Incidence of fistula occurrence in patients with cervical cancer treated with bevacizumab: data from real-world clinical practice

Background

This study aimed to determine the incidence of pelvic fistulas in cervical cancer patients treated with bevacizumab in Japanese clinical practice.

Methods

A post-marketing surveillance (PMS) study was conducted between June 2016 and February 2018 to survey physicians who treated advanced or recurrent cervical cancer patients with bevacizumab (according to the product label). The clinical/treatment status of patients with pelvic fistulas was assessed in an additional retrospective case series study.

Results

142 patients were included in the PMS study (median age 51 years; 66.9% squamous cell carcinoma; 66.2% recurrent cervical cancer; 64.1% previous radiotherapy). Patients received a median of seven bevacizumab doses. Six patients, all of whom had a history of pelvic irradiation, developed seven fistulas (4.2%; 95% confidence interval, 1.56–8.96), and five patients had also undergone pelvic surgery. The case series study of the patients who developed fistulas indicated that three patients had high cumulative bladder and rectal doses of radiation, and two of them had undergone salvage re-irradiation for pelvic recurrence. The other three patients underwent both radical hysterectomy and adjuvant radiotherapy, but did not receive an excessive radiation dose to the bladder or rectum.

Conclusions

This study found that the upper limit of the 95% confidence interval for pelvic fistula incidence did not exceed the incidence reported in the GOG 240 study. To ensure an adequate benefit-risk assessment of bevacizumab in cervical cancer patients, a comprehensive evaluation of prior treatment is essential and the possibility of unexpected fistulas, even after careful evaluation, should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10147-022-02196-8.

Safety and effectiveness of bevacizumab in Japanese patients with malignant glioma: a post-marketing surveillance study

Objective

This surveillance study was conducted to verify the post-market safety and effectiveness of bevacizumab, which was approved in Japan in 2013 for the treatment of patients with newly diagnosed and or recurrent malignant glioma.

Methods

This was a prospective, observational, multicenter post-marketing surveillance study. Patients with newly diagnosed or recurrent malignant glioma scheduled for bevacizumab treatment were enrolled. The incidence and severity of adverse drug reactions were calculated. The effectiveness of bevacizumab was assessed by the 1-year survival rate and the overall survival rate.

Results

The safety analysis set and the effectiveness analysis set each comprised 258 of the 268 enrolled patients: tumours were newly diagnosed in 80 patients (31%) and recurrent in 178 patients (68.9%). The incidence of grade ≥ 3 adverse drug reactions was 15.1%. Adverse drug reactions of special interest included 14 cerebral bleeding events and 11 infections. Of the 80 patients with newly diagnosed malignant glioma, 44 (55%) were alive throughout the 18-month observation period. The 1-year survival rate for patients with newly diagnosed glioblastoma was 78%. Median overall survival was not calculated, but 51.2% of patients were alive at the last date of observation of the last observed patient. In patients with recurrent glioblastoma, the 1-year survival rate was 38.9%, and the median overall survival was 10.2 months.

Conclusions

The results suggest no new safety concerns, and the effectiveness might be similar to previously reported data in clinical trials. Therefore, bevacizumab is considered as one of the treatment options for patients with malignant glioma in real-world clinical practice.

A water soluble prodrug of a novel camptothecin analog is efficacious against breast cancer resistance protein-expressing tumor xenografts

PURPOSE

Identification of a novel topoisomerase I inhibitor which shows superior efficacy and less individual variation than irinotecan hydrochloride (CPT-11).

METHODS

A novel camptothecin analog that is effective against breast cancer resistance protein (BCRP)-positive cells was screened, and a water soluble prodrug was generated. Antitumor activity of the prodrug was examined in BCRP-positive and -negative xenografts both as a single agent and in combination with other anti-cancer drugs.

RESULTS

A novel camptothecin analog, CH0793076, was discovered. Because CH0793076 was found to be highly lipophilic, a water soluble prodrug (TP300) was generated. TP300 is stable in an acidic solution but is rapidly converted to CH0793076 under physiological pH conditions such as in sera. This efficient prodrug activation would minimize interpatient differences in pharmacokinetic and toxicity profiles. Unlike CPT-11, TP300 does not exhibit cholinergic interaction or cause acute diarrhea at effective doses. In mouse xenograft models, TP300 showed antitumor activity against both BCRP-positive and -negative xenografts, whereas CPT-11 was less active against BCRP-positive xenografts. In addition, the effective dose range (MTD/ED(50)) for TP300 was wider than for CPT-11 and TP300 showed additive or synergistic antitumor effects in combination with other anti-cancer drugs such as capecitabine, oxaliplatin, cisplatin, bevacizumab and cetuximab.

CONCLUSION

It is therefore expected that TP300 will provide an additional treatment option for patients who will undergo chemotherapy with camptothecins.

Involvement of cyclooxygenase-2 in the tumor site-dependent production of parathyroid hormone-related protein in colon 26 carcinoma

It has been shown that in the mouse colon 26 tumor model, tumors grown in the subcutis (subcutis colon 26) caused early onset of cachectic syndromes, whereas those in the liver (liver colon 26) did not. Both interleukin (IL)-6 and parathyroid hormone-related protein (PTHrP) were involved in the development of cachectic syndromes in this tumor model. However, whether expression of PTHrP and IL-6 is differently regulated in the tumor microenvironment is unclear. In the present study, culturing the colon 26 cells under different conditions in vitro revealed that IL-6 production was increased by monolayer culture under a low-glucose condition but not by spheroid culture. In contrast, PTHrP production was increased by spheroid culture but not by monolayer culture, even under a low-glucose condition. Gene expression profiling revealed that the expression of cyclooxygenase (COX)-2 was up-regulated in both subcutis colon 26 and spheroid cultures, and that COX-2 inhibitor NS-398 suppressed PTHrP production in spheroid cultures. Furthermore, administration of NS-398 decreased the PTHrP level without affecting the tumor growth in mice bearing subcutis colon 26. These results demonstrate that production of PTHrP and IL-6 largely depends on the microenvironments in which tumors are developed or metastasized and that up-regulation of COX-2 in a necrobiotic environment leads to PTHrP production, thereby causing cachectic syndromes.

Design and synthesis of novel prodrugs of 2′-deoxy-2′-methylidenecytidine activated by membrane dipeptidase overexpressed in tumor tissues

DNA microarray analysis comparing human tumor tissues with normal tissues including hematopoietic progenitor cells resulted in identification of membrane dipeptidase as a prodrug activation enzyme. Novel prodrugs of 2'-deoxy-2'-methylidenecytidine (DMDC) including compound 23 that are activated by membrane dipeptidase (MDP) preferentially in tumor tissue were designed and synthesized to generate the active drug, DMDC, after hydrolysis of the dipeptide bond followed by spontaneous cyclization of the promoiety.

