The clinical impact of ureteroscopy for upper tract urothelial carcinoma: A multicenter study

BACKGROUND

With the development of kidney-sparing surgery and neoadjuvant chemotherapy, ureteroscopic biopsy (URSBx) has become important for the management of upper tract urothelial carcinoma (UTUC).

METHODS

We retrospectively analyzed data from 744 patients with UTUC who underwent radical nephroureterectomy (RNU), stratified into no ureteroscopy (URS), URS alone, and URSBx groups. Intravesical recurrence-free survival (IVRFS) was examined using the Kaplan-Meier method. We conducted Cox regression analyses to identify risk factors for IVR. We investigated differences between clinical and pathological staging to assess the ability to predict the pathological tumor stage and grade of RNU specimens.

RESULTS

Kaplan-Meier curves and multivariate Cox regression revealed significantly more IVR and inferior IVRFS in patients who underwent URS and URSBx. Superficial, but not invasive, bladder cancer recurrence was more frequent in the URS and URSBx groups than in the no URS group. Clinical and pathological staging agreed for 55 (32.4%) patients. Downstaging occurred for 48 (28.2%) patients and clinical understaging occurred for 67 (39.4%) patients. Upstaging to muscle-invasive disease occurred for 39 (35.8%) of 109 patients with ≤cT1 disease. Clinical and pathological grading were similar for 72 (42.3%) patients. Downgrading occurred for 5 (2.9%) patients, and clinical undergrading occurred for 93 (54.7%) patients.

CONCLUSION

URS and URSBx instrumentation will be risk factors for superficial, but not invasive, bladder cancer recurrence. Clinical understaging/undergrading and upstaging to muscle-invasive disease occurred for a large proportion of patients with UTUC who underwent RNU. These data emphasize the challenges involved in accurate UTUC staging and grading.

Clinical Significance of Intraductal Carcinoma of the Prostate After High-Dose Brachytherapy With External Beam Radiation Therapy: A Single Institution Series and an Updated Meta-Analysis

BACKGROUND

We compared oncological outcomes between prostate cancer (PCa) patients with and without intraductal carcinoma of the prostate (IDC-P) after high-dose-rate brachytherapy (HDR-BT) with external beam radiation therapy (EBRT).

METHODS

We performed a retrospective analysis of 138 patients with clinically high-risk, very high-risk, or locally advanced PCa who received HDR-BT with EBRT. Of these, 70 (50.7 %) patients were diagnosed with IDC-P; 68 (49.3 %) patients with acinar adenocarcinoma of prostate. The oncological outcomes, including biochemical recurrence-free survival (BCRFS) and clinical progression-free survival (CPFS), were assessed using Kaplan-Meier curves. Additionally, Cox proportional hazards models were used to identify significant prognostic indicators or biochemical recurrence (BCR). Meta-analysis of existing literatures was performed to evaluate the risk of BCR in patients with IDC-P after radiation therapy, compared to those without IDC-P.

RESULTS

Kaplan-Meier curves demonstrated significantly inferior BCRFS and CPFS in patients with IDC-P. Multivariate analysis revealed that IDC-P and Grade Group 5 status were associated with increased BCR risk. in our meta-analysis, IDC-P was associated with BCR (HR = 2.13, P = .003).

CONCLUSION

Amongst the patients who received HDR-BT, patients with IDC-P displayed significantly more rapid disease progression, compared with patients who did not have IDC-P.

Effect of a variant histology on the oncological outcomes of Japanese patients with upper tract urothelial carcinomas after radical nephroureterectomy: a multicenter retrospective study

Background

An earlier systematic review and meta-analysis found that patients with a certain histological variant of upper tract urothelial carcinoma (UTUC) exhibited more advanced disease and poorer survival than those with pure UTUC. A difference in the clinicopathological UTUC characteristics of Caucasian and Japanese patients has been reported, but few studies have investigated the clinical impact of the variant histology in Japanese UTUC patients.

Methods

We retrospectively enrolled 824 Japanese patients with pTa-4N0-1M0 UTUCs who underwent radical nephroureterectomy without neoadjuvant chemotherapy. Subsequently, we explored the effects of the variant histology on disease aggressiveness and the oncological outcomes. We used Cox's proportional hazards models to identify significant predictors of oncological outcomes, specifically intravesical recurrence-free survival (IVRFS), recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS).

Results

Of the 824 UTUC patients, 32 (3.9%) exhibited a variant histology that correlated significantly with a higher pathological T stage and lymphovascular invasion (LVI). Univariate analysis revealed that the variant histology was an independent risk factor for suboptimal RFS, CSS, and OS. However, significance was lost on multivariate analyses.

Conclusions

The variant histology does not add to the prognostic information imparted by the pathological findings after radical nephroureterectomy, particularly in Japanese UTUC patients.

Site-Specific Differences of Eligibility for Adjuvant Immunotherapy Among Urothelial Carcinoma Patients Treated With Radical Surgery: Results From a Multicenter Cohort Study

BACKGROUND

The CheckMate274 trial has reported enhanced disease-free survival rates in patients with stage pT3-4/ypT2-4 or pN+ urothelial carcinoma (UC) undergoing adjuvant nivolumab therapy. This study compares prognostic differences between urothelial carcinoma of the bladder (UCB) and upper tract urothelial carcinoma (UTUC).

METHODS

We retrospectively analyzed data from 719 patients with UC who underwent radical surgery, stratifying to patients at stage pT3-4 and/or pN+ without neoadjuvant chemotherapy (NAC) or at ypT2-4 and/or ypN+ with NAC (potential candidates for adjuvant immunotherapy), and to those who were not candidates for adjuvant immunotherapy. We used Kaplan-Meier curves to assess oncological outcomes, particularly nonurothelial tract recurrence-free survival (NUTRFS), cancer-specific survival (CSS), and overall survival (OS). Risk factors were identified by Cox regression analysis.

