2011年 · 第124卷第04期

Abstract：Background The expression of genes encoding a number of pathogenetic pathways involved in colorectal cancer could potentially act as prognostic markers. Large prospective studies are required to establish their relevance to disease prognosis.Methods We investigated the relevance of 19 markers in 790 patients enrolled in a large randomised trial of 5-fluorouracil using immunohistochemistry and chromogenic in situ hybridisation. The relationship between overall 10-year survival and marker status was assessed.Results Minichromosome maintenance complex component 2 (MCM2) and cyclin A were significantly associated with overall survival. Elevated MCM2 expression was associated with a better prognosis (HR=0.63, 95%CI: 0.46-0.86).Cyclin A expression above the median predicted an improved patient prognosis (HR=0.71, 95%CI: 0.53-0.95). For mismatch repair deficiency and transforming growth factor β receptor type Ⅱ (TGFBRII) overexpression there was a borderline association with a poorer prognosis (HR=0.69, 95%C/: 0.46-1.04 and HR=2.11, 95%CI: 1.02-4.40,respectively). No apparent associations were found for other markers.Conclusion This study identified cell proliferation and cyclin A expression as prognostic indicators of patient outcome in colorectal cancer。

Abstract：Background It is well known that dehydration can impair bodily functions. To evaluate the impact of hydration status under ambient environmental temperature on the immune system, 25 male collegiate wrestlers were recruited to undergo an experimental dehydration program.Methods Thirteen subjects had controlled diets with individual energy requirements to prevent body mass loss and restricted water intake to cause 4.52% dehydration; they formed the dehydrated group (DE). These subjects developed a urine specific gravity of about 1.030 in 84 hours. Twelve other subjects had no water restriction and maintained their total body weight comprised the euhydrated group (EU). Peripheral blood monocytes (PBMNC) were isolated after dehydration to perform immune response testing by being incubated with a polysaccharide fraction from fu-ling, Poria cocos (polysaccharide fraction from Poria cocos, PCPS, 1-30 μg/L), to prepare a conditioned medium termed conditioned medium of PBMNC stimulated by PCPS (PCPS-MNC-CM). More PCPS (25 μg/L) was needed in the DE group to prepare the PCPS-MNC-CM, which was assayed with a growth inhibitory curve for treated U973 cells.Results The treated U937 cells, incubated together with PCPS-MNC-CM from the DE group, exhibited a much lower nitroblue tetrazolium (NBT) positive value of (63.7±4.7)%. The concentration of interferon-gamma (IFN-Y), interleukin (IL)-1β and tumor necrosis factor (TNF)-α in PCPS-MNC-CM from subjects after dehydration was much lower than in the CM from the EU group.Conclusion The immune response to PCPS in the DE group was lower than in normally hydrated subjects。

Abstract：Background Domestic violence (DV) is not only a devastating societal problem, but also a severe medical and mental health problem worldwide. Our previous study has shown that perpetrators were with higher prevalence of self-reported symptoms than that of controls. This study based on our former large scale population-based samples is aimed to further explore the correlations between the symptoms and psychosocial factors of the perpetrators with DV. It was helpful to provide some insight into possible strategies for clinicians to reduce the symptoms of the perpetrators with DV in China.Methods From our former population-based epidemiological samples, 1098 households with a history of DV in preceding year, 318 perpetrators with DV were randomly selected. Face-to-face interviews were conducted. Symptom Checklist-90 (SCL-90) was administrated to check and classify the symptoms of perpetrators, Eysenck's personality questionnaire(EPQ), trait coping style questionnaire (TCSQ), life events scale (LES) and social supporting rating scale (SSRS) were administrated to evaluate the psychosocial factors of perpetrators. The correlation analysis was used to analyze the relationships between the symptoms and psychosocial factors of perpetrators of DV. Results The global and all subscale scores of SCL-90 were significantly positively correlated with EPQ-N, negative TCSQ and negative LES scores (P＜0.01). The global score of SCL-90 was negatively correlated with both objective and subjective SSRS (P＜0.01). The negative LES and negative TCSQ were significantly positively correlated with EPQ-N (P ＜0.01). Negative TCSQ was significantly positively correlated with negative LES and negatively correlated with subjective SSRS (P＜0.01).Conclusions The self-reported symptoms of perpetrators with DV were strongly correlated with their psychosocial factors, such as the neurotic personality, negative coping style, more negative life events and less subjective social supports. It suggested bio-psycho-socially oriented interventions were necessary to buffer the symptoms of perpetrators with DV。

