Multicenter phase II study of FOLFOX for metastatic colorectal cancer (mCRC) in Japan; SWIFT-1 and 2 study

BACKGROUND/AIMS

This study assessed the efficacy and toxicity of the FOLFOX4 (SWIFT1) and mFOLFOX6 (SWIFT2) regimens in Japanese patients with metastatic colorectal cancer (mCRC).

METHODOLOGY

Patients with mCRC were required to have ECOG performance status of 0 to 1, and to have adequate organ function. Two multicenter Phase II studies (SWIFT1/SWIFT2) were conducted in chemotherapy naive patients with mCRC.

RESULTS

112 patients were enrolled in these studies (SWIFT1: 54 patients / SWIFT2: 58 patients). The disease sites for each study were the colon in 27 patients and 28 patients, and the rectum in 27 patients and 30 patients, respectively. All patients received a median of 8 courses. After a median follow-up period of 35 months, 54 patients and 58 patients were evaluable in the respective studies, and the overall response rate was 50.0% (CR:31 PR:53). The response rate according to the sites of metastasis were as follows: liver, 54.1% (46/85); lung, 17.4% (4/23); and lymph node, 23.3% (7/30). Grade 3/4 neutropenia occurred in 14 patients (12.5%), while Grade 3/4 non-hematological toxicities were observed in 16 patients (31.0%) and Grade 3 neurotoxicity was observed in 6patients (5.4%) and 5 patients (4.5%), respectively.

CONCLUSIONS

FOLFOX4 (SWIFT1) and mFOLFOX6 (SWIFT2) regimens complying with the international standard dosage and schedule can also be administered safely and effectively in Japan.

The significance of gastrectomy in advanced gastric cancer patients with non-curative factors

BACKGROUND

The role of gastrectomy in the treatment of advanced gastric cancer patients with non-curative factors remains controversial. We investigated prognostic factors and evaluated the role of gastrectomy in such patients.

PATIENTS AND METHODS

Eighty-eight advanced gastric cancer patients with non-curative factors were prospectively studied. The patients were categorized into the following two groups: Group A: 52 patients who underwent gastrectomy and subsequently received chemotherapy, Group B: 36 patients who received chemotherapy alone.

RESULTS

The median survival times of group A and B patients were 351 and 182 days, respectively (p=0.008). Multivariate analysis showed that gastrectomy was the only positive independent prognostic factor, with no effect on the results of chemotherapy. There was no significant difference in the duration of hospital stay between patients of the two groups, while significantly longer maintenance of oral intake was observed for group A.

CONCLUSION

In advanced gastric cancer patients with non-curative factors, gastrectomy was beneficial for survival with longer maintenance of oral intake.

Discal cysts of the lumbar spine: a case report

Discal cysts--intraspinal cysts communicating with an adjacent intervertebral disc--are an uncommon cause of lumbar radiculopathy. We report a case of discal cyst of the lumbar spine. The cyst contents were bloody and clotted rapidly; no disc materials were seen. Communication between the cyst and the intervertebral disc was detected. Histopathology of the cyst wall revealed fibrous connective tissue without synovial lining cells. We hypothesise that the discal cyst was formed by haemorrhage of the epidural venous plexus caused by separation of the peridural membrane by mechanical force transmitted by an annulus fibrosis fissure. The minute segmental motion caused by the affected disc may have stimulated continuous bleeding.

Solitary myofibroma of the lumbar vertebra: adult case

We present the first known adult case of solitary myofibroma of bone, which affected a lumbar vertebra in a 33-year-old male. Radiography identified a purely lytic lesion with a sclerotic rim in the right pedicle of L1. CT showed an expansile lytic lesion with a sclerotic rim. MRI of the lesion revealed an isointense signal on T1-weighted images, an inhomogeneously hyperintense signal on T2-weighted images, and marked enhancement with gadolinium. Pathological study showed a mixed picture of nodular proliferation of spindle-shaped myoid cells and hemangiopericytomatous proliferation of short spindle/small round cells. The tumor cells were immunoreactive for smooth muscle actin and immunonegative for desmin. This case of solitary myofibroma of bone is exceptionally rare because of its occurrence in an adult older than 20 years of age and its location at an extra-craniofacial site.

In-depth analysis of high effectivity in phase II study (irinotecan and doxifluridine, an intermediate form of capecitabine) for metastatic colorectal cancer: MCSGO, Colorectal Cancer Treatment Group

13570

Background: We have already reported the results of the Phase II multicenter study [a combination of irinotecan (CPT-11) and doxifluridine (5’-DFUR) for MCRC], including the survival period (2006 GI Cancer Symposium Abst #130). In this report, we mention the details of the treatment introduced after this combination and discuss the response observed in each metastatic lesion. Methods: The subjects were 60 CPT-11 naive patients with MCRC. They had a measurable disease that satisfied the RECIST criteria and had gone through not more than one regimen of chemotherapy (median age: 64 years (28–74); male/female: 37/23; ECOG PS 0/1: 52/8; main location of metastatic lesion: liver 31, lung 13, lymph node 15). CPT-11 (150 mg/m2, i.v.) was administered on days 1 and 15, 5’-DFUR (800 mg/body, p.p.) was administered day 3 to 15 and day 17 to 28. One cycle of treatment consisted of 5 weeks. No requirements were imposed on the follow-up treatment. Results: According to the results of this regimen, ORR was 40% [23/60, CR;1, PR;23], OS was 20.5 months, and PFS was 5.9 months. The main NCI-CTC grade 3–4 adverse events included neutropenia (28.3%), fatigue (11.6%), nausea (8.3%), vomiting (6.6%), and diarrhea (5.0%).A follow-up therapy regimen was selected and implemented by each investigator. The main regimens adopted for the 49 patients who received this combination as a 1st line therapy included FOLFOX (n=10), hepatic arterial infusion (HAI) (n=10), and others (n=13). 16 patients received no follow-up therapy. The duration of treatment was 5.0 months in the case of 2nd line therapy and 3.0 months in the case of 3rd line therapy. The response rate by metastatic lesion was as follows: liver 35.4% (11/31, PR;11), lung 53.5% (7/13, CR;1, PR;6), and lymph node 46.6% (7/15, PR;7). Conclusions: The combination of CPT-11 and 5’-DFUR is effective in treating lung metastasis and HAI in treating liver metastasis was suggested.