RESULTS

Kaplan-Meier curves showed significantly lower NUTRFS, CSS, and OS for potential adjuvant immunotherapy candidates than for noncandidates in each UCB and UTUC group. NUTRFS, CSS, and OS did not differ significantly between adjuvant immunotherapy candidates with UBC or UTUC. Trends were similar among patients ineligible for adjuvant immunotherapy. Pathological T stage (pT3-4 or ypT2-4), pathological N stage, and lymphovascular invasion (LVI) were independent predictors of oncological outcomes on multivariate analysis.

CONCLUSION

The criteria for adjuvant immunotherapy candidates from the CheckMate 274 trial can also effectively stratify UC patients after radical surgery. Substantial clinical significance is attached to LVI status as well as to pathological T and N status, suggesting that LVI status should be considered when selecting suitable candidates for adjuvant immunotherapy.

Radiographic Progression at Castration-Resistant Prostate Cancer Diagnosis: A Prognostic Indicator of Metastatic Hormone-Sensitive Prostate Cancer

BACKGROUND

The critical role of radiographic assessment at the time of castration-resistant prostate cancer (CRPC) diagnosis is underscored by this study. We performed a retrospective analysis of radiographic changes in metastasis from the time of diagnosis of metastatic hormone-sensitive prostate cancer (mHSPC) to CRPC diagnosis. We also explored its impact on prognosis post-CRPC.

MATERIALS AND METHODS

We retrospectively analyzed 98 men who underwent radiographic examinations (bone scans and computed tomography [CT]) at the time of CRPC diagnosis. When radiographic studies demonstrated progression at CRPC diagnosis, patients were assigned to the radiographic progressive disease (rPD) group. The remaining patients were placed in the "non-rPD" group. The overall survival (OS) post-CRPC was compared between the 2 groups.

RESULTS

The median OS post-CRPC was significantly shorter in the rPD group (n = 50) compared to the non-rPD group (n = 48) (32 months vs. not reached, P = .0124). Multivariate analysis showed that radiographic progression and shorter time to CRPC were associated with a shorter OS post-CRPC (hazard ratio [HR] = 3.14; 95% confidence interval [CI], 1.21-8.12, P = .019).

CONCLUSION

Radiographic progression at the point of CRPC diagnosis independently predicts a shorter OS post-CRPC in patients with mHSPC. Therefore, assessing radiographic changes at the time of CRPC diagnosis could be instrumental in managing CRPC in patients with mHSPC.

Real-world outcomes of adjuvant immunotherapy candidates with upper tract urothelial carcinoma: results of a multicenter cohort study

BACKGROUND

Recent clinical trials have reported improved disease-free survival rates of patients with stage pT3-4/ypT2-4 or pN + upper tract urothelial carcinoma (UTUC) on adjuvant nivolumab therapy. However, the appropriateness of the patient selection criteria used in clinical practice remains uncertain.

METHODS

We retrospectively analyzed 895 patients who underwent nephroureterectomy to treat UTUC. The patients were divided into two groups: grade pT3-4 and/or pN + without neoadjuvant chemotherapy (NAC) or grade ypT2-4 and/or ypN + on NAC (adjuvant immunotherapy candidates) and others (not candidates for adjuvant immunotherapy). Kaplan-Meier curves were drawn to assess the oncological outcomes, including recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS). Cox proportional hazards models were used to identify significant prognostic factors for oncological outcomes.

RESULTS

The Kaplan-Meier curves revealed notably inferior RFS, CSS, and OS of patients who were candidates for adjuvant immunotherapy. Multivariate analysis revealed that pathological T and N grade and lymphovascular invasion (LVI) status were independent risk factors for poor RFS, CSS, and OS.

CONCLUSION

In total, 44.8% of patients were candidates for adjuvant immunotherapy. In addition to pathological T and N status, LVI was a significant predictor of survival, and may thus play a pivotal role in the selection of patients eligible for adjuvant immunotherapy.

Comparison of neoadjuvant and adjuvant chemotherapy for upper tract urothelial carcinoma in real-world practice: a multicenter retrospective study

BACKGROUND

Multiple studies have demonstrated the effectiveness of neoadjuvant chemotherapy and adjuvant chemotherapy in patients with upper tract urothelial carcinoma compared with surgery alone. However, no clinical trial has established the superiority of neoadjuvant chemotherapy or adjuvant chemotherapy in terms of perioperative outcomes.

METHODS

We conducted a retrospective analysis encompassing 164 upper tract urothelial carcinoma patients who underwent radical nephroureterectomy and received perioperative chemotherapy. Of these patients, 65 (39.6%) and 99 (60.4%) received neoadjuvant chemotherapy and adjuvant chemotherapy, respectively. Recurrence-free survival and cancer-specific survival were computed using the Kaplan-Meier method. Additionally, we conducted Cox regression analyses to evaluate the risk factors for recurrence-free survival and cancer-specific survival.

RESULTS

Pathological downstaging was seen in 37% of the neoadjuvant chemotherapy group. However, no pathological complete response was observed in this cohort. The Kaplan-Meier curves demonstrated significantly lower recurrence-free survival and cancer-specific survival in patients who received adjuvant chemotherapy. Multivariate Cox regression analysis revealed patients treated with adjuvant chemotherapy exhibited a marked association with inferior recurrence-free survival and cancer-specific survival.

CONCLUSION

Our study has suggested that neoadjuvant chemotherapy would be more effective in high-risk upper tract urothelial carcinoma patients compared with adjuvant chemotherapy.

Revealing the Velocity Uncertainties of a Levitated Particle in the Quantum Ground State

We demonstrate time-of-flight measurements for an ultracold levitated nanoparticle and reveal its velocity for the translational motion brought to the quantum ground state. We discover that the velocity distributions obtained with repeated release-and-recapture measurements are significantly broadened via librational motions of the nanoparticle. Under feedback cooling on all the librational motions, we recover the velocity distributions in reasonable agreement with an expectation from the occupation number, with approximately twice the width of the quantum limit. The strong impact of librational motions on the translational motions is understood as a result of the deviation between the libration center and the center of mass, induced by the asymmetry of the nanoparticle. Our results elucidate the importance of the control over librational motions and establish the basis for exploring quantum mechanical properties of levitated nanoparticles in terms of their velocity.