Augmentation of the antitumor activity of capecitabine by a tumor selective dihydropyrimidine dehydrogenase inhibitor, RO0094889

Capecitabine is an orally available fluoropyrimidine and is finally converted to 5-FU selectively in tumor tissues. In our study, we examined whether the antitumor activity of capecitabine is directly affected by a modulation of dihydropyrimidine dehydrogenase (DPD). The modulations were carried out by the overexpression of DPD in tumor cells and by tumor selective DPD inhibition. The DPD-overexpressing cells were obtained by transfection of human DPD cDNA into HCT116 human colorectal cancer cells. The HCT116 cells bearing DPD cDNA expressed about 13 times higher DPD activities than the parental HCT116 cells, and they became significantly less susceptible to capecitabine than the parental cells when transplanted into nude mice. Administration of RO0094889 that is converted to a DPD inhibitor 5-vinyluracil selectively in tumor tissues restored the antitumor activity of capecitabine against the tumor of the HCT116 cells carrying DPD cDNA and various tumors expressing DPD. As compared to 5-ethynyluracil or 5-vinyluracil, which inhibited DPD not only in tumor tissues but also in other non-cancerous tissues, the effective dose range of RO0094889 in augmenting the efficacy of capecitabine was much broader. These results indicate that the antitumor activity of capecitabine is directly affected by DPD activities in tumor tissues and therefore, the combination of capecitabine and a tumor selective DPD inhibitor, RO0094889, will be beneficial to patients who have tumors with high levels of DPD.

Design and synthesis of the tumor-activated prodrug of dihydropyrimidine dehydrogenase (DPD) inhibitor, RO0094889 for combination therapy with capecitabine

A series of tumor-activated prodrugs of the inhibitors of dihydropyrimidine dehydrogenase (DPD), an enzyme catabolizing 5-fluorouracil (5-FU: 4g), has been designed and synthesized. RO0094889 (11c) is a prodrug of 5-vinyluracil (4c), a known DPD inhibitor, and was designed to generate 4c selectively in tumor tissues by sequential conversion of 11c by three enzymes: esterase, cytidine deaminase and thymidine phosphorylase, the latter two of which are known to be highly expressed in various tumor tissues. When capecitabine (1), a tumor-activated prodrug of 5-FU, was co-administered orally with 11c, 5-FU in tumor tissues was significantly increased with only a slight increase of 5-FU in plasma as compared with oral capecitabine alone.

Coronary artery bypass grafting for dialysis patients. Effects of cardiopulmonary bypass

OBJECTIVE

To assess the efficacy and safety of cardiopulmonary bypass during coronary artery bypass grafting (CABG) in dialysis patients.

METHODS AND RESULTS

Sixty four isolated CABG patients who underwent on cardiopulmonary bypass and whose intraoperative body weight gains were accurately measured were studied retrospectively. The mean intraoperative body weight gain was 2.61 +/- 0.9 kg/m2 in the study group and 1.06 +/- 0.6 kg/m2 in controls, i.e.) 100 patients selected at random from CABG patients during the same period using cardiopulmonary bypass without chronic renal faulure, showing a statistically significant difference. Complete revascularization was successful in 98% of patients. Postoperative nonlethal complications involved brain infarction in 1 patient (1.7%), reintubation in 1 (1.7%), and paralytic ileus in 2 (3.4%). All were successfully extubated within 24 hours of surgery, and no sternal wound complications were found. Hospital mortality was 6.3% (4/64). Actuarial survival rates at 3, 5 and 8 years including all deaths were 90%, 70% and 56%, and estimated by cardiac deaths were 95%, 90%, and 90% respectively. Cardiac event free rates were 90%, 73% and 61% at 3, 5 and 8 years after CABG.

CONCLUSIONS

In CABG for dialysis patients, the use of cardiopulmonary bypass demonstrates significant merits, and may expect long-term survival with minimal postoperative complications.

A physiologically based pharmacokinetic analysis of capecitabine, a triple prodrug of 5-FU, in humans: the mechanism for tumor-selective accumulation of 5-FU

PURPOSE

To identify the factors governing the dose-limiting toxicity in the gastrointestine (GI) and the antitumor activity after oral administration of capecitabine, a triple prodrug of 5-FU, in humans.

METHOD

The enzyme kinetic parameters for each of the four enzymes involved in the activation of capecitabine to 5-FU and its elimination were measured experimentally in vitro to construct a physiologically based pharmacokinetic model. Sensitivity analysis for each parameter was performed to identify the parameters affecting tissue 5-FU concentrations.

RESULTS

The sensitivity analysis demonstrated that (i) the dihydropyrimidine dehydrogenase (DPD) activity in the liver largely determines the 5-FU AUC in the systemic circulation, (ii) the exposure of tumor tissue to 5-FU depends mainly on the activity of both thymidine phosphorylase (dThdPase) and DPD in the tumor tissues, as well as the blood flow rate in tumor tissues with saturation of DPD activity resulting in 5-FU accumulation, and (iii) the metabolic enzyme activity in the GI and the DPD activity in liver are the major determinants influencing exposure to 5-FU in the GI. The therapeutic index of capecitabine was found to be at least 17 times greater than that of other 5-FU-related anticancer agents, including doxifluridine, the prodrug of 5-FU, and 5-FU over their respective clinical dose ranges.

CONCLUSIONS

It was revealed that the most important factors that determine the selective production of 5-FU in tumor tissue after capecitabine administration are tumor-specific activation by dThdPase, the nonlinear elimination of 5-FU by DPD in tumor tissue, and the blood flow rate in tumors.

Early results and characteristic problems associated with cardiac surgery in long-term dialysis patients

OBJECTIVE(S)

To analyze early results and characteristic problems that develop after cardiac surgery on dialysis patients.

METHODS

One hundred fourteen patients on maintenance dialysis underwent cardiac surgery. Their mean age was 63.5 +/- 9.7 years, and 87 (76%) were male. The causes of chronic renal failure were diabetes mellitus in 41 (36%) and chronic glomerulonephritis in 40 (35%). Patients had previously been on dialysis for a mean duration of 7.8 +/- 5.6 years (range; 0.25-24 years).