Abstract：Background Accurate intraoperative diagnosis of sentinel lymph node (SLN) metastases enables the selection of patients for axillary lymph node dissections during the same operation, reducing the need for a second operation. The present study aimed to prospectively compare the GeneSearchTM Breast Lymph Node (BLN) Assay with touch imprint cytology (TIC) for intraoperative evaluation of SLNs.Methods SLNs were sectioned in 1.5-3.0 mm pieces. TIC was performed on all pieces and the BLN Assay and postoperative histology evaluations were performed on different alternating node pieces. Overall performance of the BLN Assay was compared with that of TIC relative to the postoperative histology results.Results A total of 90 patients enrolled in the study. Complete intraoperative data for both the BLN Assay and TIC were collected in 86 patients. The sensitivity, specificity, and overall accuracy of the BLN Assay were 82%, 97%, and 92%,respectively on a per patient basis compared with those of TIC which were 67%, 100%, and 90%.Conclusions Performance of the BLN Assay was superior to that of TIC and the additional application of TIC did not help improve the total sensitivity and accuracy of the intraoperative assessment. The existence of ectopic breast tissue might be a possible cause of false positive for the BLN assay. In addition, the BLN Assay complements histopathology assessment and can minimize sampling error without increasing pathologists' workload。

Abstract：Background The incidence of vancomycin-resistant enterococci (VRE) appeared to be increasing in China, but very few nosocomial outbreaks have been reported. Our hospital had experienced an outbreak of VRE since March 2008 to March 2009. The objective of this study was to analyze the molecular features of the isolates and the control measures used to eradicate a VRE outbreak in a tertiary institution in China.Methods We characterized VRE isolates from 21 infected and 11 colonized inpatients from a single hospital by pulsed field gel electrophoresis (PFGE), multilocus sequence typing (MLST), the analysis of Tn 1546-like elements and virulence genes detection. Infection control measures, including more environmental disinfection, screening for VRE colonization,contact precautions, education and strict antibiotic restriction, were implemented to control the outbreak.Results During the outbreak, a total of 32 VRE strains were obtained. There were 21 strains found in Emergency Intensive Care Unit (EICU), 9 isolates from Geriatric Ward, and two from other units. All the isolates harbored the vanA gene, however,four of them exhibited the VanB phenotype. Meanwhile, MLST analysis revealed that all isolates belonged to clonal complex (CC) 17. With the infection-control measures, the epidemic was constrained in two units (EICU and Geriatric Ward). After March 2009, no further case infected with VRE was detected in the following one-year period.Conclusion The outbreak was controlled by continuous implementation of the infection control programme, and more rigorous infection control policy is needed。

Abstract：Background In recent years, increasing numbers of patients are accepting neoadjuvant chemotherapy before their operation in order to get a better prognosis. But chemotherapy has many side-effects. We have observed that patients who accepted neoadjuvant chemotherapy are more sensitive to anesthetics. The aim of this study was to determine the median effective dose (EC50) of intravenous anesthetics for neoadjuvant chemotherapy patients to lose consciousness during target-controlled infusion.Methods Two hundred and forty breast cancer patients undergoing elective operations were assigned to six groups according to treatment received before their operation and the use of intravenous anesthetics during anesthesia;non-adjuvant chemotherapy+propofol group (group NP, n=40), Taxol+propofol group (group TP, n=40),adriamycine+cyclophosphamide+5-Fu+propofol group (group CP, n=40), non-adjuvant chemotherapy+etomidate group (group NE, n=40), taxol+etomidate group (group TE, n=40), adriamycine+cyclophosphamide+5-Fu+etomidate group (group CE, n=40). We set the beginning effect-site concentration (Ce) of propofol as 3.0 μg/ml and etomidate as 0.2μg/ml. The concentration was increased by steps until the patient was asleep, (OAAS class Ⅰ-Ⅱ), then gave fentanyl 3μg/kg and rocuronium 0.6 mg/kg and intubated three minutes later. The patients' age, height, and weight were recorded.BIS was recorded before induction, at the initial effect-site concentration and at loss of consciousness. The effect-site concentration was recorded when patient lost consciousness.Results There were no significant differences between groups in general conditions before treatment; such as BIS of consciousness, age, sex and body mass index. The EC50 of propofol in the NP, TP and CP groups was 4.11 μg/ml (95%CI: 3.96-4.26), 2.94 μg/ml (95% CI: 3.36-3.47) and 2.91 μg/ml (95% CI: 3.35-3.86), respectively. The EC50 of etomidate in the NE, TE and CE groups was 0.61 μg/ml (95% CI: 0.55-0.67), 0.38 μg/ml (95% CI: 0.33-0.44), and 0.35 μg/ml (95%CI: 0.34-0.36), respectively. There was no significant difference of BIS level before induction or in BIS50 level in any group when patients lost consciousness.Conclusions The EC50 of intravenous anesthetics to cause loss of consciousness in neoadjuvant chemotherapy groups is lower than in the control group. There was no significant difference of BIS level at which patients lost consciousness。