The Efficacy and Safety of a Low Relative Dose Intensity of Cabazitaxel in Patients With Metastatic Castration-resistant Prostate Cancer

BACKGROUND/AIM

Clinical trials have shown that the efficacy of a reduced dose of cabazitaxel (20 mg/m2 every 3 weeks) was not inferior to that of the standard dose (25 mg/m2 every 3 weeks). However, the efficacy of even lower relative dose intensities, such as 20 mg/m2 every 4 weeks, have not been evaluated conclusively. The aim of this study was to investigate the efficacy and safety of a low relative dose intensity of cabazitaxel in patients with metastatic castration-resistant prostate cancer in the real world.

PATIENTS AND METHODS

We retrospectively analyzed 101 consecutive patients treated with cabazitaxel for docetaxel-refractory metastatic castration-resistant prostate cancer. The progression-free and overall survival after introduction of cabazitaxel and prostate-specific antigen response rate were assessed as oncological outcome measures.

RESULTS

The patients were divided into two groups (relative dose intensity >60%, n=74 and ≤60%, n=27). Both progression-free and overall survivals were significantly better in the >60% group than in the ≤60% group (median 5 and 2 months, p<0.01, and 15 and 6 months, p<0.01, respectively). In multivariate analyses, visceral metastasis and relative dose intensity ≤60% were prognostic factors for shorter progression-free and overall survivals (p=0.04, p<0.01, respectively). The incidence of adverse events was not significantly different between groups.

CONCLUSION

The cabazitaxel relative dose intensity ≤60% group had significantly shorter progression-free and overall survivals than the >60% group, whereas the incidence of adverse events was not significantly different. The results suggested that reducing the relative dose intensity of cabazitaxel to ≤60% may not be recommended.

Predictive factors for disease progression after salvage radiation therapy in biochemical recurrent patients treated by radical prostatectomy

Objective

Salvage radiation therapy (SRT) is standard treatment for patients after radical prostatectomy (RP). However, the optimal timing of SRT remains to be elucidated.

Material and methods

We retrospectively reviewed 133 prostate cancer (PCa) patients who underwent SRT for biochemical recurrence after RP. Disease progression was defined as repeated prostate-specific antigen (PSA) level more than 0.2 ng/mL, greater than the post-SRT nadir or radiographic progression. A receiver operating characteristic curve analysis was used to identify the optimal pre-SRT PSA level for predicting progression after SRT. Cox regression analyses were performed to elucidate the association between clinicopathologic characteristics and disease progression.

Results

Fifty-one PCa patients (38.4%) experienced disease progression after SRT. The optimal cutoff value of the pre-SRT PSA for predicting disease progression was 0.44 ng/mL. In multivariable analysis, pre-SRT PSA >0.44 ng/mL was a significant independent predictor of post-SRT disease progression [hazard ratio (HR): 2.02, P = 0.02]. Although the pre-SRT PSA >0.44 ng/mL did not maintain its independent association with disease progression in the multivariable analysis of patients with adverse pathology (HR: 1.63, P = 0.22), PSA within 4 weeks after RP as a continuous variable was significantly associated with disease progression (HR: 1.19, P = 0.04).

Conclusions

Our results highlight that in PCa patients who undergo RP, SRT should be performed before their PSA reaches 0.44 ng/mL. In patients with adverse pathology disease, a high PSA level within the 4 weeks after RP might identify those who are likely to have disease progression, and these patients might require systemic therapy.

Feasibility of Novel Technique of Flexible Cystoscopic En Bloc Snare Resection of Bladder Tumor: f-ESRBT

Background: En bloc resection of bladder tumors (ERBT) has been used as a treatment option to improve pathologic diagnostic accuracy in non-muscle invasive bladder cancer. We report on the feasibility of a novel ERBT technique using an electrosurgical snare with flexible cystoscope: flexible cystoscopic En bloc Snare Resection of Bladder Tumor (f-ESRBT). Methods: We used the electrosurgical snare to resect a superficial bladder tumor after injection of 50% glucose in the submucosa at the tumor base. We collected each resected tumor with a basket catheter and coagulated the resected area with a coagulation electrode. A flexible cystoscope was used for all procedures. Results/Discussion: We performed 10 operations. Mean tumor size was 10.2 ± 7.3 mm and mean surgery time was 13.8 ± 6.8 minutes. All procedures were performed without complications. Results showed f-ESRBT to be simple and minimally invasive and to enable accurate pathologic diagnoses. Conclusion: f-ESRBT is a feasible treatment option for small and non-muscle invasive bladder cancer.

Percutaneous cryoablation versus partial nephrectomy for cT1b renal tumors: An inverse probability weight analysis

PURPOSE

To investigate differential clinical outcomes in patients treated with partial nephrectomy (PN) vs. percutaneous cryoablation (PCA) for cT1b renal tumors.

MATERIALS AND METHODS

We retrospectively analyzed the records of 119 patients who had undergone PN (n = 90) or PCA (n = 29) for cT1b renal tumors. Inverse probability weighting (IPW) was used for balancing patient demographics, including renal function and tumor complexity. Perioperative complications, renal function preservation rates, and oncological outcomes such as local recurrence-free, metastasis-free, cancer-specific, and overall survival were compared using IPW-adjusted restricted mean survival times (RMSTs).

RESULTS

PCA was more likely to be selected for octogenarians (odds ratio: 11.4, 95% confidence interval [CI]: 3.33-45.1). During the median follow-up of 43 months in the PCA group and 36.5 months in the PN group, unablated local residue or local recurrence was noted in 6 patients in the PCA group and local recurrence was noted in 4 patients in the PN groups. Of the 6 patients in the PCA group, 4 underwent salvage PCA, and local control had been achieved at the last visit. In the IPW-adjusted population, PCA had significantly worse local recurrence-free survival compared with PN (IPW-adjusted RMST difference: -22.7 months, 95% CI: -45.3 to -0.4, P = 0.046). IPW-adjusted RMST for metastasis-free survival (P = 0.23), cancer-specific survival (P = 0.77), and overall survival (P = 0.11) did not differ between PCA and PN. In addition, PN was not a predictor for local control failure at the last visit (odds ratio: 0.30, 95%CI: 0.05-1.29). There were no statistically significant differences between PN and PCA in renal function preservation or overall/severe complication rates.