RESULTS

Fourteen (12%) were emergent cases. Eighty six patients (75%) received isolated coronary artery bypass grafting (CABG), and 10 patients underwent operations in which CABG was combined with other cardiac procedures. Twelve patients (14%) of the isolated CABG patient group (86 patients) were restricted to non-clamping bypass procedure due to severe calcification of the ascending aorta. Calcification score, which was represented by the sum of all involved coronary artery segments, was also significantly higher in dialysis patients than in the control group (4.5 +/- 2.4 segments vs. 1.5 +/- 2.1 segments, p < 0.05). Hospital mortality was 8.8% (10/114) overall, and 7% (6/86) in isolated CABG patients. The causes of deaths were as follows: intestinal necrosis in 3, arrhythmia in 2, cerebral infarction in 1, low output syndrome in 1, and sepsis in 3 (mediastinitis, pneumonia, and prosthetic valve infection).

CONCLUSIONS

Long-term dialysis is a major risk factor in cardiac surgery. However, because the surgical results proved to be acceptable, long-term dialysis patients should not be denied cardiac surgery.

One-stage thoracic aortic aneurysm treatment and coronary artery bypass grafting

OBJECTIVE

The treatment of thoracic aortic aneurysm accompanied by ischemic heart disease presents a surgical challenge and has up to now shown a high hospital mortality rate. This report discusses the factors contributing to improved results in these cases.

METHODS

We conducted a retrospective analysis of the records of 24 consecutive patients who had undergone replacement of thoracic aorta with combined coronary artery bypass grafting (CABG) between May 1991 and October 1998. Fifteen patients received total arch replacement (Arch-with-CABG Group), and the other 9 patients received the Bentall operation (Bentall-with-CABG Group). These results were compared with those patients who had undergone replacement of the thoracic aorta without CABG (Without-CABG Group).

RESULTS

In the combined CABG groups, the overall operative mortality rate was 16.7%. In comparison with the Arch-without-CABG Group, there was a significantly longer cardiopulmonary bypass time and longer selective cerebral perfusion time in the Arch-with-CABG Group. However, no significant difference was observed in postoperative complications between the two groups. In addition, there was no significant difference in either actuarial survival or the cardiac-event-free rate at 5 years between the replacement of thoracic aorta with- and without-CABG Groups (83.1% vs. 90.4%, and 78.5% vs. 77.7%, respectively). No reoperation and no late death were observed during the follow-up period (mean 21.3 months).

CONCLUSIONS

We concluded that replacement of the thoracic aorta combined with CABG can be carried out safely, and that revascularization for coronary artery disease is useful for preventing any occurrence of cardiac event.

Technical aspects and outcome of in situ right internal thoracic artery grafting to the major branches of the circumflex artery via the transverse sinus

BACKGROUND

Little is known about the anatomic limitations of in situ right internal thoracic artery (RITA) grafting to the circumflex artery.

METHODS

To evaluate the technical aspects and outcome of revascularization of the proximal and distal major branches of the circumflex artery (obtuse marginal [OM] branch and posterolateral [PL] branch), a total of 145 patients who possessed a graftable branch of the circumflex artery were enrolled into the prospective project. There were 73 patients who had the PL branch as a primary target and 72 patients with OM branches, which were allocated by a blinded observer who reviewed the preoperative angiography.

RESULTS

Changes of primary target vessels were required in 9 patients (6.2%), yielding an overall success rate of RITA grafting of 93.8%. The success rates of RITA grafting to the OM branch and the PL branch were 95.8% (69/72; CI 88.3% to 99.1%) and 91.7% (67/73; CI 83.0% to 96.9%), respectively. The univariate analysis identified grafting under hypothermic ventricular fibrillation as predictors of inability to use in situ RITA grafting for revascularization of the circumflex artery. RITA grafting to the PL branch is not identified as a predictor. Postoperative angiography in 136 patients revealed only one occlusion (0.75%) of the RITA graft anastomosed to the marginal artery. There were no significant differences in patency rates between left and right ITA grafts.

CONCLUSIONS

This prospective study showed that in situ RITA was, in most cases, able to reach most branches of the major circumflex artery and demonstrated an excellent patency rate.

Coronary artery bypass grafting for dialysis patients: usefulness of multiarterial bypass

This study assessed the efficacy of multiarterial bypass in coronary artery bypass grafting (CABG) in dialysis patients. Eighty dialysis patients who underwent CABG were divided into 2 groups. Group A consisted of 38 patients in whom the left internal thoracic artery and additional saphenous vein graft (SVG) had been used. Group B consisted of 42 patients in whom 2 or 3 arterial grafts and additional SVGs had been used. No mediastinitis was shown in either group. Actuarial survival rates, including all deaths, and estimated by cardiac deaths at 8 years, were 28% and 83%, respectively, in Group A and 93% and 100%, respectively, in Group B with a significant difference (p = 0.014 and 0.016, respectively). Cardiac event-free rates at 8 years were 43% and 96% in Groups A and B, respectively, with a significant difference (p = 0.0016). Multiarterial grafting improved long-term results after CABG for dialysis patients compared with single internal thoracic artery grafting with minimal complications related to graft harvesting.

Bilateral internal thoracic artery use for dialysis patients: does it increase operative risk?

BACKGROUND

The efficacy and risk of using the bilateral internal thoracic artery (BITA) for coronary artery bypass grafting in dialysis patients is virtually unknown.

METHODS

Twenty-five patients on dialysis who underwent coronary artery bypass grafting using the BITA were retrospectively studied (BITA group). For comparison purposes, 52 patients on dialysis who underwent coronary artery bypass grafting using the left ITA were selected (LITA group).

RESULTS

No wound healing problems occurred in the BITA group. Mean postoperative bleeding volume was 1,427 +/- 808 mL and 800 +/- 508 mL in the BITA and LITA groups, respectively (p = 0.00009). Blood transfusions for the BITA and LITA groups required an average of 6.8 and 6.2 units of packed red blood cells, respectively, with no significant difference. Five patients in the BITA group (20%) showed severe atherosclerotic deterioration of the ascending aorta, precluding clamping. Hospital mortality was 4% (1 of 25 patients) in the BITA group and 7.7% (4 of 52 patients) in the LITA group, with no significant difference (p = 0.49).

CONCLUSIONS

In patients on dialysis, especially those with severe atherosclerotic or calcified deterioration of the ascending aorta, coronary artery bypass grafting using BITA grafting (arterial in situ conduits) may offer the easiest and most suitable solution without increased operative risk.

