Survival impact of sequential chemotherapy following pembrolizumab for recurrent or metastatic head and neck squamous cell carcinoma

BACKGROUND

Pembrolizumab alone or combined with chemotherapy is the standard of care for first-line treatment of patients with recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC) with positive programmed death-ligand 1 combined positive scores. However, data on second-line chemotherapy following pembrolizumab are scarce.

METHODS

A single-center, retrospective study was conducted to determine the efficacies of pembrolizumab and pembrolizumab plus chemotherapy as first-line treatments and the efficacy of second-line chemotherapy for patients with R/M HNSCC who were refractory or intolerant to first-line treatment.

RESULTS

Fifty-four patients were treated with pembrolizumab, and 29 received second-line therapy, with 27 opting for cetuximab-containing regimens. The median progression-free survival (PFS), overall survival (OS), and PFS on next-line therapy for first-line treatment were 4.7 (95% confidence interval [CI], 2.1-8.7), 22.1 (95% CI, 12.6-not reached), and 15.6 months (95% CI, 9.7-not reached) in the pembrolizumab group and 5.4 (95% CI, 3.3-6.8), 15.8 (95% CI, 8.6-not reached), and 13.7 months (95% CI, 8.1-not reached) in the pembrolizumab plus chemotherapy group, respectively. The overall response rate and median PFS for second-line treatment were 48.3% (95% CI, 30.4-67.0) and 6.1 months (95% CI, 2.30-8.84). The median OS for patients who received second-line treatment was 18.4 months, which was superior to the median OS of 6.0 months for patients who received the best supportive care (log-rank p = 0.10).

CONCLUSION

This study indicates that cetuximab-containing second-line chemotherapy can improve outcomes in R/M HNSCC, even after first-line therapy failure or intolerance.

Safety and Efficacy of Gemcitabine Plus Cisplatin Against Recurrent/Metastatic Nasopharyngeal Carcinoma: A Retrospective Study

BACKGROUND/AIM

Although gemcitabine plus cisplatin (GC) prolongs survival in patients with recurrent or metastatic nasopharyngeal carcinoma (R/M NPC) compared with fluorouracil plus cisplatin, no study has evaluated the efficacy and safety of GC in nonendemic regions, including Japan, yet. Therefore, we assessed the safety and efficacy of GC in Japanese patients with R/M NPC.

PATIENTS AND METHODS

We retrospectively reviewed patients with R/M NPC who received GC treatment at the Aichi Cancer Center Hospital from January 2017 to March 2020. The main eligibility criteria were histologically confirmed NPC, Eastern Cooperative Oncology Group performance status (ECOG PS) of 0-2, and locally recurrent disease unsuitable for local treatment or metastatic disease. The regimen was administered every 3 weeks (gemcitabine, 1,000 mg/m2 on days 1 and 8; cisplatin, 80 mg/m2 on day 1).

RESULTS

Fourteen patients (median age, 58 years) were included in the study. Two patients had an ECOG PS of 2 and 11 exhibited nonkeratinizing histology. Of the eight patients with measurable lesions, one exhibited complete response and seven exhibited partial response, with an objective response rate of 75%. Median progression-free survival and overall survival were 7.7 and 24.2 months, respectively. Common grade 3 or 4 adverse events included neutropenia (64%), thrombocytopenia (14%), and febrile neutropenia (14%). The median relative dose intensity of gemcitabine and cisplatin was 62% and 60%, respectively. No treatment-related deaths occurred.

CONCLUSION

The GC regimen demonstrates promising activity and is tolerable in Japanese patients with R/M NPC.

Changes in serum DAMPs and cytokines/chemokines during near-infrared photoimmunotherapy for patients with head and neck cancer

BACKGROUND

Near-infrared photoimmunotherapy (NIR-PIT) for head and neck cancer is a recently developed therapy. However, there is limited data on patients receiving NIR-PIT in real clinical settings.

METHODS

Seven NIR-PIT sessions were administered to five patients with head and neck squamous cell carcinoma (HNSCC). Serum damage-associated molecular patterns (DAMPs) (HMGB1 and Hsp70 levels), and cytokine and chemokine production, were compared before and after NIR-PIT.