CONCLUSIONS

In patients with cT1b renal tumor, although the local recurrence rate is higher for PCA than for PN, PCA provides comparable distant oncologic outcomes. PCA can be an alternative treatment option for elderly, comorbid patients, even those with cT1b renal tumors.

Long-term outcomes of radical prostatectomy versus low-dose-rate brachytherapy in patients with intermediate-risk prostate cancer: Propensity score matched comparison

PURPOSE

To compare long-term outcomes of radical prostatectomy (RP) and low-dose-rate brachytherapy (LDR-BT) using propensity score-matched analysis in patients with clinically localized, intermediate-risk prostate cancer (PCa).

METHODS

Between October 2003 and March 2014, our institution treated 1241 patients with intermediate-risk PCa (RP: n = 531; LDR-BT: n = 710). Biochemical recurrence (BCR) was defined as prostate-specific antigen (PSA) levels of 0.2 ng/ml or greater for RP, and as PSA nadir plus 2 ng/ml or higher (Phoenix definition) for LDR-BT. We calculated propensity scores by multivariate logistic regression based on covariates that included age, pretreatment PSA, biopsy Gleason grade, the percentage of positive biopsy cores (PPBC), and clinical T stage.

RESULTS

Median follow-up was 108 months for RP and 99 months for LDR-BT. After propensity score adjustment, a total of 642 (321 each) patients remained for further analysis. Kaplan-Meier curves showed no statistically significant difference in overall survival (OS) (p = 0.99). LDR-BT was associated with improved BCR-free survival and salvage therapy-free survival  compared to RP (p < 0.001), and RP was associated with improved metastasis-free survival (MFS, p < 0.001).

CONCLUSION

BCR cannot be a surrogate for survival comparison, primarily due to differences between treatment modalities in how this term was defined post-therapy. Long-term follow-up showed that RP was associated with lower MFS in intermediate-risk PCa. However, this has not yet translated into superior OS.

Laparoscopic partial nephrectomy for the horseshoe kidney with indocyanine green fluorescence guidance under the modified supine position

Introduction

Owing to the complexity of their blood supply, renal tumors in horseshoe kidneys are sometimes technically challenging to resect through laparoscopic procedures.

Case presentation

A 75‐year‐old man presented with a 3‐cm lower‐pole mass in the right moiety of the horseshoe kidney. Indocyanine green administration allowed for the identification of the tumor's feeding artery, which was selectively clamped to perform laparoscopic partial nephrectomy. During the procedure, the patient was positioned in the modified supine position (30° semi‐lateral position), which enabled us to approach the branch of the left renal artery. Postoperative pathologic examination of the resected mass confirmed the diagnosis of pT1a clear cell renal cell carcinoma with negative surgical margins.

Conclusion

Our novel laparoscopic approach with indocyanine green fluorescence in the modified supine position facilitates the identification of and access to the tumor's feeding artery. This technique is advantageous for laparoscopic partial nephrectomy in patients with horseshoe kidney.

Laparoscopy-Assisted Cutaneous Vesicostomy in Combination with Radical Nephrectomy in an Adult Patient with Neurogenic Bladder and Difficulty with Permanent Urinary Catheterization

Background: Cutaneous vesicostomy is a urinary diversion for chronic urinary retention caused by neurogenic bladder. In this procedure, urine is drained directly from the bladder into a pouch attached to the lower abdomen, where the use of a catheter is unnecessary. Although complications of this procedure have been described, such as stoma stenosis, bladder prolapse, bladder calculi, and peristomal dermatitis, it is useful for patients who have difficulty with permanent bladder catheterization. The laparoscopy-assisted technique for cutaneous vesicostomy has not been described in the existing literature. In this report, we describe the case of an adult patient with chronic urinary retention caused by a neurogenic bladder who underwent laparoscopy-assisted cutaneous vesicostomy. Case Presentation: A 61-year-old man with intellectual disability was referred to our department because of macroscopic hematuria and urinary retention. Abdominal ultrasonography and computed tomography images showed excessive bladder dilation and bilateral hydronephrosis. A left kidney tumor was found incidentally. We diagnosed left renal carcinoma and chronic urinary retention caused by a neurogenic bladder. We suspected that the hematuria resulted from the renal cancer or from mucosal or submucosal vessel injury caused by excessive dilation of the bladder. Because of the patient's intellectual disability, self-intermittent catheterization or management of a urethral catheter was not possible. Therefore, we performed left radical nephrectomy laparoscopically followed by laparoscopy-assisted cutaneous vesicostomy under general anesthesia. By using laparoscopy, we could construct the vesicostomy in the bladder dome with less tension, and no stomal complications had occurred at 7 months postoperatively. Conclusion: Laparoscopy-assisted cutaneous vesicostomy was a safe and feasible surgical technique in our adult patient with chronic urinary retention. This procedure may be considered effective for patients having difficulty with permanent urinary catheterization.

Red cell distribution width predicts time to recurrence in patients with primary non-muscle-invasive bladder cancer and improves the accuracy of the EORTC scoring system

PURPOSE

To investigate the clinical prognostic value of red cell distribution width (RDW) in patients with non-muscle-invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

We retrospectively evaluated 582 consecutive patients with primary NMIBC. The efficacy of preoperative RDW at predicting treatment outcome was assessed. A cut-off point for predicting recurrence was also identified. Uni- and multivariable analyses of time to recurrence (TTR) and progression were conducted. Harrell's concordance index (c-index) was used to evaluate the additive value of RDW to the European Organization of Research and Treatment of Cancer (EORTC) risk scoring model for recurrence.

RESULTS

According to the receiver operating characteristic curve of RDW for recurrence, a RDW ≥ 14.5% was classified as high. In the multivariable analysis, a high RDW could independently predict shorter TTR (subdistribution hazard ratio [SHR]: 2.65, 95% confidence interval [CI]: 1.83-3.84, P < 0.001), irrespective of tumor characteristics. No significant relationship was observed between RDW and time to progression (SHR: 1.75, 95% CI: 0.76-4.08, P = 0.19). Adding binary-coded RDW to the EORTC risk scoring model significantly improved its discriminatory performance in assessing recurrence risk (c-index: 0.62, improvement: 0.052, P < 0.001). High RDW was associated with shorter TTR in patients treated with bacillus Calmette-Guerin in the multivariable analysis (SHR: 2.0, 95% CI: 1.01-3.98, P = 0.047).