Abstract：Background Intrathecal anesthesia is commonly used for cesarean section. Bupivacaine and ropivacaine have all been used as intrathecal drugs. The minimum effective local anesthetic dose (MLAD) of intrathecal ropivacaine for nonobstetric patients has been reported. However, few data are available on the MLAD of hyperbaric ropivacine for obstetric patients and the relative potency to bupivacaine has not been fully determined. In this study, we sought to determine the MLAD of intrathecal ropivacaine and bupivacaine for elective cesarean section and to define their relative potency ratio.Methods We enrolled forty parturients undergoing elective cesarean section under combined spinal-epidural anesthesia and randomized them to one of two groups to receive intrathecal 0.5% hyperbaric ropivacaine or bupivacaine.The initial dose was 10 mg, and was increased in increments of 1 mg, using the technique of up-down sequential allocation. Efficacy was accepted if adequate sensory dermatomal anesthesia to pin prick to T7 or higher was attained within 20 minutes after intrathecal injection, and required no supplementary epidural injection for procedure until at least 50 minutes after the intrathecal injection.Results The intrathecal MLAD was 9.45 mg (95%confidence interval (CI), 8.45-10.56 mg) for ropivacaine and 7.53 mg (95%CI, 7.00-8.10 mg) for bupivacaine. The relative potency ratio was 0.80 (95% Cl, 0.74-0.85) for ropivacaine/bupivacaine when given intrathecally in cesarean section.Conclusion Ropivacaine is 20% less potent than bupivacaine during intrathecal anesthesia for cesarean delivery。

Abstract：Background As one of the most commonly diagnosed diseases, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterized by a variety of complex symptoms. Anxiety and depression are two of the most prevalent clinical manifestations of patients with CP/CPPS, and have adverse effects on the health of the subjects and prognosis of comorbidities. Such psychological disorders, however, have not been deeply and thoroughly studied in China. The aim of this study was to investigate the prevalence and severity of psychological disorders in Chinese adults with CP/CPPS.Methods From April 2008 to June 2009, 80 patients and 40 age-matched healthy men participating in a voluntary health examination were recruited. The majority of the subjects completed the questionnaires on the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) as well as the hospital anxiety and depression scale (HADS).Results Of all the participants, 77 (96.3%) patients and 37 (92.5%) healthy controls completed the questionnaires. The average NIH-CPSI total score was 21.0±9.5 for the patients and 2.2±1.5 for the controls (P=0.03). Of the 77 patients with CP/CPPS, 48 (62.3%), 5 (6.5%), and 1 (1.2%) had anxiety symptoms, depression symptoms, or both anxiety and depression symptoms, respectively. For the controls, the average HADS anxiety and depression scores in patients were 14.5±6.8 and 5.2±4.5, which were both significantly higher than in controls. Moreover, the prevalence and the symptom scores of both the HADS anxiety and depression were higher for the younger age group (＜35 years) than for the older age group (＜35 years).Conclusions This preliminary study revealed that male patients with CP/CPPS had a higher prevalence of psychological disorders than in the control subjects. Moreover, the differences of the prevalence and severity of the psychological symptoms between the two different age groups may imply that psychological disorders related to CP/CPPS may be relieved with increasing age. The present study indicated that psychological evaluation is important in men with CP/CPPS, especially in younger men。

