Efficacy of Lenvatinib Combined with Transcatheter Intra-Arterial Therapies for Patients with Advanced-Stage of Hepatocellular Carcinoma: A Propensity Score Matching

This study aimed to evaluate the effect of lenvatinib (LEN) combined with transcatheter intra-arterial therapy (TIT) for advanced-stage hepatocellular carcinoma (HCC) after propensity score matching (PSM). This retrospective study enrolled 115 patients with advanced-stage HCC who received LEN treatment. The patients were categorized into the LEN combined with TIT group (n = 30) or the LEN monotherapy group (n = 85). After PSM, 38 patients (LEN + TIT group, n = 19; LEN monotherapy group, n = 19) were analyzed. The median overall survival (OS) in the LEN + TIT group was significantly higher than that in the LEN monotherapy group (median survival time (MST): 28.1 months vs. 11.6 months, p = 0.014). The OS in the LEN combined with transcatheter arterial chemoembolization and LEN combined with hepatic arterial infusion chemotherapy groups was significantly higher than that in the LEN monotherapy group (MST 20.0 vs. 11.6 months, 30.2 vs. 11.6 months, p = 0.048, and p = 0.029, respectively). Independent factors associated with OS were alpha-fetoprotein and LEN combined with TIT. The indications for LEN combined with TIT were age <75 years and modified albumin bilirubin (m-ALBI) grade 1. We concluded that LEN combined with TIT may improve prognosis compared with LEN monotherapy in patients with advanced-stage HCC.

Case Report: A case of complete response to entrectinib in NTRK fusion gene-positive parotid gland cancer

Introduction

Expression of the NTRK gene is rare in solid tumors but is highly prevalent in salivary gland secretory carcinomas. Here, we report a case of a complete response to entrectinib in a patient with NTRK fusion gene-positive parotid carcinoma.

Case description

The patient was a 44-year-old man who underwent total left parotidectomy and left cervical lymph node dissection for a left parotid tumor at 24 years of age. The histopathological diagnosis was mammary analog secretory carcinoma. Postoperatively, the patient received only radiation therapy. Sixteen years after the surgery, the patient became aware of a mass in the left parotid region. A close examination revealed local recurrence and multiple cervical lymph node metastases. S-1 monotherapy was started as chemotherapy but was discontinued 3 years later because of disease progression. As there was no standard treatment, a comprehensive genomic profiling test using a next-generation sequencer was performed, and the ETV6-NTRK3 fusion gene was identified. Entrectinib, an NTRK inhibitor, was immediately administered at a dose of 600 mg/day. The local recurrence rapidly shrank grossly from the beginning of treatment, and a complete response was observed 6 months later. However, creatinine levels exhibited an increase at week 68 of treatment; consequently, entrectinib dosage was lowered to 400 mg/day, leading to an immediate improvement in creatinine levels. Entrectinib was associated with additional side effects, including dysgeusia, fatigue, dizziness, and weight gain, all of which were also alleviated by the reduction in entrectinib dose. Thirty months after treatment initiation, the patient maintained a complete response and continued to receive entrectinib.

Conclusion

The NTRK fusion gene should always be checked in the presence of salivary gland secretory carcinoma.

The impact of curative conversion therapy aimed at a cancer-free state in patients with hepatocellular carcinoma treated with atezolizumab plus bevacizumab

BACKGROUND AND AIMS

We aimed to validate the predictive factors for tumor response and the prognostic impact of conversion therapy aimed at cancer- and drug-free states in patients with unresectable hepatocellular carcinoma (u-HCC) undergoing atezolizumab plus bevacizumab (Atez/Bev) therapy.

METHODS

This retrospective study enrolled 156 patients who were Child-Pugh class A with u-HCC treated using Atez/Beva. The profile of objective response was investigated using decision-tree analysis. Progression-free, recurrence-free, and overall survival were assessed.

RESULTS

The progression-free and overall survival were 6.1 and 18.0 months, respectively. Objective response and disease control rates were 32.0% and 84.0%, respectively. Decision-tree analysis revealed that neutrophil-to-lymphocyte ratio (NLR) <3, modified albumin-bilirubin grade (m-ALBI) 1 or 2a, and age < 75 were sequential splitting variables for the objective response, respectively. In the multivariate analysis, NLR <3 and m-ALBI grade 1 or 2a were identified as predictive factors for objective response. We successfully achieved eligibility for conversion therapy in 17 patients after Atez/Bev therapy significant response. Following conversion therapy, the curative therapy group, including surgical resection or radiofrequency ablation (RFA), had significantly higher recurrence-free survival than did the transcatheter arterial chemoembolization (TACE) and Atez/Bev discontinuation (surgical resection or RFA; not reached vs. TACE; 5.3 months, p = 0.008, Atez/Bev discontinuation; 3.9 months, p = 0.048, respectively) groups.

CONCLUSIONS

NLR <3 and m-ALBI grade 1 or 2a were predictive factors for conversion therapy, leading to cancer- and drug-free states in patients with u-HCC undergoing Atez/Bev therapy. Moreover, surgery or RFA may be suitable for conversion therapy for cancer-free status.

Safety of Early Bevacizumab Administration after Central Venous Port Placement for Patients with Colorectal Cancer

Bevacizumab (BEV) requires an adequate withdrawal period to avoid BEV-related complications during major surgery. However, the safety of BEV administration immediately after surgical placement of the central venous (CV) port, a minor surgery, is still unclear. This study aimed to investigate whether BEV is safe when administered early after CV port placement. We retrospectively evaluated 184 patients with advanced colorectal cancer (CRC) treated with a BEV-containing regimen and divided them into two groups according to the interval between CV port implantation and chemotherapy initiation, with the early administration group being ≤7 days and late administration group being >7 days. Complications were then compared between the two groups. The early-administration group was significantly older and had a higher rate of colon cancer than the late-administration group. Overall, 24 (13%) patients developed CV port-related complications. Male sex was a risk factor for complications (odds ratio [OR], 3.154; 95% CI, 1.19-8.36). The two groups showed no significant difference in the frequency of complications (p = 0.84) or patient characteristics (after the inverse probability of treatment weighting, p = 0.537). In conclusion, the frequency of complications is not affected by the timing of BEV initiation after CV port implantation. Thus, early BEV administration after CV port placement is safe.

