A patient with calcified miliary brain metastases from lung adenocarcinoma is reported. Electron microscopic study of the metastatic tumour cells showed membranous inclusion bodies in mitochondria. (fig a and b) and cerebellar hemispheres. The nodules were frequently present in areas in contact with CSF but showed no mass effect. There was no enhancement of nodules after contrast medium injection. The same abnormal nodules were seen on MRI. PET scan showed decreased blood flow and brain metabolism throughout the cerebrum. Angiography of both internal carotid and vertebral arteries was normal.An open biopsy with wedge resection of a nodule in the left parietal lobe was performed. Histology showed metastatic adenocarcinoma with calcification within the necrotic parts. Electron microscopic examination of the tumour cells demonstrated that some mitochondria contained membranous inclusion bodies (fig e and f). These membranous bodies were not observed in other intracytoplasmic organelles.After the biopsy procedure adenocarcinoma of the lung was confirmed at the ninth cytological examination of sputum. Brain CT performed four months after the patient's admission showed that the number of metastatic calcifications had increased and that each nodule had enlarged (fig c and d). He began to have convulsions and died after 8 months in hospital. Necropsy was declined by his family. DiscussionMadow and Alpers4 first used the histopathological term "encephalitic metastatic carcinoma" to describe numerous inconspicuous plaques formed exclusively in the grey matter. However, they did not observe nodules which were visible to the naked eye or calcification. There have been only two cases of multiple calcified brain metastases detected on brain CT and confirmed by histological examination. 6The primary lesions in these cases were lung adenocarcinoma5 and pancreatic acinarcell carcinoma.6 The observations in these cases and in our case suggest a close relationship between such a characteristic metastatic pattern and adenocarcinoma. None of the three cases showed contrast enhancement on CT imaging. Repeated brain CT showed that the size of the calcified nodules continued to increase, although they might grow slower than ordinary metastatic brain tumours.It is known that artificial myelin figures are found in mitochondria due to inadequate glutaraldehyde fixation.7 However, the mitochondrial changes we have described were observed only in tumour cells and may represent or reflect high rate of metabolism in such malignant cells.

A prospective, randomized, controlled trial of nutritional effects of branched-chain-enriched amino acid (BCAA) solution was undertaken in 173 surgical patients with gastric cancer. Eighty-six and 87 patients underwent subtotal and total gastrectomy, respectively. The effects were evaluated in total parenteral nutrition (TPN) in an isocaloric/isonitrogenous setting where the major difference between the group was the amount of BCAA received. Each 80 patients in the control and the BCAA groups completed the trial. The group receiving BCAA-enriched amino acid solution demonstrated a statistically significant improvement on days 2 and 3 in nitrogen balance in patients with total gastrectomy. Three-methyl-histidine excretion gradually decreased after day 1, and the values on day 7 were significantly lower than those on day 1 in the BCAA group in both those receiving subtotal and total gastrectomy. There were no significant differences of serum albumin and rapid turnover proteins between the control and BCAA groups in both those receiving subtotal and total gastrectomy. Plasma BCAA level and BCAA to aromatic amino acid (AAA) ratio were significantly higher, and AAA level was significantly lower in the BCAA group than in the control group. There were no serious complications encountered during the observation period in both groups. These results indicated that a BCAA-enriched amino acid solution can improve metabolism and maintains good nitrogen retention without increasing side effects as compared with a conventional amino acid solution for nutritional support of patients who have received subtotal or total gastrectomy.