Abstract：Background The adjunction of ultrasound to nerve stimulation has been proven to improve single-injection peripheral nerve block quality. However, few reports have been published determining whether ultrasound can facilitate continuous nerve blocks. In this study, we tested the hypothesis that the addition of ultrasound to nerve stimulation facilitates femoral nerve blocks with a stimulating catheter.Methods In this prospective randomized study, patients receiving continuous femoral nerve blocks for total knee replacement were randomly assigned to either the ultrasound guidance combined with stimulating catheter group (USNS group; n=60) or the stimulating catheter alone group (NS group; n=60). The primary end point was the procedure time (defined as the time from first needle contact with the skin until correct catheter placement). The numbers of needle passes and catheter insertions, onset and quality of femoral nerve blocks, postoperative pain score, and early knee function were also recorded.Results The procedure time was significantly less in the USNS group than in the NS group (9.0 (6.0-22.8) minutes vs.13.5 (6.0-35.9) minutes, P=0.024). The numbers of needle passes and catheter insertions were also significantly less in the USNS group. A greater complete block rate was achieved at 30 minutes in the USNS group (63.3% vs. 38.3%;P=0.010). The postoperative pain score, the number of patients who required bolus local anesthetic and intravenous patient-controlled analgesia, and knee flexion on the second postoperative day were not significantly different between the two groups of patients.Conclusions Ultrasound-assisted placement of a stimulating catheter for femoral nerve blocks decreases the time necessary to perform the block compared with just the nerve-stimulating technique. In addition, a more complete blockade is achieved using the ultrasound-assisted technique。

Abstract：Background Surgical stress causes a helper T-cell type 2 (Th2)-dominant status and disturbs the Th1/Th2 cytokine balance. Anesthesia can suppress the stress response to surgery, therefore it may inhibit the imbalance in the Th1/Th2 ratio. In this study, we assessed if propofol anesthesia and sevoflurane anesthesia influence the Th1/Th2 cytokine balance, and which anesthesia method better attenuates this ratio.Methods Twenty-eight patients with an American Society of Anesthesiologists (ASA) physical status of I undergoing laparoscopic cholecystectomy were selected. They were randomly allocated into two groups of 14. Group 1 received propofol anesthesia by a target-controlled-infusion (TCI) pump and group 2 received sevoflurane anesthesia.Non-invasive blood pressure, heart rate, and end-expiration CO2 partial pressure were monitored during anesthesia. The depth of anesthesia was measured using the bispectral index (BIS), and maintained between 50 and 60. During surgery we adjusted the doses of propofol and sevoflurane according to the BIS. Samples of peripheral blood were taken before the induction of anesthesia (T1), after the induction of anesthesia (T2), at the beginning of surgery (T3), at the end of surgery (T4) and on the first day after surgery (D1). Blood samples were analyzed to give the Th1/Th2 ratio and plasma level of cortisol.Results Non-invasive blood pressure, heart rate and end-expiration CO2 partial pressure were not notably different in the two groups. At T4, the percentage of T1 cells was higher in group 1 and had statistical significance (P ＜0.05). The percentage of T2 cells was not significantly different in the two groups. At T4, the difference in the Th1/Th2 ratio was significantly different. At T3, T4, and D1, the plasma level of cortisol was lower in group 1(P ＜0.05).Conclusion Compared with sevoflurane, propofol can preferably promote Th cells to differentiate into Th1 cells and inhibit surgical stress. Propofol may therefore be immunoprotective for such patients。

Abstract：Background Human immunodeficiency virus/acquired immure deficiency syndrome (HIV/AIDS)-related stigma is an obstacle to the implementation of treatment, care, and support programs for people living with HIV/AIDS. This study explored the association of the HIV knowledge with the attitudes toward HIV/AIDS.Methods A cross-sectional survey was conducted in HIV epidemic rural areas with 5355 participants. Their knowledge and attitudes about HIV/AIDS were assessed, and the associations of HIV transmission and non-transmission knowledge with negative attitudes towards the HIV/AIDS were analyzed.Results Negative attitudes were significantly correlated with the HIV non-transmission knowledge and the correlation was higher than that with HIV transmission knowledge among participants who were male, 20 years old and migrant workers, students and respondents of and above junior high school. However, among those who were female, age 30 and older, illiterate with primary school education, negative attitudes were significantly associated with HIV non-transmission knowledge and the association was lower than that with HIV transmission knowledge.Conclusions HIV transmission knowledge and non-transmission knowledge have different influences on negative attitudes towards HIV/AIDS among different demographic subgroups。