Investigation of 5-FU disposition after oral administration of capecitabine, a triple-prodrug of 5-FU, using a physiologically based pharmacokinetic model in a human cancer xenograft model: comparison of the simulated 5-FU exposures in the tumour tissue between human and xenograft model

The nonlinear pharmacokinetics of capecitabine, a triple prodrug of 5-FU preferentially activated in tumour tissues, was investigated in human cancer xenograft models. A physiologically based pharmacokinetic (PBPK) model integrating the activation process of capecitabine to 5-FU and 5-FU elimination was constructed to describe the concentration/time profiles of capecitabine and its three metabolites, including 5-FU, in blood and organs. All the biochemical parameters (enzyme kinetic parameters, plasma protein binding and tissue binding of capecitabine and its metabolites) integrated in this model were measured in vitro. The simulated curves for the blood and tumour concentrations of capecitabine and its metabolites can basically describe the observed values. A simple prodrug of 5-FU, doxifluridine, is known to be activated to 5-FU to some extent in the gastrointestinal (GI) tract, causing diarrhoea, which is the dose limiting side effect of doxifluridine. Consequently, the therapeutic index (the ratio of 5-FU AUC in the tumour to that in GI) after the administration of effective dose capecitabine was predicted by this PBPK model and found to be five times and 3000 times greater than that of doxifluridine and 5-FU, respectively. This was compatible with the previous result for the difference in the ratio of the toxic dose to the minimum effective dose between capecitabine and doxifluridine, suggesting that 5-FU preferentially accumulates in tumour tissue after oral administration of capecitabine compared with the other drugs (doxifluridine and 5-FU). The 5-FU AUC in tumour tissue of human cancer xenograft models at the minimum effective dose was comparable with those estimated for humans at the clinical dose. In addition, the predicted therapeutic indices at the respective doses were correlated well between humans and mice (xenograft model). These results suggest that the 5-FU AUC in human tumour tissue at its clinically effective dose can be predicted based on the PBPK model inasmuch as the 5-FU AUC in a human cancer xenograft model at its effective dose may be measured or simulated.

The impact of chronic renal failure on atherosclerosis of the internal thoracic arteries

BACKGROUND

Little is known about the impact of renal failure on atherosclerotic changes in the internal thoracic artery (ITA).

METHODS

A total of 20 consecutive patients on chronic dialysis who underwent coronary artery bypass grafting (CABG) during April 1998 through September 1999 were investigated. The 20 control patients were selected from the same interval to rigorously match risk factors. Atherosclerosis of the ITA collected from each patient was analyzed using the subjective evaluation proposed by Kay and colleagues.

RESULTS

There were no cases of greater than 25% atherosclerotic luminal narrowing among a total of 35 ITA specimens from dialysis patients. The degree of atherosclerosis was not significantly different from that of the specimens from matched patients (p = 0.18). No calcification was found in ITA grafts either microscopically or macroscopically. The number of elastic lamellae, an index of the elasticity of the ITA graft, was not significantly different from those obtained from the matched patients. Analysis of preoperative coronary angiography revealed that coronary calcification was significantly more frequent in dialysis patients (15 patients, 75%) than in matched patients (p < 0.05). By analysis of postoperative angiography in dialysis patients, no evidence of atherosclerotic changes was found in 28 opacified ITAs. In addition, despite the presence of calcification in the native coronary, no calcification was evident along the entire length of the ITAs.

CONCLUSIONS

This study revealed the minimal impact of chronic renal failure on atherosclerotic changes in the ITA. The results of this study support the continued use of ITA grafting in dialysis patients.

Investigation of 5-FU disposition after oral administration of capecitabine, a triple-prodrug of 5-FU, using a physiologically based pharmacokinetic model in a human cancer xenograft model: comparison of the simulated 5-FU exposures in the tumour tissue between human and xenograft model

The nonlinear pharmacokinetics of capecitabine, a triple prodrug of 5-FU preferentially activated in tumour tissues, was investigated in human cancer xenograft models. A physiologically based pharmacokinetic (PBPK) model integrating the activation process of capecitabine to 5-FU and 5-FU elimination was constructed to describe the concentration/time profiles of capecitabine and its three metabolites, including 5-FU, in blood and organs. All the biochemical parameters (enzyme kinetic parameters, plasma protein binding and tissue binding of capecitabine and its metabolites) integrated in this model were measured in vitro. The simulated curves for the blood and tumour concentrations of capecitabine and its metabolites can basically describe the observed values. A simple prodrug of 5-FU, doxifluridine, is known to be activated to 5-FU to some extent in the gastrointestinal (GI) tract, causing diarrhoea, which is the dose limiting side effect of doxifluridine. Consequently, the therapeutic index (the ratio of 5-FU AUC in the tumour to that in GI) after the administration of effective dose capecitabine was predicted by this PBPK model and found to be five times and 3000 times greater than that of doxifluridine and 5-FU, respectively. This was compatible with the previous result for the difference in the ratio of the toxic dose to the minimum effective dose between capecitabine and doxifluridine, suggesting that 5-FU preferentially accumulates in tumour tissue after oral administration of capecitabine compared with the other drugs (doxifluridine and 5-FU). The 5-FU AUC in tumour tissue of human cancer xenograft models at the minimum effective dose was comparable with those estimated for humans at the clinical dose. In addition, the predicted therapeutic indices at the respective doses were correlated well between humans and mice (xenograft model). These results suggest that the 5-FU AUC in human tumour tissue at its clinically effective dose can be predicted based on the PBPK model inasmuch as the 5-FU AUC in a human cancer xenograft model at its effective dose may be measured or simulated.

Growth potential of left internal thoracic artery grafts: analysis of angiographic findings

BACKGROUND

The growth potential of the internal thoracic artery (ITA) is still undetermined, and little is known about the long-term effects of anastomosing it to the coronary artery.

METHODS

Fifty-three patients whose left ITA (LITA) had been anastomosed to the left anterior descending (LAD) coronary artery underwent coronary angiography within 1 month of operation and in late follow-up (mean interval: 4.5 +/- 1.5 years). The diameter ratios of LITA to LAD were designated as the matching ratio.

RESULTS

In follow-up, the diameter of the LITA increased from 1.83 +/- 0.40 to 2.46 +/- 0.53 mm in the 29 patients with progressive proximal native coronary stenosis. However, late results indicate that the matching ratio did not vary according to the location of the LITA anastomosis on the LAD (proximal portion: 1.13 +/- 0.16, distal portion 1.19 +/- 0.13), and reached an upper limit of about 1.4.

CONCLUSIONS

Growth potential of the LITA is limited by the diameter of the coronary artery onto which it is anastomosed. The most effective procedure for enhancing the growth potential of the LITA is to anastomose as proximally as possible onto the LAD.

Long-term results of bilateral internal thoracic artery grafting

BACKGROUND

Little is known about the long-term results of the uniform group of patients who had bilateral internal thoracic artery (ITA) grafting with the method of left ITA-to-left anterior descending coronary artery and right ITA-to-circumflex artery.