RESULTS

The serum concentration of HMGB1 increased after NIR-PIT (p = 0.031, Wilcoxon test) in all patients except one who did not achieve a clinical response. Chemokines MIP-1α (CCL3) and MIP-1β (CCL4) increased significantly 1-3 days after treatment (CCL3, p = 0.0036; CCL4, p = 0.0016, Wilcoxon test). A low pre-treatment neutrophil-to-lymphocyte ratio (NLR) was associated with a better response to therapy and survival.

CONCLUSIONS

The release of DAMPs, and cytokine/chemokine production, were detected in the patients' peripheral blood. The baseline NLR may predict patient outcomes in response to NIR-PIT.

Significant dependency of left atrial strain on left ventricular longitudinal motion

BACKGROUND

The effects of left ventricular longitudinal function on the left atrial strain, including the left atrial reservoir function, have not been adequately quantified.

METHODS

A total of 124 patients who underwent echocardiography were enrolled in this study. Left atrial strain analysis was performed using two-dimensional speckle tracking echocardiography, and the left atrial volume was derived using the modified Simpson's method. The peak left atrial strain (LAS) and left atrial expansion index (LAEI), as indices of left atrial reservoir function, were measured. The global longitudinal strain (GLS) and mitral annular plane systolic excursion (MAPSE), which are indices of contractile motion toward the left ventricular apex, were also measured. The correlation between LAS and candidate determinants, including left ventricular systolic longitudinal function, was evaluated, and multivariate regression analysis was performed.

RESULTS

A significant correlation was found between LAS and left ventricular systolic longitudinal functions, GLS (r = 0.63, p < 0.001), and MAPSE (r = 0.65, p < 0.001). Two models, which were selected by multiple regression analyses for LAS, included GLS or MAPSE as independent determinants. GLS and MAPSE were also the strongest predictors, among other factors.

CONCLUSION

LAS, when determined by evaluating the left atrial reservoir function, was significantly associated with left ventricular function, especially the systolic longitudinal function. Left ventricular function should be considered when assessing left atrial function by LAS.

Association Between 18F-Fluorodeoxyglucose Uptake and Mutation Status of Epidermal Growth Factor Receptor in Sinonasal Tract Cancer

BACKGROUND/AIM

The Warburg effect of cancer has been applied to detect various carcinomas though the 18F-fluorodeoxyglucose (18F-FDG) uptake on positron emission tomography with computed tomography (PET/CT). 18F-FDG-PET/CT in lung cancer predicted the mutation status of epidermoid growth factor receptor (EGFR). This study aimed to investigate whether 18F-FDG uptake parameters were significantly related to EGFR mutation status in patients with sinonasal tract squamous cell carcinoma (STSCC).

PATIENTS AND METHODS

Twenty-nine tumor specimens of primary STSCC from patients with definitive treatment were collected.

RESULTS

The 18F-FDG uptake from primary tumors was not different between mutant- and wild-status of EGFR on either Mann-Whitney U-test or the receiver operating curve. A metabolic tumor volume of ≥25 with the minimum p-value from the log-rank test for STSCC-specific survival was associated with a significantly shorter STSCC-specific, disease-free, local recurrence-free survival on the univariate and multivariate analyses adjusted for the clinical stage, treatment, and EGFR status.

CONCLUSION

18F-FDG-PET/CT did not predict mutation of the EGFR status in STSCC.

A novel technique in transoral robotic surgery: A case report of rotating and switching technique

BACKGROUND

Transoral robotic surgery (TORS) for tongue base lesions located above the operative field is predominantly an upward procedure, which makes surgery difficult.

METHODS

To illustrate our technique for this procedure, we report the case of an 82-year-old male with a p16-negative oropharyngeal carcinoma of the tongue base who underwent TORS. The field of view was turned upside down, and the operation switched the typical left- and right-arm functions. The daVinci Xi was docked, the 0° endoscope was rotated 180°, and the first arm was switched to the right hand and the third arm to the left hand.

RESULTS

Although the lesion extended from the tongue base to the soft palate and mobile tongue, the planned resection line was followed.

CONCLUSIONS

This technique improves operability by allowing downward manipulation and preventing the left and right arms from crossing. Further validation of the technique's effectiveness and safety is needed.