Significance of ramucirumab following atezolizumab plus bevacizumab therapy for hepatocellular carcinoma using real-world data

AIM

Few studies have reported the efficacy and safety of ramucirumab (RAM) after atezolizumab plus bevacizumab (Atezo/Beva) treatment and the overall associated outcomes. Thus, we aimed to evaluate the therapeutic effects and safety of RAM post-treatment with Atezo/Beva.

METHODS

This retrospective study enrolled 46 patients with unresectable hepatocellular carcinoma who were treated with RAM. The patients were classified into the RAM administered following Atezo/Beva failure (n = 12) or RAM administered following other drug failure (n = 34) groups. Progression-free survival (PFS), overall survival (OS), and adverse event (AE) rates were assessed.

RESULTS

There were significant differences in the objective response rates and disease control rates between the RAM administered following Atezo/Beva and RAM administered following others groups (objective response rate 33.3%. vs. 0.0%, p = 0.001; disease control rate 83.3% vs. 32.3, p = 0.001). Although there was no significant difference in the OS rates, the median PFS rates in the RAM administered following Atezo/Beva group was significantly higher than in the RAM administered following others group (PFS 3.9 months. vs. 1.9 months, p = 0.047). The AE rates were comparable between the two groups; ascites was the most common AE (45.6%). Using decision tree analysis, the presence of splenomegaly and body mass index (BMI) < 19.8 were the first and second splitting variables for RAM-related ascites, respectively.

CONCLUSIONS

The therapeutic effect of RAM increased in patients with Atezo/Beva failure. Patients with splenomegaly and low BMI should be monitored for ascites during RAM treatment.

The beneficial impact of metabolic dysfunction-associated fatty liver disease on lenvatinib treatment in patients with non-viral hepatocellular carcinoma

AIM

Lenvatinib is used to treat advanced hepatocellular carcinoma (HCC). Metabolic dysfunction-associated fatty liver disease (MAFLD) is becoming a major etiology of HCC. We aimed to evaluate the impact of MAFLD on the efficacy of lenvatinib.

METHODS

We enrolled 320 patients with HCC who were treated with lenvatinib. All patients were classified into the MAFLD (n = 155) and non-MAFLD (n = 165) groups. Independent factors for overall survival (OS) were analyzed. In the stratification analysis, HCC was categorized as non-viral (n = 115) or viral HCC (n = 205).

RESULTS

The OS rate was significantly higher in the MAFLD group than in the non-MAFLD group (median 21.1 vs. 15.1 months, p = 0.002). Multivariate analysis demonstrated that, in addition to albumin-bilirubin grade and Barcelona Clinic Liver Cancer stage, MAFLD was identified as an independent factor for OS (HR 0.722, 95% CI 0.539-0.966, p = 0.028). In the stratification analysis, the OS rate was significantly higher in the MAFLD group than in the non-MAFLD group among patients with non-viral HCC (median 21.1 vs. 15.1 months, p = 0.002), but not in patients with viral HCC. Furthermore, MAFLD was an independent negative risk factor for OS in patients with non-viral HCC (HR 0.506, 95% CI 0.297-0.864, P < 0.01). However, MAFLD was not an independent factor for OS in patients with viral HCC.

CONCLUSIONS

MAFLD was a beneficial factor for survival in patients with HCC treated with lenvatinib. Moreover, the better OS of the MAFLD group was more pronounced in patients with non-viral HCC. Lenvatinib may be a suitable agent for patients with non-viral HCC and MAFLD.

Deterioration of liver function and aging disturb sequential systemic therapy for unresectable hepatocellular carcinoma

This study aimed to investigate the clinical characteristics of patients with unresectable hepatocellular carcinoma (HCC), who were eligible for sequential systemic therapy. We evaluated 365 patients with HCC who underwent systemic therapy after 2017. The overall survival (OS) was 13.7 months, 19.2 months, and 35.6 months in the first-line, second-line, and third-line or later therapy groups, respectively. Multivariate analysis revealed that the modified-albumin-bilirubin (m-ALBI) grade, macrovascular invasion, extrahepatic spread, discontinuation due to adverse events (AEs), and sequential therapy were independent factors for OS. At the end of each therapy, the ALBI score was significantly worse among patients with discontinuation due to AEs than among those without. The conversion rate to second-line and third-line therapy among patients with discontinuation due to AEs was significantly lower than that among patients without (30.4% vs. 69.2%, p < 0.001; 6.7% vs. 58.3%; p < 0.001, respectively). In the decision tree analysis, m-ALBI grade 1 or 2a and non-advanced age were selected splitting variables, respectively, for sequential systemic therapy. In conclusion, sequential therapy prolonged the OS of unresectable HCC. Additionally, good hepatic function and non-advanced age were clinically eligible characteristics for sequential systemic therapy.

The Clinical Impact of Hepatic Arterial Infusion Chemotherapy New-FP for Hepatocellular Carcinoma with Preserved Liver Function

Background: Systemic treatments are recommended for advanced hepatocellular carcinoma (HCC) in preserved liver function. However, their effects are unsatisfactory in some tumor conditions, particularly macrovascular invasion (MVI) including major portal vein tumor thrombus (PVTT). We compared the efficacy of hepatic arterial infusion chemotherapy (HAIC) regimens New-FP and sorafenib for various tumor conditions in preserved liver function. Methods: We retrospectively collected the data of 1709 patients with HCC who were treated with New-FP or sorafenib. Survival was assessed after propensity score matching. Subgroup analyses were conducted: cohort 1 (no MVI or extrahepatic spread (EHS)), cohort 2 (MVI only), cohort 3 (EHS only), cohort 4 (MVI and EHS), and cohort 5 (major PVTT). Results: The New-FP group had a longer median survival time (MST) than the sorafenib in the whole analysis (18 vs. 9 months; p < 0.0001). New-FP demonstrated a longer MST compared with sorafenib in cohort 2 and cohort 4. In cohort 5, the MST of the New-FP group was 16 months, while that of sorafenib was 6 months (p < 0.0001). For major PVTT-HCC, the response rate of New-FP was 73.0%. The MST of patients who achieved complete response with New-FP was 59 months. Conclusions: HAIC using New-FP is promising for patients with MVI- and major PVTT-HCC in preserved liver function.