METHODS

Late follow-up study was performed in the first consecutive 203 patients (mean age, 62.6 +/- 9.1 years) who underwent isolated coronary artery bypass grafting with the left ITA anastomosed to the left anterior descending coronary artery and the right ITA to major branches of the circumflex artery. The patients were grouped according to the patency of ITA grafts demonstrated by early postoperative angiography (Both patent (BP) group, 168 patients: both ITAs showed complete patency; Not patent (NP) group, 23 patients: at least one ITA was dysfunctional).

RESULTS

Actuarial 7-year survival in all patients was 89.3% +/- 3.1%. The cumulative probability of event-free survival for cardiac death, myocardial infarction, intervention, and angina at 7 years was 96.6% +/- 1.8%, 98.0% +/- 1.5%, 86.7% +/- 3.2%, and 90.7% +/- 2.9%, respectively. NP group had more myocardial infarction and angina than the BP group, but was not statistically significant. Because of failed grafts at the early angiography, intervention was performed more frequently in NP group (p < 0.01).

CONCLUSIONS

Our results of actuarial 7-year survival and the cumulative probability of event-free survival were at least comparable to the results of other similar studies using bilateral ITA. The freedom from angina appeared to be better than in the previous study. Overall our study supports the continued use of this method of ITA grafting.

Complete revascularization of the left anterior descending coronary artery

OBJECTIVE

To assess the efficacy of complete revascularization of the left anterior descending coronary artery.

METHODS

To obtain such revascularization, 81 patients required the use of such complex techniques as the onlay patch technique or double bypasses during bypass grafting.

RESULTS

The onlay patch technique was used in 39 (48%) and double bypasses in 42 (52%). The wall motion in all anterior segments of the left ventricle showed an improving trend postoperatively. The patency rate was 99% overall, and the bypass grafts to the left anterior descending coronary artery were all patent with flow in all left anterior descending coronary artery areas. Perioperative myocardial infarction occurred in only 1 patient (1.2%), and hospital mortality was 2.5% (2/81). Long-term results of 79 hospital survivors were as follows: the mean follow-up time was 77 months (3 to 236); the actuarial survival rate including all deaths and estimated by cardiac death was 90% and 95% at the eighth postoperative year respectively; the cardiac event free rate at the fifth and eighth postoperative year was 90% and 63% respectively. A total of 8 cardiac events were observed. Excluding 3 cardiac deaths, no cardiac events were clearly attributable to the left anterior descending coronary artery.

CONCLUSIONS

Complete revascularization of the left anterior descending coronary artery using these techniques improved the anterior wall motion in the left ventricle and cardiac performance at low risk, and provided excellent long-term results.

An acoustically evoked short latency negative response in profound hearing loss patients

In our auditory brainstem response (ABR) tests, a peculiar V-shaped negative wave at around 3 4 ms latency was observed. At present, this acoustically evoked short latency negative response (ASNR) is poorly understood. In order to study its appearance and origin, the ABR data of 3104 tests during 1980-98 were reviewed. The ASNR was found only in profound hearing loss ears under intense stimuli (80-120 dB nHL). Out of the total 653 profound hearing loss patients (981 ears), the click-evoked ASNRs were present in 80 patients (12.3%), 117 ears (11.9%). The age range was from 8 months to 70 years. Demographic outcome revealed significant higher appearance rates in young subjects especially in the 20-30 years group. The ASNR was excluded from an artifact by its reproducibility over time, equipment and institutes. Moreover, it became absent after external auditory canal occlusion, which simply blocked the air conduction without any influence upon scalp potentials or equipment. It had neural response characteristics that the latency and amplitude shortened and increased respectively in response to the increase of stimulus intensity. Because the peculiar V-shaped waveform obviously differs from ABR, the ASNR was not interpreted as a potential generated from the conventional auditory pathway. On the other hand, the ASNR individuals were of good vestibular function in sharp contrast with their poor hearing. This suggests the probable relation between the ASNR and the vestibular system. The saccule and vestibular nucleus are hypothesized to be the sense organ and the origin of the response respectively.

The design and synthesis of a new tumor-selective fluoropyrimidine carbamate, capecitabine

To identify an orally available fluoropyrimidine having efficacy and safety profiles greatly improved over those of parenteral 5-fluorouracil (5-FU: 1), we designed a 5-FU prodrug that would pass intact through the intestinal mucisa and be sequentially converted to 5-FU by enzymes that are highly expressed in the human liver and then in tumors. Among various N4-substituted 5'-deoxy-5-fluorocytidine derivatives, a series of N4-alkoxycarbonyl derivatives were hydrolyzed to 5'-deoxy-5-fluorocytidine (5'-DFCR: 8) specifically by carboxylesterase, which exists preferentially in the liver in humans and monkeys. Particularly, derivatives having an N4-alkoxylcarbonyl moiety with a C4-C6 alkyl chain were the most susceptible to the human carboxylesterase. Those were then converted to 5'-deoxy-5-fluorouridine (5'-DFUR: 4) by cytidine deaminase highly expressed in the liver and solid tumors and finally to 5-FU by thymidine phosphorylase (dThdPase) preferentially located in tumors. When administered orally to monkeys, a derivative having the N4-alkoxylcarbonyl moiety with a C5 alkyl chain (capecitabine: 6) The highest AUC and Cmax for plasma 5'-DFUR. In tests with various human cancer xenograft models, capecitabine was more efficacious at wider dose ranges than either 5-FU or 5'-DFUR and was significantly less toxic to the intestinal tract than the others in monkeys.

[Surgical results of valvular heart disease combined with myocardial revascularization]

Risk factors for hospital death after combined valvular and coronary artery bypass surgery were examined in 131 consecutive cases between October 1988 and December 1999. These accounted for 8.0% of all 1,644 cases of coronary revascularization surgery and 15.3% of all 854 cases of valvular heart disease surgery. 84 men and 43 women underwent combined valvular and coronary artery bypass surgery. The mean age of the patients was 68.9 +/- 3.9 (22-86) years old. Numbers of cases comprised 58 undergoing aortic valve surgery, 63 undergoing mitral valve surgery, and 10 undergoing eight patients died during hospitalization after the operation: four due to cardiac death and four due to non-cardiac death. We studied pre- and perioperative risk factors for hospital death by means of multivariate analysis. As the major factors, ischemic mitral regurgitation, chronic renal failure, and duration of cardiopulmonary bypass were identified as three major predictors of hospital death. Ischemic mitral regurgitation was the strong predictor (p = 0.03) with 5 hospital deaths out of 38 ischemic mitral regurgitation cases (13.1%), whereas only 3 hospital deaths were seen in 93 other cases (3.2%) operated on in the same period. Over all operation results were not unfavorable, indicating that combined operations may be electively performed if severe coronary artery disease was present. The surgical results with ischemic mitral regurgitation are as yet not well documented and will require further study.