Utilization of ultrasound in photoimmunotherapy for head and neck cancer: a case report

BACKGROUND

Photoimmunotherapy (PIT) is a new cancer treatment based on a different mechanism from conventional treatments that combines the administration of a photoabsorber and laser illumination. PIT has two characteristics: a high selectivity of target cells and the possibility of effects beyond the illuminated area. It is thus a potentially effective treatment for a wide variety of cancers.

CASE PRESENTATION

We herein report a patient with oropharyngeal squamous cell carcinoma with superficial cervical lymph node recurrence. Intraoperative ultrasound confirmed the localization of the lesion and major vessels near the tumor. We punctured the tumor with catheters of laser illumination under ultrasound guidance. Laser illumination was able to be performed safely without causing serious adverse events, and the effect on the illuminated site was fully exhibited.

CONCLUSIONS

Ultrasound allows for the intraoperative monitoring of each localized area and the puncture status easily in real-time. Accurate utilization of ultrasound is extremely important in PIT.

Impact of age for overall survival in head and neck sarcoma

The purpose to the present study is to research the association between age at surgery and survival outcomes of patients with sarcoma in head and neck. Twenty-six patients with head and neck sarcoma who underwent by surgery from 2003 to 2017 were enrolled in the present observation study. Patients who did not undergo chemotherapy were significantly older age at surgery by Mann-Whitney U test. Fifty-five was the cutoff age that predicted death by receiver operating curve analysis. Shorter survival rates of overall, disease-specific, local recurrence-free and disease-free were associated with older age by log-rank test. Age (≥55 years/<55 years) was correlated with shorter overall survival by multivariate analysis of Cox's proportional hazards model adjusting with chemotherapy (absence/presence). In conclusion, older age predicts worse overall survival in head and neck sarcoma.

Lymph Node Ratio in Head and Neck Cancer with Submental Flap Reconstruction

This study aimed to investigate the relationship between the lymph node ratio (LNR) and survival results of patients with head and neck squamous cell carcinoma (HNSCC) reconstructed by a submental artery flap (SMAF) to limit tumor size. This study retrospectively recruited 49 patients with HNSCC who underwent both primary resection and neck dissection with SMAF reconstruction. The LNR was the ratio of the number of metastatic lymph nodes to the sum number of examined lymph nodes. A LNR of 0.04 was the best cut-off value for HNSCC-specific death on receiver operating curve analysis. Patients with LNRs > 0.04 were univariately related to cancer-specific, disease-free, distant metastasis-free, and locoregional recurrence-free survival than those with LNRs ≤ 0.04 by log-rank test. In a Cox’s proportional hazards model with hazard ratio (HR) and 95% confidence interval (CI) adjusting for pathological stage, extranodal extension and or surgical margins, the LNR (>0.04/≤0.04) predicted multivariate shorter cancer-specific (HR = 9.24, 95% CI = 1.49−176), disease-free (HR = 3.44, 95% CI = 1.23−10.3), and distant metastasis-free (HR = 9.76, 95% CI = 1.57−187) survival. In conclusion, LNR for patients of HNSCC with SMAF reconstruction for limited tumor size was a prognostic factor for survival outcomes.

A Case of Salvage Maxillectomy for Recurrent Oral Cancer After Boron Neutron Capture Therapy During the COVID-19 Pandemic

BACKGROUND

During the COVID-19 pandemic, pedicle flaps instead of free flap transfer were recommended for head and neck reconstruction to reduce infection risk. Boron neutron-capture therapy in Japan was clinically approved in 2020 as a salvage radiotherapy for recurrent head and neck cancer following chemoradiotherapy. The efficacy and safety of salvage surgery following boron neutron-capture therapy remain unclear.

CASE REPORT

We describe a 57-year-old male with crT4aN0M0 oral cancer after three different forms of radiotherapy including boron neutron-capture therapy, treated by salvage partial maxillectomy with both buccal fat pad and nasoseptal flaps. His postsurgical course was successful, without tracheostomy, and he had no Clavien- Dindo grade 3 or 4 complications. The pathological diagnosis was T4a squamous cell carcinoma with a negative surgical margin. No recurrence or metastasis had occurred at 113 days postoperatively. No opioid consumption was needed postoperatively.