No significant financial relationships to disclose.

Clinical usefulness of oral granisetron hydrochloride for alleviation of delayed nausea and vomiting induced by CPT-11

This open label pilot study evaluated the safety and efficacy of the oral 5-HT3 receptor antagonist granisetron for prophylaxis of delayed chemotherapy-induced nausea and vomiting (CINV) in 30 patients with advanced or recurrent colorectal cancer. Patients were studied during two cycles of a 5-week regimen with irinotecan (CPT-11) and UFT. Patients received prophylactic anti-emetic therapy that included intravenous granisetron. If Grade 1 or higher severity gastrointestinal symptoms occurred during 6 days after CPT-11 administration in Cycle 1, then oral granisetron was administered daily for the following 5 days of CPT-11 in Cycle 2. Sixteen patients (53.3%) experienced delayed CINV in Cycle 1. The incidence of Grade 2 or higher vomiting was 32.1% and 27.7% in Cycles 1 and 2 in males (P = 0.554) respectively, and 54.6% and 32.4% in females (P = 0.001) respectively. Granisetron is effective against delayed Grade 2 or higher vomiting induced by CPT-11/UFT in female patients, although granisetron alone may not sufficiently control nausea induced by this regimen.

Association between hydration volume and symptoms in terminally ill cancer patients with abdominal malignancies

BACKGROUND

To explore the association between hydration volume and symptoms during the last 3 weeks of life in terminally ill cancer patients.

PATIENTS AND METHODS

This was a multicenter, prospective, observational study of 226 consecutive terminally ill patients with abdominal malignancies. Primary responsible physicians and nurses evaluated the severity of membranous dehydration (dehydration score calculated from three physical findings), peripheral edema (edema score calculated from seven physical findings), ascites and pleural effusion (rated as physically undetectable to symptomatic), bronchial secretion, hyperactive delirium (Memorial Delirium Assessment Scale), communication capacity (Communication Capacity Scale), agitation (Agitation Distress Scale), myoclonus and bedsores.

RESULTS

Patients were classified into two groups: the hydration group (n=59) who received 1 l or more of artificial hydration per day, 1 and 3 weeks before death, and the non-hydration group (n=167). The percentage of patients with deterioration in dehydration score in the final 3 weeks was significantly higher in the non-hydration group than the hydration group (35% versus 14%; P=0.002), while the percentages of patients whose symptom scores for edema, ascites and pleural effusion increased were significantly higher in the hydration group than the non-hydration group (44% versus 29%, P=0.039; 29% versus 8.4%, P <0.001; 15% versus 5.4%, P=0.016; respectively). After controlling for multiple covariates and treatment settings, the association between hydration group and dehydration/ascites score was statistically significant. Subgroup analysis of patients with peritoneal metastases identified statistically significant interaction between hydration group and dehydration/pleural effusion score. There were no significant differences in the degree of bronchial secretion, hyperactive delirium, communication capacity, agitation, myoclonus or bedsores.

CONCLUSIONS

Artificial hydration therapy could alleviate membranous dehydration signs, but could worsen peripheral edema, ascites and pleural effusions. It is suggested that the potential benefits of artificial hydration therapy should be balanced with the risk of worsening fluid retention symptoms. Further clinical studies are strongly needed to identify the effects of artificial hydration therapy on overall patient well-being, and an individualized treatment and close monitoring of dehydration and fluid retention symptoms is strongly recommended.

Novel and global approach of the complex and interconnected phenomena related to the contact line movement past a solid surface from hydrophobized silica gel

