Basic and clinical research on photodynamic therapy at Tokyo Medical University Hospital

BACKGROUND AND OBJECTIVES

We have been engaged in basic and clinical research on photodynamic therapy (PDT) and photodynamic diagnosis (PDD) for more than 25 years.

STUDY DESIGN/MATERIALS AND METHODS

PDT for 264 centrally located early-stage lung cancer lesions yielded an initial complete response (CR) rate of 84.8%. PDT is now becoming a standard option for centrally located stage 0 (TisN0M0) and stage I (T1N0M0) lung cancer. It is an attractive option for elderly patients in poor physical condition.

RESULTS

Recent results of interstitial PDT for peripheral-type lung cancers suggest that it may be a promising local curative treatment modality for lesions less than 1.0 cm in diameter.

CONCLUSIONS

In this article, we introduce our recent clinical trials of PDT for lung cancers (both central and peripheral), and new techniques of PDD in sentinel node navigation biopsy for breast cancers. Moreover, we introduce basic research on cancers and infectious diseases in order to expand the clinical applications of PDT.

ABCB1 C3435T polymorphism influences methotrexate sensitivity in rheumatoid arthritis patients

OBJECTIVE

Methotrexate (MTX) is most widely used for the treatment of rheumatoid arthritis (RA). However, it has certain drawbacks with regard to individual differences in its therapeutic effects as well as the differences in the patients' response to MTX therapy. We investigated whether multi-drug resistance-1 (ABCB1) C3435T, reduced folate carrier-1 (RFC1) G80A, 5-aminoimidazole-4-carboxamide ribonucleotide transformylase (ATIC) C347G and a 6bp-deletion polymorphism in the 3'-untranslated region of the thymidylase synthase (TYMS) gene are predictive of MTX sensitivity and its adverse effects.

METHODS

Patients whose last maintenance dosage of MTX was <or= 6 mg/week were regarded as responders, while patients whose last maintenance dosage of MTX was > 6 mg/week or those in whom MTX therapy was changed due to poor response to MTX were regarded as non-responders. The data of 124 RA patients who had received MTX treatment were retrospectively analyzed for polymorphisms in the ABCB1, RFC1, ATIC and TYMS genes, MTX sensitivity and MTX toxicity.

RESULTS

There were no significant differences in MTX sensitivity among the genotypes of RFC1, ATIC and TYMS genes. ABCB1 3435TT cases included statistically significantly more non-responders than 3435CC cases according to univariate analysis (crude odds ratio (OR) = 8.91, p = 0.001) and multivariate analysis (adjusted OR = 8.78, p = 0.038). There were no significant differences in MTX toxicity among the genotypes of all the genes.

CONCLUSION

These results suggested that the genetic diagnosis of ABCB1 C3435T can be applied to determine MTX sensitivity for the treatment of RA patients. However, further pharmacokinetics studies are required in this regard.

Photodynamic therapy using Laserphyrin for centrally located early stage lung cancer

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Background: In central type early stage lung cancer, the tumor must be located only as far as the segmental bronchi and be carcinoma in situ or with only limited invasion into the bronchial wall. Laserphyrin (mono-L-aspartyl chlorine e6, NPe6) is a second generation photosensitize and approved by the Japanese government and has been on sale from June 2004. Methods: Four h after the administration of Laserphyrin 40 mg/m2, we irradiated using diode laser (100 mJ/cm2). Before PDT, we evaluated the tumor lesions and tumor depth using autofluorescence bronchoscopy and endobronchial ultrasonography (EBUS), and we confirmed the area of laser irradiation. Results: From February 1980 to December 2005, a total number of 204 patients with 264 lesions of centrally located early stage lung cancer underwent photodynamic therapy (PDT) in the Department of Thoracic Surgery, Tokyo Medical University Hospital. There were 185 clinical stage 0 lesions and 79 stage I lesions. CRs and PRs were obtained in 224 lesions (84.8%) and 40 lesions (15.2%) out of 264 lesions. From July 2004 to December 2005, we performed Laserphyrin-PDT for 28 lesions of centrally located early stage lung cancer in Tokyo Medical University Hospital. The rate of CR was 92.9% (26 lesions) in 28 lesions. For Laserphyrin-PDT, Skin photosensitivity was very low and the clean-up bronchoscopies were not frequently needed, and the period of hospitalization was shorter compared to that for Photofrin-PDT. Conclusions: We conclude that PDT using Laserphyrin will be a standard option for stage 0 (TisN0M0) and stage I (T1N0M0) centrally located early stage lung cancer.