CONCLUSION

Pathological negative margins were achieved in this case and there were no severe complications. Further accrual of cases salvage surgery following boron neutron-capture therapy is required to clarify treatment strategies for recurrent head and neck cancer.

A novel procedure of secondary voice prosthesis insertion from the inside out: The modified Fukuhara method

OBJECTIVE

To present a new procedure for inserting a secondary voice prosthesis from the inside to the outside, which improves on the method previously reported by Fukuhara et al.

METHODS

A flexible nasopharyngoscope was used to puncture pharynx (or transplanted jejunum) from the inside to the outside. In this method, it was possible to use the PROVOX® Vega^TM Puncture Set as it is used for the placement of the voice prosthesis.

RESULTS

We were able to place the PROVOX® Vega^TM in all cases we experienced. Most of the cases had a history of radiation therapy. The time required for surgery ranged from 11-59 minutes (mean: 29 minutes) and there was no measurable amount of bleeding.

CONCLUSION

This new method using the PROVOX® Vega^TM Puncture Set, which is designed for the original purpose of voice prosthesis implantation, was therefore found to be safe and effective.

Lymph node ratio as a predictor for minor salivary gland cancer in head and neck

Background

We investigate whether pathological continuous variables of lymph nodes were related with survival results of carcinomas of minor salivary gland carcinoma in head and neck.

Methods

Forty-four cases with minor salivary gland carcinoma who underwent both primary resection and neck dissection were retrospectively enrolled. The pathological continuous variables were evaluated by the number of positive lymph nodes, lymph node ratio, and log odds of positive lymph nodes. Receiver operating curve analysis was used for the cut-off values of the carcinoma-specific death. Log-rank test and Cox’s proportional hazards model were used for uni−/multi-variate survival analyses adjusting for pathological stage, respectively.

Results

Lymph node ratio = 0.05 as well as log odds of positive lymph nodes = − 2.73 predicted the carcinoma-specific death. Both lymph node ratio and log odds of positive lymph nodes were significantly related with survival outcomes by the univariate analysis. Lymph node ratio ≥ 0.05 was associated with shorter disease-specific (hazard ratio = 7.90, 95% confidence interval = 1.54–57.1), disease-free (hazard ratio = 4.15, 95% confidence interval = 1.48–11.2) and overall (hazard ratio = 4.84, 95% confidence interval = 1.05–24.8) survival in the multivariate analysis.

Conclusion

A higher lymph node ratio of minor salivary gland carcinoma is a predictor of shorter survival results.

Supraclavicular Artery Flap for Oral Reconstruction Prior to Esophagectomy During the COVID-19 Pandemic: A Case Report

BACKGROUND

During the coronavirus disease 2019 (COVID19) pandemic, pedicle flaps (instead of free flaps) were recommended for reconstruction following wide resection for patients with head and neck cancer, in order to reduce the use of medical resources. Currently, there are no established treatment guidelines for patients with head and neck cancer with synchronous esophageal cancer.

CASE REPORT

We present a 68-year-old male with cT4aN2cM0 oral floor and synchronous cT1bN1M0 esophageal cancers who had defective reconstruction following oral tumor resection before esophagectomy during the pandemic. At the initial surgery, the oral resected defect was reconstructed using supraclavicular artery flap. The subsequent esophagectomy was reconstructed by gastric tube reconstruction. Both postoperative courses were successful, without the need for postoperative ventilator use. The days from initial or second surgery to discharge were 14 or 16 days, respectively.

CONCLUSION

This case had achieved negative surgical margins and recovered oral intake with tracheostomy decannulation. Further case accruement using supraclavicular artery flap is required for patients with head and neck cancer and synchronous esophageal cancer.