In this work a generalized hydrodynamic theory for water flow into a mesoporous matrix from hydrophobized silica gel is suggested. Although we examine a fluid dynamics problem, the motion of the water-gas-solid contact line past a hydrophobized silica gel surface, motivation for such research derives from the investigation of a novel principle of mechanical energy dissipation, called surface dissipation, and its attached machine element, named a colloidal damper (CD). Similar to a hydraulic damper, this absorber has a cylinder-piston structure, but oil is replaced by a colloid consisting of a mesoporous matrix and a lyophobic liquid. Here, the mesoporous matrix is from silica gel modified by linear chains of alkyldimethylchlorosilanes and water is the associated lyophobic liquid. Mainly, the colloidal damper energy loss can be explained by the dynamic contact angle hysteresis in advancing (liquid displaces gas) and receding motion (gas displaces liquid); such hysteresis occurs due to the geometrical and chemical heterogeneities of the solid surface. Although this new kind of dissipation could be attractive for many applications, the subject remains almost unexplored in the scientific literature. Many different, complex, and interconnected aspects are related to this subject: capillary hydrodynamics, slippage effect, contact angle hysteresis, estimation of dissipated energy, thickness optimization of the grafted layer on the surface of the mesoporous matrix, etc. For this reason, a novel and global approach to all the complex and interconnected phenomena related to the contact line movement past a solid surface from hydrophobized silica gel is proposed. Our approach has a modest experimental basis but this is compensated for with rich references to other experimental and theoretical work oriented to the study of surface phenomena in such systems. We tried to sort the existing results and to find the right place for each in building our global view of the problem. This work is structured as follows. The measurement technique of the hysteresis loop is described. From experimental data one calculates the dissipated energy versus length of the grafted molecule on the silica gel surface. These results are justified by flow analysis. Generalized hydrodynamic theory means here that the basic structure of the Navier-Stokes equations is kept, but in order to include the relation between macroscopic flow and molecular interactions, slip is allowed on the solid wall. The nanopillar architecture of the silica gel hydrophobic coating is described. Concepts of slip and contact angle hysteresis are detailed and their connection is revealed. During adsorption, water penetrates the pore space by maintaining contact with the top of the coating molecules (region of -CH(3) groups); after that, water is forced into and partially or totally fills the space between molecules (region of -CH(2) groups). In such circumstances, at the release of the external pressure, desorption occurs. An original energetic-barriers approach is proposed to understand the filling of the nanosize canals which occur in the hydrophobic grafted layer. Employing this energetic-barriers approach, one finds the optimum length of the grafted molecule which maximizes the dissipated energy of the CD reversible cycle. Such results are useful for the appropriate design of ultrahydrophobic surfaces in general, and for the optimal design of a hydrophobic coating of a mesoporous matrix destined for CD use.

Communication about the ending of anticancer treatment and transition to palliative care

BACKGROUND

Communication about the ending of anticancer treatment and transition to palliative care is a difficult task for oncologists. The primary aims of this study were to clarify family-reported degree of emotional distress and the necessity for improvement in communication methods when communicating about the ending of anticancer treatment, and to identify factors contributing to the levels of emotional distress and the necessity for improvement.

METHODS

A multi-center questionnaire survey was conducted on 630 bereaved family members of cancer patents who received specialized palliative care in Japan. A total of 318 responses were analyzed (effective response rate, 62%).

RESULTS

Thirty-nine percent of the bereaved family members reported that they were 'very distressed' in receiving information about the ending of anticancer treatment, and 19% reported 'considerable' or 'much' improvement was necessary in the communication methods. High-level emotional distress was significantly associated with younger patient age, female family gender, the experience of the physician stating she/he could do nothing for the patient, the physician's unwillingness to explore their feelings, and prognostic disclosure of definite survival periods without probabilities or ranges. High levels of perceived necessity for improvement in the communication methods were significantly associated with the experience of the physician stating she/he could do nothing for the patient, physicians not explaining treatment goals in specific terms, physicians not pacing the explanation with the state of family preparation, physicians not being knowledgeable about the most advanced treatments, and the atmosphere not being relaxing enough to ask questions.

CONCLUSIONS

In receiving the information about ending anticancer treatment, a considerable number of families experienced high levels of emotional distress and felt a need for improvement of the communication methods. The strategies to alleviate family distress could include: (i) assuring that physicians will do their best to achieve specific goals, without saying that they can do nothing for the patient; (ii) providing information, including estimated prognosis, in careful consideration of families' preparation and the uncertainty for each patient; (iii) exploring families' emotions and providing emotional support; (iv) acquiring knowledge about advanced treatments; and (v) making the atmosphere relaxing enough to allow families to ask questions.

Pharmacokinetics of flunixin in the cat: enterohepatic circulation and active transport mechanism in the liver

The plasma and urine pharmacokinetics of flunixin-meglumine (FNX) in cats were examined using a total of 12 adult animals. After an intravenous injection of FNX (2 mg/kg), the plasma concentration time curves showed a profile of a two-compartment open model with an elimination half-life of 6.6 h. In spite of high plasma protein binding (>99%), the V(d)beta was unusually large, 0.7 L/kg. Although the recovery of FNX from urine was only 0.4% of the dose, the estimated inherent renal clearance closely corresponded to the renal plasma flow rate, indicating that a renal active tubular secretion was involved in the pharmacokinetics of FNX. Cholestyramine (ChSA), an anion exchanger, was orally administered immediately before the FNX injection in order to determine the involvement of enterohepatic circulation in FNX pharmacokinetics. The elimination phase of the profile of FNX was prevented by the concomitant administration of ChSA, so it was concluded that the drug undergoes enterohepatic circulation in cats. Pravastatin (PV) is a specific substrate of the type-2 organic anion transporting polypeptide transporter (OATP-2) in human liver cells. The effect of a concomitant intravenous injection of PV with FNX was examined in order to determine the involvement of OATP-2 like transporter in the pharmacokinetics. The V1 and total body clearance were decreased after the injection of PV. In conclusion, at least two active transport mechanisms are involved in the pharmacokinetics of FNX in cats. One pathway is renal tubular secretion and the other is sinusoidal active uptake by liver cells. The latter may be responsible for the enterohepatic circulation of FNX in cats.

