Utility and optimal management of planned drug holidays during lenvatinib treatment in patients with unresectable differentiated thyroid cancer: a real-world multi-center study

PURPOSE

Lenvatinib achieves favorable therapeutic outcomes for patients with radioactive iodine therapy refractory differentiated thyroid cancer (DTC); however, its use is associated with a high incidence of adverse events. To avoid severe adverse events, planned drug holidays (PDH) have been proposed. This study aimed to evaluate treatment effects, identify prognostic factors, and investigate the usefulness of PDH in patients with unresectable DTC who received lenvatinib across the multi-institutions.

METHODS

Fifty-one patients with unresectable DTC treated with lenvatinib were evaluated retrospectively. Overall survival (OS) and progression-free survival (PFS) were calculated, and prognostic factors were assessed. OS, PFS, and time to treatment failure (TTF) were compared between patients with and without PDH. Lenvatinib administration schedule was evaluated in PDH.

RESULTS

The 3-year OS and PFS rate were 53.5% and 42.1%, respectively. Multivariate analysis revealed that presence of maximum size of lung metastasis ≥10 mm was independent prognostic factor for poorer OS and PFS, and histology other than papillary thyroid carcinoma was the independent prognostic factor for poorer PFS. Twenty-five patients (49%) treated with PDH. There were significant differences in OS, PFS, and TTF between patients with and without PDH. Various schedules were used in PDH. Eight (32%) patients required switch to the different administration schedule.

CONCLUSION

Our results suggest that PDHs may extend OS, PFS, and TTF. In patients with PDH, various schedules used for lenvatinib administration highlight the difficulty in determining a uniform administration schedule. Therefore, it is crucial to consider the optimal lenvatinib administration schedule on a case-by-case basis.

Novel radical pelvectomy technique to treat chondrosarcoma in a large-breed dog

Surgical management of chondrosarcoma with hemipelvectomy is well described, but there have been no reports on extensive excision involving bilateral pubis and unilateral ischium. This report describes a novel pelvectomy technique for the treatment of chondrosarcoma in a large-breed dog. A 12-year-old Labrador Retriever presented for tenesmus due to a large, intra-pelvic mass which was confirmed on computed tomography (CT). Surgery involved removal of the entire left ischium and both pubic bones with preservation of both hind limbs. Histopathology confirmed the diagnosis of a high-grade chondrosarcoma with tumour-free margins of less than 3 mm. The dog recovered well following surgery and regained ambulation within 9 days. Four months postoperatively, the dog had no ongoing pain or tenesmus and only a mild gait abnormality in the left hind limb. Pelvectomy involving the entire pubis and unilateral ischium was well tolerated in a large-breed dog. This technique may offer a novel surgical option to treat neoplasia previously considered too extensive for complete excision.

Cyclooxygenase-2 expression is associated with chemoresistance through cancer stemness property in hypopharyngeal carcinoma

Cyclooxygenase-2 (COX-2) is one of the two isoforms of COX, an enzyme that catalyzes the conversion of arachidonic acid to prostaglandins. COX-2 is associated with the progression in various types of cancer, and its expression has been associated with a poor prognosis in head and neck squamous cell carcinoma (HNSCC). Furthermore, COX-2 expression has been associated with resistance to anticancer drugs. However, the precise mechanism of COX-2 for chemoresistance in HNSCC has not been fully elucidated. The present study aimed to investigate the effect of COX-2 on cancer stem cell (CSC) property and to reveal its effect on chemoresistance using in vitro and clinicopathological assays in HNSCC cells and tissues. The current study analyzed the immunohistochemical expression levels of COX-2 and clinicopathological factors using matched samples of pretreatment biopsy and surgical specimens from patients with hypopharyngeal carcinoma who underwent tumor resection with preoperative chemotherapy, including docetaxel. Additionally, the chemoresistance to docetaxel with or without a COX-2 inhibitor (celecoxib) was examined in HNSCC cell lines by MTS assays. To evaluate the association of COX-2 expression with stemness property, the expression levels of CSC-associated genes after exposure to celecoxib were assessed by reverse transcription-quantitative PCR. A sphere formation assay was also performed using ultra-low attachment dishes and microscopic imaging. The immunohistochemical analysis of biopsy specimens revealed a negative association between COX-2 expression in biopsy specimens and the pathological effect of induction chemotherapy in surgical specimens. The cell survival rate under exposure to docetaxel was decreased by the addition of celecoxib. COX-2 inhibition led to downregulation of CSC-associated gene expression and sphere formation. The present findings suggested that COX-2 expression may be associated with chemoresistance through the cancer stemness property, and inhibition of COX-2 may enhance chemo-sensitivity in HNSCC. Therefore, COX-2 may be an attractive target for the treatment of HNSCC.

Cyclo-oxygenase-2 Expression Is Associated With Lymph Node Metastasis in Oropharyngeal Squamous Cell Carcinoma Under the New TNM Classification

BACKGROUND

This study aimed to investigate p16 and COX2 expression in oropharyngeal squamous cell carcinoma (OPSCC), and evaluate the prognostic role of COX2 expression under the new TNM classification.

MATERIALS AND METHODS

Biopsy specimens obtained from 75 patients with OPSCC were stained for p16 and COX2 expression immunohistochemically. The results and clinical records were analyzed retrospectively.

RESULTS

Fifty-nine patients (79%) were positive for p16. COX2 expression was correlated with poor relapse-free survival in patients overall, and in p16-positive patients. Smoking was positively associated with COX2 expression. Moreover, both positive COX2 expression and anterior wall tumor subsite were independently correlated with lymph node metastasis, which was the only independent prognostic factor in p16-positive OPSCC.