Total lesion glycolysis as a predictor of clinical T3-4a laryngeal cancer with laryngectomy or nonlaryngectomy

The purpose of the present study is to investigate whether the 18F-fluorodeoxyglucose (18F-FDG) uptake parameter is related to survival outcomes for patients with clinical T3-T4a laryngeal cancer with various definitive treatments including total laryngectomy (TL). Parameters of 18F-FDG uptake in the primary tumors of 46 cases which were assessed by positron emission tomography with computed tomography were enrolled in the present observation study. Monovariate or multivariate survival analyses were performed with log-rank test or Cox regression model, with the hazard ratio (HR) and 95% confidence interval (CI), respectively. Cutoff values of the 18F-FDG uptake parameters were determined by the lowest P-value for monovariate overall survival. In the monovariate analysis, both metabolic tumor volume ≥13.1 and total lesion glycolysis (TLG) ≥46.5 were significantly associated with shorter overall survival, and TLG ≥46.5 was also related to a reduction in distant metastasis-free survival. In the multivariate analysis adjusting for clinical T classification (cT4/cT3) and treatment group (TL/non-TL), TLG (≥46.5/<46.5) was associated with both poorer overall (HR: 3.16, 95% CI: 1.10-9.49) and distant metastasis-free (HR: 8.91, 95% CI: 1.93-62.6) survival. In conclusion, TLG is a predictor for survival in laryngeal cancer.

Importance of left ventricular contraction for left atrial reservoir function

BACKGROUND

The determinants of left atrial (LA) reservoir function have not been clarified.

METHODS

To elucidate the effect of left ventricular (LV) contraction on LA reservoir volume (ΔV_LA), volume change due to mitral annular downward motion and aortic root anterior motion, which are related to LV contraction during systole, was calculated in 72 consecutive subjects [42 patients without any cardiac disease (control group), 13 patients with heart failure with reduced ejection fraction (HFrEF group) and 17 with preserved ejection fraction (HFpEF group)]. LA volume was calculated using the modified Simpson's method of bi-plane 2-D echocardiograms. ΔV_LA was the difference between the maximum and minimum LA volumes. LA volume change according to mitral annular motion (ΔV_MA) and aortic root motion (ΔV_AR) were calculated by assuming an oval frustum and dented wedge, respectively.

RESULTS

In the normal control group, ΔV_AR + ΔV_MA was 11.7 ml on average, correlating to ΔV_LA (r = 0.55, p < 0.01), and the contribution rate to LA reservoir volume ((ΔV_AR + ΔV_MA)/ΔV_LA) was 56% on average. In both, the HFrEF and HFpEF groups, ΔV_AR, ΔV_MA, and the contribution rate were significantly smaller than those in normal control group. Stroke volume correlated to ΔV_AR and ΔV_MA. The larger the maximum LA volume was, the smaller the contribution rate was. The smaller the rate was, the higher the systolic pulmonary artery pressure was.

CONCLUSIONS

Both mitral annular motion and aortic root anterior motion, which are related to ventricular contraction, are important for the LA reservoir volume recruitment.

p16-positive oropharyngeal cancer with rare thyroid metastasis : A case report

Thyroid metastasis is rarely diagnosed, and the treatment outcomes in p16-positive oropharyngeal squamous cell carcinoma patients with rare thyroid metastasis have not been fully investigated. Here we describe the case of a patient with p16-positive oropharyngeal squamous cell carcinoma who was diagnosed with cT4 N2M1 with rare thyroid metastasis. The patient was a current smoker and was positive for human papillomavirus DNA, with disease progression at 49 days and death at 113 days after completion of cisplatin-based concurrent chemoradiotherapy. J. Med. Invest. 67 : 189-191, February, 2020.

Treatment outcome and pattern of recurrence of sinonasal squamous cell carcinoma with EGFR-mutation and human papillomavirus

The objective of our study was to clarify the clinical features of EGFR-mutated sinonasal squamous cell carcinoma (SNSCC) and human papilloma virus (HPV)-related SNSCC. Patients with SNSCC treated from April 2008 to June 2019 at our institution were retrospectively reviewed. We examined EGFR mutation and HPV status for all patients. Main outcomes were overall survival, recurrence, and outcome of each treatment modality. A total of 85 patients with SNSCC were enrolled in this study. EGFR mutations and HPV DNA were detected in 24 (28%) and 7 (8%) patients, respectively. Patients with EGFR-mutated SNSCC showed a worse overall survival (OS) than those with EGFR wild-type in the multivariate analysis (p = 0.037). No death was observed in HPV-positive SNSCC. The cumulative incidence of local recurrence was significantly higher in EGFR mutant than EGFR wild-type tumors (p = 0.03). In patients with EGFR mutations, treatment with induction chemotherapy significantly improved OS (p = 0.01). EGFR-mutated SNSCC have a high-risk feature for recurrence and requires intensive attention for treatment and observation. A new treatment approach, such as EGFR tyrosine kinase inhibitors, may be needed.