Abstract：Background Large drusen is a known risk factor for the development of late complications of age-related macular degeneration (AMD) and drusen reduction has been found by our previous study. To prospectively evaluate the efficacy and safety of prophylactic laser treatment in Chinese patients with bilateral soft drusen, we examined the structure and function of the macula 8 years after treatment.Methods Ten patients with more than 10 soft drusen (＞125 mm) and best corrected visual acuity ＞20/25 in each eye participated in the study. One eye, with relatively more drusen, was exposed to an argon laser (514 nm) to achieve a barely visible retinal lesion. The contralateral eye was used as a control. Fluorescein angiography, Amsler tests,Fourier-domain optical coherence tomography and visual evoked potential tests were carried out 8 years later.Results No choroidal neovascularization was seen in the laser-treated eyes or control eyes. There were no significant differences in visual acuity or P100 latency and amplitude between the laser treated eyes and contralateral eyes (t=1.685,1.184; P＞0.05). The thickness of the retinal pigment epithelium of the treated eyes was less than that of the contralateral eyes (t=-4.540; P ＜0.05). The full retinal thickness in treated eyes was slightly, but insignificantly, reduced relative to contralateral eyes (t=-1.746; P ＞0.05).Conclusions The treatment was associated with a reduction in retinal pigment epithelium thickness elevation compared with the contralateral eyes. Macular function was not impaired。

Abstract：Background Generalized glucocorticoid resistance syndrome is a rare familial or sporadic condition characterized by generalized, partial, target-tissue insensitivity to glucocorticoids. This syndrome is partially caused by mutations in human glucocorticoid receptor (hGR) gene. The clinical spectrum of generalized glucocorticoid resistance is broad, ranging from fatigue or no symptoms to severe hypertension with hypokalemic alkalosis. The purpose of this study was to explore the genetic disorder of glucocorticoid resistance syndrome.Methods We identified a 56-year-old male patient diagnosed with generalized glucocorticoid resistance syndrome accompanied with an adrenocortical adenoma. This asymptomatic patient referred to Peking Union Medical College Hospital for treatment of his adrenal incidentaloma. Endocrinological evaluation consistently revealed his elevated serum cortisol level. Total RNA was extracted from the patient's peripheral blood mononuclear leukocytes (PBMLs) and entire coding region of hGR alpha was amplified by reverse transcription (RT)-PCR. To confirm the possible mutation identified by sequencing RT-PCR products, genomic DNA sequence of hGR gene from the patient and 50 healthy controls was analyzed by PCR and directly sequencing.Results A heterozygotic (C→T) substitution at nucleotide position of 1667 (exon 5) in GR alpha gene was found in this patient by sequencing of RT-PCR products of hGR gene. This substitution was also identified at genomic DNA level and it was absent in 100 chromosomes from 50 unrelated health controls. This substitution resulted in a threonine to isoleucine substitution (ACT→ATT) at amino acid 556 in the ligand-binding domain of GR alpha. Conclusion Generalized glucocorticoid resistance in this patient might be caused by a novel heterozygotic mutation in the ligand-binding domain of the GR alpha。

Abstract：Calcifying tendinopathy is a tendon disorder with calcium deposits in the mid-substance presented with chronic activity-related pain, tenderness, local edema and various degrees of incapacitation. Most of current treatments are neither effective nor evidence-based because its underlying pathogenesis is poorly understood and treatment is usually symptomatic. Understanding the pathogenesis of calcifying tendlinopathy is essential for its effective evidence-based management. One of the key histopathological features of calcifying tendinopathy is the presence of chondrocyte phenotype which surrounds the calcific deposits, suggesting that the formation of calcific deposits was cellmediated.Although the origin of cells participating in the formation of chondrocyte phenotype and ossification is still unknown, many evidences have suggested that erroneous tendon cell differentiation is involved in the process. Recent studies have shown the presence of stem cells with self-renewal and multi-differentiation potential in human,horse, mouse and rat tendon tissues. We hypothesized that the erroneous differentiation of tendon-derived stem cells (TDSCs) to chondrocytes or osteoblasts leads to chondrometaplasia and ossification and hence weaker tendon, failed healing and pain, in calcifying tendinopathy. We present a hypothetical model on the pathogenesis and evidences to support this hypothesis. Understanding the key role of TDSCs in the pathogenesis of calcifying tendinopathy and the mechanisms contributing to their erroneous differentiation would provide new opportunities for the management of calcifying tendinopathy. The re-direction of the differentiation of resident TDSCs to tenogenic or supplementation of MSCsprogrammed for tenogenic differentiation may be enticing targets for the management of calcifying tendinopathy in e future。