CONCLUSION

The p16-positive rate in this study was comparable with that in the USA and Europe, and higher than that in other Asian countries. COX2 expression might affect the prognosis of p16-positive OPSCC through promoting lymph node metastasis.

Abstract 914: COX-2 expression is associated with chemoresistance through cancer stemness property in head and neck squamous cell carcinoma

Introduction: COX-2 is one of the two isoforms of cyclooxygenase, an enzyme that catalyzes the conversion of arachidonic acid to prostaglandins. COX-2 is considered to be associated with progression in various cancers, and its expression has been reported to have an impact on poor prognosis in head and neck squamous cell carcinomas (HNSCCs). Furthermore, COX-2 expression has been shown to be associated with resistance to anticancer drugs. However, the precise mechanism of COX-2 for chemoresistance in HNSCC is not fully elucidated. The aim of the present study was to investigate the impact of COX-2 on cancer stem cell property, and to reveal its effect on chemoresistance by in vitro and clinicopathological assays. Methods: We examined the chemoresistance to docetaxel with or without COX-2 inhibitor (celecoxib) in HNSCC cell lines (FaDu, Detroit512) by MTS assays. To evaluate the association of COX-2 expression with stemness property, we assessed alteration of expression levels of the genes related to cancer stem cell (CSC) property after exposure to celecoxib by quantitative real-time PCR. We also performed a sphere formation assay using ultra low attachment dishes and microscopic imaging. Moreover, we analyzed immunohistochemical expressions of COX-2 and clinicopathological factors by using matched samples of pre-treatment biopsy and surgical specimens from hypopharyngeal carcinoma patients who had undergone trans-oral tumor resection with preoperative induction chemotherapy including docetaxel. Results: Cell survival rate under exposure to docetaxel was decreased by addition of celecoxib. COX-2 inhibitor downregulated the expression of Oct3/4 and Nanog. Sphere formation was inhibited by co-culture with COX-2 inhibitor, especially in FaDu cells. Immunohistochemical study in biopsy specimens revealed a negative correlation between COX-2 expression in biopsy specimens and pathological effect of induction chemotherapy in surgical specimens. Conclusion: The present study suggests that COX-2 expression is associated with cancer stemness property, and inhibition of COX-2 has a possibility to enhance chemosensitivity in HNSCCs. Furthermore, initial COX-2 expression in biopsy specimens may predict the effect of chemotherapy in HNSCCs. These results indicate that COX-2 can be an attractive target for the treatment of HNSCC.

Citation Format: Shin Saito, Hiroyuki Ozawa, Yorihisa Imanishi, Mariko Sekimizu, Yoshihiro Watanabe, Fumihiro Ito, Yuichi Ikari, Nana Nakahara, Kaori Kameyama, Kaoru Ogawa. COX-2 expression is associated with chemoresistance through cancer stemness property in head and neck squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 914.

Pretreatment monocyte counts and neutrophil counts predict the risk for febrile neutropenia in patients undergoing TPF chemotherapy for head and neck squamous cell carcinoma

Background

Febrile neutropenia (FN) is the most serious hematologic toxicity of systemic chemotherapy. However, accurate prediction of FN development has been difficult because the risk varies largely depending on the chemotherapy regimen and various individual factors.

Methods

We retrospectively analyzed diverse clinical factors including pretreatment hematological parameters to clarify the reliable predictors of FN development during chemotherapy with a docetaxel, cisplatin, and fluorouracil (TPF) regimen in patients with head and neck squamous cell carcinoma.

Results

Among the 50 patients, grade ≥3 neutropenia, grade 4 neutropenia, and FN developed in 36 (72%), 21 (42%), and 12 (24%) patients, respectively. Multivariate logistic regression revealed that a pretreatment absolute monocyte count (AMC) <370/mm³ is an independent predictor of TPF chemotherapy-induced FN (odds ratio=6.000, p=0.017). The predictive performance of the model combining AMC and absolute neutrophil count (ANC), in which the high-risk group was defined as having an AMC <370/mm³ and/or ANC <3500/mm³, was superior (area under the curve [AUC]=0.745) to that of the model with a cutoff for AMC alone (AUC=0.679).

Conclusions

On the basis of our results, we recommend primary prophylactic use of granulocyte colony-stimulating factor and/or antibiotics selectively for patients predicted to be at high risk for TPF chemotherapy-induced FN.

Synovial sarcoma of the maxillary sinus: an extremely rare case with excellent response to chemotherapy

This paper presents an extremely rare case of synovial sarcoma arising from the maxillary sinus, which resulted in a clinically complete response to chemotherapy. Synovial sarcoma is a rare soft tissue malignant tumor, most commonly affecting the extremities. While ~10% occur in the head and neck region, synovial sarcoma of the sinonasal tract is extremely rare, with only 11 cases having been reported previously. As with other sarcomas, the standard treatment is complete resection while allowing for a safe margin, but this is often difficult in the head and neck area due to the complicated anatomy there. This makes the treatment of head and neck sarcoma challenging and leads to the need for a multimodal approach in advanced cases. However, the exact efficacy of chemotherapy is not well understood. In this report, we present a case of unresectable maxillary sinus synovial sarcoma that was successfully treated by chemotherapy followed by radiation therapy. A 53-year-old Japanese man was referred to our hospital with a history of left nose obstruction over the previous couple of years. Computed tomography/magnetic resonance imaging revealed a tumor arising from the maxillary sinus that extended to adjacent tissues. A biopsy was performed, and the tumor was diagnosed as synovial sarcoma. Since the tumor was unresectable, neoadjuvant chemotherapy was administered. The response was excellent, and the tumor became undetectable under endoscopy and radiological imaging. This provided us with a clinical evaluation of “complete response”. The treatment was concluded with definitive radiotherapy and two more cycles of adjuvant chemotherapy. The patient remains free of disease 12 months after treatment. Synovial sarcoma of the head and neck is a rare entity; complete resection is the treatment of choice but (neo)adjuvant chemotherapy can be considered in unresectable cases, as we show here in the present case.