Lenvatinib prolongs the progression-free survival time of patients with intermediate-stage hepatocellular carcinoma refractory to transarterial chemoembolization: A multicenter cohort study using data mining analysis

Tyrosine kinase inhibitors are considered for use in patients with hepatocellular carcinoma (HCC) refractory to transarterial chemoembolization (TACE). The aim of the present retrospective study was to identify factors associated with progression-free survival (PFS) and to evaluate the indications for lenvatinib treatment in patients with intermediate-stage HCC refractory to TACE using a data-mining analysis. A total of 171 patients with intermediate-stage HCC refractory to TACE were included. All patients were classified into three groups according to their HCC treatment: Lenvatinib (n=45), sorafenib (n=53) and TACE (n=73) groups. PFS time was calculated using the Kaplan-Meier method and analyzed using a log-rank test. Factors associated with PFS time were evaluated using multivariate and decision-tree analyses. The median PFS time was 5.8, 3.2 and 2.4 months in the lenvatinib, sorafenib and TACE groups, respectively (P<0.001). In the Cox regression analysis, lenvatinib treatment and being within the up-to-seven criteria were identified as independent factors for PFS (lenvatinib, P<0.0001; within up-to-seven, P=0.001). The decision-tree analysis revealed that patients beyond the up-to-seven criteria, treated with lenvatinib and with albumin-bilirubin (ALBI) grade 1 had a longer PFS time (245.2±107.9 days) than patients beyond the up-to-seven criteria, treated with lenvatinib and with ALBI grade 2 (147.1±78.6 days). Additionally, lenvatinib was independently associated with longer PFS time in patients with intermediate-stage HCC refractory to TACE. Therefore, lenvatinib may be recommended for patients who have intermediate-stage HCC refractory to TACE, ALBI grade 1 and who are within the up-to-seven criteria.

Patterns of Gene Expression in Western Corn Rootworm (Diabrotica virgifera virgifera) Neonates, Challenged with Cry34Ab1, Cry35Ab1 and Cry34/35Ab1, Based on Next-Generation Sequencing

With Next Generation Sequencing technologies, high-throughput RNA sequencing (RNAseq) was conducted to examine gene expression in neonates of Diabrotica virgifera virgifera (LeConte) (Western Corn Rootworm, WCR) challenged with individual proteins of the binary Bacillus thuringiensis insecticidal proteins, Cry34Ab1 and Cry35Ab1, and the combination of Cry34/Cry35Ab1, which together are active against rootworm larvae. Integrated results of three different statistical comparisons identified 114 and 1300 differentially expressed transcripts (DETs) in the Cry34Ab1 and Cry34/35Ab1 treatment, respectively, as compared to the control. No DETs were identified in the Cry35Ab1 treatment. Putative Bt binding receptors previously identified in other insect species were not identified in DETs in this study. The majority of DETs (75% with Cry34Ab1 and 68.3% with Cry34/35Ab1 treatments) had no significant hits in the NCBI nr database. In addition, 92 DETs were shared between Cry34Ab1 and Cry34/35Ab1 treatments. Further analysis revealed that the most abundant DETs in both Cry34Ab1 and Cry34/35Ab1 treatments were associated with binding and catalytic activity. Results from this study confirmed the nature of these binary toxins against WCR larvae and provide a fundamental profile of expression pattern of genes in response to challenge of the Cry34/35Ab1 toxin, which may provide insight into potential resistance mechanisms.

Complementarity to an miRNA seed region is sufficient to induce moderate repression of a target transcript in the unicellular green alga Chlamydomonas reinhardtii

MicroRNAs (miRNAs) are 20-24 nt non-coding RNAs that play important regulatory roles in a broad range of eukaryotes by pairing with mRNAs to direct post-transcriptional repression. The mechanistic details of miRNA-mediated post-transcriptional regulation have been well documented in multicellular model organisms. However, this process remains poorly studied in algae such as Chlamydomonas reinhardtii, and specific features of miRNA biogenesis, target mRNA recognition and subsequent silencing are not well understood. In this study, we report on the characterization of a Chlamydomonas miRNA, cre-miR1174.2, which is processed from a near-perfect hairpin RNA. Using Gaussia luciferase (gluc) reporter genes, we have demonstrated that cre-miR1174.2 is functional in Chlamydomonas and capable of triggering site-specific cleavage at the center of a perfectly complementary target sequence. A mismatch tolerance test assay, based on pools of transgenic strains, revealed that target hybridization to nucleotides of the seed region, at the 5' end of an miRNA, was sufficient to induce moderate repression of expression. In contrast, pairing to the 3' region of the miRNA was not critical for silencing. Our results suggest that the base-pairing requirements for small RNA-mediated repression in C. reinhardtii are more similar to those of metazoans compared with the extensive complementarity that is typical of land plants. Individual Chlamydomonas miRNAs may potentially modulate the expression of numerous endogenous targets as a result of these relaxed base-pairing requirements.

Small interfering RNA-mediated translation repression alters ribosome sensitivity to inhibition by cycloheximide in Chlamydomonas reinhardtii

Small RNAs (sRNAs; ∼20 to 30 nucleotides in length) play important roles in gene regulation as well as in defense responses against transposons and viruses in eukaryotes. Their biogenesis and modes of action have attracted great attention in recent years. However, many aspects of sRNA function, such as the mechanism(s) of translation repression at postinitiation steps, remain poorly characterized. In the unicellular green alga Chlamydomonas reinhardtii, sRNAs derived from genome-integrated inverted repeat transgenes, perfectly complementary to the 3' untranslated region of a target transcript, can inhibit protein synthesis without or with only minimal mRNA destabilization. Here, we report that the sRNA-repressed transcripts are not altered in their polyadenylation status and they remain associated with polyribosomes, indicating inhibition at a postinitiation step of translation. Interestingly, ribosomes associated with sRNA-repressed transcripts show reduced sensitivity to translation inhibition by some antibiotics, such as cycloheximide, both in ribosome run-off assays and in in vivo experiments. Our results suggest that sRNA-mediated repression of protein synthesis in C. reinhardtii may involve alterations to the function/structural conformation of translating ribosomes. Additionally, sRNA-mediated translation inhibition is now known to occur in a number of phylogenetically diverse eukaryotes, suggesting that this mechanism may have been a feature of an ancestral RNA interference machinery.