Serum CD109 levels reflect the node metastasis status in head and neck squamous cell carcinoma

Background

Various biomarkers are being developed for the early diagnosis of cancer and for predicting its prognosis. The aim of this study is to evaluate the diagnostic significance of serum CD109 in head and neck squamous cell carcinoma (HNSCC).

Methods

The serum CD109 levels in a total of 112 serum samples collected before and after surgery from 56 HNSCC patients were analyzed with an enzyme‐linked immunosorbent assay (ELISA). The clinical factor that showed a statistically significant association with both the preoperative serum CD109 level, and the CD109 index: which was defined as the ratio of the preoperative serum CD109 level to the postoperative serum CD109 level, were assessed. The correlations between the serum CD109 levels and lymph node density (LND), pathological features such as lymphatic invasion, and serum SCC antigen levels were also assessed.

Results

The ELISA measurement revealed that preoperative serum CD109 levels were elevated in patients with node metastasis‐positive and stage IV disease, in comparison to those with node metastasis‐negative and Stage I+II+III disease, respectively. A multiple regression analysis indicated that serum CD109 level was significantly associated with the node metastasis status. A Spearman's rank correlation analysis also revealed a positive correlation between the preoperative serum CD109 level and LND. Furthermore, the probabilities of the overall and relapse‐free survival were significantly lower in patients with a preoperative serum CD109 level of ≥38.0 ng/ml and a CD109 index of ≥1.6, respectively, than in others. There was no significant correlation between the serum CD109 and SCC antigen levels.

Conclusions

The serum CD109 levels were elevated in patients with advanced stage disease, reflecting the node metastasis status. CD109 in sera could be a novel prognostic marker for HNSCC involving lymph node metastasis.

Eosinophil prognostic scores for patients with head and neck squamous cell carcinoma treated with nivolumab

Although nivolumab, a programmed cell death 1 (PD‐1) inhibitor, is a standard therapy for platinum‐refractory recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC), no definitive biomarkers have been reported thus far. This study aimed to select promising prognostic markers in nivolumab therapy and to create a novel prognostic scoring system. In this retrospective cohort study, we reviewed patients with R/M HNSCC who were treated with nivolumab from April 2017 to April 2019. We developed a prognostic score for immune checkpoint inhibitor (ICI) therapy that was weighed using hazard ratio–based scoring algorithms. Significant variables were selected from the multivariate Cox proportional hazard analyses on overall survival (OS). A total of 85 patients with HNSCC were analyzed in the present study. The relative eosinophil count (REC), the ratio of eosinophil increase (REI), and Eastern Cooperative Oncology Group Performance Status (ECOG PS) were selected as variables affecting the prognostic score. The patients were divided into four groups: very good (score = 0), good (score = 1), intermediate (score = 2), and poor (score = 3). The OS hazard ratios were 2.77, 10.18, and 33.21 for the good, intermediate, and poor risk groups compared with the very good risk group, respectively. The Eosinophil Prognostic Score is a novel prognostic score that is effective for predicting the prognosis of HNSCC patients treated with nivolumab. This score is more precise as it includes changes in biomarkers before and after the treatment.

Association between treatment package time and clinical predictors in oropharyngeal cancer

The aim of the present study is to investigate the association of treatment package time with the survival outcomes and clinical parameters in patients with oropharyngeal squamous cell carcinoma.A total of 49 patients who underwent definitive treatment were enrolled. The treatment package time was calculated in days from the start of any treatment to the completion of all treatments, including postoperative treatment and salvage surgery for residual tumor.On univariate analyzes, treatment package time ≥118 days, sake index ≥60, Brinkman index ≥450, maximum standardized uptake value ≥42.45, and the presence of synchronous cancer were significantly associated with shorter oropharyngeal squamous cell carcinoma-specific survival. Moreover, a treatment package time of ≥118 days was significantly correlated with shorter overall survival and distant metastasis-free survival. On multivariate analyzes, Brinkman index ≥450 was significantly associated with shorter oropharyngeal squamous cell carcinoma-specific and locoregional recurrence-free survival, and the presence of synchronous cancer was significantly associated with shorter overall and distant metastasis-free survival.In conclusion, a relatively long treatment package time was a predictor of low survival outcomes in oropharyngeal squamous cell carcinoma by univariate analysis.

