Randomized phase II study of biweekly CHOP and dose-escalated CHOP with prophylactic use of lenograstim (glycosylated G-CSF) in aggressive non-Hodgkin's lymphoma: Japan Clinical Oncology Group Study 9505

BACKGROUND

CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) is accepted as the best available standard treatment for first-line chemotherapy in aggressive non-Hodgkin's lymphoma (NHL). However, the therapeutic efficacy of CHOP remains unsatisfactory, particularly in high-intermediate risk and high risk patients, and a new strategy is warranted in this patient population. The aim of the present study was to explore a suitable therapeutic-intensified regimen for the treatment of aggressive NHL.

PATIENTS AND METHODS

Between May 1995 and July 1998, a total of 70 patients with high-intermediate risk or high risk aggressive NHL, according to the International Prognostic Index, were enrolled and randomly assigned to receive either eight cycles of standard CHOP (cyclophosphamide 750 mg/m(2), doxorubicin 50 mg/m(2), vincristine 1.4 mg/m(2) and prednisolone 100 mg for 5 days) every 2 weeks, or six cycles of dose-escalated CHOP (cyclophosphamide 1500 mg/m(2), doxorubicin 70 mg/m(2), vincristine 1.4 mg/m(2) and prednisolone 100 mg for 5 days) every 3 weeks. Lenograstim (glycosylated rHuG-CSF), at a dose of 2 micro g/kg/day s.c., was administered daily from day 3 until day 13 with biweekly CHOP and until day 20 with the dose-escalated CHOP. The primary endpoint was complete response rate.

RESULTS

The complete response rate was 60% [21 of 35; 95% confidence interval (CI) 42% to 76%] with biweekly CHOP and 51% (18 of 35; 95% CI 34% to 69%) with dose-escalated CHOP. The major toxicity was grade 4 neutropenia and was more frequent in the dose-escalated CHOP arm (86%) than in the biweekly CHOP arm (50%). Grade 4 thrombocytopenia was also more frequent in the dose-escalated CHOP arm (20%) than the biweekly CHOP arm (3%). Non-hematological toxicities were acceptable in both arms. One treatment-related death (due to cardiac arrhythmia) was observed in a dose-escalated CHOP patient. Progression-free survival at 3 years was 43% (95% CI 27% to 59%) in the biweekly CHOP arm and 31% (95% CI 16% to 47%) in the dose-escalated CHOP arm. Although seven patients were deemed ineligible by central review of the pathological diagnosis, the results for both eligible and all enrolled patients were similar.

CONCLUSIONS

Similar complete response rates and progression-free survival rates, but lower toxicity, indicated that biweekly CHOP was superior to dose-escalated CHOP in the treatment of aggressive NHL. Based on these results, the Lymphoma Study Group of the Japan Clinical Oncology Group is conducting a randomized phase III study comparing biweekly CHOP with standard CHOP in newly diagnosed patients with advanced-stage aggressive NHL.

Gas gangrene in patient with atherosclerosis obliterans

Clostridia are the main cause of nontraumatic spontaneous gas gangrene. Poor blood flow due to arterial occlusion exacerbates the anaerobic condition. Fulminant gas gangrene in a 54-year-old man with atherosclerosis obliterans was treated by revascularization of the iliac artery using endarterectomy, and his gangrenous lower leg was amputated. However, he died from renal failure.

Thoracoscopic esophagectomy combined with mediastinoscopy via the neck

Although thoracoscopic techniques have been introduced to esophageal surgery, the identification of the left recurrent laryngeal nerve and lymph node dissection along the nerve remain quite difficult. A mediastinoscopic technique via the neck enables an excellent visual field to be created in the upper mediastinum, especially near the left recurrent laryngeal nerve. Therefore, a thoracoscopic esophagectomy combined with this technique allows mediastinal lymph nodes along the left recurrent laryngeal nerve to be easily and safely dissected.

Endoscopic total parathyroidectomy by the anterior chest approach for renal hyperparathyroidism

BACKGROUND

During the past 3 years, minimally invasive procedures have been adopted for the surgical treatment of primary hyperparathyroidism, and we have tried to perform endoscopic total parathyroidectomy for renal hyperparathyroidism.