No significant financial relationships to disclose.

Recurrence of ovarian endometrioma after laparoscopic excision

BACKGROUND

To analyse risk factors that influence the recurrence of endometrioma after laparoscopic excision.

METHODS

A total of 224 patients who had a minimum of 2 years of post-operative follow-up after laparoscopic ovarian endometrioma excision were studied retrospectively. Recurrence was defined as the presence of endometrioma more than 2 cm in size, detected by ultrasonography within 2 years of surgery. Fourteen variables (age, presence of infertility, pain, uterine myoma, adenomyosis, previous medical treatment of endometriosis, previous surgery for ovarian endometriosis, single or multiple cysts, the size of the largest cyst at laparoscopy, unilateral or bilateral involvement, co-existence of deep endometriosis, revised American Society for Reproductive Medicine (ASRM) score, post-operative medical treatment and post-operative pregnancy) were evaluated to assess their independent effects on the recurrence using logistic regression analysis.

RESULTS

The overall rate of recurrence was 30.4% (68/224). Significant factors that were independently associated with higher recurrence were previous medical treatment of endometriosis [odds ratio (OR) = 2.324, 95% confidence interval (95% CI) = 1.232-4.383, P = 0.0092) and larger diameter of the largest cyst (OR = 1.182, 95% CI = 1.004-1.391, P = 0.0442). Post-operative pregnancy was associated with lower recurrence (OR = 0.292, 95% CI = 0.028-0.317, P = 0.0181).

CONCLUSIONS

Previous medical treatment of endometriosis or large cyst size was a significant factor that was associated with higher recurrence of the disease. Post-operative pregnancy is a favourable prognostic factor.

Development of serum IgM antibodies against superantigens of Staphylococcus aureus and Streptococcus pyogenes in Kawasaki disease

To serologically determine the association of microbial superantigens and the pathogenesis of Kawasaki disease (KD), we conducted a case-control study. Serum IgG and IgM antibodies against staphylococcal enterotoxin A (SEA), SEB, SEC, toxic shock syndrome toxin-1 (TSST-1), and streptococcal pyrogenic exotoxin A (SPEA) were measured by an enzyme-linked immunosorbent assay in 293 serum samples from 65 KD patients on clinical days 1-28 and 120 control samples. The administration of immunoglobulin products, which contain high concentrations of IgG antibodies against all the superantigens, directly elevated antitoxin IgG antibodies in KD patients. In contrast, antitoxin IgM antibodies were not detected in immunoglobulin products. Actually, we found a significant elevation of IgM antibodies against SEA in KD patients in the first (median titre: 0.020, P < 0.01 versus control), second (0.024, P < 0.001), third (0.030, P < 0.001) and fourth (0.038, P < 0.001) weeks, compared to the controls (0.015). Significant differences of IgM antibodies were also true for SEB, TSST-1, and SPEA throughout the first to fourth weeks, and for SEC throughout the second to fourth weeks. The prevalence of KD patients having high IgM titres (> mean + 2SD of control values) to the 5 superantigens was increased with the clinical weeks, and reached 29-43% of KD subjects at the fourth week. This is the first study that describes kinetics of IgM antibodies against superantigens and clarifies the serological significance throughout the clinical course of KD. Our results suggest that multiple superantigens involve in the pathogenesis of KD.