Nursing care for dialysis patients in Japan

In Japan, the number of chronic renal failure patients requiring dialysis treatment is increasing by approximately 10,000 patients a year, totalling 229,538 or 1,801.2 patients per one million population at the end of December, 2002 according to the survey conducted by the Japanese Society for Dialysis Therapy. The primary disease is diabetic nephropathy (28.1% of patients), and with greater numbers of long-term and elderly patients, the incidence and severity of complications continue to increase. Dialysis units provide more diversified care, but budget cuts in health care make it difficult to secure sufficient personnel, and the workload on nurses has intensified. In this study, a survey of 157 out of 300 randomly selected dialysis facilities in Japan was made regarding nursing systems and nurses' concerns for medical care of dialysis patients.

Quantitative assessment of right ventricular structural abnormalities by right ventricular polar mapping of single photon emission computed tomogram

The identification of right ventricular (RV) abnormalities is clinically important in the evaluation of arrhythmogenic substrates in right ventricular-originated ventricular tachycardia (RVT). The purpose of this study was to determine the diagnostic benefit of quantitative analysis in RV single photon emission computed tomography (SPECT) imaging with (99m)Tc-tetrofosmin/sestamibi in patients with RVT. Thirty patients with RVT (15 with idiopathic RVT and 15 with arrhythmogenic right ventricular cardiomyopathy (ARVC)) were compared with 27 control subjects (including 11 with right bundle branch block) with regard to the semiquantitative RV uptake score in each of six segments and the quantitative RV extent score in polar coordinate map displays by SPECT imaging. The RV total score and RV extent score were compared with the RV global function. Perfusion abnormalities were more frequently detected (P = 0.0001) in the ARVC group (59/90, 65.6%) than in the idiopathic RVT group (4/90, 4.4%) or controls (1/162, 0.6%). The RV extent score in the ARVC group (53.0 +/- 24.8) was significantly higher than that in the idiopathic RVT group (8.4 +/- 10.1) or controls (1.2 +/- 4.9). The RV extent score correlated well with the regional RV perfusion score (P < 0.0001) and with the RV ejection fraction (P < 0.0001). Non-invasive RV perfusion mapping using a (99m)Tc-labelled tracer is useful for the quantitative evaluation of RV substrates in patients with ARVC.

Process of apoptosis induced by TNF-alpha in murine fibroblast Ltk-cells: continuous observation with video enhanced contrast microscopy

Apoptosis is originally defined by unique morphological changes of dying cells, and the biochemical hallmark associated with apoptosis is internucleosomal DNA fragmentation. However, few report has shown the precise time course of the apoptotic events. The present study was designed to try to clarify apoptotic processes using a video-enhanced contrast-differential interference contrast (VEC-DIC) microscopy. The morphological changes of murine fibroblast Ltk-cells treated with TNF-alpha were divided into four stages: (i) pre-apoptotic, (ii) cytoplasmic shrinkage, (iii) membrane blebbing, and (iv) ballooning. Almost of the cells underwent cytoplasmic shrinkage and membrane blebbing within 6 hours after TNF-alpha exposure, and at about 9 hours, they were in the ballooning stage. Based on these data, we investigated the relationship between morphological changes and other biochemical features. The earliest event was exposure of phosphatidyl-serine at the cytoplasmic membrane, which was already observed in the pre-apoptotic stage. Loss of mitochondrial membrane potential was observed in the cytoplasmic shrinkage stage. Caspase-8/-3 activities already started increasing in the pre-apoptotic stage, and reached their peak at 6 hours after TNF-alpha exposure. DNA fragmentation occurred in the late phase of the membrane blebbing.

Combination of stereotactic radiosurgery and cytokine gene-transduced tumor cell vaccination: a new strategy against metastatic brain tumors

OBJECT

To determine if the combination of radiosurgery and tumor cell vaccine would enhance the therapy of metastatic lesions of the central nervous system (CNS), the authors examined the antitumoral effects of radiosurgery and cytokine-transduced tumor cell vaccine.

METHODS

Fifty-five rats underwent intracranial implantation of 5 x 10(3) MADB 106 cells. On Day 3 after tumor implantation, 34 rats were inoculated in the flank with nonirradiated MADB 106 cells that had been retrovirally transduced to express granulocyte-macrophage colony-stimulating factor or interleukin-4. Twenty-seven rats (17 animals that had received the vaccine and 10 that had not) underwent radiosurgery performed using a gamma knife at maximum doses of 32 Gy on Day 5. No animals in the untreated group or in the vaccine-alone groups survived longer than 21 days. Animals treated by ra diosurgery alone displayed prolonged survival in comparison with untreated animals (p < 0.0001), but only one of 10 animals survived longer than 55 days. In contrast, 14 of 17 animals that received the combination therapy of radiosurgery and vaccination survived longer than 55 days (p = 0.0003 compared with animals that underwent radiosurgery alone). On Day 55, the long-term survivors were challenged by parental MADB 106 cells, which were implanted in the contralateral hemisphere. All animals from the combination therapy groups survived longer than 50 days after this challenge, but the single survivor from the radiosurgery-alone group died of tumor growth in 27 days.

CONCLUSIONS

The combination of radiosurgery and cytokine gene-transduced tumor cell vaccine markedly prolonged animal survival and protected animals from a subsequent challenge by parental tumor cells placed in the CNS. The data provided by this study indicate that this combination therapy represents a strategy that may have clinical applicability for single and/or multiple metastatic brain tumors.