METHODS

Five 5-mm trocars were inserted through the skin of the anterior chest under a general anesthesia. Carbon dioxide was then insufflated up to 4 mmHg, and the endoscopic surgery was performed.

RESULTS

Endoscopic procedure was successfully performed in five patients. The mean duration of total parathyroidectomies was 236 min. No evidence of injury to the recurrent laryngeal nerve was observed in any cases. At follow-up, the serum calcium and parathyroid hormone levels had returned to within the normal range in all patients. Postoperative cosmetic status was excellent.

CONCLUSION

We believe that endoscopic total parathyroidectomy by the anterior chest approach will find a role in the treatment of renal hyperparathyroidism.

Identification of GFAT1-L, a novel splice variant of human glutamine: fructose-6-phosphate amidotransferase (GFAT1) that is expressed abundantly in skeletal muscle

Glutamine:fructose-6-phosphate amidotransferase (GFAT1) is the rate-limiting enzyme in the hexosamine biosynthetic pathway, which plays an important role in hyperglycemia-induced insulin resistance. To evaluate the role of GFAT1 expression, we analyzed the expression profiles of GFAT1 mRNA in various human tissues using reverse transcriptase-polymerase chain reaction. We report here the identification and cDNA cloning of a novel GFAT1 splice variant expressed abundantly in skeletal muscle and heart. This subtype, designated GFAT1-L, contains a 54-bp insertion within the GFAT1 coding sequence. Recombinant GFAT1-L protein possessed functional GFAT activities and biochemical characteristics similar to GFAT1. Previously, GFAT1 was considered a simplex enzyme. The identification of a novel GFAT1 subtype possessing functional enzymatic activity and tissue-specific expression should provide additional insight into the mechanism of skeletal muscle insulin resistance and diabetes complications.

Endoscopic thyroidectomy and parathyroidectomy by the axillary approach. A preliminary report

BACKGROUND

The use of endoscopic procedures leads to a reduction in the size of the surgical scar, making it more inconspicuous. In this paper, we evaluated the merits and limits of endoscopic neck surgery.

METHODS

Between August 1999 and July 2000, 102 patients underwent neck surgery in our department for thyroid or parathyroid disease. Twenty-eight of them were treated by the axillary. A 12-mm and two 5-mm trocars were inserted through the skin of the axilla. Carbon dioxide was then insufflated up to 4 mmHg, and the endoscopic surgery was performed.

RESULTS

Endoscopic procedures were performed successfully in 26 cases (19 thyroidectomies and seven parathyroidectomies). There were two conversions to open procedures. The mean operating times for the thyroidectomies and parathyroidectomies were 212 and 171 min, respectively. No evidence of injury to the recurrent laryngeal nerve was observed in any of the cases. The postoperative cosmetic status of the patients was excellent.

CONCLUSION

We believe that endoscopic thyroidectomy and parathyroidectomy by the axillary approach will find a role in the treatment of endocrine diseases in the neck.

Superficialization of hemodialysis access using a video-assisted procedure

Brachiocephalic fistula is one of the main options to gain blood access for hemodialysis. Although the fistula is easy to establish, puncture becomes increasingly difficult because the cephalic vein runs deep and fibrous tissue is being continually deposited over the cephalic vein. Although superficialization-i.e., the removal of fibrous tissue along the basilic vein-has been performed with conventional surgery, the long incision along the cephalic vein induces the buildup of hard fibrous tissue so that puncture may remain difficult even after the operation. To avoid this problem, we tried superficialization of hemodialysis access using a video-assisted procedure and obtained a good result.

Central administration of neuromedin U activates neurons in ventrobasal hypothalamus and brainstem

Neuromedin U (NMU) is a peptide isolated from the porcine spinal cord. Recently, two receptors for NMU have been identified and characterized. A recent study indicated that NMU is an anorectic chemical in the brain. The present study shows that NMU has an action in the brain to inhibit food intake in rats. Intracerebroventricular injection of NMU inhibited dark-phase feeding. Animals injected with NMU showed a strong increase in Fos-immunoreactive nuclei in the paraventricular nucleus (PVN) and supraoptic nucleus (SON) of the hypothalamus, and in the parabrachial nucleus of the brain stem. Double immunohistochemistry revealed that a high number of oxytocin-immunoreactive neurons in the PVN and SON contained Fos after intracerebroventricular injection of NMU. In addition, a small proportion of vasopressinergic cells within the PVN and SON were found to contain Fos. The effect of NMU on the hypothalamus and brain stem contributes to the inhibitory effects of NMU on feeding behavior.

