a 40 year old male who received an operation for II c type early gastric carcinoma at the lesser curvature of the lower gastric body. Analysis of the resected specimen showed a 45×35 mm sized lesion of type H c carcinoma with a regular granular pattern on the H c floor. The histopathological type was signet ring cell carcinoma with mostly mucosal invasion. Detailed histopathological study revealed scattered, minute, 1-2 mm size cancer foci with extensive none cancer invaded mucosa, so called patch or sanctuary lesion. Reconstruction of the multiple cancer foci suggested the progress of multicentric carcinogenesis in the pathological fileld of gastric mucosa.

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Nephroblastoma (Wilms' tumor) is rare in adult life. We report here a case of “adult Wilms' tumor”. A 35 years old male was admitted to the hospital, complaining of macroscopic hematuria and back pain. In the resected left kidney, a 6.5×4.5×2.5cm sized whitish mass involving parenchyma was found. Histologic specimen revealed a nephroblastoma (Wilms' tumor) composed of blastematous cells with darkly staining oval nuclei and rather scanty cytoplasm. Rarely, structures suggesting small tubuli and glomeruli were identified. The specimen was immunologically positive for vimentin and negative for cytokeratin.

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Many cases of early esophageal cancer in which the depth of invasion is limited to the submucosal layer with no lymph-node metastasis have recently been reported in Japan, although minute early esophageal cancer with diameter less than 1.0cm is considered to be uncommon. W e report a case of minute early esophageal cancer with a size of 0.5×0.4cm as a formalin-fixed specimen. This small cancer was also found to be multicentric. The lesion was located endoscopically 35cm from the incisors, and was seen as a small red depressed area. Lugol staining revealed two small unstained areas. A total thoracic esophageal resection was performed. We prepared serial sections of these lesions and observed them microscopically. The two small lesions that were not stained with Lugol's solution were found to be independent multicentric cancers. The histological type was well-differentiated squamous cell carcinoma with cancer pearls, and the depth of invasion was limited to the lamina muscularis mucosae of the esophageal wall.

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We report two rare cases of hepatocellular carcinoma (HCC) with continuously developing tumor thrombus from the hepatic vein (HV) to the right atrium (RA) via the inferior vena cava (IVC) . In the first case, we could not diagnose the IVC occlusion by the tumor thrombus until the symptoms and signs developed late in the course, and the patient died suddenly. In the second case with leg edema and venous dilatation of the abdominal walls, we investigated the vascular involvement by computed tomography with the benefit of the previous experience of case 1, and detected a tumor thrombus from the HV to the RA via the IVC. Although the HCC was thought to be growig in a different manner from its etiology, macroscopic aspect and grade of cellular atypism, the HCC was expected to possibly invade the vascular network, sooner or later. W e conclude that computed tomography is the most enlightening and indispensable examination available for the detection of tumor thrombus along the HV, IVC and RA in case of HCC, because a tumor thrombus might be a critical factor in the prognosis.

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A 30-year-old woman suffered with short bowel syndrome since she had recur-ring mesenteric fibroma and underwent bowel resection three times. She needed intravenous hyperalimentation after the last operation. Computed tomographic (CT) scans and sono-grams, taken seven months after nutrition support, showed multiple, well-defined lesions of the liver which were thought to represent metastatic malignancy. She died of cachexia. Autopsy showed focal fatty infiltration of the liver.

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