Japanese patients not seeking kidney transplants

In Japan, the number of patients seeking kidney transplants has declined in recent years. To investigate the reasons for this decline, a questionnaire was given to 73 haemodialysis patients treated at the Tokiwa-Tatsumi Clinic. The resulting data showed the percentage of patients seeking transplants declined from 61% in 1992 to 19.2% in 1999. The reasons given for not seeking transplants were the improvements of physical condition and resultant quality of life (QOL) due to progress in dialysis therapy, upgraded social welfare support, uncertainties of transplant medicine, loss of expectations due to limited availability of transplant kidneys and aging of patients. Meanwhile, the number of patients on dialysis continues to increase by approximately 10,000 a year, and the mean age of patients rises. To reduce this number, greater effort must be directed toward preventive medical care as well as educating the public regarding transplant medicine.

[Usefulness of right ventricular Doppler index for predicting outcome in patients with dilated cardiomyopathy]

OBJECTIVES

Left ventricular Doppler index (LVDI) is believed to be a useful echocardiographic index of systolic and diastolic ventricular function. However, the usefulness of right ventricular Doppler index (RVDI) remains uncertain, especially in dilated cardiomyopathy. The predictive value of RVDI for estimating long-term cardiac events, including cardiac death, was investigated.

METHODS

Fifty-nine consecutive patients with dilated cardiomyopathy (41 males and 18 females, mean age 52 +/- 15 years) were enrolled in this follow-up study. RVDI and LVDI were calculated as follows: DI = (isovolumic contraction time + isovolumic relaxation time)/ejection time.

RESULTS

During a follow-up period of 3.7 +/- 3.0 years, 27 (46%) of the patients exhibited cardiac events, including cardiac death (n = 9), heart failure (n = 16) and tachyarrhythmias (n = 2) requiring in-hospital treatment. Patients with these cardiac events had higher LVDI and RVDI at the initial follow-up examination, and RVDI had a significant linear correlation with LVDI (LVDI = 0.550 + 0.452 x RVDI, r = 0.530, p = 0.0001). The 6-year survival rate was significantly lower in patients with both LVDI > or = 0.78 and RVDI > or = 0.49 than in other patients (50% vs 75%, respectively, p = 0.009). Cox proportional hazards model analysis showed that RVDI > or = 0.49 was the independent predictor of cardiac events (p = 0.0153) and cardiac death (p = 0.0003).

CONCLUSIONS

RVDI is clinically useful for estimating the outcome of patients with dilated cardiomyopathy.

Detection of cardiac calcinosis in hemodialysis patients by whole-body scintigraphy with 99m-technetium methylene diphosphonate

A noninvasive method for the diagnosis of cardiac calcinosis, a life-threatening complication in hemodialysis patients with end-stage renal disease (ESRD), has not, as yet, been firmly established. We tested whether whole body scanning with 99m-technetium methylene diphosphonate (MDP) might visualize cardiac calcinosis. In 19 consecutive chronic hemodialysis ESRD patients (13 males and 6 females, aged 40-81, mean 63 +/- 8 years) with cardiovascular disease [mitral annular calcinosis and/or calcified aortic valve (n = 4), hemodialysis cardiomyopathy (n = 1), coronary artery disease (n = 9) and peripheral artery atherosclerotic disease (n = 6)], MDP uptake in the heart was compared to that in 7 non-ESRD controls with hyperparathyroidism due to adenoma. Cardiac and lung field MDP uptake was confirmed in only 3 (16%) and 5 (26%) of the 19 ESRD subjects, respectively, but was absent in controls. Positive cardiac uptake was related to cardiac calcified complications (mobile intracardiac calcinosis, myocardial calcinosis and mitral annular calcification) and the duration of hemodialysis (p = 0.015). While it was statistically insignificant, subjects showing MDP uptake were elder and had higher serum Ca or Ca x P product and lower intact parathyroid hormone levels. These results suggest that cardiac calcinosis in ESRD patients can be detected noninvasively by myocardial scintigraphy with 99m-technetium MDP.

[Intracardiac floating thrombi in patients with acute pulmonary thromboembolism]

The mortality and morbidity associated with residual intracardiac floating thrombi in patients with acute pulmonary thromboembolism remain uncertain. Thirteen patients (2 men and 11 women, mean age 56 +/- 15 years) with pulmonary thromboembolism underwent echocardiography within 24 hours from onset of symptoms. Four patients (31%) had floating intracardiac thrombi in the right heart: 3 in the right atrium and one in the inferior vena cava. The time to evaluation by echocardiography was shorter than in the patients without thrombi. The thrombi disappeared shortly (3.2 +/- 2.4 hr) after thrombolysis without adverse effects in these patients. After thrombolysis, clinical symptoms improved and pressure gradient between the right ventricle and right atrium decreased significantly (p < 0.01) from baseline 47 +/- 6 to 26 +/- 5 mmHg. Major bleeding complications occurred in 3 (43%) of the patients who underwent thrombolysis. Right-side intracardiac floating thrombus was easily detectable by early echocardiography. Thrombolytic agents are likely to be effective in patients with intracardiac floating thrombi.

Hypoparathyroidism potentiates cardiovascular complications through disturbed calcium metabolism: possible risk of vitamin D(3) analog administration in dialysis patients with end-stage renal disease

BACKGROUND/AIM

Progressive cardiovascular calcification in dialysis patients with end-stage renal disease (ESRD) is a serious complication; however, the precise mechanism remains uncertain. We tested whether metabolic calcium abnormalities and hypoparathyroidism might have a correlation with cardiovascular complications in ESRD patients.