[Diagnosis of the postoperative local recurrence of rectal cancer by FDG-PET--a case report]

Positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG) as the tracer of glucose metabolism was performed to identify a postoperative recurrent lesion of rectal cancer. A 66-year-old-man underwent trans-sacral local resection of the rectum for rectal cancer in 1992. A local recurrent mass was discovered, and abdomino-perineal resection of the rectum was performed in 1999. The serum CEA level increased gradually August in 2000, but there was no sign of recurrence on CT or MRI. FDG-PET was performed to reveal a presacral recurrent lesion. Total pelvic evisceration combined with resection of the sacrum, and a bilateral ureterostomy were performed in April 2001. The beneficial role of FDG-PET in the diagnosis of the postoperative local recurrence of rectal cancer is emphasized.

Embryonic development in the eggs of the silkworm, Bombyx mori, exposed to the space environment

To investigate the effects of cosmic radiation and microgravity on embryogenesis and organogenesis in Bombyx eggs, two different stages of eggs, the early stage after oviposition and the diapause-terminated eggs, were loaded on the US Space Shuttle/Atlantis (STS-84) for a 9 day flight. More than 85% of the early stage eggs hatched in the flight sample and the ground control. In the diapause-terminated eggs, the percentage of unhatched eggs were 43% in the ground control and 56% in the flight sample. In these eggs, uncompleted embryonic reversal was observed two-fold higher percentage in the flight sample than in the ground control. The incidence of abnormality such as the larvae with segmental fusion and the appearance of abnormal crescent marking in the flight sample was significantly higher than that in the ground control. This was also observed in the 1st and 2nd filial generation of the flight sample. From these results, unsuccessful blastokinesis and the abnormal appearance was discussed in relation to cosmic radiation and microgravity.

[Significance of liver resection for multiple hepatic metastases from colorectal cancer]

In colorectal cancer, liver metastasis is the most common and most important prognostic factor. To elucidate the significance of liver resection, we examined 72 cases (H2: 29 cases, H3: 43 cases). The 3-year survival rate for H2 and H3 patients was 71.5% and 4.5%, respectively. The liver resection rate in H2 and H3 patients was 58.6% (17/29) and 16.3% (7/43), respectively. In H2 patients the 3-year survival rate of those with liver resection and non-resection was 71.3% and 9.2%, respectively (p < 0.001). However, in H3 patients the 3-year survival rate in liver resection and non-resection patients was 80.0% and 43.9%, respectively (not significant). Many therapies, such as liver resection, hepatic arterial infusion, and systemic chemotherapy, were attempted for patients with hepatic metastases. Our data show that liver resection can prolong the survival of H2 patients only. On the other hand, hepatic arterial infusion therapy prolongs the survival of H3 patients only. Systemic chemotherapy does not prolong the survival of either H2 or H3 patients.

[Tumor markers for colorectal cancer]

CEA and CA19-9 are the two most common tumor markers for colorectal cancer that are currently utilized clinically. The positive rate of CEA is 40-60% and that of CA19-9 is 30-50%. Simultaneous use of the two markers is useful in evaluating the therapeutic effect and monitoring the recurrence of advanced colorectal cancer. Surgical specimens may also provide useful information for the appropriate treatment of patients. Using surgically resected lymph nodes, we examined micrometastasis to assess the spread of the cancer cells and the malignant potential of colorectal cancer. Immunohistochemical analysis using anti-cytokeratin antibody revealed no significant impact of micrometastasis on patient prognosis, while RT-PCR assay using CEA as a genetic marker suggested a positive value in predicting a rapid recurrence. Among various molecular markers, we found that CDC25B phosphatase was a powerful prognostic factor for colorectal cancer. Diagnosis of the existence and malignant potential of cancer cells, together with serum tumor marker levels, may help to construct a more useful system for the better treatment of colorectal cancer.

Genetic changes induced in human cells in Space Shuttle experiment (STS-95)

BACKGROUND

Results of past space experiments suggest that the biological effect of space radiation could be enhanced under microgravity. To assess the radiation risk for humans during long-term spaceflight, it is very important to clarify whether human cells exhibit a synergistic effect of radiation and microgravity.

HYPOTHESIS

If significant synergism occurs in human cells, genetic changes induced during spaceflight may be detected by using human tumor HCT-116 cells which are hypermutable due to a defect in the DNA mismatch repair system.

METHODS

Cultured HCT-116 cells were loaded on the Space Shuttle Discovery (STS-95) and grown during the 9-d mission. After landing, many single-cell clones were isolated, microsatellite repetitive sequences in each clone were amplified by PCR, and mutations in the microsatellite loci were detected as changes in the length of PCR fragments. Mutation frequencies of ouabain-resistant phenotype were also analyzed.

RESULTS

The frequencies of microsatellite mutations as well as ouabain-resistant mutations in the flight sample were similar to those of the ground control samples. Some cells were treated in space with bleomycin which mimics the action of radiation, but the frequencies of microsatellite mutations were not significantly different between the flight and the ground control samples.

CONCLUSION

Under the present flight conditions, neither space radiation (about 20 mSv during this mission) nor microgravity caused excess mutations in human cells.

[Informed consent on pain management]

Informed consent is an essential concern to provide medical services centered on patient's needs. Its significant role is not to avoid legal responsibility but to respect patient's individuality. It emphasizes the necessities for sharing medical information including its uncertainty, listening carefully to a patient about his/her questions and anxieties and being worried with him/her in regard to the best ways coping with sufferings. In this article we describe important aspects concerning informed consent on pain management at clinical situations. It is necessary for physicians not only to have knowledge for pain management but also to get technique for appropriate explanation about analgesics.