CONCLUSIONS

RDW was an independent, significant prognostic factor of TTR in patients with primary NMIBC. Adding RDW to the EORTC risk model significantly improved the model's predictability for tumor recurrence.

Short-term impact of androgen deprivation therapy on bone strength in castration-sensitive prostate cancer

OBJECTIVES

To prospectively evaluate changes in bone quality and bone mineral density after androgen deprivation therapy in castration-sensitive prostate cancer.

METHODS

A total of 32 patients with castration-sensitive prostate cancer who were scheduled for androgen deprivation therapy for >12 months were included. The bone mineral density of the femoral neck and lumbar spine was evaluated before, and 6 and 12 months after androgen deprivation therapy. Bone metabolic (serum undercarboxylated osteocalcin, tartrate-resistant acid phosphatase 5b and procollagen type I propeptides) and bone quality markers (plasma pentosidine and homocysteine) were measured before, and 3, 6 and 12 months after androgen deprivation therapy.

RESULTS

The median patient age was 71 years. A total of 17 patients were treated primarily with androgen deprivation therapy, and 15 were treated with androgen deprivation therapy in combination with definitive radiotherapy. Bone quality markers did not change substantially after androgen deprivation therapy. Bone mineral density decreased significantly after 12 months of androgen deprivation therapy. Serum undercarboxylated osteocalcin and tartrate-resistant acid phosphatase 5b levels increased significantly 3 months after androgen deprivation therapy, but procollagen type I propeptides levels stayed unchanged.

CONCLUSIONS

Bone quality markers do not change substantially after androgen deprivation therapy, whereas bone mineral density decreases significantly. Bone turnover markers might play an important role in monitoring bone health during androgen deprivation therapy.

Two-step technique of early adrenal artery ligation in open adrenalectomy of giant right adrenal pheochromocytomas: Three case reports

Introduction

Surgical manipulation of a pheochromocytoma carries the risk of releasing catecholamines into bloodstream leading to severe intraoperative hypertension.

Case presentation

We present three patients with right adrenal pheochromocytoma over 10 cm diameter: a 40‐year‐old woman, 63‐year‐old man, and 66‐year‐old woman. They were diagnosed by 123I‐MIBG scintigraphy and received preoperative antihypertensive treatment with 16 mg/day of doxazosin. Open adrenalectomy was performed with early right adrenal artery ligation between the inferior vena cava and ventral aorta (Step 1) as well as between the tumor and upper pole of the right kidney (Step 2). There was no severe intraoperative hypertension, and no recurrence was observed over 33 months, postoperatively.

Conclusion

Early adrenal artery ligation may stop tumor blood supply and significantly reduce the catecholamine release. Our technique was thought to be safe and useful for preventing severe intraoperative hypertension in giant right adrenal pheochromocytoma.

[CLINICAL PRESENTATION AND OUTCOMES OF PENILE FRACTURE: RETROSPECTIVE ANALYSIS OF 16 PATIENTS]

(Background) Penile fracture as a result of sexual activity is exceedingly rare. Therefore, few studies have investigated it specifically in Japan. (Methods) We evaluated the clinical features and complications of all patients with penile fractures treated at Jikei University Hospital between 2005 and 2017. A total of 16 patients were identified and their etiologies, symptoms, treatment strategy, operative approach, and complications were reviewed. (Results) The median patient age was 41 years (range: 22-67). We were able to identify the etiology in 15 patients: 5 patients (31%) had suffered the fracture during sexual intercourse and 4 (25%) during masturbation. All patients were not suspected of having urethral injury. Eight patients underwent magnetic resonance imaging (MRI) prior to surgical repair. Disruption of tunica albuginea could be identified in all 7 patients with decent descriptions of the findings recorded for review. All patients underwent surgery, and the ruptured tunica albuginea was repaired. None of the patients developed erectile dysfunction (ED) but 1 patient (6%) had postoperative penile curvature. (Conclusions) Penile fracture most frequently occurred during sexual intercourse and masturbation. Our series had no ED, but longer follow-up is needed to draw definitive conclusions.

Ultracold Dipolar Molecules Composed of Strongly Magnetic Atoms

In a combined experimental and theoretical effort, we demonstrate a novel type of dipolar system made of ultracold bosonic dipolar molecules with large magnetic dipole moments. Our dipolar molecules are formed in weakly bound Feshbach molecular states from a sample of strongly magnetic bosonic erbium atoms. We show that the ultracold magnetic molecules can carry very large dipole moments and we demonstrate how to create and characterize them, and how to change their orientation. Finally, we confirm that the relaxation rates of molecules in a quasi-two-dimensional geometry can be reduced by using the anisotropy of the dipole-dipole interaction and that this reduction follows a universal dipolar behavior.

Emergence of Chaotic Scattering in Ultracold Er and Dy

We show that for ultracold magnetic lanthanide atoms chaotic scattering emerges due to a combination of anisotropic interaction potentials and Zeeman coupling under an external magnetic field. This scattering is studied in a collaborative experimental and theoretical effort for both dysprosium and erbium. We present extensive atom-loss measurements of their dense magnetic Feshbach-resonance spectra, analyze their statistical properties, and compare to predictions from a random-matrix-theory-inspired model. Furthermore, theoretical coupled-channels simulations of the anisotropic molecular Hamiltonian at zero magnetic field show that weakly bound, near threshold diatomic levels form overlapping, uncoupled chaotic series that when combined are randomly distributed. The Zeeman interaction shifts and couples these levels, leading to a Feshbach spectrum of zero-energy bound states with nearest-neighbor spacings that changes from randomly to chaotically distributed for increasing magnetic field. Finally, we show that the extreme temperature sensitivity of a small, but sizable fraction of the resonances in the Dy and Er atom-loss spectra is due to resonant nonzero partial-wave collisions. Our threshold analysis for these resonances indicates a large collision-energy dependence of the three-body recombination rate.