METHODS

A series of 48 ESRD patients with cardiovascular diseases and/or congestive heart failure, aged 36-82 (61 +/- 12) years, 23 male and 25 female, were enrolled in this study. Serum total calcium (Ca, mmol/l), inorganic phosphate (mmol/l), and intact parathyroid hormone (iPTH, pg/ml) levels were determined in all cases.

RESULTS

Organic heart disease was confirmed in 28 patients (58.3%), including 15 with coronary artery disease: 8 with aortic aneurysm, 8 with stenotic valvular heart disease, 9 with excessive mitral annular calcification, 3 with dialysis cardiomyopathy, and 7 with obstructive arterial disease. Serum iPTH measurement revealed hypoparathyroidism (iPTH <60) in 20 of 48 (41.7%) and hyperthyroidism (iPTH >/=200) in 13 of 48 (27.1%) subjects. The 20 patients with low iPTH had a higher prevalence of valvular heart disease, a higher total Ca level corrected for serum albumin (2.70 +/- 0.30 in low iPTH vs. 2.47 +/- 0.30 in normal iPTH, 2.35 +/- 0.20 in high iPTH, p = 0.003) and a higher tendency of vitamin D(3) analog use (65% in low iPTH vs. 33% in normal iPTH and 46% in high iPTH, p = 0.078). Moreover, corrected serum Ca exhibited a negative logarithmic correlation with serum iPTH: corrected Ca = -0.284x log (iPTH) + 3.021 (r = 0.637, p = 0.0001). Multiple logistic regression analysis revealed diabetes and hypoparathyroidism (iPTH <60) as risk factors for cardiovascular complications in ESRD.

CONCLUSION

These results suggest that hypercalcemia and hypoparathyroidism in conjunction with vitamin D(3) use might play an important role in cardiovascular complications of chronic dialysis patients.

Long-term site-related differences in the progression and regression of the idiopathic mitral valve prolapse syndrome

The natural history of uncomplicated mitral valve prolapse (MVP) is not clearly understood. To determine the site-related differences in regression and progression of MVP, 112 patients with idiopathic MVP were enrolled in this echocardiographic follow-up study. Cardiovascular complications, including dysarrhythmias (n = 3, 2.7%), overt congestive heart failure (n = 4, 3.6%), progression of mitral regurgitation over one grade (n = 28, 25.0%), newly confirmed chordal rupture (n = 1, 0.9%), and surgical repair (n = 2, 1.8%), were observed in these patients during a follow-up period of 1-13 years (mean, 4.0 +/- 2.8 years). Multivariate analysis and Kaplan-Meier analysis revealed that posterior leaflet prolapse and significant mitral regurgitation (grade >/=2) were considerable risks for cardiovascular complications. Regression of MVP was seen in 17 (18.7%) of the anterior prolapse patients; however, new prolapse was observed in 40 (35.7%) patients, mainly in posterior prolapse patients. These results suggest that site-related differences exist in uncomplicated MVP prognosis and that MVP in the posterior leaflet has a poor outcome compared to that in the anterior leaflet.

Scintigraphic evidence for a specific long-chain fatty acid transporting system deficit and the genetic background in a patient with hypertrophic cardiomyopathy

The mechanism of cardiac uptake of long-chain free fatty acids has not been fully determined. We encountered a hypertrophic cardiomyopathy patient who showed a lack of cardiac uptake of 2 different types of long-chain fatty acid analogues on the scintigraphic images. Flow cytometric analysis revealed no platelet or monocyte CD36 molecule expression (type I CD36 deficiency) and his CD36 gene showed homozygous mutation for 478C to T substitution, leading to an abnormal CD36 amino acid sequence. These findings strongly suggest that a specific transporting system rather than a simple diffusion is commonly involved in the cardiac uptake of long-chain free fatty acids in humans, and that the CD36 protein is the most likely candidate for the specific transporter and to explain scintigraphic defects on fatty acid imaging.

Reflections by the families of organ donors in Japan

The number of kidney grafts in Japan is remarkably small compared to that in Europe and America. We conducted a questionnaire survey to donor families in order to examine problems surrounding kidney grafts, from their viewpoints. Thirty one families of post-mortem kidney donors responded and the majority perceived the donation positively. The survey also revealed that in most cases, donation was decided by the family without knowing the patient's wishes, families who made organ donations were apprehensive about Japanese society being critical of organ donations, and some families later regretted their decision of organ donation. In Japanese society, organ donation continues to face some resistance. It is important that medical professionals concerned with organ grafts understand with compassion the feelings of donor families, and make a greater effort in developing public understanding and support for organ grafts.

Fast spin-echo MR of the articular cartilage in the osteoarthrotic knee. Correlation of MR and arthroscopic findings

PURPOSE

The objective was to assess the efficacy of fast spin-echo (FSE) imaging in the detection of articular cartilage abnormality in osteoarthrosis of the knee.

MATERIAL AND METHODS

We studied 356 articular surfaces in 73 knees that had been examined by both MR imaging and arthroscopy. The MR images were obtained with FSE imaging (TR/TE 4200/100) on a 0.5 T unit. The surface abnormalities of the articular cartilage that were detected by MR imaging were compared with the arthroscopic findings.

RESULTS

The overall sensitivity and specificity of MR in detecting chondral abnormalities were 60.5% (158/261) and 93.7% (89/95) respectively. MR imaging was more sensitive to the higher grade lesions: 31.8% (34/107) in grade 1; 72.4% (71/98) in grade 2; 93.5% (43/46) in grade 3; and 100% (10/10) in grade 4. The MR and arthroscopic grades were the same in 46.9% (167/356), and differed by no more than 1 grade in 90.2% (321/356) and 2 grades in 99.2% (353/356). The correlation between arthroscopic and MR grading scores was highly significant with a correlation coefficient of 0.705 (p < 0.0001).