Long-term results of root reconstruction using the Carrel patch

OBJECTIVE

The treatment of annuloaortic ectasia in patients, including those with Marfan syndrome, ascending aortic dissection, and other disorders of the ascending aorta and aortic valve presents a surgical challenge that has, unfortunately, shown high hospital mortality up to now. Improvements in graft materials and advanced surgical techniques have, however, begun to reduce hospital mortality.

SUBJECTS AND METHODS

We retrospectively analyzed the records of 47 consecutive patients who undergoing aortic root reconstruction using the Carrel patch between January 1991 and March 1999.

RESULTS

Postoperative complications included myonephrotic metabolic syndrome caused by femoral artery cannulation in 2 patients. Reexploration was done to halt bleeding in 2 patients. In 1 of 4 acute dissection patients, retrograde filling of the false lumen was demonstrated postoperatively. Overall surgical mortality in this series was 2.1% (1 of 47). The cardiac-event free rate was 98% at 5 years and 88% at 8 years. Actual survival is 97.8% at 8 years. No anastomosis complications were seen during follow-up (average: 32.7 months) (about 2.73 years).

CONCLUSION

Surgery is considered feasible in any anatomic variation of aortic root disease, even in coronary ostial minimal dislocation, and the Carrel patch holds hope in preventing of anastomotic pseudaneurysm and ensuring long-term survival. Our experience suggests that modified Bentall operation, or aortic root remodeling using the Carrel patch, has few late-term complications, even in Marfan patients.

Ultrasonographic demonstration of manipulation-related aortic injuries after cardiac surgery

OBJECTIVES

This study was performed to evaluate the frequency and risk factors associated with new aortal lesions induced by surgical manipulation and their correlation with postoperative stroke.

BACKGROUND

Little is known about the causative mechanism of intraoperative atheroembolism after cardiac surgery.

METHODS

Epiaortic echocardiography was performed before cannulation and after decannulation in 472 patients undergoing cardiac surgery with extracorporeal circulation.

RESULTS

A new lesion in the ascending aortal intima was identified in 16 patients (3.4%) after decannulation. New lesions were severe, with mobile lesions or disruption of the intima in 10 patients. Six of the severe lesions were related to aortic damping and the other four to aortic cannulation. Three patients in this group had postoperative stroke. Univariate analysis identified only the maximal thickness of the atheroma near the aorta manipulation site as a predictor of new lesions. The incidence of new lesions was 11.8% if the atheroma was approximately 3 to 4 mm thick and as high as 33.3% if the atheroma was >4 mm, but only 0.8% when it was <3 mm. Total 10 patients (2.1%) sustained neurological complications. Arteriosclerosis obliterans, atherosclerosis of the aorta and new mobile lesions were identified as predictors of strokes.

CONCLUSIONS

This study demonstrated an association between new lesions created by surgical maneuvers and postoperative stroke. Embolic strokes were more likely to occur if new lesions were complicated with intimal disruption, especially of the mobile type. Modifications in surgical procedures will be needed if thick plaque (especially >4 mm) is noted near the manipulation site.

Cardiac operations in patients with severe pulmonary impairment

Many reviews concerning pulmonary complications after cardiac surgical procedures in patients with serious pulmonary disease have been published. However, no strict pulmonary function guidelines were proposed to help the clinician identify the patients at greater risk. We considered whether a low pulmonary function became a risk factor of cardiac operations. We conducted a retrospective analysis of records of 32 patients with severely impaired preoperative pulmonary function who had undergone cardiac operations between July 1988 and March 1999. There was 1 hospital death. The over-all mortality rate was 3.1% (1 of 32). However, this death could not be directly attributed to postoperative pulmonary complications. Postoperative pulmonary complications were seen in 2 patients (6.3%) who required tracheostomy due to atelectasis and pneumonia. No late deaths due to pulmonary complications were observed during the follow-up period. The actual survival rate is 68% at 7 years. A low pulmonary function did not, by itself, become a risk factor of cardiac operations, although a pulmonary function test can be used to alert the clinician to possible postoperative complications, including the requirement of tracheostomy. Especially strict control of postoperative respiration is necessary in patients with forced expiratory volume (FEV) of 1.0 <= 800 ml and/or FEV1.0/BSA <= 600 ml/m2.

Craniocervical and aortic atherosclerosis as neurologic risk factors in coronary surgery

BACKGROUND

Advanced age is associated with increased systemic atherosclerosis and is a consistent neurologic risk factor after coronary artery bypass grafting (CABG).

METHODS

We studied prospectively whether varying degrees of a total atherosclerotic score derived from the brain, carotid arteries, and ascending aorta predicted postoperative neuropsychologic (NP) dysfunction and stroke in 177 elderly patients (> or = 60 years) undergoing CABG.

RESULTS

Group L (low total atherosclerotic score) had rates of NP dysfunction of 25% and 4%, group I (intermediate) had rates of 33% and 22%, and group H (high) had rates of 79% and 43% on postoperative days 1 and 7, respectively (p < 0.001). The incidence of stroke was higher in group H (14.3%) than in groups I and L (7.8% and 0.9%; p = 0.013). Stepwise logistic regression analysis demonstrated the significant predictors of NP dysfunction on postoperative day 7 to be total atherosclerotic score, peripheral vascular disease, and diabetes mellitus, and those of stroke to be total atherosclerotic score, peripheral vascular disease, and hyperlipidemia.

CONCLUSIONS

Perioperative evaluation of craniocervical and aortic atherosclerosis is useful to identify a high-risk patient at postoperative NP dysfunction and stroke after CABG.

Analysis by early angiography of right internal thoracic artery grafting via the transverse sinus : predictors of graft failure

BACKGROUND

There has been debate regarding whether technically demanding right internal thoracic artery (RITA) grafting via the transverse sinus can be extensively applied to patients in high-risk groups, such as patients with a small body size, elderly patients, and woman with relatively smaller coronary artery and internal thoracic artery (ITA) diameters.