Anisotropic relaxation dynamics in a dipolar Fermi gas driven out of equilibrium

We report on the observation of a large anisotropy in the rethermalization dynamics of an ultracold dipolar Fermi gas driven out of equilibrium. Our system consists of an ultracold sample of strongly magnetic 167Er fermions, spin polarized in the lowest Zeeman sublevel. In this system, elastic collisions arise purely from universal dipolar scattering. Based on cross-dimensional rethermalization experiments, we observe a strong anisotropy of the scattering, which manifests itself in a large angular dependence of the thermal relaxation dynamics. Our result is in good agreement with recent theoretical predictions. Furthermore, we measure the rethermalization rate as a function of temperature for different angles and find that the suppression of collisions by Pauli blocking is not influenced by the dipole orientation.

Reaching Fermi degeneracy via universal dipolar scattering

We report on the creation of a degenerate dipolar Fermi gas of erbium atoms. We force evaporative cooling in a fully spin-polarized sample down to temperatures as low as 0.2 times the Fermi temperature. The strong magnetic dipole-dipole interaction enables elastic collisions between identical fermions even in the zero-energy limit. The measured elastic scattering cross section agrees well with the predictions from the dipolar scattering theory, which follow a universal scaling law depending only on the dipole moment and on the atomic mass. Our approach to quantum degeneracy proceeds with very high cooling efficiency and provides large atomic densities, and it may be extended to various dipolar systems.

Bose-Einstein condensation of erbium

We report on the achievement of Bose-Einstein condensation of erbium atoms and on the observation of magnetic Feshbach resonances at low magnetic fields. By means of evaporative cooling in an optical dipole trap, we produce pure condensates of 168Er, containing up to 7×10(4) atoms. Feshbach spectroscopy reveals an extraordinary rich loss spectrum with six loss resonances already in a narrow magnetic-field range up to 3 G. Finally, we demonstrate the application of a low-field Feshbach resonance to produce a tunable dipolar Bose-Einstein condensate and we observe its characteristic d-wave collapse.

Narrow-linewidth light source for a coherent Raman transfer of ultracold molecules

We describe a tunable two-color CW light source sufficient for realizing a coherent Raman transfer between two molecular states that are more than 0.5 eV (120 THz) apart. The simultaneous frequency stabilization of 901 nm and 655 nm light was achieved by locking diode lasers to a single ultralow expansion cavity with dual wavelengths coating. By utilizing offset-locking and optical phase-locked loop (OPLL), we ensured a large mode-hop free tuning range (> 2 GHz). The obtained short term linewidth (<10 Hz) and the linear drift of frequency (65 mHz/s) were both sufficient to eliminate the influence of laser linewidths on the efficiency of coherent Raman transition.

Coherent transfer of photoassociated molecules into the rovibrational ground state

We report on the direct conversion of laser-cooled 41K and 87Rb atoms into ultracold 41K87Rb molecules in the rovibrational ground state via photoassociation followed by stimulated Raman adiabatic passage. High-resolution spectroscopy based on the coherent transfer revealed the hyperfine structure of weakly bound molecules in an unexplored region. Our results show that a rovibrationally pure sample of ultracold ground-state molecules is achieved via the all-optical association of laser-cooled atoms, opening possibilities to coherently manipulate a wide variety of molecules.

Lack of antibodies against the antigen domain 2 epitope of cytomegalovirus (CMV) glycoprotein B is associated with CMV disease after renal transplantation in recipients having the same glycoprotein H serotypes as their donors

Cytomegalovirus (CMV) reinfection of seropositive individuals has been associated with adverse outcomes in organ transplantation and is a frequent cause of congenital infection. Previously we demonstrated that mismatching of CMV glycoprotein H (gH) serotypes was associated with CMV disease after renal transplantation. Because the antigen domain 2 (AD2) epitope of glycoprotein B (gB) is conserved among CMV isolates and is one of the known targets of neutralizing antibodies, in this study we investigated whether antibodies against the epitope contribute to protection from CMV reinfection in renal transplantation, irrespective of gH serological matching. For this purpose, the gB and gH serology and clinical outcomes were analyzed retrospectively for 77 transplant recipients in the donor positive/recipient positive setting, who were managed by preemptive strategy. We found that there was a good negative correlation between the numbers of antigenemia-positive cells and the levels of antibodies against gB AD2 in the CMV-gH antibody matched group, but not in the CMV-gH antibody mismatched group. None of the recipients with antibodies against both gB AD2 and strain-specific epitopes of gH have experienced CMV disease during 6 month after transplantation, while 28% of those who lacked either/both antibody response needed preemptive therapy. Because the outcome was statistically significant, antibodies against gB AD2 can be a useful indicator to predict emergence of CMV disease for preemptive therapy, in addition to antibodies against the mismatched gH types.

Gene expression of myostatin during development and regeneration of skeletal muscle in Japanese Black Cattle1

Myostatin is a specific negative regulator of skeletal muscle growth and is regarded as one of the most important factors for myogenesis. The aim of the current study was to analyze the developmental change in the gene expression of myostatin and an adipogenic transcription factor (peroxisome proliferator-activated receptor lambda2) in the semitendinosus muscle of Japanese Black Cattle throughout the whole life cycle. An additional aim was to compare the temporal expression patterns of myostatin and relevant myogenic regulatory factors (MRF) mRNA during muscle regeneration after frostbite injury at 16 mo of age. The developmental pattern of myostatin gene expression exhibited 2 peaks: the greatest expression occurred in utero (P <0.05) and the second greatest occurred at 16 mo of age (P <0.05). The greatest level of peroxisome proliferator-activated receptor lambda2 expression was observed at 16 mo of age (P <0.05), which paralleled myostatin expression. During frostbite-induced muscle regeneration, gene expression for myostatin and 4 MRF; i.e., Myf5, MyoD, myogenin and MRF4, showed contrasting responses. Myostatin mRNA dramatically declined by 68.1 and 82.6% at 3 and 5 d after injury (P <0.05), respectively, which paralleled its protein expression, and was restored at 10 d. In contrast, the expressions of all 4 MRF mRNA were low initially but increased by 5 d after injury (P <0.05) and then remained constant or decreased slightly. These results suggest that myostatin may play a role in muscle marbling in the fattening period by decreasing myogenesis and increasing adipogenesis, and that the interaction between myostatin and MRF genes may take place at an early stage of skeletal muscle regeneration.