CONCLUSION

FSE sequence was less sensitive to mild cartilage abnormality but useful in detecting moderate to severe abnormality and in evaluating the degree of articular cartilage abnormality.

Traction injuries of the brachial plexus: signal intensity changes of the posterior cervical paraspinal muscles on MRI

PURPOSE

Our goal was to evaluate MR signal intensity change of the posterior cervical paraspinal muscles in brachial plexus traction injuries to determine the value of this finding in the diagnosis of nerve root avulsion.

METHOD

MR images of 11 consecutive patients, 7 with nerve root avulsion and 4 without nerve root avulsion, were retrospectively analyzed, focusing on the signal intensity of the paraspinal muscles.

RESULTS

Among the seven patients with nerve root avulsion, T2- or T2*-weighted MR images showed increased signal intensity in the deep posterior paraspinal muscles in five and traumatic meningocele in four. The signal intensity of the posterior paraspinal muscles was normal in all patients without nerve root injuries.

CONCLUSION

MR signal intensity change in the deep posterior cervical paraspinal muscles is related to denervation and suggests the presence of nerve root avulsion.

Gadolinium-enhanced MR imaging of the wrist in rheumatoid arthritis: value of fat suppression pulse sequences

OBJECTIVE

To determine the usefulness of fat-suppressed gadolinium (Gd)-enhanced MR imaging of the wrist in patients with rheumatoid arthritis (RA).

DESIGN AND PATIENTS

Fat-suppressed Gd-enhanced T1-weighted spin-echo (SE) images were obtained and compared with other standard techniques in 38 wrists of 27 patients (22-77 years) with RA. Scoring based on the degree of synovial enhancement of each joint was developed and the total scores (J-score) were correlated with radiographic stage, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and symptomatic change in the follow-up study.

RESULTS

Synovial proliferations showed marked enhancement in all the wrists. In addition, contrast enhancement in the bone marrow and tenosynovium was seen in 36 and eight wrists respectively. Fat-suppressed Gd-enhanced T1-weighted images demonstrated these abnormalities better than other techniques. The J-scores correlated well with values of CRP (P = 0.0034), but not with radiographic stages and ESR.

CONCLUSION

Fat-suppressed Gd-enhanced T1-weighted SE images can clearly demonstrate most of the essential lesions in RA including the proliferative synovium, bone erosion, bone marrow inflammatory change, and tenosynovitis. Scoring based on the extent of Gd-enhancement of synovium can be useful in the assessment of the inflammatory status.

[Magnetic resonance imaging of sacral insufficiency fractures: characteristic features and differentiation from sacral metastasis]

Seven patients with sacral insufficiency fractures and seven patients with sacral metastasis were studied with MR imaging. The diagnoses were confirmed with other imaging modalities and clinical follow-up. The insufficiency fractures appeared as bands of abnormal signal: low signal intensity on T1-weighted images and slightly low to iso signal intensity on T2-weighted images. The lesions were delineated better on T1-weighted images than on T2-weighted images. The sacral alae were involved in all patients; five patients had bilateral lesions. The lesions that run across the sacral body were seen in three cases. Inclined coronal images were useful in demonstrating the pattern of distribution of the sacral insufficiency fractures. In three patients with follow-up MR studies, the lesions were markedly reduced or disappeared. The sacral metastatic tumors were of low signal in density on T1-weighted images and iso to high signal in density on T2-weighted images. The extent and distribution patterns of the lesions were various. It is possible to differentiate sacral insufficiency fractures from sacral metastases based on their distribution patterns on MRI. However, if the diagnosis is uncertain or if the symptoms persist or become worse, follow-up MR studies may be necessary.

Atypical appearance of adrenal pseudocysts

We report 2 cases of adrenal pseudocysts that resulted from hemorrhage into a normal adrenal gland and that showed atypical imaging features on computerized tomography and ultrasonography. The presence of a solid component within the mass and/or central calcification, which is unlike the typical features of adrenal pseudocyst, suggested a diagnosis of adrenal tumor. The solid component diminished on computerized tomography in 26 days in case 1 and in 16 days in case 2, which seemed to represent resolving hematoma. The atypical appearance of these adrenal pseudocysts, especially the changeable pattern of the solid component within the mass, should be kept in mind to ensure a correct preoperative diagnosis.

Relationship between cytosolic Ca2+ level and contractile tension in canine basilar artery of chronic vasospasm

In order to study the role of the Ca2+/calmodulin/myosin light chain kinase system in the development of chronic vasospasm caused by subarachnoid hemorrhage, the cytosolic Ca2+ level ([Ca2+]i), measured with fura-2, a fluorescent Ca2+ indicator, and contractile tension were measured simultaneously, and their quantitative correlation was examined in basilar arterial tissue obtained from the canine "two-hemorrhage" model. Sixteen adult mongrel dogs were divided into two groups, control (n = 8) and vasospasm (n = 8), and were killed 7 days after the first experimental subarachnoid hemorrhage. In basilar arterial tissue loaded with fura-2, 1) [Ca2+]i in the resting condition was not significantly different between the two groups; 2) the increment in [Ca2+]i induced by 40 mmol/L K+ stimulation was significantly smaller in vasospastic tissue (P < 0.01); and 3) 40 mmol/L K(+)-induced tension development per cross-sectional area for a fixed increment in [Ca2+]i was significantly greater in vasospastic tissue (P < 0.01). In tissue not loaded with fura-2, active myogenic tone, which was tentatively represented by the ratio of tonus relaxed with 10(-4) mol/L papaverine to initial resting tone, was significantly greater in vasospastic tissue (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Lymphocytic adenohypophysitis: an immunohistochemical study

Lymphocytic adenohypophysitis is a rare inflammatory disorder of the anterior pituitary gland. In some cases, there is evidence of concurrent autoimmune disease. We present the case of a 39-year-old woman who developed visual disturbance during the early postpartum period. Magnetic resonance imaging revealed an intrasellar mass with suprasellar extension. Study of the tumor tissue showed diffuse infiltration of the entire pituitary gland by lymphocytes and plasma cells. Immunohistochemical examination revealed that the majority of the infiltrating lymphocytes were T cells that might have modulated the immunoreaction to the anterior pituitary gland. We suggest that the disorder is related to cell-mediated immunity as well as humoral immunity.