Expression of second class of KIP protein p57KIP2 in human colorectal carcinoma

p57KIP2, the second class of KIP family protein, is one of the negative regulators of the cell cycle. To elucidate the role of p57KIP2 in colorectal normal mucosa and cancer, we examined the expression of p57KIP2 protein in 110 pairs of colorectal non-tumor and cancer tissues. Immunohistochemical analysis showed that p57KIP2 was weakly detected in the normal colonic epithelium and lymph follicles. A unique expression pattern of p57KIP2 was exclusively noted in the elastic fibers within the walls of relatively large blood vessels (diameter > 100 microm). In cancer tissues, p57KIP2 protein was localized mainly in nuclei. Using the mean percentage of nuclear p57KIP2 expression (25%) as the cut-off value, we divided our cases into those with high expression (n = 44, 40%) and low expression (n = 66, 60%) of p57KIP2 among 110 colorectal cancer cases tested. The clinical and pathological survey showed a significant correlation between low expression of p57KIP2 and large tumor size (p < 0.05) or the presence of tumors in females (p < 0.01). Survival analysis showed that p57KIP2 expression did not influence prognosis. RT-PCR analysis was also performed using RNA extracts from 6 colorectal cancer tissues. When the levels of p57KIP2 mRNAs were compared with expression of p57KIP2 protein, a clear correlation was found, suggesting that expression of the p57KIP2 protein may be regulated at the transcription level. The present study revealed p57KIP2 expression in colorectal cancer and suggests that p57KIP2 may not play a central role in the progression of colorectal cancer.

[Clinical significance of micrometastasis to lymph nodes in gastrointestinal tract cancers]

Surgery is the main therapy for malignancies of the gastrointestinal tract. Lymph node metastasis is one of the major factors in predicting patients' clinical course and choosing appropriate adjuvant therapy after surgery. The concept of micrometastasis to regional lymph nodes emerged over 10 years ago, but its significance has been controversial. To clarify the relevance of micrometastasis of gastrointestinal tract cancers, we have established RT-PCT based-diagnostic methods using multi-markers such as CEA, CK20, and Mage 3. Prospective studies have shown that not a few micrometastasis-positive patients with carcinoma of the colon, stomach, and esophagus suffered disease recurrence, even though they did not show histologically positive lymph node metastasis. They were initially diagnosed as node-negative, and thus predicted to be disease free. A retrospective study of 62 patients with stage II node-negative colorectal cancer showed that 5-year overall survival was 78.2% among micrometastasis-positive patients, against 95.3% micrometastasis-negative patients. Moreover, there was a marked difference in 5-year disease-free survival, with 61.4% versus 88.4%, respectively. These data warrant further prospective study with a large population since RT-PCR based detection systems for micrometastasis appear to have the potential to improve conventional diagnosis and therapy for colorectal cancer.

Useful applications of DNA repair tests for differential diagnosis of atypical dyschromatosis symmetrica hereditaria from xeroderma pigmentosum

Dyschromatosis symmetrica hereditaria (DSH) is a hereditary skin disease characterized by the presence of pigmented and hypopigmented macules on the extremities and freckles on the face. However, if clinical features are not fully developed in infantile patients, it is difficult to differentiate DSH from xeroderma pigmentosum by clinical features alone. A 2-year-old boy (patient 1), revealed atypical features of DSH with slight susceptibility to sunburn. However, his grandfather (patient 4) who was 67 years old, revealed typical features of DSH, which helped to make an exact diagnosis in patient 1. For patient 2, a 5-year-old boy, and patient 3, a 3-year-old girl, it was more difficult to make a diagnosis because there were no family members with DSH features. DNA repair ability was tested for all four cases by means of unscheduled DNA synthesis and colony formation of skin fibroblasts after ultraviolet light irradiation, which resulted in an accurate diagnosis of DSH. We propose that these tests be performed to make a diagnosis of DSH in the case of poor or atypical clinical symptoms.

[Hospice and palliative care in the outpatient department]

In the medical environment, information disclosure to patients and respect of autonomy have spread rapidly. Today, many terminally-ill cancer patients wish to spend as much time at home as possible. In such situations the patient who has been informed that curative treatments are no longer expected to be beneficial can now hope to receive home care and visiting care from hospice/palliative care services. The essential concepts of hospice/palliative care are symptom management, communication, family care and a multidisciplinary approach. These concepts are also important in the outpatient department. In particular, medical staff need to understand and utilize management strategies for common symptoms from which terminally-ill cancer patients suffer (ex. cancer pain, anorexia/fatigue, dyspnea, nausea/vomiting, constipation, hypercalcemia and psychological symptoms). They also need to know how to use continuous subcutaneous infusion for symptom management in the patients last few days. The present paper explains the clinical practices of hospice/palliative care in the outpatient department. Also discussed is support of individual lives so that maximum QOL is provided for patients kept at home.