An evolutionary expressed sequence tag analysis of Drosophila spermatheca genes

This study investigates genes enriched for expression in the spermatheca, the long-term sperm storage organ (SSO) of female Drosophila. SSO genes are likely to play an important role in processes of sexual selection such as sperm competition and cryptic female choice. Although there is keen interest in the mechanisms of sexual selection at the molecular level, very little is known about the female genes that are involved. In the present study, a high proportion of genes enriched for expression in the spermatheca are evolving rapidly. Most of the rapidly evolving genes are proteases and genes of unknown function that could play a specialized role in the spermatheca. A high percentage of the rapidly evolving genes have secretion signals and thus could encode proteins that directly interact with ejaculate proteins and coevolve with them. In addition to identifying rapidly evolving genes, the present study documents categories of genes that could play a role in spermatheca function such as storing, maintaining, and utilizing sperm. In general, candidate genes discovered in this study could play a key role in sperm competition, cryptic female choice of sperm, and sexually antagonistic coevolution, and ultimately speciation.

Community analysis of a mercury hot spring supports occurrence of domain-specific forms of mercuric reductase

Mercury is a redox-active heavy metal that reacts with active thiols and depletes cellular antioxidants. Active resistance to the mercuric ion is a widely distributed trait among bacteria and results from the action of mercuric reductase (MerA). Protein phylogenetic analysis of MerA in bacteria indicated the occurrence of a second distinctive form of MerA among the archaea, which lacked an N-terminal metal recruitment domain and a C-terminal active tyrosine. To assess the distribution of the forms of MerA in an interacting community comprising members of both prokaryotic domains, studies were conducted at a naturally occurring mercury-rich geothermal environment. Geochemical analyses of Coso Hot Springs indicated that mercury ore (cinnabar) was present at concentrations of parts per thousand. Under high-temperature and acid conditions, cinnabar may be oxidized to the toxic form Hg2+, necessitating mercury resistance in resident prokaryotes. Culture-independent analysis combined with culture-based methods indicated the presence of thermophilic crenarchaeal and gram-positive bacterial taxa. Fluorescence in situ hybridization analysis provided quantitative data for community composition. DNA sequence analysis of archaeal and bacterial merA sequences derived from cultured pool isolates and from community DNA supported the hypothesis that both forms of MerA were present. Competition experiments were performed to assess the role of archaeal merA in biological fitness. An essential role for this protein was evident during growth in a mercury-contaminated environment. Despite environmental selection for mercury resistance and the proximity of community members, MerA retains the two distinct prokaryotic forms and avoids genetic homogenization.

Transfection of single-stranded hepatitis A virus RNA activates MHC class I pathway

Although infection of single-stranded RNA viruses can enhance expression of major histocompatibility complex (MHC) class I genes, the mechanism underlying this process remains unclear. Recent studies have indicated that exposure of non-immune cells to double-stranded deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) of viral origin can directly increase the expression of MHC class I and related molecules without immune cell interaction. In this report, we show that transfection of single-stranded hepatitis A virus RNA into cultured hepatocytes results in the induction of genes for MHC class I, LMP2 and transporter for antigen processing (TAP1), in addition to the generation of viral proteins. We suggest that this stimulatory effect is due to the double-stranded RNA formed during replication of single-stranded viral RNA, and involves both double-stranded, RNA-dependent protein kinase PKR and the secretion of IFNbeta.

Transverse sinus-tentorium splitting approach for pineal region tumors--case report

A 15-year-old boy with a large pineal region mass was admitted to our institute. The tentative diagnosis was mixed germ cell tumor. Tumor resection was carried out via a transverse sinus-tentorium splitting approach. The tumor tissue was completely resected, and no operative complication other than transient vertical gaze paresis was noted. The histological diagnosis was mixed germ cell tumor composed of mature and immature teratoma, germinoma, and embryonal carcinoma. After three courses of chemotherapy, the patient underwent external irradiation. He remained asymptomatic with no signs of recurrence 42 months after the surgery. The combination of the infratentorial supracerebellar approach and the occipital transtentorial approach provides excellent views and work space above and below the tentorial notch. Transverse sinus section is not mandatory for this approach, but sectioning of the unilateral transverse sinus and the tentorium along the rectal sinus allows retraction of the falx and the underlying brain to the opposite side. Thus, a much wider horizontal and vertical projection is obtained. This approach enables safer and more extensive tumor removal for large pineal region tumors.

Low-grade B-cell lymphoma of mucosa-associated lymphoid tissue in the thymus of a patient with pulmonary amyloid nodules

Low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-type lymphoma) is a rare thymic tumor, with only seven previous cases described worldwide to date. We describe the only case to have presented with pulmonary amyloid nodules. A 63-year-old Japanese female was found to have an anterior mediastinal tumor and multiple bilateral pulmonary nodules during a medical check-up in 1990 followed by chest radiography and computerized tomography. Because the mediastinal tumor grew larger, she was referred to the National Cancer Center Hospital East and hyperglobulinemia was pointed out. The thymus was resected through median sternotomy and pulmonary nodules were also resected through left thoracotomy. The solid and nodular tumor with several small satellite extensions and cyst formation was completely confined to within the thymus and the resected pulmonary nodules consisted of solid masses with a rough surface. Histologically, monotonous medium-sized centrocyte-like cells occupied the medulla of the thymus and infiltrated Hassall's corpuscles (lymphoepithelial lesions) and the resected pulmonary nodules consisted of eosinophilic amorphous deposits which showed birefringence on Congo Red staining. Immunohistochemically, the tumor cells were positive for CD20 and CD79a. IgG and kappa light chain restrictions were also found in plasmacytoid cells in the tumor. Clonal rearrangement of the immunoglobulin heavy chain gene was demonstrated by polymerase chain reaction. We diagnosed this case as low-grade B-cell MALT-type lymphoma in the thymus and nodular pulmonary amyloidosis. Since the patient had only localized amyloid deposits in the lung far from the thymic malignant lymphoma and had high serum immunoglobulins, the pulmonary amyloid deposits might be derived from a circulating precursor associated with hyperglobulinemia.