Increased expression of proapoptotic BMCC1, a novel gene with the BNIP2 and Cdc42GAP homology (BCH) domain, is associated with favorable prognosis in human neuroblastomas

Differential screening of the genes obtained from cDNA libraries of primary neuroblastomas (NBLs) between the favorable and unfavorable subsets has identified a novel gene BCH motif-containing molecule at the carboxyl terminal region 1 (BMCC1). Its 350 kDa protein product possessed a Bcl2-/adenovirus E1B nineteen kDa-interacting protein 2 (BNIP2) and Cdc42GAP homology domain in the COOH-terminus in addition to P-loop and a coiled-coil region near the NH2-terminus. High levels of BMCC1 expression were detected in the human nervous system as well as spinal cord, brain and dorsal root ganglion in mouse embryo. The immunohistochemical study revealed that BMCC1 was positively stained in the cytoplasm of favorable NBL cells but not in unfavorable ones with MYCN amplification. The quantitative real-time reverse transcription-PCR using 98 primary NBLs showed that high expression of BMCC1 was a significant indicator of favorable NBL. In primary culture of newborn mice superior cervical ganglion (SCG) neurons, mBMCC1 expression was downregulated after nerve growth factor (NGF)-induced differentiation, and upregulated during the NGF-depletion-induced apoptosis. Furthermore, the proapoptotic function of BMCC1 was also suggested by increased expression in CHP134 NBL cells undergoing apoptosis after treatment with retinoic acid, and by an enhanced apoptosis after depletion of NGF in the SCG neurons obtained from newborn mice transgenic with BMCC1 in primary culture. Thus, BMCC1 is a new member of prognostic factors for NBL and may play an important role in regulating differentiation, survival and aggressiveness of the tumor cells.

Biphasic clinical course and early white matter abnormalities may be indicators of neurological sequelae after status epilepticus in children

Clinical course and serial neuroimaging findings are not fully described in children who have had neurological sequelae following status epilepticus. We found four patients who had neurological sequelae out of 42 children with status epilepticus in 2004. MRI studies were reviewed with specific attention to diffusion-weighted images (DWI) and the apparent diffusion coefficient (ADC). Proinflammatory cytokines, including tumor necrosis factor-alpha and interleukin-6, were measured in the cerebrospinal fluid (CSF) (3 patients). The clinical course showed biphasic; initial status epilepticus and neurological exacerbation along with seizure recurrence four to five days after onset. Within three days after initial status epilepticus, CT (all patients) and MRI (2 patients) did not show any abnormalities. From four to ten days after onset, MRI demonstrated diffuse hyperintensity in the cerebral white matter on DWI and hypointensity on ADC maps in all patients. Diffuse brain atrophy progressed thereafter. Tumor necrosis factor-alpha or interleukin-6 was elevated in all patients. A biphasic clinical course may be a specific feature for neurological sequelae. The preferential white matter involvement on MRI and elevated CSF cytokines indicate that glial dysfunction may play an important role in the pathophysiology of status epilepticus-associated cerebral damage.

Genotyping of single Cryptosporidium oocysts isolated from sewage and river water

The study was designed to genotype individual Cryptosporidium oocysts using an 18S rRNA gene-based semi-nested PCR and direct sequencing procedure. Positive PCR amplification was observed in all single C. parvum HNJ-1 oocyst samples tested. Semi-nested PCR and direct sequencing was applied to Cryptosporidium oocysts isolated from sewage and river water. The procedure could genotype 54% of FITC-stained single oocysts isolated from sewage and 32% from river water. The predominant genotype in both sewage and river water was C. parvum genotype 1, accounting for 33 and 25%, respectively, of all the FITC-stained intact Cryptosporidium oocysts present.

[Concomitant off-pump coronary artery bypass and left lower lobectomy for lung cancer with pneumoconiosis]

Surgical strategy for patients for lung cancer with coronary disease remains controversial. We performed concomitant off-pump coronary artery bypass grafting (off-pump CABG: OPCAB) and left lower lobectomy with ND 2a lymph nodes dissection for lung cancer with pneumoconiosis. After CABG, due to fixed adhesion of peribronchial lymph node, left lower lobectomy was hard to carry out. Postoperative management was done with much difficulty for massive sputum and pneumonia caused by chronic inflammatory lung disease. As a result, postoperative course has been uneventful for 2 years after operation. In the concomitant OPCAB and lung resection with chronic inflammatory lung disease, whether the synchronous or 2 periods operation was appropriate was still unknown. We think that careful pre- and intraoperative assessment for this disease is important.