Respective roles of cyclobutane pyrimidine dimers, (6-4)photoproducts, and minor photoproducts in ultraviolet mutagenesis of repair-deficient xeroderma pigmentosum A cells

The role of UV light-induced photoproducts in initiating base substitution mutation in human cells was examined by determining the frequency and spectrum of mutation in a supF tRNA gene in a shuttle vector plasmid transfected into DNA repair deficient cells (xeroderma pigmentosum complementation group A). To compare the role of two major UV-induced photoproducts, cis-syn cyclobutane-type pyrimidine dimers (CPDs) and pyrimidine (6-4) pyrimidone photoproducts (6-4PPs), each photoproduct was removed from UV-irradiated plasmid by photoreactivation before transfection. Removal of either CPDs or 6-4PPs by in vitro photoreactivation reduced the mutation frequency while keeping the mutation distribution and the predominance of G:C-A:T transitions as UV-irradiated plasmid without photoreactivation, indicating that both cytosine-containing CPDs and 6-4PPs were premutagenic lesions for G:C-A:T transitions. On the other hand, A:T-G:C transitions were not recovered from plasmids after the removal of 6-4PPs, whereas this type of mutation occurred at a significant level (11%) after the removal of CPDs. Thus, the premutagenic lesions for the A:T-G:C transition are 6-4PPs. Removal of both CPDs and 6-4PPs resulted in the disappearance of mutational hot spots and random distribution of mutation as observed in unirradiated control plasmids. However, the mutational spectrum of photoreactivated plasmids differed significantly from that of unirradiated plasmids. A characteristic feature is a high portion of A:T-T:A transversions (11%) in the photoreactivated plasmid. This mutation is due to nondipyrimidinic "minor" photoproducts, and the mutation spectrum suggests that TA*, the major photoproduct of thymidylyl-(3'-5')-deoxyadenosine, is the premutagenic lesion for this mutation. This is the first report revealing the distinct mutagenic roles of the major UV photoproducts and "minor" photoproducts by the use of (6-4)photolyase.

Expression of a mammalian DNA photolyase confers light-dependent repair activity and reduces mutations of UV-irradiated shuttle vectors in xeroderma pigmentosum cells

Photoreactivation is one of the DNA repair mechanisms to remove UV lesions from cellular DNA with a function of the DNA photolyase and visible light. Two types of photolyase specific for cyclobutane pyrimidine dimers (CPD) and for pyrimidine (6-4) pyrimidones (6-4PD) are found in nature, but neither is present in cells from placental mammals. To investigate the effect of the CPD-specific photolyase on killing and mutations induced by UV, we expressed a marsupial DNA photolyase in DNA repair-deficient group A xeroderma pigmentosum (XP-A) cells. Expression of the photolyase and visible light irradiation removed CPD from cellular DNA and elevated survival of the UV-irradiated XP-A cells, and also reduced mutation frequencies of UV-irradiated shuttle vector plasmids replicating in XP-A cells. The survival of UV-irradiated cells and mutation frequencies of UV-irradiated plasmids were not completely restored to the unirradiated levels by the removal of CPD. These results suggest that both CPD and other UV damage, probably 6-4PD, can lead to cell killing and mutations.

[Development of a model which makes it possible to test injectable bone substitutes and evaluation of a calcium phosphate cement]

New percutaneous filling techniques are beginning to be used in bone tumor pathology. The purpose of this study was to develop a reproducible model for testing new injectable bone substitutes. A closed cancellous bone defect was created in the distal femoral condyles of rabbit. Bone defect was filled by a percutaneous injection. Several situations were tested: spontaneous evolution of unfilled cavities, evolution of cavities filled either with a conventional orthopedic cement (PMMA), either with a mixed collagen-hydroxyapatite material, either with a biomaterial derived from the vegetal protein zein, either with a calcium phosphate cement brushite type. The new bone formation was quantified in the defect for each group in which several delays were tested. A bone defect of reproducible size was obtained consistently. A partial bone formation was observed in the unfilled group. The best bone formation rate was obtained in the phosphate cement group. This model showed the interest of injectable biomaterials and more precisely the interest of the phosphate calcium cements as brushite.

A genetic effect of altered gravity: mutations induced by simulated hypogravity and hypergravity in microsatellite sequences of human tumor cells

To determine the possible genetic effects of gravity alterations, we analyzed mutation induction in microsatellite sequences of human tumor cells treated with simulated hypogravity provided by a clinostat or hypergravity by a centrifuge. Microsatellite mutations were detected as changes in the size of polymerase chain reaction (PCR)-amplified allelic markers. The frequencies of mutant clones in cultures treated with simulated hypogravity for 24 or 48 h were almost the same as those of controls, but after 72 h of treatment, the mutant frequencies had increased significantly in all three microsatellite loci examined. Significantly higher mutant frequencies were similarly detected in cultures treated for 72 h with a hypergravity condition as low as 18xg, but not detected in 24 or 48 h treated cultures. These findings clearly show that gravity alterations that last for 3 days can induce microsatellite mutations in human cells. A genetic effect of gravity change, therefore, is established for the first time. Moreover, high frequencies of microsatellite mutations were induced by 12-O-tetradecanoylphorbol-13-acetate (TPA) which activates protein kinase C-mediated signal transduction pathways and causes genetic instability. These findings suggest that gravity change induces microsatellite mutations by modulating the pattern of gene expression involved in signal transduction pathways.