Phase I study of cisplatin and docetaxel plus mitomycin C in patients with metastatic non-small cell lung cancer

BACKGROUND

Docetaxel, cisplatin and mitomycin C are some of the active drugs used in the treatment of patients with metastatic non-small cell lung cancer (NSCLC). The purpose of this study was to determine the maximum tolerated dose (MTD) and recommended dose of the three drugs in combination for such patients.

METHODS

Chemotherapy-native patients with metastatic NSCLC were enrolled in this study. The doses of docetaxel and cisplatin were fixed at 60 and 80 mg/m2, respectively. It was planned to increase the dose of mitomycin C from 4 to 6 and 8 mg/m2. All drugs were administered on day 1 and repeated every 3-4 weeks.

RESULTS

All six patients received 60 mg/m2 of docetaxel and 80 mg/m2 of cisplatin, three of them with 4 mg/m2 of mitomycin C (level 1) and the other three with 6 mg/m2 of mitomycin C (level 2). Two of the three level 2 patients experienced dose-limiting toxicities (DLTs) in first cycle: febrile neutropenia and grade 3 hyponatremia. Based on these data, the MTD was concluded to be 60 mg/m2 for docetaxel, 80 mg/m2 for cisplatin and 6 mg/m2 for mitomycin C. Evaluation of the data from all of the cycles, however, showed that four of the six patients experienced DLTs.

CONCLUSIONS

The addition of mitomycin C to docetaxel and cisplatin resulted in relatively high toxicities. It was impossible to use a high enough dose of mitomycin C to improve the survival of NSCLC patients. We therefore concluded that further evaluation of this combination is unwarranted.

Follicular thyroglobulin suppresses iodide uptake by suppressing expression of the sodium/iodide symporter gene

A major function of the thyrocyte is to take up and concentrate iodide. This is needed for thyroid hormone synthesis and is accomplished by the sodium iodide symporter (NIS), whose expression and activity are up-regulated by TSH. Recently, we reported that follicular thyroglobulin (TG) is a potent suppressor ofthyroid-specific gene expression and can overcome TSH-increased gene expression. We suggested this might be a negative feedback, autoregulatory mechanism that counterbalanced TSH stimulation of follicular function. In this report, we support this hypothesis by coordinately evaluating TG regulation of NIS gene expression and iodide transport. We show that physiological concentrations of TG similarly and significantly suppress TSH-increased NIS promoter activity, NIS protein, and NIS-dependent iodide uptake as well as RNA levels. We show, in vivo, that TG accumulation at the apical membrane of a thyrocyte facing the follicular lumen is associated with decreased uptake ofradioiodide. It is likely, therefore, that TG suppresses NIS-dependent iodide uptake and NIS gene expression in vivo, as is the case in vitro. RNA levels of NIS and vascular endothelial growth factor/vascular permeability factor, which has been reported to be TSH regulated and possibly associated with TSH-increased iodide uptake, are coordinately decreased by follicular TG as a function of concentration and time. Also, removal of follicular TG from the medium, but not TSH, coordinately returns NIS and vascular endothelial growth factor/vascular permeability factor RNA levels to their TSH-stimulated state. TG accumulated in the follicular lumen appears, therefore, to be a negative feedback regulator of critical TSH-increased follicular functions, iodide uptake, and vascular permeability.

Long-term results of ventrolateral thalamotomy for patients with Parkinson's disease

This study evaluated the long-term outcome for 53 patients with idiopathic Parkinson's disease treated by stereotactic thalamotomy between 1977 and 1996 at our institute. Significant reduction of tremor and rigidity of the contralateral extremities persisted throughout the follow-up period (mean 8.8 years) in 44 patients who underwent unilateral thalamotomy. These effects resulted in postoperative improvement of activity of daily life (ADL) with reduced dosage of levodopa. The effect of surgery on akinesia was limited and postoperative progression of akinesia was related to the postoperative deterioration of ADL. Multivariate analysis disclosed that the preoperative akinesia score was the critical factor for poor outcome. Nine patients underwent bilateral thalamotomies at a mean interval of 56 months. Five patients were obviously benefited from the second thalamotomy. The only perioperative complication was large intracerebral hematoma at the lesion site in one patient. This study confirmed the reliable and persistent effect of thalamotomy. Patients with Parkinson's disease whose disability is mainly caused by tremor and/or rigidity will be benefited from this procedure. Second thalamotomy, contralateral to the initial side, may be indicated if the ADL deteriorates due to the progression of the symptoms on the non-treated side. Patients disabled by advanced akinesia are not good candidates for thalamotomy.

Prognostic factors in clinical stage I non-small cell lung cancer

BACKGROUND

Management of patients with early-stage lung cancer but a poor prognosis is controversial.

METHODS

Between January 1987 and December 1994, 365 patients with clinical stage I disease underwent surgical resection at our hospital. Eight preoperative clinical variables were entered into univariate and multivariate analyses to determine their impacts on 5-year survival.

RESULTS

The 3-year and 5-year survival rates were 78.1% and 66.5%, respectively. In the multivariate analysis, clinical T2 status and preoperative high serum carcinoembryonic antigen levels were independent significant factors indicative of a poor prognosis (hazard ratio, 2.20 and 1.88, respectively). Patients with both of these factors had 3-year and 5-year survival rates of 65% and 38% (p<0.001), and the risk of death for this subgroup was 4.14 times greater than that of the overall clinical stage I population.

CONCLUSIONS

A subgroup with clinical T2 disease and preoperative high serum carcinoembryonic antigen levels had a significantly poorer prognosis among patients with clinical stage I lung cancer. For this subgroup, a complete preoperative staging workup and multimodal therapy, especially induction chemotherapy, instead of surgical intervention alone could be beneficial.

Surgical correction of trigonocephaly: theoretical basis and operative procedures

Trigonocephaly involves premature fusion of both the metopic suture and the sutures in the skull base. Surgical treatment by opening of the prematurely fused metopic suture and expansion of the anterior cranial base by creating "neosutures" was used to treat three children with trigonocephaly. The combination of lateral canthal advancement and radical forehead remodeling achieved excellent results. These procedures can also prevent the development of midface hypoplasia such as hypotelorism. The two younger patients, aged 0 and 6 months, achieved rapid bone growth in the defects and normalization of intercanthal and interpupillary distances. The older patient, aged 8 years, retained some skull defects at follow-up. The optimal age for surgery is 3-6 months, which allows good cosmetic results and minimizes visual repercussions with relatively low perioperative risks.