Central muscarinic activities of an M1-selective agonist: preferential effect on reversal of amnesia

Effects of FKS-508 (AF102B; cis-2-methylspiro (1,3-oxathiolane-5,3')-quinuclidine), a novel M1-selective agonist, on central muscarinic responses in mice were examined in comparison with oxotremorine. FKS-508 was slightly less potent (6 times) in reversal of scopolamine-induced amnesia (passive avoidance failure), but far less potent (260 and 55 times) in producing hypothermia and tremor than oxotremorine. These results show that the selective M1 agonist FKS-508 differentiates highly between the central muscarinic effects.

Beneficial effects of FKS-508 (AF102B), a selective M1 agonist, on the impaired working memory in AF64A-treated rats

The effects of FKS-508 [AF102B; cis-2-methylspiro(1,3-oxathiolane-5,3')quinuclidine], a selective M1 muscarinic receptor agonist, were examined to predict the possible activity on memory disorders using a T-maze and radial-arm maze task in experimental amnesia models. The amnesia models were produced by bilateral intracerebroventricular injection of ethylcholine aziridinium ion (AF64A), a selective cholinotoxin, in rats. Repeated administrations of FKS-508 (5 mg/kg/day, i.p.) for 5 weeks significantly ameliorated impaired performance of AF64A-treated rats (AF64A-rats) in a delayed alternation task in the T-maze. Repeated administrations of FKS-508 (1 and 5 mg/kg/day, p.o.) for 5 weeks significantly ameliorated acquisition failures of AF64A-rats in a radial-arm maze task. Single administration of FKS-508 (1 and 5 mg/kg, p.o.) significantly reduced the incorrect choices of AF64A-rats in a radial-arm maze task with 6 hr-delay time. No abnormalities in general behaviors, such as loss of appetite and ataxia, were observed in rats treated with FKS-508 repeatedly during 5 weeks. Our present results showed that FKS-508 can ameliorate memory impairments in AF64A-rats with central cholinergic hypofunction without causing any behavioral abnormalities. FKS-508 may be considered as a candidate for the clinical examination of the cholinergic hypothesis of senile dementia of the Alzheimer type.

Chondrosarcoma of the posterior fossa--case report

The authors describe a case of well differentiated (grade I) chondrosarcoma in a 52-year-old male. The tumor originated in the posteromedial wall of the left petrous bone and extended into the posterior fossa and cervical spine. He showed impaired functions of the left VII to XII cranial nerves. Plain skull x-rays demonstrated erosion of the left petrous and occipital bones, with speckled calcifications. Computed tomography showed a huge mass of slightly high density with mushroom-like calcifications, which was poorly enhanced by contrast medium. Inversion recovery magnetic resonance imaging clearly defined the low-intensity lesion, while the long spin-echo image depicted the tumor as mixed-intensity. On electron microscopic examination, the tumor cells were rich in Golgi apparatus, endoplasmic reticulum, glycogen granules and mitochondria in the cytoplasm, and formed many vacuoles crossing the cell membrane. These vacuoles were suggested to play an important role in matrix formation. Thirty nine other reported cases of chondrosarcoma are reviewed, and the two reported posterior fossa chondrosarcomas are compared with that of ours.

[Nocardial brain abscess: case report]

A 25-year-old man, who was slightly immunosuppressed, presented headache and right motor weakness due to multiple brain abscesses disseminated from lung abscess. They were diagnosed, by bacteriological examination, as nocardial brain abscesses (nocardia asteroides) 4 weeks after the first operation. In spite of delay in the diagnosis, he was relieved by operations (three times) and chemotherapy including high doses of Sulfamethoxazole-Trimethoprim. He was eventually discharged. We stress the necessity of early diagnosis and the efficacy of Sulfamethoxazole-Trimethoprim for nocardial brain abscess.

Amelioration of experimental amnesia (passive avoidance failure) in rodents by the selective M1 agonist AF102B

Effect of AF102B (cis-2-methylspiro-(1,3-oxathiolane-5,3')-quinuclidine) on experimental amnesia was examined using a passive avoidance task in rodents. The amnesia was produced by anti-cholinergic agents, AF64A (intracerebroventricularly) and scopolamine (subcutaneously). AF102B ameliorated the memory deficits in AF64A-treated rats at 0.1-1 mg/kg, i.p. and at 1-5 mg/kg p.o. and in scopolamine-treated mice at 1-10 mg/kg, i.p. These results suggest that AF102B may compensate for central cholinergic defects and could be developed as a possible therapeutic drug for senile dementia of the Alzheimer type.