A new bioactive bone cement: its histological and mechanical characterization

We have developed a bioactive bone cement using CaO-SiO 2-P 2O 5-CaF 2 glass powders and ammonium phosphate solution, and investigated its histological and mechanical characteristics in vivo. A bone defect was drilled in proximal metaphysis of the rat tibia and filled with the bioactive bone cement in paste form or polymethylmethacrylate (PMMA) bone cement in the dough state. The cements were allowed to harden in situ. Histological examination demonstrated direct bonding between the new cement and bone by 4 weeks. The bioactive bone cement did not degrade up to 24 weeks postimplantation. The inflammatory reaction to the bioactive bone cement was less intense than the reaction induced by PMMA. Changes in the mechanical properties of the cement in vivo were studied by implanting hardened cylindrical specimens of both types of cement into the hindlimb muscles of rats for 12 weeks. The compressive strength of the bioactive cement increased significantly after implantation, and reached 68 MPa in 1 week and 73 MPa in 4 weeks. These values were comparable to those of PMMA, and were maintained up to 12 weeks after implantation. This bioactive bone cement hardens in situ within a few minutes with negligible rise of temperature and can be easily handled as a paste for filling bone cavities of different shapes. In addition, this cement has good osteoconductive and bone bonding potential and fairly high mechanical strength. Therefore, this new cement could be used both as a bioactive bone cement and bone defect filler.

A heat-generating bioactive glass-ceramic for hyperthermia

Glass plates of the chemical composition: CaO (29.0), SiO 2 (31.0), Fe 2O 3 (40.0), B 2O 3 (3.0), P 2O 5 (3.0) in weight ratio were heated to 1050 degrees C at a rate of 5 degrees C/min and then cooled to laboratory temperature. The resulting glass-ceramic containing magnetite and wollastonite crystals showed high-saturation magnetization. The bonding ability of this new glass-ceramic to bone tissue was evaluated using rabbit tibiae, and compared with glass of the same composition. This glass-ceramic formed a Ca, P-rich layer on its surface and bonded tightly with bone within 8 weeks of implantation. However, the glass did not form this Ca, P-rich layer, nor had it bonded with bone at 25 weeks. The bone-heating ability of this glass-ceramic was investigated by applying a max. 300-Oe, 100-kHz magnetic field. The granules of the glass-ceramic filled in the rabbit tibiae heated the whole surrounding bone to more than 42 degrees C and maintained this temperature for 30 min. Bioactive ceramics reinforce the mechanical strength of bone tissue. Furthermore, this heat-generating bioactive glass-ceramic can be used for hyperthermic treatment of bone tumors.

DCRY is a Drosophila photoreceptor protein implicated in light entrainment of circadian rhythm

BACKGROUND

Light is the major environmental signal for the entrainment of circadian rhythms. In Drosophila melanogaster, the period(per) and timeless (tim) genes are required for circadian behavioural rhythms and their expression levels undergo circadian fluctuations. Light signals can entrain these rhythms by shifting their phases. However, little is known about the molecular mechanism for the perception and transduction of the light signal. The members of the photolyase/cryptochrome family contain flavin adenine dinucleotide (FAD) as chromophore and are involved in two diverse functions, DNA repair and photoreception of environmental light signals.

RESULTS

We report the cloning of a new member of this family, dcry, from Drosophila. Northern blot analysis shows that this gene is expressed in various tissues. The dcry mRNA is expressed in a circadian manner in adult heads, while such rhythmic fluctuation is abolished in the clock-defective per0 and tim0 mutants. The circadian expression is dampened down in constant darkness. The over-expression of the dcry gene alters the light-induced phase delay in the locomotor activity rhythms of flies.

CONCLUSION

These results suggest that DCRY is a circadian photoreceptor and that its expression is regulated by circadian clock genes.

Specificity of mutations in the PMS2-deficient human tumor cell line HEC-1-A

The spectrum of mutations was determined at the hypoxanthine-guanine phosphoribosyltransferase (hprt) locus in the human uterine tumor cell line HEC-1-A which is defective in the mismatch repair gene hPMS2. The mutation frequency at the hprt locus in HEC-1-A was about two orders higher than that in wild type repair-proficient cells. The fifty-eight mutations detected were exclusively point mutations, with frameshifts of one base deletion/addition predominating (66%) the remaining were base substitutions. All the frameshift mutations occurred at sites of monotonous repeating sequences, including six consecutive guanine bases site which was the hot spot for the addition of one G that contributed 60% of the total mutations. Although the observed specificity of mutations in HEC-1-A apparently resembled that of the hMLH1-deficient cell line HCT116 [Ohzeki, S., Tachibana, A., Tatsumi, T., Kato, T., 1997. Spectra of spontaneous mutations at the hprt locus in colorectal carcinoma cell lines defective in mismatch repair. Carcinogenesis, 18, 1127-1133.], the pronounced increase of +/-1 bp frameshifts and the reduced incidence of C-->T transitions at the CpG site suggest that the hPMS2 gene product may have an additional function in the mismatch repair process independent of it's role in the hMutLalpha heterodimer.

Cockayne syndrome without typical clinical manifestations including neurologic abnormalities

Although patients with mild symptoms of atypical Cockayne syndrome (CS) have been described, there has not been a report of a patient with CS whose only clinical manifestation was cutaneous photosensitivity. Cells from patients with CS show UV sensitivity, reduced recovery of RNA synthesis, but normal UV-induced unscheduled DNA synthesis. On the other hand, the patients with UV-sensitive syndrome have only cutaneous photosensitivity and skin freckles, whereas those cells respond to UV radiation in a similar fashion to the CS cells. We describe a patient with CS who showed only photosensitivity without typical clinical manifestations of CS, but his cells showed UV sensitivity, reduced recovery of RNA synthesis, and normal unscheduled DNA synthesis after UV radiation similar to CS cells. Furthermore, the patient was assigned to complementation group B of CS on the basis of the results of complementation analysis. The present report suggests that CS has a wider spectrum than that considered previously.