Tumor necrosis factor-alpha up-regulation in spontaneously proliferating cells derived from bovine leukemia virus-infected cattle

We previously reported that tumor necrosis factor alpha (TNF-alpha) was one of the cytokines that contributed to the leukemogenesis caused by bovine leukemia virus (BLV). To determine if the spontaneous cell proliferation observed in the late disease stages, such as persistent lymphocytosis and lymphosarcoma, correlated with the expression level of TNF-alpha, we analyzed the mRNA expression levels for TNF-alpha in spontaneously proliferating PBMCs derived from BLV-infected cattle. The mean mRNA expression level for TNF-alpha was higher in the spontaneously proliferating PBMCs derived from BLV-infected cattle than in non-spontaneously proliferating PBMCs from normal cattle. The TNF-alpha protein level in the PBMCs was determined by flow cytometric analysis, and it was noted that most of the cells expressing membrane-bound TNF-alpha in the spontaneously proliferating cells were CD5+ or sIgM+-cells. Additionally, in order to determine if this spontaneous proliferation can be blocked by anti-bovine TNF-alpha MAb, the spontaneously proliferating PBMCs from a BLV-infected cattle were cultured in the presence of the MAb. The addition of this MAb at the beginning of the 72 h-cultivation clearly inhibited spontaneous proliferation of cells in a dose-dependent manner, indicating the direct involvement of TNF-alpha in the spontaneous proliferation of PBMCs during the late disease stage. These data suggest that an aberrant expression of TNF-alpha might contribute to the progression of bovine leukosis in animals which develop persistent lymphocytosis of B-cells or B-cell lymphosarcoma.

Onset of steroid-induced osteonecrosis in rabbits and its relationship to hyperlipaemia and increased free fatty acids

OBJECTIVES

To clarify the initial onset time of osteonecrosis after the start of steroid treatment and its relation to the onset of abnormal lipid metabolism.

METHODS

Animal models were prepared by administering methylprednisolone to rabbits using five different steroid regimens.

RESULTS

A single, acute ischaemic event suggested by the frequency, size or number of necrotic foci within the proximal femur was not different among the groups. Histological evidence of osteonecrosis first occurred 1-2 weeks after initial steroid administration. At the same time there were significantly abnormal elevations in serum lipids, which persisted for between 1 and 2 weeks after the initial corticoid treatment. Triglycerides, total cholesterol and free fatty acids were markedly elevated in all groups; these lipid abnormalities were significantly present in the rabbits with osteonecrosis but not in the rabbits without osteonecrosis.

CONCLUSIONS

This study shows that (i) osteonecrosis appears in rabbits shortly after corticoids are first administered, and (ii) osteonecrosis in rabbits is chronologically associated with the onset of hyperlipaemia and increased free fatty acids. This supports the occurrence of intraosseous fat embolism as a cause of osteonecrosis.

Real-time blood-pool images of contrast enhanced ultrasound with Definity in the detection of tumour nodules in the liver

Lower mechanical index (MI) technique with newer microbubble agents has been introduced into clinical practice as a newer ultrasound (US) imaging. However, the efficacy in detecting tumour nodules has not been proven scientifically. The aim of this study was to elucidate the efficacy of a blood-pool image of real-time contrast-enhanced US under low MI in detecting liver tumours. 15 rabbits with VX-2 tumour were used; the number of implantations was none in two rabbits, one in four, two in five and three in four. US equipment was APLIO (Toshiba) with linear probe (3.5/7.0 MHz). The number, location and size of tumour nodules were examined by non-contrast tissue harmonic imaging (NC-US) or contrast-enhanced pulse subtraction harmonic imaging (C-US) under extra-low MI (MI 0.065) with the injection of Definity (30 microl kg(-1)). The number of tumour nodules detected by both NC-US and C-US were consistent with the histopathological results in five rabbits - two with none, two with one nodule and one with two nodules. In the other 10 rabbits, C-US showed all the implanted tumours and small daughter nodules around them that were confirmed by histopathology. However, NC-US failed to demonstrate two implanted nodules and all the daughter nodules. On the basis of the histopathological results, detectability of implanted tumour was not significantly different between NC-US (24/26, 92.3%) and C-US (26/26, 100%). However C-US was superior to NC-US in delineating the nodules and in detecting small daughter nodules. The sizes of the implanted tumour nodules measured by histopathology correlated closely with those measured by C-US. Real-time blood-pool images by pulse subtraction harmonic imaging under extra-low MI with Definity will contribute to the improvement of the ultrasound delineation and detection of liver tumours.