Abstract：Despite considerable published papers regarding Ebstein's anomaly (EA) patients receiving open-heart tricuspid valve replacement, non-cardiac emergency surgeries were rarely reported. We report a case of emergency decormpressive craniotormy in a patient with EA. Anesthesiologists should pay special attention to the complications and anesthetic management during the non-cardiac surgeries performed in EA patients.hile papers regarding Ebstein's anomaly (EA)patients receiving open-heart tricuspid valve replacement are numerous, the reports of non-cardiac emergency surgeries have not been to the same degree.We report a case of emergency decompressive craniotomy in a patient with EA. This case report describes the symptoms and anesthetic management during the surgery。

Abstract：Unlike other non-gynecologic solid tumors, such as breast cancer, lung cancer, metastasis to bone from endometrial carcinoma is rare, metastasis to extremity is extremely rare. We report a 51-year-old multiparous woman with FIGO Stage IVb Grade 2 endometrial adenocarcinoma which metastasized to left lower extremity bone. She received an amputation of left lower extremity below the knees, and a total abdominal hysterectomy and bilateral salpingo-oophorectomy, and followed by systemic chemotherapy, radiation therapy to the pelvis and progestational agent. She had a complete response to above treatments, and disease-free survival for 10 months. After recurrence, she received chemotherapy, radiotherapy and progestational agent once again. She had lived 56 months and is still alive by the time of report. Metastasis of endometrial carcinoma to extremity bone can rarely occur and should be considered when the patient with endometrial carcinoma complained of unexplained pain and swelling associated with extremity bone。

Abstract：Endometriosis coexisting with a dermoid cyst of the ovary is extraordinarily rare, although these both benign conditions are said to be common in women in the reproductive age group. There are only two previous case reports, which is evident from our literature review from January 1960 through January 2010. Acute abdomen is one of the greatest diagnostic challenges and easily ignored by the clinicians to exclude the possibility of gynecologic illness. A 35-year-old woman was referred by the doctor in Family clinic. She experienced a three-day period of severe right lower abdominal pain and intermittent vomiting. Ultrasonography identified a bilocular, cystic, hypoechoic, and hyperechoic tumor, 7 cm×6 cm×6 cm in the right adnexal region. Laparoscopic cystectomy was performed under the impression of ovarian cyst with torsion or hemorrhage. The frozen section was benign and appendiceal status was adequate. Histopathologic examination described an ovarian cyst composed of endometrial-type lining with stroma cells (endometriosis) and benign terotoma tissue with plenty of skin appendages and sebaceous glands. We report this unusual and interesting ovarian mass to remind physicians that the usage of the Endobag after cystectomy, the benefits on minimizing operative time, spilled opportunity, and postoperative complications. Laparoscopic techniques for large ovarian masses might be considered. The experience of the surgeon is also very important to prevent misdiagnosis or complication. Further follow up is mandatory for this simultaneous finding of ovarian endometriosis with coincidental dermoid cyst as a separate pathology in single ovary of such a nature. It also presents a challenge to the clinicians and to the pathologists。

Abstract：In rare instances, stroke may preceed a diagnosis of cancer and be the first clinical evidence of an underlying malignancy.Cerebral infarction mostly complicates lymphomas, carcinomas, and solid tumors. Malignancy-related thromboembolism can present as acute cerebral infarction, nonbacterial thrombotic endocarditis and migratory thrombophlebitis. It is generally attributed to a cancer-related hypercoagulable period, chronic dissemiated intravascular coagulopathy (DIC), or tumor embolism. We reported a case of malignancy-releated thromboembolism from an undiagnosed pancreatic adenocarcinoma in a 54-year-old man, who presented with recurrent ischemic stroke due to chronic DIC. He died of the underlying malignancy despite the appropriate institution of anticoagulation therapy.This case emphasizes that cerebral infarction may be the first manifestation of an undiagnosed cancer. If there is laboratory or clinical evidence associated with DIC, patients with a cerebral infarct of an unknown etiology should be investigated for a malignant process. The optimal method of anticoagulation in cancer patients with thromboembolic disease (TED) remains unclear。