Relative biological effectiveness of accelerated heavy ions for induction of morphological transformation in Syrian hamster embryo cells

Syrian hamster embryo cells were used to study the morphological transformation induced by accelerated heavy ions with different linear energy transfer (LET) ranging from 13 to 400 keV/micron. Exponentially growing cells were irradiated with 12C or 28Si ion beams generated by the Heavy Ion Medical Accelerator in Chiba (HIMAC), then inoculated to culture dishes. Morphologically altered colonies were scored as transformants. Over the LET range examined, the frequency of transformation induced by the heavy ions increased sharply at very low doses no greater than 5 cGy. The relative biological effectiveness (RBE) of the heavy ions relative to X-rays first increased with LET, reached a maximum value of about 7 at 100 keV/micron, then decreased with the further increase of LET. Our findings confirmed that high LET heavy ions are much more effective than X-rays for the induction of in vitro cell transformation.

The relative biological effectiveness of accelerated carbon ions with different LET for inducing mitotic crossing over and intragenic reversion of the white-ivory allele in Drosophila larvae

PURPOSE

To evaluate the relative biological effectiveness (RBE) of accelerated carbon ions generated with a synchrotron for inducing mutations as a function of linear energy transfer (LET), using the loss of heterozygosity for wing-hair mutations and the reversion of the mutant white-ivory eye-colour in Drosophila melanogaster.

MATERIALS AND METHODS

The measurements were made using a combined mutation assay system so that induced mutant wing-hair clones as well as revertant eye-colour clones can be detected simultaneously in the same fly. Larvae were irradiated at the age of 72+/-6 h post-oviposition with X-rays or carbon ions with LET values of 13, 60 and 95 keV/microm.

RESULTS

The RBE of carbon ions for producing wing-hair mosaic spots increased with increasing LET values. The RBE for the induction of eye-colour mutants did not change with LET. The estimated RBE values were found to be in the range 2 to 6.5 for the wing-hair and nearly unity for the eye-colour mosaic spot mutations.

CONCLUSIONS

RBE-LET relationships were obtained for the induction of wing-hair and eye-colour mosaic spots. These relationships suggest that more complex types of DNA damage, such as nonrejoinable strand breaks that increase with LET, may be responsible for inducing the wing-hair mutation, while more simple forms of molecular damage induce reversion in the white-ivory allele.

Low levels of apoptosis and proliferative activity in colorectal villous tumors: comparison with tubular tumors

In order to clarify the cell kinetics of colorectal villous tumors (VT), 21 villous adenomatous areas and 12 carcinomatous areas within villous adenomas were investigated for proliferative activity and apoptosis and compared with a series of 41 tubular tumors (TT), demonstrating elements of intramucosal carcinomas as well as tubular adenomas (so-called carcinoma in tubular adenoma). Proliferation was estimated in terms of Ki-67 labeling indices and mitotic indices, and apoptosis was assessed by DNA nick-end labeling to give apoptotic indices. Apoptotic indices of villous adenomatous and carcinomatous regions were significantly lower than the values for their tubular counterparts. Ki-67 labeling indices were also significantly lower for adenoma components. Apoptotic indices, Ki-67 labeling indices and mitotic indices increased with atypia raised in tubular adenoma components. Correlations of mitotic indices with apoptotic indices, Ki-67 labeling indices with apoptotic indices and mitotic indices with Ki-67 labeling indices were found for each villous tumor group and tubular tumor group, and the apoptosis and proliferation ratios for villous tumors were relatively low, suggesting a tendency for greater growth due to less cell deletion. Although this is only one of the biological features of villous tumor groups, it might play a major role in generation of malignancy.

Biomechanical characterization of a biodegradable calcium phosphate hydraulic cement: a comparison with porous biphasic calcium phosphate ceramics

Biomechanical properties of a biodegradable calcium phosphate hydraulic cement (CPHC) were tested with rabbits. The cement was composed of beta-tricalcium phosphate (beta-TCP), monocalcium phosphate monohydrate (MCPM), and calcium sulfate hemihydrate (CSH), beta-TCP-MCPM-CSH cement. Cylinders of 4.7 mm in diameter and 10 mm in length were put into bone cavities created in the distal epiphysis of femurs in rabbits. Cylinders of the same size of porous biphasic calcium phosphate ceramics (BCPC, 75% hydroxyapatite and 25% beta-TCP) were implanted as references. Two, 4, 12, and 16 weeks after the operation, the rabbits were sacrificed. Histomorphometry showed that the cement was resorbed, leaving only 7.67 +/- 1.81% of bone cavity after 12 weeks. Newly formed bone occupied 34.59 +/- 4.00% of the cavity. Cylindrical bone-material composites were cut out with a small dental burr. Compressive force was applied to the specimens and compressive strength, elastic modulus, and toughness were calculated. The same tests were performed on cylinders of normal bone from the same site, which served as controls. The compressive strength and the toughness of the cement-bone composite were higher than those of normal bone and porous ceramics 12 weeks after the operation (p < 0.05). At 16 weeks the compressive strength and the toughness returned to the normal bone values. The elastic modulus of the porous ceramic-bone composite was higher than the normal bone at 4, 12, and 16 weeks after surgery (p < 0.05). We found that the beta-TCP-MCPM-CSH cement is replaced by new bone and that the cement-new bone composite has similar or better mechanical properties than normal bone within 16 weeks. This study suggests the usefulness of a particular cement for filling bone defects or for temporary fixation of orthopedic implants.