Functional expression of Candida albicans drug efflux pump Cdr1p in a Saccharomyces cerevisiae strain deficient in membrane transporters

Analysis of the transport functions of individual Candida albicans plasma membrane drug efflux pumps is hampered by the multitude of endogenous transporters. We have stably expressed C. albicans Cdr1p, the major pump implicated in multiple-drug-resistance phenotypes, from the genomic PDR5 locus in a Saccharomyces cerevisiae mutant (AD1-8u(-)) from which seven major transporters of the ATP-binding cassette (ABC) family have been deleted. High-level expression of Cdr1p, under the control of the S. cerevisiae PDR5 promoter and driven by S. cerevisiae Pdr1p transcriptional regulator mutation pdr1-3, was demonstrated by increased levels of mRNA transcription, increased levels of nucleoside triphosphatase activity, and immunodetection in plasma membrane fractions. S. cerevisiae AD1-8u(-) was hypersensitive to azole antifungals (the MICs at which 80% of cells were inhibited [MIC(80)s] were 0.625 microg/ml for fluconazole, <0.016 microg/ml for ketoconazole, and <0.016 microg/ml for itraconazole), whereas the strain (AD1002) that overexpressed C. albicans Cdr1p was resistant to azoles (MIC(80)s of fluconazole, ketoconazole, and itraconazole, 30, 0.5, and 4 microg/ml, respectively). Drug resistance correlated with energy-dependent drug efflux. AD1002 demonstrated resistance to a variety of structurally unrelated chemicals which are potential drug pump substrates. The controlled overexpression of C. albicans Cdr1p in an S. cerevisiae background deficient in other pumps allows the functional analysis of pumping specificity and mechanisms of a major ABC transporter involved in drug efflux from an important human pathogen.

Clinical significance of tissue blood flow during esophagectomy by laser Doppler flowmetry

OBJECTIVES

We sought to investigate the effect of tissue blood flow on the incidence of anastomotic leakage during esophagectomy.

METHODS

Reconstruction was done with a gastric tube, and all cases involved cervical anastomosis. Tissue blood flow of 43 patients was measured with a laser Doppler flowmeter before emplacement and after anastomosis during surgical intervention. The reconstruction route and tissue blood flow before emplacement and that after anastomosis were analyzed as possible factors influencing anastomotic leakage.

RESULTS

Tissue blood flow after anastomosis with leakage was 9.1 +/- 2.0 mL/min per 100 g, and that without leakage was 13.7 +/- 2.9 mL/min per 100 g. Tissue blood flow with leakage was significantly lower than that without leakage (P <.01, unpaired t test). Twenty-one patients had tissue blood flow after anastomosis of greater than 13 mL/min per 100 g, and none of them had leakage, whereas 5 patients had blood flow of less than 10 mL/min per 100 g, and all 5 had leakage.

CONCLUSION

Tissue blood flow can be an important and useful indicator of the presence of current anastomotic leakage. Low tissue blood flow after anastomosis may mediate for appropriate surgical or pharmacologic interventions to detect, localize, and counteract leakage.

Operational tolerance induced by pretreatment with donor dendritic cells under blockade of CD40 pathway

BACKGROUND

Dendritic cells can mount immune response as competent antigen presenting cells. Recently, it has been reported that immature dendritic cells induce prolongation of allograft survival. However, the ability of mature dendritic cells to induce operational tolerance is unclear. Therefore, in this study, we examined the ability of splenic mature dendritic cells to induce operational tolerance to fully allogeneic antigens using mouse heterotopic heart transplantation model.

METHODS

CBA (H2k) mice received i.v. injections with donor splenic dendritic cells or B cells in the absence or presence of monoclonal antibody (mAb) specific for CD40 ligand or CD80/CD86 2 weeks before transplantation of a C57BL/10 (H2b) heart.