Bovine Posterior Pituitary Extract Stimulates Prolactin Release from the Anterior Pituitary Gland In Vitro and In Vivo in Cattle

It has been reported that the posterior pituitary (PP) gland contains a potent, unknown prolactin (PRL)-releasing factor (PRF) in rats. PRFs are assumed to be produced in neurones located within the hypothalamus, and to be peptidergic in nature. However, little is known about PRFs in domestic animals. To characterize the PRF in the PP of domestic animals, the present study examined the PRL-releasing activity of an acidic extract from bovine PP (bPP) in vitro and in vivo in cattle. First, the PRL-releasing effect of bPP extract was compared with that of PRL-releasing peptide (PrRP), and thyrotropin-releasing hormone (TRH) from cultured bovine anterior pituitary cells. The extract significantly increased PRL concentrations in the culture medium, at doses of 0.002 and 0.02 eq./ml (one eq. is the PP extract from one animal), compared with the control (p < 0.05). PrRP failed to stimulate the release of PRL. TRH significantly increased PRL concentrations in the culture medium, at doses from 10(-9) to 10(-7) M, compared with the control (p < 0.05). The rate of increase in the PRL concentration, by 0.02 eq./ml bPP extract, was significantly greater than that in TRH (p < 0.05). Secondly, plasma PRL responses to the intravenous (i.v.) injection of bPP extract (0.5 eq./head), PrRP [3.59 mug/kg body weight (BW)], TRH (1 mug/kg BW), and a dopamine receptor antagonist (sulpiride, 0.1 mg/kg BW), were examined in calves. PrRP failed to stimulate PRL release; however, plasma PRL increased immediately following the injection of bPP extract, TRH and sulpiride. The PRL-releasing effect of i.v. injections of TRH and sulpiride was more potent than that of bPP extract. Finally, plasma PRL responses to the intra-hypothalamic injection of bPP extract were examined in calves. The intra-hypothalamic infusion (arcuate nucleus) of 0.0625 eq./head of bPP extract strongly stimulated PRL release in calves (p < 0.05). The present results show that PP contains a physiologically potent PRF in cattle.

Prevention of Overlooked Bullae During Video-Assisted Thoracic Surgery (VATS) with a Combination of High Frequency Jet Ventilation (HFJV) and Positive End-Expiratory Pressure (PEEP) for Spontaneous Pneumothorax

BACKGROUND

Overlooked bullae have been reported to contribute to the higher incidence of recurrence of pneumothorax following video-assisted thoracic surgery (VATS). In this study, we investigated whether high frequency jet ventilation (HFJV) + positive end-expiratory pressure (PEEP) prevented overlooking of bullae by blowing up the bullae and inflating the lungs moderately during VATS for spontaneous pneumothorax patients.

METHODS

A total of 31 patients with spontaneous pneumothorax who underwent VATS were enrolled in this study. We examined the number, size, and location of bullae with and without HFJV+PEEP during VATS.

RESULTS

More bullae were found with HFJV + PEEP than without HFJV + PEEP in 15 of the 31 patients. Significantly more bullae smaller than 2 cm in diameter were detected with HFJV + PEEP than without HFJV + PEEP. In the patients with 1 - 3 bullae, the detection rate was significantly higher with HFJV + PEEP than without HFJV + PEEP. All bullae confirmed with VATS were detected only in one case (3.2 %) on preoperative chest X-ray, and in two cases (6.5 %) on chest CT. The recurrence rate of pneumothorax following VATS with HFJV + PEEP was 3.3 % (1/31).

CONCLUSION

Our results suggested that VATS combined with HFJV and PEEP might prevent the overlooking of bullae and reduce the postoperative recurrence of spontaneous pneumothorax.