METHODS AND RESULTS

Of the 1456 patients who underwent isolated coronary artery bypass grafting between January 1989 and December 1998 at Kumamoto Central Hospital, 393 patients (mean age, 62.4+/-9.0 years) with the RITA anastomosed to the major branches of the circumflex artery were studied. Left ITA grafting was performed in 384 patients, and in 369, the in situ left ITA was anastomosed to the left anterior descending coronary artery using standard methods. Early postoperative angiography was performed in 381 patients. The RITA was occluded in 4 patients, and string-like artery and significant stenosis were present in 11 and 7 patients, respectively; RITA graft patency was thus 94.1%. Of the preoperative variables and angiographic data, simple and multiple logistic regression analyses identified decreased severity of native stenosis, diffuse sclerosis of native vessels, and residual side branches of the ITA as independent predictors of nonfunctional grafts. The method of ITA grafting did not influence the patency of the graft.

CONCLUSIONS

The excellent patency rate demonstrated by this study, the largest angiographic study to date of RITA grafting via the transverse sinus, indicates that this technique can provide reliable revascularization of the left ventricle and that it has the potential to be applied to a wide variety of patients with diseased circumflex arteries.

Coronary artery bypass grafting in dialysis patients

BACKGROUND

To analyze the characteristic problems of coronary artery bypass grafting in patients with chronic renal failure.

METHODS

Fifty-one consecutive dialysis patients who required isolated coronary bypass grafting over a 9-year period were studied retrospectively.

RESULTS

Nine patients (18%) had emergent operation, 4 of whom had intraaortic balloon counterpulsation instituted preoperatively. A mean of 3.3 +/- 1.0 bypasses per patient were grafted; 14 patients (27%) had bypass with two arterial grafts, 13 (25%) of which used left internal mammary artery and gastroepiploic artery and one of which used bilateral internal mammary artery grafts. A mean of 4.2 +/- 2.6 coronary artery segments were calcific according to American Heart Association classification. Eight patients (16%) required operative modifications to avoid manipulating calcific plaques on the ascending aorta. Four patients (7.8%) died, and 15 had nonlethal complications. The actuarial survival rates in 47 hospital survivors at 1, 3, and 5 years were overall 89%, 84%, and 71%, respectively, and estimates for cardiac deaths 93%, 93%, and 82%, respectively. Cardiac event-free rates after coronary artery bypass grafting were 83% and 65% for 3- and 5-year periods, respectively.

CONCLUSIONS

Calcification of coronary arteries and the ascending aorta is a serious problem in long-term dialysis patients. However using arterial grafts, preferentially, in situ, seems to provide a practical alternative to minimize manipulating the ascending aorta during coronary artery bypass grafting, with acceptable perioperative morbidity and mortality rates and long-term survival.

Bileaflet mechanical valve (St. Jude Medical valve) replacement in long-term dialysis patients

BACKGROUND

Few reports exist on the results of bileaflet mechanical valve (St. Jude Medical prosthesis; St. Jude Medical, Inc, St. Paul, MN) replacement in long-term dialysis patients.

METHODS AND RESULTS

We retrospectively reviewed 12 patients, ranging in age from 50 to 86, undergoing long-term renal dialysis who had also undergone mechanical valve replacement at our institution. Operative procedures included aortic valve replacement, aortic and mitral valve replacement, aortic valve replacement and mitral annuloplasty, mitral valve replacement, and modified Bentall's operation. There was 1 hospital death (8.3%). During the mean follow-up period of 37.1 months (range: 5-87 months), there were 2 noncardiac late deaths. Bleeding from the esophageal varix and from a duodenal ulcer occurred in 1 patient with end-stage liver cirrhosis. There were no other major cases of bleeding or cerebrovascular accidents. There were no valve-related complications. All the survivors demonstrated excellent clinical improvement under the NYHA functional classification.

CONCLUSIONS

Our study demonstrated good early and long-term results of mechanical valve replacement in patients undergoing long-term dialysis. These favorable results support the continued use of mechanical valves in dialysis patients.

In situ right internal thoracic artery graft for revascularization of circumflex artery. Early results and long-term angiographic follow up

In 285 patients, the right internal thoracic artery, routed through the transverse sinus, was in most cases anastomosed to the circumflex branches. In 278 cases, the left internal thoracic artery was simultaneously used for revascularization of the left anterior descending artery. Two patients died (mortality rate 0.7%). Postoperative early angiography on 278 patients revealed a high graft patency of 97.8% for the right internal thoracic artery and 96.9% for the left internal thoracic artery. A long-term follow-up study was performed on the first consecutive 115 patients who survived the operation. Seven patients died, 2 due to cardiac causes. Angiographic assessment was performed in 73 patients (67%) at an interval of 28.8 to 93.1 months (mean 58.9 months). Five right internal thoracic arteries were occluded and sledlike right internal thoracic artery grafts were present in 2 patients. Two of them had been confirmed in the previous early study to be not patent. Insufficient data was obtained in 4 patients. The perfect patency rate of the right internal thoracic artery was 89.9% (62/69). Five left internal thoracic arteries were occluded, providing a perfect patency rate of 92.3%. There was no significant difference between the success rate using the right internal thoracic artery and that resulting from using the left internal thoracic artery. We conclude that coronary revascularization using this technique provides good clinical results and excellent early and late patency of the right internal thoracic artery.

[Evaluation of the results of the combined maze procedure for chronic atrial fibrillation with organic heart disease]

To examine the surgical indications and the results of the maze procedure, we reviewed 30 cases who underwent the maze procedure concomitantly with other open heart surgery from October 1995 to October 1997.: the average age was 60.9 years (37 to 75 years) and mean follow up period was 12.3 months (1 to 25 months). The modified maze procedure described by Kosakai and associates was applied in all patients. Twenty one patients (72.4%) regained atrial rhythm and eight patients (27.6%) sustained atrial fibrillation in the follow up periods. The left atrial diameter measured by echocardiography and cardiothoracic ratio were significantly larger in the latter group of patients, compared with those who recovered normal sinus rhythm (63.8 +/- 19.5 versus 51.2 +/- 7.8 mm and 67.7 +/- 8.1 versus 59.2 +/- 5.4%). In order to perform the combined maze procedure, cardiac arrest time and cardiopulmonary bypass time were extended for 56.9 minutes and 65.9 minutes, respectively, compared with the cases without a maze procedure. Four patients (brady atrial fibrillation 2, brady junctional rhythm 1, and complete AV block 1) required permanent pacemaker implantation. There was no operative death, but one patient who underwent the maze procedure and AVR + MAP + TAP died after 4 months due to pulmonary infection, sepsis and multiple organ dysfunction. This patient had shown low output syndrome for 3 days postoperatively. Having considered the data that the preoperative ejection fraction was 51%, cardiopulmonary bypass and cardiac arrest time were 200 min and 165 min respectively, occurrence of low cardiac output had been influenced by prolonged aortic cross-clamp. No late deaths have been observed in follow up period. In conclusion, maze procedure should not be performed in patients who have enlarged left atrium or complex cases requiring relatively longer operative time.