Quantitative trait loci mapping for fatty acid composition traits in perirenal and back fat using a Japanese wild boar x Large White intercross

Here, we analysed quantitative trait loci (QTL) for fatty acid composition, one of the factors affecting fat quality, in a Japanese wild boar x Large White cross. We found 25 significant effects for 17 traits at 13 positions at the 5% genome-wise level, of which 16 effects for 12 traits at 10 positions were significant at the 1% level. QTL for saturated fatty acids (SFA) in back fat were mapped to swine (Sus scrofa) chromosomes (SSC) 1p, 9 and 15. QTL for unsaturated fatty acids in back fat were mapped to SSC1p, 1q, 4, 5, 9, 15 and 17. Using a regression model that fits back fat thickness as a covariate, two of the QTL for linoleic acid content on SSC4 and SSC17 were not significant, but one QTL for total SFA composition was detected on SSC5 with correction for back fat thickness. Wild boar alleles at six of seven QTL tended to increase SFAs and to decrease unsaturated fatty acids. QTL for fatty acid composition in perirenal fat were mapped on SSC2, 3, 4, 5, 6, 14, 16 and X. QTL for melting point (in back fat samples) were mapped on SSC1, 2 and 15. Wild boar alleles in QTL on SSC1 and SSC15 were associated with elevated melting points whereas those on SSC2 were associated with lower melting point measurements.

Blinking and superficial punctate keratopathy in patients with diabetes mellitus

AIM

To evaluate blinking patterns in patients with diabetes mellitus and whether blinking contributes to the formation of superficial punctate keratopathy in diabetic patients.

METHODS

We examined 163 patients with type II diabetes mellitus and 76 without diabetes. Blinks were recorded, analysed using six parameters, and compared between patients with and without diabetes. Multivariate regression analysis was performed to assess the influence of other ocular factors, such as status of tear lipid layer, tear breakup time, corneal sensitivity, the result of cotton thread test, or blinking rate related to superficial punctate keratopathy.

RESULTS

In patients with diabetes, the average mean and maximum interblinking times were longer, the average coefficient of variation of interblinking time was higher, and the average blinking rates were lower than those in patients without diabetes. Multivariate regression analysis revealed that the status of tear lipid layer and tear breakup time were significantly relevant to superficial punctate keratopathy (P < 0.01).

CONCLUSION

Interblinking time was longer in diabetic patients, resulting in a decreased blinking rate. The prevalence of superficial punctate keratopathy cannot be predicted from blinking patterns in patients with diabetes.

Japanese multicenter phase II and pharmacokinetic study of rituximab in relapsed or refractory patients with aggressive B-cell lymphoma

BACKGROUND

To evaluate the efficacy and feasibility of rituximab monotherapy in Japanese patients with relapsed or refractory aggressive B-cell lymphoma.

PATIENTS AND METHODS

Sixty-eight patients were treated with rituximab at 375 mg/m(2) by eight consecutive weekly infusions. Pretreatment variables affecting overall response rate (ORR) and progression-free survival (PFS) and the relationship between pharmacokinetic parameters and efficacy were analyzed.

RESULTS

The ORRs of 68 enrolled patients and 57 eligible patients were 35% [95% confidence interval (CI) 24% to 48%] and 37% (95% CI 25% to 51%), respectively. Median PFS of 53 evaluable patients was 52 days, whereas time to progression of 21 eligible responders was 245 days. Mild to moderate infusion-related toxicities were observed frequently at the first infusion, but all of them were reversible. Elevated lactate dehydrogenase (LDH) and refractoriness to prior chemotherapy were unfavorable factors affecting ORR and PFS (P <0.01). Serum trough levels of rituximab and area under the concentration-time curve for responders were higher than for non-responders (P <0.05).

CONCLUSIONS

Eight consecutive weekly infusions of rituximab have significant anti-lymphoma activity for relapsed or refractory aggressive B-cell lymphoma. Several pretreatment variables and serum rituximab levels are useful for predicting its efficacy.

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.

Occurrence of clostridia in commercially available curry roux

The occurrence of clostridia was investigated in a total of 60 commercially available curry roux samples. Clostridia were isolated from 37 (62%) samples, and Clostridium perfringens was isolated from 7 (12%) samples. The isolates of C. perfringens did not produce enterotoxin. The frequency of occurrence was higher by the enrichment broth culture detection method than by the agar plate or pouch method. These findings suggest that enrichment broth culture is necessary for the detection of clostridia.

SA channel mediates superoxide production in HUVECs

Superoxide production in response to cyclic stretch (1 Hz, 20% in length) was investigated in human umbilical vein endothelial cells (HUVECs). The basal production of superoxide without stretch increased gradually, while the production of superoxide with stretch increased significantly as compared to that without stretch and it became significant 80 min after the onset of cyclic stretch (P<0.05, n=8-14). The superoxide production increased in a stretch-dependent manner and became significant when stretch was more than 10% (p<0.05, n=11-16). To investigate the involvement of SA channel, we added Gd3+ or EGTA in the reaction solution and examined the stretch-induced superoxide production. In cells stretched in the presence of 20 microM Gd3+, the stretch-induced superoxide production was significantly inhibited (at 120 min, p<0.05, n=8-18). The cyclic stretch-induced superoxide production was also significantly inhibited by the removal of extracellular Ca2+ with 5 mM EGTA (at 120 min, p<0.05, n=8-18). Neither the application of Gd3+ nor the removal of extracellular Ca2+ significantly changed the basal production of superoxide. These data suggest that the stretch-induced superoxide production increases in time- and stretch-dependent manner and that the stretch-induced superoxide production in HUVECs is regulated by Ca2+ influx through SA channels.

