Malignant pleural effusion is characterized by fluid buildup between the lung and the chest wall due to cancer cells in the pleura. Most cases are caused by lung cancer, breast cancer, ovarian cancer, or malignant lymphoma. Urothelial carcinoma is a rare cause of malignant pleural effusions and is difficult to diagnose by cytological examination. We report a case of malignant pleural effusion due to urothelial carcinoma. An 80-year-old man presented with right back pain. After close examination, he was diagnosed with ureteral cancer. During the course of treatment, a unilateral pleural effusion was found, and cytological and histological examinations were performed on suspicion of malignant pleural effusion. Cytological examination revealed numerous round-to-ovoid cells with irregularly enlarged nuclei. Immunohistological studies were performed on cell block specimens, and urothelial carcinoma was diagnosed. Cytological examination of malignant pleural effusions may require estimation of the primary site. It is important to take a multifaceted approach that considers not only the cytological findings but also the clinical findings and medical history.

A 69-year-old man had been treated with total arch replacement for acute Stanford type A aortic dissection. He had cardiac failure at 9 years after his previous operation. Computed tomography and transesophageal echocardiography showed re-dissection of the aortic root and aortic regurgitation. He was referred to our hospital for surgical treatment. In the second operation, aortic root replacement was performed. Re-dissection of the aortic root at the site of the non-coronary sinus was noted intraoperatively, and intraoperative findings suggested necrosis of the aortic wall related to the use of GRF glue. Care should be taken to ensure proper use of GRF glue. The aortic root replacement using a Freestyle valve provided good hemodynamic function and low thrombogenicity. The use of this valve in this case which had residual dissection of the descending aorta seemed useful because of the excellent hemodynamic function without anticoagulant therapy.

Surgical treatment of abdominal aortic aneurysms in elderly patients aged over 90 is rare, and the surgical indications in such patients is controversial. Two cases of abdominal aortic aneurysm successfully treated surgically are reported. The first case was a 92-year-old woman, who manifested a severe abdominal pain without hypotension. An impending rupture of an abdominal aortic aneurysm was suggested on enhanced CT scan, and emergency surgery was indicated. The aneurysm was replaced with a woven Dacron Y-graft. Postoperatively, the patient's social activity returned to the preoperative level. The second case was a 91-year-old man, in whom an increasing abdominal aortic aneurysm had been pointed out on UCG and enhanced CT scan. Because he was socially very active for his age, elective surgery was indicated. The aneurysm was resected and replaced with a woven Dacron I-graft. Postoperatively, the patient overcame a respiratory complication and was eventually discharged without any physical complication. Although he was able to climb mountains before the surgery, he lost some physical activity after the surgery. Because of the potential decrease in physical strength especially in very elderly patients, the general risk evaluation did not always correspond to a precise evaluation and prediction of postoperative activity. It is therefore necessary to be flexible in deciding on the surgical indications in each case.

With the diagnosis of metastatic tumor of the lung suspected, we had a chance to experience a histopathological case of carcinoma of the uterine cervix (adenoid squamous cell carcinoma), which was thought to coexist with carcinoid tumor. In this paper, we report the results of cytological as well as histological examinations of the case.
The patient was as 43-year-old woman. She visited our hospital, complaining about abnormally prolonged uterine bleeding (metrorrhagia). Cytodiagnosis was performed with a Papanicolaou smear. A microscopic examination revealed squamous cell carcinoma occurring together with adenocarcinoma. A similar finding was obtained by cervical biopsy. Thus, the case was diagnosed as adenoid squamous cell carcinoma.
Then the patient underwent radical hysterectomy and lymphadenectomy, followed by chemotherapy. After leaving the hospital, she was put under doctor-monitored observation. About 4 years after the surgery, a chest x-ray examination found abnormal shadows. For inspection, bronchoscopy was performed. Carcinoid of the lung was diagnosed through histopathological as well as electron microscopic examination of specimens taken from bronchial polyps during bronchoscopy. At the same time a cytologic study was conducted. It also revealed neoplasms strongly suspected of caricinoid tumors. Retrospective studies of cytological and histopathological images of the uterine cervix when the patient first visited us found only adenocarcinoma and squamous cell carcinoma, but no signs of carcinoid tumors. However, the immunohistological staining of NSE and chromoganins A, both neuroendocrine markers, showed positive findings in some adenocarcinomatous parts of the tissues of the unterine cervix. Therefore, we considered that the cervical cancer is compounded of adenoid squamous cell carcinomas and tumors having properties of neuroendocrine cells.
From this, we concluded that it is necessary to take into account a differential diagnosis of neuroendocrine tumors including carcinoid of the uterine cervix when less differentiated adenocarcinoma and squamous cell carcinoma are suspected in histological and cytological examinations. Furthermore, we thought it important to make a definite diagnosis after meticulous examinations by immunohistological staining and electron microscopy.

A 72-year-old man was admitted with an abnormal shadow on chest X-ray. Chest CT and aortography showed double saccular aneurysms at the aortic arch and the descending thoracic aorta. Three-dimensional CT was useful to detect the association between the arch aneurysm and neck vessels. Graft replacement, from the distal arch to the descending thoracic aorta, was performed by the lateral approach with hypothermic arrest and open proximal method. The aorta had severe atherosclerotic changes and the intima was absent at the orifices of the aneurysms. Pathological examination showed the aneurysmal wall to be composed of fibrous tissue without medial components. These macroscopic and pathological findings of aneurysms corresponded with double pseudo-aneurysms originating from the penetrating atherosclerotic ulcer.

A case of successful surgical treatment for a ruptured infected aneurysm of the abdominal aorta is presented. A 63-year-old man was admitted with a history of persistent fever of unknown cause and lumbago. During medical treatment, a new abdominal pulsatile mass was revealed on physical examination. Leucocytosis and elevation of C-reactive protein were demonstrated. Abdominal echogram and CT scan showed a ruptured aneurysm of the abdominal aorta. Ruptured infected aneurysm of abdominal aorta was diagnosed, and an emergency operation was performed. We found a tight inflammatory adhesion around the aneurysm, but there was no abcess formation. The aneurysm had the mural thrombi and necrotic tissue. As usual infected tissue was removed as possible with aneurysmectomy, and an artificial graft was replaced. The culture of the aneurysmal wall tissue was negative, but the infiltration of the inflammatory cells, mainly neutrophilic segmented leukocytes, were found on pathological examination. He is doing well without recurrent infection at 8 months after operation. Twenty five cases of infected abdominal aortic aneurysm (AAA) were reported in Japan, and 21 cases of them received surgical treatment. Management of infected AAA is discussed.

During the one-year period from April 1992 through March 1993, we measured 25, 498 blood samples by the use of a sequential multichannel autoanalyzer, which our hospital installed in August 1991. Of the total, 4, 707 samples were thoroughly examined under the microscope. They included those from the patients for which physicians indicated laboratory testing, those samples whose white cell counts were less than 3, 000/μlor more than 10, 000/μl, the cases in which the amount of hemoglobin was less than 10.0g/dl, and the samples which defied blood typing. The result was that three cases of myelodysplastic syndrome were detected, although the autoanalyzer failed to find any abnormalities in these three cases.
Laboratory technicians in hospital are so busy that they hardly have time enough for thoroughgoing examination of hemogram. Nevertheless, the recent experience has brought home to us the importance of a microscopic scrutiny, into hemogram and its application to diagnosis.