Acute traumatic subdural hematoma originating from a convexity meningioma--case report

A 68-year-old male presented with a traumatic subdural hematoma originating from a convexity meningioma the day after a motorcycle accident. Computed tomography disclosed a right temporal subdural and/or epidural mass. Emergent craniotomy revealed a convexity meningioma with thin subdural hematoma. The underlying brain was apparently healthy. The histological diagnosis was angiomatous meningioma with hemorrhagic foci. The operative and histological findings indicated that the tumoral tissue was the source of the subdural hematoma.

Suprasellar granular cell tumor

A 75-year-old female presented with a suprasellar granular cell tumor. Computed tomography (CT) revealed a high dense suprasellar mass with strong postcontrast enhancement. Magnetic resonance imaging showed a round suprasellar mass, which was hyperintense on the T1-weighted images with nonhomogeneous enhancement after the administration of gadolinium-diethylenetriaminepenta- acetic acid, and hypointense on the T2-weighted images. Cerebral angiography demonstrated no abnormal findings. The tumor was partially removed via a right frontotemporal craniotomy. The histological diagnosis was suprasellar granular cell tumor. Her postoperative course was uneventful other than mild and transient diabetes insipidus. She has remained asymptomatic without CT evidence of tumor regrowth for 20 months after the surgery. Immunohistochemical studies showed positive reaction for S-100 protein in the tumor cell nuclei, but no reaction for glial fibrillary acidic protein, neurofilament protein, Leu-7, oxytocin, beta-endorphin, adrenocorticotropic hormone, and vimentin. This case provides additional evidence for the astrocytic origin of suprasellar granular cell tumor.

Progress in the management of patients with aneurysmal subarachnoid hemorrhage: a single hospital review for 20 years. Part II: Aged patients

BACKGROUND

We have reported improvement in the outcome of the younger patients with aneurysmal subarachnoid hemorrhage in the preceding article. The purpose of this article is to study if the same management protocol has simultaneously benefited the elderly patients.

METHODS

One hundred twenty-nine patients with aneurysmal subarachnoid hemorrhage, over 70 years old, who were consecutively admitted to Kagawa Prefectural Central Hospital from July 1972 to December 1992, were reviewed. Patient grouping and outcome evaluation were the same as those of younger patients.

RESULTS

Changes in treatment protocol in this period, which were similar to those of the younger counterparts, resulted in an increased number of patients who actually underwent aneurysm clipping. Although the outcome evaluated at 6 months after initial hemorrhage was significantly poorer than that of the younger counterparts, there have been some improvements during the study period. Patients in good clinical condition at 6 months' follow-up (Glasgow Outcome Scale: Good Recovery) increased from 37.5% to 42.9% in grades I-II and from 0% to 23.1% in grade III, respectively.

CONCLUSIONS

The improvement in the outcome of elderly patients was less remarkable than that observed in younger patients. Significantly higher incidence of preoperative rebleeding and postoperative symptomatic vasospasm has proven to be the major cause of mortality and major morbidity at present. More careful and sophisticated perioperative care is required in elderly patients with aneurysmal subarachnoid hemorrhage.

Progress in the management of patients with aneurysmal subarachnoid hemorrhage: a single hospital review for 20 years. Part I: Younger patients

BACKGROUND

This study was carried out to clarify if there has been any improvement in the outcome of patients with aneurysmal subarachnoid hemorrhage during the past 20 years. Because elderly patients have apparently poorer prognoses than younger patients, patients older than 70 years were analyzed separately in the following article.

METHODS

Five hundred seventy-one patients with aneurysmal subarachnoid hemorrhage, under 70 years, who were consecutively admitted to Kagawa Prefectural Central Hospital from July 1972 to December 1992, were reviewed. These patients were divided into four groups according to the time of admission. The ultimate outcome was evaluated by means of Glasgow Outcome Scale 6 months after the ictus.

RESULTS

Changes in treatment protocol in this period included the induction of early surgery and the invention of a variety of modalities for the treatment of cerebral vasospasm. This resulted in a distinct increase in patients who actually underwent direct aneurysm clipping. Outcome has been significantly improved during this period, especially in patients with Hunt and Kosnik grade III (p<0.05, chi2). Patients in good clinical condition at follow-up (Glasgow Outcome Scale: good recovery) increased from 8.7% to 60.7%. Mortality decreased from 28.7% to 10.7%.

CONCLUSIONS

Current therapeutic modalities have significantly improved the outcome of patients with aneurysmal subarachnoid hemorrhage. Rebleeding before early surgery remains as a major cause of unfavorable outcome and further progress on this subject is mandatory.

Combined cisternal drainage and intrathecal urokinase injection therapy for prevention of vasospasm in patients with aneurysmal subarachnoid hemorrhage

The effect of cisternal drainage and intrathecal urokinase injection in preventing symptomatic vasospasm (SVS) after aneurysmal subarachnoid hemorrhage was studied in 60 patients with uniform background (Hunt & Kosnik grade III, younger than 70 yrs, undergoing surgery within 72 hrs after hemorrhage). The incidence of permanent neurological deficits caused by vasospasm was 5/16 without cisternal drainage, 5/34 with drainage alone, and 1/10 with drainage and urokinase injection. Analysis of patients without postoperative cisternal drainage showed the amount of subarachnoid clot on the initial computed tomographic scan was closely related to the occurrence of SVS (p < 0.05, unpaired t test). Analysis of patients with cisternal drainage showed the amount of bloody cerebrospinal fluid (CSF) drained during the 10 days after surgery and the duration of drainage placement were critical in preventing vasospasm (p < 0.05, unpaired t test). Greater CSF drainage significantly reduced the incidence of permanent neurological deficits caused by vasospasm (p < 0.01, chi 2), but significantly increased the incidence of hydrocephalus requiring shunt procedures (p < 0.01, chi 2). Urokinase injection via cisternal drainage achieved a further reduction in the occurrence of SVS. Intrathecal thrombolytic therapy after aneurysmal surgery is an effective method for SVS prophylaxis, and CSF drainage (> 1500 ml for 10 days) enhances the effect.