Development of the amygdalohypothalamic projection in the mouse embryonic forebrain

The amygdalohypothalamic projection, a major component of the stria terminalis, is involved in the conduction of emotional and olfactory information integrated in the amygdala to the hypothalamus to elicit emotional reactions. Despite the extensive studies on functional aspects of the amygdaloid complex, developmental mechanisms of the amygdala and related structures are still poorly understood. To investigate the development of the amygdalohypothalamic projection in the mouse embryonic brain, carbocyanine dye was applied to the amygdala to label the growing axons anterogradely and to the hypothalamus to label the amygdaloid neurons retrogradely. The initial outgrowth of the stria terminalis was found to be as early as E11.5. The pathway crossed in a saddle over the internal capsule, another prominent connection in the developing forebrain of the mammalian embryo. Bipolar immature neurons were distributed along the stria terminalis at the telencephalo-diencephalic boundary, and the internal capsule was also surrounded by these cells. These cells expressed immunoreactivities to calretinin and the lot-1 antigen which has been shown to be involved in guidance of the developing lateral olfactory tract. Ultrastructural analysis revealed an adherens-like junction between the stria terminalis and the apposed cells, implying contact-mediated guidance. These results suggest that, in the development of the stria terminalis, the axonal outgrowth is guided by a mechanism similar to that of the developing lateral olfactory tract, a major amygdalopetal connection.

Suppression of Postoperative Systemic Inflammatory Response Syndrome with Clarithromycin following Lung Cancer Surgery

We examined whether clarithromycin (CAM), a 14-membered macrolide, can control the postoperative systemic inflammatory response syndrome that occurs following lung cancer surgery. In the control group (n = 16), prophylactic antibiotics (flomoxef) were administered for 4-7 days following surgery. In the CAM group (n = 10), 400 mg/day of CAM were administered orally for 14 days prior to surgery and for 7 days following surgery, in addition to the postoperative administration of flomoxef. The incidence and duration of the systemic inflammatory response syndrome in the CAM group (30%, 0.3 days) were significantly lower than those in the control group (81%, 1.6 days). There were no significant differences between the control and CAM groups in both the amount and frequency of nonsteroidal anti-inflammatory drugs following surgery. In conclusion, our study suggests that CAM may suppress the postoperative systemic inflammatory response syndrome in lung cancer patients.

Cryptosporidium monitoring system at a water treatment plant, based on waterborne risk assessment

The water volume required for daily monitoring of Cryptosporidium (which can statistically ensure an annual risk of infection below 10(-4)), was assessed by evaluating the applicability of the Poisson lognormal (PLN) distribution in microbial risk assessment. PLN showed as good a fit to the observed data as to the negative binomial distribution. From the estimated PLN distributions for the source and finished water, the efficacy of the oocyst removal by the conventional water treatment process was estimated to follow log-normal distribution (median = 3.16 log10, 95% CI = 4.27-2.05 log10). The 365 consecutive negative results of daily monitoring for 180 L of finished water were found to be statistically equivalent to the annual risk of infection below 10(-4). This research also suggested the possibility of applying a qualitative detection method, such as CC-PCR, as a routine monitoring method for the quantitative risk management.

[The evaluation of the complications and its management in 800 patients who underwent the thoracoscopic surgery]

Thoracoscopy has been applied to almost all thoracic surgery as shown (table 1). Besides an opportunity to follow and encounter a trouble during surgery using thoracoscopy, so that it is necessary to become skilled in the prediction and management of complication. Nowadays, there are two options on surgery using thoracoscopy, thoracoscopic surgery (TS) is performed only on in a port and on a mini-thoracotomy with a few ports (video-assisted thoracoscopic surgery: VATS). When changing into emergency or converting into open thoracotomy, a muscle sparing thoracotomy could be available. The symptoms which occurred in the thorax are fundamentally similar during both TS and VATS procedure. However, peculiar dangerous factor existed according to the difference in internal organs, procedures, and diseases. Critical complications during surgery were as follows, i.e., injury of pulmonary vessels and bronchus, tension pneumothorax of the opposite lung and tumor implantation of the chest wall. Basically, standard practice is the most important to avoid an accident and determine whether converting to open thoracotomy should be employed. In the present commentary, we would like to present our experiences and propose regarding management.