Coronary artery bypass grafting in patients with systemic lupus erythematosus

OBJECTIVE

Few reports exist on the results of coronary artery bypass grafting (CABG) in patients with systemic lupus erythematosus (SLE).

METHODS

We retrospectively reviewed eight CABG in seven SLE patients. In early and late postoperative angiography, all grafts were evaluated for occlusion, development of string sign, or presence of significant stenosis. The early and late results were compared. The pathological studies were performed on the segments of the internal thoracic artery (ITA) and saphenous vein collected from each patient. Atherosclerosis of the ITA was analyzed using the subjective evaluation proposed by Kay et al. (Kay HR, Korns ME, Flemma RJ, Tector AJ, Lepley D. Atherosclerosis of the internal mammary artery. Ann Thorac Surg 21;1976:504-507) scale 0-4 (0 = normal, 1 = minimal disease, 2 = less than 25% luminal narrowing, 3 = 25-50% narrowing, and 4 = greater than 50% narrowing).

RESULTS

The patients consisted of three men and four women with a mean age of 59.8 years. Co-morbid diseases were frequent and there were three patients (37.5%) with renal failure (two dialysis patients, one with renal dysfunction) and two patients with severe atherosclerosis of the aorta. The ITA was used in four patients. Saphenous vein graft was used in seven patients. Concomitant procedures included aortic valve replacement and mitral annuloplasty, mitral valvuloplasty and tricuspid annuloplasty, mitral valve replacement and tricuspid annuloplasty (TAP). There was one hospital death (12.5%). Early patency rates were 87.5% (21/24). No other atherosclerotic changes or stenosis suggesting vasculitis were noted. In pathological studies, there was no significant atherosclerosis in the six ITA specimens from four patients, although three patients had degree two atherosclerosis. No vasculitis was found in ITA or saphenous vein grafts. During the mean follow-up period of 35.3 months (range, 5-91 months), there was one non-cardiac late death. Late restudy (in three patients, 12, 57 and 64 months later respectively) revealed no deterioration in either ITA or vein grafts. Overall prognosis after the operation in SLE patients appears to be good. No other cardiac events were observed, and patients demonstrated marked clinical improvement.

CONCLUSIONS

CABG in SLE patients can be performed with acceptable morbidity and mortality. Our data so far reveals no evidence to preclude the use of ITA and vein grafts in SLE patients.

[The ratio of cervical subacute necrotizing lymphadenitis occupying superficial lymphadenopathy and its clinical findings]

INTRODUCTION

Diseases in which cervical lymphadenopathy is a chief complaint are commonly observed. These cases are associated with a good prognosis, high fever and pain which usually recovers without medication. This condition is referred to as subacute necrotizing lymphadenitis (SNL). We investigated cases of SNL that were correctly diagnosed by biopsy.

OBJECT AND METHODS

We examined cases of SNL that were correctly diagnosed by biopsy in the Naha Prefectural hospital between April 1987 and March 1997. We statistically analyzed the ratio of occurrence and clinical findings (age, sex, season of occurrence, physical characteristics, clinical progress, blood findings, therapy, and prognosis).

RESULTS

In a total of 629 cases, a biopsy specimen from the body surface of the area affected by lymphadenopathy was obtained. Among these cases, SNL was diagnosed in 54 accounting for 9% of the total body surface biopsies and 13% of the cervical lymphadenopathic biopsies. Sex: Of the 54 subjects, 18 were males and 36 females. AGE: Most of the subjects (87%) ranged from 10 to 30 years of age. Season of occurrence: The number SNL cases decreased from 1993. Many cases occurred in the cold season, from October to March.

CLINICAL FINDINGS

Forty cases were investigated as fever, swelling, pain and complications. FEVER: Six cases (15%) were not associated with fever and 34 cases (85%) exhibited fever. Swelling: All subjects demonstrated swelling for at least one week and the longest duration of swelling was six months. Swelling continued for two to three months on average. Thirty-five cases (88%) showed swelling on one side only, left or right, and five cases (12%) showed swelling on both sides. PAIN: Ten cases (25%) were without pain and 30 cases (75%) with some pain.

COMPLICATIONS

Twelve cases (30%) had complications including six of drug allergy, four of dermatitis, and some cases of diabetes mellitus and hyperthyroidism. Eleven of 54 cases (20%) were admitted to the hospital. Blood findings: The white blood cell level decreased in 30 of 37 cases (82%). As shown below, increased levels of CRP (6/34), ESR (4/31) and LDH (17/31) were observed.

THERAPY

Steroids were administered in 24 of 36 cases and were effective in all cases. Antibiotics were administered in 25 of 31 cases and were effective in six cases (19%)) and ineffective in 10 cases (32%). The condition in nine cases (29%) worsened. Pain killers were employed in 26 of 32 cases. They were effective 18 cases (56%) and ineffective in eight cases (25%). No subjects died. The prognoses were good and all patients recovered without sequela.

CONCLUSION

SNL was detected in a large number of patients with cervical lymphadenopathy who visited our hospital, if patients who were not diagnosed correctly by biopsy were included. Many patients exhibited lymphadenopathy on one side (88%). This result was slightly higher than that previously reported. SNL is considered to be related to allergy or upper respiratory infections. This disease often occurs in cold seasons and patients often exhibit complications such as drug allergies or antoimmune diseases.

[A case of atypical Miller Fisher syndrome associated with antiphospholipid antibodies]

We report a 56-year-old man with external ophthalmoplegia and ataxic gait following a diarrhea, being diagnosed atypical Miller Fisher syndrome (FS). On admission, he had severe diplopia and bilateral external ophthalmoplegia were observed. The deep tendon reflexes were decreased on the right upper extremity. He could not walk straight and his tandem gait was impaired. Serum IgG anticardiolipin antibody (aCL) and APTT-lupus anticoagulant (LA) were found to be increased. The serum of the patient had low titer of anti-GQ 1 b and anti-GM 1 antibodies. After the first immunoadsorption therapy, his ophthalmoplegia was improved moderately, but peripheral facial palsy appeared. He was treated with immunoadsorption again, then all neurologic symptoms improved and a follow-up study revealed normalized aCL and LA titers. There have been no previous reports of FS associated with antiphospholipid antibody. The low titer of serum anti-GQ1b and anti-GM 1 antibodies in this patient suggests that the antiphospholipid antibodies, such as aCL and LA, may be linked to the pathogenesis of FS.