Thermal damage threshold of brain tissue--histological study of heated normal monkey brains

The thermal damage threshold of normal brain tissue was evaluated from immediate and delayed histological changes caused by hyperthermia treatment of normal monkey (Macaca fuscata) brains. A 2450 MHz microwave antenna and an antenna cooling system devised by our group were used for interstitial hyperthermia treatment. The antenna within the cooling system was inserted through a small craniectomy under general anesthesia. The temperature at a reference point, 4 mm radially away from the surface of the cooling system, was maintained at 42, 43, 44, 45, or 46 degrees C for 60 minutes. Eighteen animals were treated and sacrificed immediately after the treatment, while nine animals were treated and sacrificed 7 days after the treatment. The histological changes were studied microscopically on sections stained with HE or Kluver-Barrera's method. The non-survival experiment demonstrated that areas heated at 44 degrees C or below showed no obvious irreversible changes. The survival experiment showed areas heated at 44 degrees C or above developed coagulative necrosis. These histological findings indicate that thermal damage occurs in normal brain tissue after heating at 44 degrees C or above for 60 minutes, suggesting that the safety limit for brain hyperthermia is 43 degrees C for 60 minutes.

Extracranial vertebral artery aneurysm causing spinal subarachnoid hemorrhage--case report

A 48-year-old female presented with spinal subarachnoid hemorrhage (SAH) due to the rupture of an extracranial vertebral artery (VA) aneurysm. The aneurysm arose from the junction of the third and the fourth segments of the left VA just inside the dura mater, and was partially coated with Biobond. This is only the second such case reported. We recommend complete four-vessel angiography in evaluating patients with SAH, with special attention given to the extracranial VA if spinal SAH is suspected.

Neuropsychological outcome and social recovery of head-injured patients

The Wechsler Adult Intelligence Scale and Yatabe-Guilford personality test were administered to 123 patients hospitalized for head injury who had made a relatively good recovery. Intelligence quotient (IQ) was correlated with clinical condition based on the Glasgow Coma Scale and duration of coma. More severely injured patients tended to show a greater decline in IQ. The type of lesion, as described by computed tomography, was also an important factor in predicting the outcome of intellectual function. The mean IQ of patients with diffuse injury, such as diffuse axonal injury and diffuse brain swelling, and intracerebral hematoma, was significantly lower than that of the control subjects, especially performance IQ (PIQ). Several patients demonstrated improved IQ level during the initial year. In particular, PIQ improved more than verbal IQ. The difference between the IQ of patients achieving social recovery and not was significant (p < 0.001). Causes of difficulty in returning to previous work were decreased IQ and personality change, such as lack of cooperativeness. Neuropsychological evaluation is important in predicting social recovery and selecting necessary neuropsychological rehabilitation.

[Neuropsychological outcome of head injury in children]

Wechsler Intelligence Scale for Children-Revised (WISC-R) and Yatabe-Guilford personality test were administered to 31 children who had been hospitalized for head injury and made a GR or MD by the Glasgow Outcome Scale (GOS). The type of lesion, as defined by CT scan categories, was an important factor to prognosticate the outcome of intellectual function. The IQ, especially performance IQ, of acute subdural hematoma (EDH) or severe diffuse brain injury (DBI) was lower than that caused by other types of lesion. Several children demonstrated improvement in IQ level during the initial year. The difference between the IQ of the children who could return to previous school life and that of the children who could not was significant. One of the causes of difficulty in returning to previous school life is decreasing IQ and personality change such as social disadaptability. Neuropsychological evaluation is important in predicting school recovery and deciding proper neuropsychological rehabilitation.

Six strains of human immunodeficiency virus type 1 isolated in Japan and their molecular phylogeny

Five strains of human immunodeficiency virus type 1 (HIV-1) were isolated from five Japanese hemophilia patients. Two isolates, HIV-1[GUN-1] and HIV-1[GUN-2], were from brother patients with hemophilia B and the other three isolates, HIV-1[GUN-3], HIV-1[GUN-4], and HIV-1[GUN-5], were from hemophilia A patients. Another HIV-1 strain, HIV-1[GUN-6], was isolated from a Canadian male homosexual with AIDS. The restriction endonuclease cleavage maps of the proviral genomes of these six HIV-1 strains revealed that they were apparently different from each other. The phylogenetic trees constructed using restriction maps and nucleotide sequences were quite similar, indicating that phylogenetic analyses of Japanese HIV-1 isolates can be done using restriction maps of the proviruses. Phylogenetic analyses showed that they were more closely related to HIV-1s which had been reported to be isolated from homosexual patients in the United States than those isolated from African patients. In particular, GUN-1 and GUN-2 isolates were on the branch of a San Francisco isolate, ARV2, while GUN-5 and GUN-6 isolates were on the branch of HTLV-IIIB-related isolates.

[Analysis of long-term social rehabilitation of brain contusion]

164 patients with brain contusion were evaluated with respect to social rehabilitation. 70 out of 134 patients (66.7%), said to have had good recovery or moderate disability by the Glasgow Outcome Scale (GOS), returned to full or partial employment. Factors such as age, Glasgow Coma Scale (GCS) at admission, duration of unawareness, fibrin and fibrinogen degradation product (FDP) were the most important in predicting social recovery. The Wechsler Adult Intelligence Scale (WAIS) was applied in 33 patients. The IQs of the patients who returned to their job fully tended to be higher than those who could not. In the majority of patients, impaired capacity for work was caused not only by physical deficits, but by mental retardation described as such as IQ score.

Cerebral sinus thrombosis in patient with ulcerative colitis--case report

Left transverse sinus thrombosis developed in a 27-year-old male with ulcerative colitis. The diagnosis was based on cerebral angiography and magnetic resonance (MR) imaging, the latter of which clearly delineated the intraluminal thrombus. Serial MR images demonstrated thrombus organization. The use of this method in the diagnosis of cerebral sinus thrombosis might reduce the need for cerebral angiography.