Endogenous nitric oxide-mediated relaxation and nitrinergic innervation in the rabbit prostate: the changes with aging

BACKGROUND

Nitric oxide (NO) plays the key role in the non-adrenergic non-cholinergic (NANC) nerve-mediated relaxation of prostate. We tried to determine whether nitrinergic innervation of the prostate is reduced with aging, and whether a reduction of this innervation alters the relaxant properties of prostatic tissue.

METHODS

The prostate isolated from young rabbits at the age of 3 months and aged rabbits at the age of 24 months was used. Pharmacologic experiments using electrical field stimulation (EFS) were performed on strips of prostate. Nitrinergic nerves were identified histochemically by the presence of NADPH diaphorase reactivity.

RESULTS

The prostate weighed 0.34 +/- 0.06 g in the young and 0.78 +/- 0.13 g in the aged (P < 0.01). Electrical stimulation caused frequency-dependent relaxation that was inhibited by N-nitro-L-arginine and increased by L-arginine. Maximum relaxant rates of noradrenaline-induced tone were 41.3 +/- 1.8% and 22.7 +/- 0.6% in the young and the aged (P < 0.01), respectively. Exogenous NO caused concentration-dependent relaxation of the prostate. Both relaxation induced by electrical stimulation and exogenous NO were inhibited by LY83583 (a guanylate cyclase inhibitor). In all specimens, NADPH diaphorase activity was observed in the smooth muscle layer of the prostatic stroma and capsule. However, NADPH diaphorase positive nerves were significantly less in the aged than in the young (P < 0.01).

CONCLUSIONS

As a result of these findings, it is suggested that both NO-mediated relaxation and nitrinergic innervation are reduced with aging in this animal model.

Timing of surgery in aortic stenosis

In adults with valvular stenosis, the importance of prompt aortic valve replacement once symptoms occur is well known. The operative mortality for aortic valve replacement has improved dramatically over the past 4 decades and remains the only effective therapy for severe symptomatic aortic stenosis. Aortic valve replacement in patients with left ventricular dysfunction has a high operative mortality, although those patients who do not undergo surgery at all have an even worse outcome. While issues to consider include the presence or absence of coronary artery disease and expected hemodynamics of the prosthetic valve compared with the native valve, when in doubt, one should err on the side of surgical intervention. Elderly age is not a contraindication to aortic valve replacement for severe symptomatic aortic stenosis, although there is a higher prevalence of comorbid disease and higher operative mortality. Life expectancy is significantly prolonged and quality of life is significantly improved in the elderly who survive surgery. Indications for surgery in asymptomatic patients are controversial. We do not recommend valve replacement in asymptomatic patients at this time due to the known risks of surgery and a prosthetic valve and the lack of evidence for benefit of early surgery. Patients undergoing coronary bypass surgery should be considered for concomitant aortic valve surgery for moderate aortic stenosis that is expected to progress to severe stenosis in less than 5 years.

Influence of butyric and lactic acids on the beta-glucuronidase activity of Clostridium perfringens

The beta-glucuronidase activity of intact cells of Clostridium perfringens was not influenced by the presence of either 0.09 or 0.19% lactic or butyric acids. In contrast, the enhanced enzyme activity of intact cells due to sodium deoxycholate was significantly decreased by the presence of these acids. These results suggest the possibility that the development of cancer due to the intake of a high fat diet may be inhibited by the presence of organic acids produced by intestinal bacteria.

General synthetic route to chiral flexible biphenylphosphine ligands: the use of a chiral additive enables the preparation and observation of metal complexes incorporating the enantiopure form

[figure: see text] The enantio- and diastereomerically pure metal complex of a chirally flexible BIPHEP ligand is obtained through enantiomer-selective coordination of a BIPHEP-Ru complex with enantiopure 3,3'-dimethyldiaminobinaphthyl, DM-DBN, followed by epimerization of the remaining BIPHEP-Ru enantiomer to complex with DM-DABN. Thus, an efficient and general synthetic route to a variety of substituted BIPHEP ligands from biphenol and observation of the enantiomerically pure BIPHEP ligands in their Ru(II) complexes are described.

Multiple endothelial injury in epicardial coronary artery induces downstream microvascular spasm as well as remodeling partly via thromboxane A2

OBJECTIVES

The study was undertaken to develop a coronary microvascular spasm model in pigs by repeated epicardial coronary artery endothelial injury.

BACKGROUND

The pathophysiologic mechanisms responsible for coronary microvascular spasm remain unclear, in large part because a suitable animal model has yet to be found.

METHODS

Balloon endothelial denudation was done just distal to the site of an implanted Doppler flowmeter in the left anterior descending coronary artery (LAD) every two weeks for a total of four times. Changes in LAD blood flow by intracoronary administration of vasoactive agents were assessed before each denudation.

RESULTS

In the epicardial LAD endothelial denudation pigs, decreases in LAD blood flow caused by acetylcholine were augmented. Before denudation, it was - 15 +/- 4%, and at week 8 (i.e., two weeks after the fourth denudation) it was -100% (i.e., zero flow [p < 0.01]). The LAD flow changes in response to 5-hydroxytryptamine (5-HT) changed from an increase to a decrease, accompanied by medial thickening of microvessels in the LAD perfusion area. These flow responses were observed without significant changes in LAD diameter. In contrast, the LAD blood flow responses to acetylcholine and 5-HT did not change throughout the experiment in pigs given aspirin and a thromboxane A2 (TXA2) synthase inhibitor orally.

CONCLUSIONS

This microvascular spasm model indicates that hypersensitivity to vasoactive substances in the microvascular beds as well as microvascular remodeling are brought about partly through TXA2. This model should be useful for examining the pathophysiology and treatment of microvascular angina.

[A case of simultaneous off-pump CABG and left lower lobectomy via left anterolateral thoracotomy]

Surgical management for simultaneous pulmonary resection and cardiac surgery remains controversial. We report a case of coexisting lung carcinoma and angina pectoris who was managed successfully with a concomitant operation via the left anterolateral thoracotomy through the fourth intercostal space. After left lower lobectomy, left anterior descending and distal circumflex arteries were anastomosed with composite left internal thoracic and radial artery grafts without use of cardiopulmonary bypass. Both less invasive CABG and curative resection of lung carcinoma were achieved with these procedures.