Effects of intracerebroventricular injection of AF64A on learning behaviors in rats

The effects of intracerebroventricular (ICV) injection of ethylcholine aziridinium ion (AF64A) (3 nmole/2 microliter, each lateral ventricule), a putative selective cholinotoxin, on learning behaviors and choline acetyltransferase (ChAT) activity were studied in rats. AF64A-treated rats (AF64A-rat) exhibited deficient performance in a passive avoidance task and a delayed alternation task in the T-maze, but demonstrated superior avoidance response in a two-way shuttle avoidance task. These changes in learning behaviors were associated with the selective decrease of hippocampal ChAT activity. Physostigmine (0.1 mg/kg, i.p.) significantly improved the retention latency of AF64A-rats in the passive avoidance task. AF64A-rats receiving physostigmine (0.2 mg/kg, i.p.) exhibited a slight but not significant improvement of performance in the delayed alternation task in the T-maze. These findings suggested that ICV injection of AF64A may be useful for producing an experimental amnesia model with hippocampal cholinergic hypofunction like Senile dementia of the Alzheimer type (SDAT), if appropriate learning tests are selected.

Germ cell tumors (germinoma and yolk sac tumor) in unusual sites in the brain

This report presents three cases of primary intracranial germ cell tumor encountered in unusual sites, or essentially non-midline structures. The three provided the opportunity to examine surgically obtained tissues with the electron microscope. The histological diagnosis was initially made by light microscopic observations. The first case was a 10-year-old boy in whom the tumor occupied the right thalamic and basal ganglionic region and was diagnosed as a yolk sac tumor. The second an 11-year-old boy who presented with a mass lesion on the left thalamic and basal ganglionic region, diagnosed as germinoma. The third was a 39-year-old man who presented with multiple tumors in the ventricular system and posterior fossa, also diagnosed as germinoma. Among the three cases, neither diabetes insipidus nor ophthalmologic disorder was manifested. Extensive examination and autopsy findings indicated that these intracranial lesions had not metastasized from primary extracranial tumors, including those of the genital organs.

Morphological and immunological change in the predominant type of leukaemic cells in a patient with T-cell chronic lymphocytic leukaemia

A case of T-cell chronic lymphocytic leukaemia is described. Intracerebellar tumour was demonstrated by the characteristic feature of contrast-enhanced computerized tomography and was evidenced by surgical procedure. Histological examination revealed lymphocyte infiltration in the cerebellum. Initially, the majority of leukaemic cells were mature, medium-sized lymphocytes with surface marker phenotype of E+, OKT3+, OKT4+, OKT6-, OKT8-. In the terminal stage, large atypical lymphocytes which were morphologically distinct from the original lymphocytes and had different surface marker phenotype of E+, OKT3+, OKT4-, OKT6-, OKT8+, Leu7+ became increasingly prominent. The remaining medium-sized lymphocytes were morphologically and immunologically unchanged. Subsequently, the disease developed to a more aggressive pattern and the patient died in spite of chemotherapy.

Lateral flagellar antigen of Vibrio alginolyticus and Vibrio harveyi: existence of serovars common to the two species

The antigenicity of lateral (L-) flagella of two marine vibrios, Vibrio alginolyticus and V. harveyi, was studied, and the two species were found to have common antigenicity of their flagella. Antisera against L-flagella were prepared by immunizing rabbits with highly purified L-flagellar filaments. H-Agglutination tests with the anti-L-flagella antisera showed that four H-serovars existed in these species and that two of them were shared by the two species. Cross reactivity between H-serovars of these two species and other vibrios having lateral flagella, such as V. parahaemolyticus, V. campbellii, V. proteus, or V. fluvialis, was not observed in the H-agglutination test, although partial common antigenicity was observed in the gel diffusion test with flagellin monomers. These observations suggest that surface antigenic determinants of the lateral flagella of V. alginolyticus and V. harveyi are specific to these two species but internal antigenic determinants buried in the flagellar filaments are partially shared with other vibrio species.

Lateral flagellum of Vibrio fluvialis: a species-specific antigen

Antiserum against lateral flagella (L flagella) of Vibrio fluvialis AQ 0007 was prepared, and H agglutination tests of V. fluvialis strains were carried out with the antiserum. Thirty-seven strains isolated from human patients, marine products, or seawater were tested. All strains, except three which had lost the ability to form L flagella, agglutinated with that antiserum. The antiserum did not agglutinate other vibrio species having L flagella, whereas antisera against L flagella of other vibrios did not agglutinate V. fluvialis. These results suggest that the L flagellar antigen of V. fluvialis is common and specific to the species, and is a useful tool for serological identification of the organism.

Immunohistochemical localization of Na+, K+-ATPase in the choroid plexus

To determine if canine and rat choroid plexus Na+,K+-ATPase can be localized by immunoperoxidase staining after fixation and embedding, we prepared rabbit antiserum to purified canine kidney medulla Na+,K+-ATPase. When sodium dodecylsulfate polyacrylamide electrophoretic gels of purified canine kidney Na+,K+-ATPase and canine kidney microsomes were treated with antiserum followed by [125I]protein A and autoradiography, the canine microsomes and purified Na+,K+-ATPase showed a prominent radioactive band coincident with the alpha-, beta- and gamma-subunits of the purified canine kidney enzyme. When the rabbit immunoglobulin that was purified from the Na+,K+-ATPase antiserum through DEAE-cellulose ion exchange chromatography was used for immunoperoxidase staining of the choroid plexus fixed with Bouin's fixative, intense immunoreactive staining was present on the epithelial cells of both choroid plexuses but was not found in the tissue around the vessel. The staining was especially confined to apical surfaces of the epithelial cells. The same procedure was performed in the canine kidney, and immunostaining was obtained in the tubules where Baskin and Stahl described the enzyme localization. No staining was seen with pre-immune serum of the normal rabbit. We concluded that both the canine and rat choroid plexus are rich in Na+,K+-ATPase, which plays an important role in cerebrospinal fluid (CSF) secretion.