Cerebral blood flow changes during localized hyperthermia

Hyperthermia is becoming a potent therapeutic method for malignant brain tumors, either alone or in combination with radiation therapy. The heat response of organized tissues includes other factors besides the inherent cellular thermosensitivity, that is, tissue pH, PaO2, and nutrient supply, all of which are largely influenced by the tissue blood flow. In this study, the regional cerebral blood flow (rCBF) changes in 15 Japanese normal monkey brains during interstitial microwave hyperthermia were investigated by the hydrogen clearance method. Under general anesthesia and controlled respiration, a parieto-occipital craniectomy, 4 x 4 cm, was performed. A microwave antenna was inserted into the brain to a depth of 2.0 cm, and the brain tissue was heated with 2450 MHz microwave irradiation. The intracerebral temperatures and rCBF were measured in the white matter 1 cm from the brain surface. During hyperthermia, the rCBF linearly increased at a rate of 10% per 1 degrees C temperature rise. Heating at 42 degrees C for 180 minutes resulted in a constant increase in rCBF. The perfusion rate returned to the control levels after the termination of heating. Above 45 degrees C, the rCBF transiently increased and then started to decline during heating. No consistent results were obtained with heating at 43 degrees C. These results show that normal monkey brain tissues respond to hyperthermia by an rCBF increase as long as the threshold values of tissue temperature (43 degrees C) and exposure time (40-60 minutes) are not exceeded. Excessive heating may lead to irreversible damages to normal tissue and vasculature.

Cerebral blood flow and the thermal properties of the brain: a preliminary analysis

Safe and effective use of hyperthermia for the treatment of brain tumors requires precise control of the distribution of temperatures (that is, the thermal field) within the tumor and within the adjacent brain. Major influences upon the distribution of temperatures include the passive thermal properties of the brain, such as its specific heat (Cb), and the contribution of cerebral blood flow (CBF). Recently, an electrical-mechanical analog model of heat flow within the brain has been developed from which an expression for CBF has been derived: CBF = Cb/(tau rho c) where tau is the thermal decay constant, rho is the density of blood, and c is its specific heat. To test this model a series of experiments was carried out in adult dogs in which stereotaxically implanted microwave antennas operating at 2450 MHz, fluoro-optical thermometry probes, and platinum electrodes were used to simultaneously measure CBF by thermal washout and hydrogen clearance techniques. The correlation coefficient for estimates of CBF derived by the two methods in 52 paired observations was 0.89. Measurements of CBF were more reliable at increased distances from the microwave antenna, since CBF is sensitive to the degree of temperature elevation (delta T). The ratio of post-heating CBF to pre-heating CBF varies linearly with delta T and has a correlation coefficient of 0.86. When values of CBF determined by the hydrogen clearance method were employed in the above equation, it was possible to derive Cb as 0.70 +/- 0.08 cal/gm-degrees C. Use of this value for Cb in this equation produces estimates of CBF by thermal clearance that are within 10% of the values for CBF as measured by the hydrogen clearance method. It is concluded that this model of thermal flow within the brain may have heuristic value for treatment planning and that microwave antennas and fluoro-optical probes may represent a new methodology for the clinical estimation of CBF. These methods have recently been employed in patients undergoing combined hyperthermia and chemotherapy.

Hyperthermia for brain tumors: improved delivery with a new cooling system

Hyperthermia has emerged as an adjunct to other forms of brain tumor therapy. Interstitial microwave irradiation is an effective method of inducing localized brain hyperthermia. One of the problems with this technique, however, is the overheating of tissue adjacent to the antenna. In this study, a cooling system for the interstitial microwave antenna was developed for the purpose of providing uniform and accurate heating by the elimination of overheating. The ability to generate more uniform hyperthermic fields was evaluated in normal monkey brains. Six monkeys under general anesthesia and controlled respiration underwent parietooccipital craniectomies 4 x 4 cm in size. The antenna cooling system was constructed of a silicone tube 5.0 mm in outer diameter. Silicone-coated interstitial microwave antennae 1.5 mm in diameter were used. A single antenna or a square array (1.6 cm on a side) of 4 antennae was inserted into the brain with the coupled system to a depth of 2 cm. The brain tissue was heated by 2450-MHz microwave irradiation. Temperature distributions were mapped using nonperturbing thermocouples. These thermal profiles were compared with those generated without the cooling system. In the experiments with the single antenna, the antenna cooling system eliminated the overheating and rapid radial falloff in temperature, without a reduction of the hyperthermic field. In the four-antennae experiments using the cooling system, the thermal field was dramatically flattened with minimal reduction in size; however, the area maintained at a therapeutic temperature range (42-45 degrees C) was significantly enlarged by the cooling system.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fundamental study of differential hypothermia treatment of brain tumor using an interstitial microwave antenna]

An interstitial microwave antenna system was devised for differential hypothermia treatment. It was evaluated for its ability to induce localized brain hyperthermia in hypothermic monkey. Ten brain hyperthermia trials have been performed in 6 monkeys. Under general anesthesia, the animals were put into ice water bath to keep the total body temperature at 30 degrees C. Following parieto-occipital craniectomy, a microwave antenna of 1.5 mm in diameter was inserted into the brain at depth of 2 cm, and the brain tissue was heated by 2450 MHz microwave irradiation. Thermal distribution was measured by thermistor probes and local cerebral blood flow (1-CBF) before and after heating was simultaneously measured by hydrogen clearance method. After the experiment, the animals were sacrificed and histopathological changes of the heated brain tissue were studied. Under total body hypothermia of 30 degrees C, the maximum cross-sectional diameter of the heated brain to 37 degrees C or above was about 4 cm. The temperature profile on the vertical plane presented a bell-shaped distribution. The 1-CBF of the heated brain increased with the elevation of the brain temperature and the blood flow at 37 degrees C is nearly twice as much as that of 30 degrees C. After one hour DH treatment, necrotic tissue was noted along the antenna axis where the temperature was maintained more than 50 degrees C, and this change was not recognized at a distance of 1 cm from the antenna where the temperature was maintained at 42 degrees C. This study indicates that interstitial microwave hyperthermia system can be used effectively to heat the localized brain tissue.

Lymphoid adenohypophysitis

A rare case of lymphoid adenohypophysitis in a 28-year-old woman with temporal relation to pregnancy is described. A CT scan disclosed a round, contrast-enhancing sellar mass simulating pituitary adenoma, and endocrine evaluation showed mild hypopituitarism. Histological examination of the specimen obtained by transsphenoidal hypophysectomy after uneventful natural labour showed marked diffuse infiltration of mature lymphocytes with many germinal centers within lymphoid follicles. This finding was the same as previously reported. The present case makes a total of 15 cases reported in the world literature up to date. To our knowledge, no report has been documented in Japan.