RESULTS

When donor dendritic cells were injected i.v. 2 weeks before transplantation, rejection response was accelerated compared with that of naive mice [median survival time (MST) = 7 and 8 days, respectively]. However, when CD40 pathway was blocked by anti-CD40 ligand mAb, i.v. injection of donor dendritic cells but not B cells induced indefinite graft survival (MST >100 and 20 days, respectively). Mice treated with anti-CD40 ligand mAb alone rejected their grafts with a MST of 18 days. Intravenous injection of donor dendritic cells and B cells in combination with anti-CD80/CD86 mAbs was less effective to induce graft prolongation (MST = 9.5 and 13 days, respectively).

CONCLUSIONS

Therefore, under blockade of CD40 pathway, mature dendritic cells were tolerogens in vivo independent of CD80/86 pathways.

Endoscopic thyroidectomy by the axillary approach

Neck surgery has recently become one of the newest fields for the application of endoscopic surgery because the resultant scar is small and inconspicuous. Still, some patients feel even a small scar on the neck is not cosmetically acceptable. We therefore have developed a new technique of endoscopic thyroidectomy by the axillary approach that leaves no scar on the neck at all. When this method is used, the small scar in the axilla is completely covered by the patient's arm in a natural manner. The cosmetic result is excellent, and sensory loss in the neck is negligible because the area of surgical dissection is small. We believe that endoscopic thyroid surgery by the axillary approach will find a role in the treatment of thyroid disease.

The technique for heterotopic cardiac transplantation in mice: experience of 3000 operations by one surgeon

INTRODUCTION

The mouse heterotopic fully vascularized cardiac transplantation model has come into widespread use. However, the technique is still difficult. Therefore, simple anastomosis was introduced.

METHODS

The donor ascending aorta was sutured end-to-side to the recipient abdominal aorta and the donor pulmonary artery was anastomosed to the recipient inferior vena cava. The main point was only 4 stitches on 1 side between proximal and distal anastomosis of the recipient aorta and inferior vena cava.

RESULTS

When beginners tried to perform the same procedure, they were able to complete the first successful procedure after 11 trials and achieved 90% success after 78 operations.

SUMMARY

The simple anastomosis is safe and shortens the operation time.

Importance of thymus to maintain operational tolerance to fully allogeneic cardiac grafts

BACKGROUND

The effectiveness of donor-specific blood transfusion (DST) before transplantation has been established. Anti-CD4 monoclonal antibody (anti-CD4) augments the ability of DST to induce indefinite prolongation. Therefore, we investigated the importance of thymus to maintain the unresponsiveness to alloantigens.

METHODS

CBA mice were pretreated with 0.25 mL of DST or two doses of anti-CD4 before transplantation of a C57BL/10 heart. Some mice were thymectomized.

RESULTS

Naive CBA mice rejected C57BL/10 grafts acutely with a median survival time of 7 days. When mice were pretreated with anti-CD4 plus DST 4 weeks before transplantation, all grafts survived indefinitely (>100 days), whereas mice treated with DST alone or anti-CD4 alone rejected acutely (median survival time, 7 and 12 days, respectively). To investigate the importance of thymus, mice pretreated with anti-CD4 plus DST 4 weeks before transplantation were thymectomized or underwent a sham operation 1 day before grafting. Mice with the sham operation accepted grafts indefinitely, whereas thymectomized mice rejected the majority of the grafts (median survival time, 20 days).

CONCLUSIONS

The thymus is important in maintaining the operational tolerance induced by anti-CD4 plus DST 4 weeks before grafting.

Cavernous angioma of the corpus callosum mimicking an astrocytic tumor--case report

A 49-year-old female presented with a mass at the genu of corpus callosum manifesting as vertiginous sensation persisting for a couple of months. The preoperative diagnosis based on neuroimaging was astrocytic tumor, probably an oligodendroglioma. The mass was totally excised through a left interhemispheric approach without postoperative neurological deficits. Histological examination of the mass revealed only vascular components with tiny hemorrhage, compatible with cavernous angioma. Cavernous angioma at the genu of corpus callosum is very rare, and definitive diagnosis can be achieved only through surgery. Surgical intervention should be considered before starting radiotherapy without histological confirmation.