An examination of the cutoff value of the depth of invasion for prophylactic neck dissection in stage I/II tongue cancer

Background: In stage-I/stage-II oral tongue cancer, the cutoff value of depth of invasion (DOI) for prophylactic neck dissection is controversial.Objectives: To examine the relationship between the DOI and the rate of occult lymph node metastasis. In addition, to examine the relationship between the DOI evaluated by magnetic resonance imaging (MRI) and pathological DOI.Materials and methods: In this retrospective study, 95 patients with clinical T1-2/N0M0 oral tongue cancer were enrolled. The rate of occult lymph node metastasis per DOI between 2 and 11 mm was calculated from the total pathological lymph node metastasis and delayed neck metastasis cases. We measured DOI using MRI and compared DOI obtained from pathology.Results: The total rate of occult lymph node metastasis was 23.9%. In the rate of occult lymph node metastasis per DOI, there were two peaks at point of 5 to 6 mm and 9 to 10 mm. And there was a significant correlation between the DOI evaluated by MRI and the pathological DOI (Pearson's correlation coefficient was 0.87).Conclusions and significance: There was no consistent increase in the rate of occult lymph node metastasis per DOI. MRI was a useful modality to measure the DOI.

Prognostic Value of Age and Distant Metastasis in Differentiated Thyroid Carcinoma Undergoing Salvage Surgery

AIM

To investigate the association between survival outcomes and clinicopathological factors, including pathological restaging based on the UICC8^th, among patients with recurrence differentiated thyroid carcinoma undergoing salvage surgery of local site.

PATIENTS AND METHODS

A total of 54 patients who underwent salvage surgery of local site for recurrence differentiated thyroid carcinoma were enrolled. The optimal cutoff ages at salvage surgery for predicting death and cancer-specific death were determined by receiver operating curve analysis. Overall and cancer-specific survivals were determined using log-rank test and Cox's proportional hazards model.

RESULTS

Univariate analysis showed that age and the presence of distant metastasis at salvage surgery were significantly associated with overall survival (p=0.01 and p<0.05, respectively) and cancer-specific survival (p=0.02 and p=0.01, respectively). The optimal cutoff age at salvage surgery for predicting the detection of both death (p=0.01) and cancer-specific death (p=0.02) was 65 years. Multivariate analysis showed that age ≥65 years and the presence of distant metastasis were significantly associated with shorter overall survival (p<0.01 and p=0.03, respectively) and shorter cancer-specific survival (p<0.01 and p=0.01, respectively).

CONCLUSION

Older age and the presence of distant metastasis at salvage surgery of local site were identified as predictors for poor survival outcomes in recurrence differentiated thyroid carcinoma.

Safety and Efficacy of Salvage Neck Dissection Following Carbon-ion Radiotherapy with Chemotherapy for a Patient with Mucosal Malignant Melanoma of Head and Neck

Mucosal malignant melanoma of the head and neck is a rare diagnosis. The safety and efficacy of salvage neck dissection following carbon–ion radiotherapy with concurrent chemotherapy are not well described, and carbon–ion radiation protocols have not been fully developed. A 77 year old woman with crT0N1M0 mucosal melanoma of the head and neck achieved a complete response following initial treatment with carbon–ion radiotherapy and concurrent chemotherapy. She was treated with salvage neck dissection for as a cervical lymph node metastasis 16 months after initial treatment. She experienced neither Clavien-Dindo Grade 3 or 4 postoperative complications nor subsequent recurrence of disease at 3 months following salvage neck dissection. Surgical specimens may be useful for future precision oncology based on the molecular biology of recurrence melanoma with poor prognosis.

Gross tumor volume in sinonasal tract cancer as a predictor of local recurrence after chemoradiotherapy

Objective

This study investigated whether gross tumor volume of the primary tumor before treatment was a predictor for local recurrence in patients with resectable sinonasal tract squamous cell carcinoma who were treated by chemoradiotherapy.

Methods

A total of 24 patients were enrolled. Pretreatment gross tumor volume of primary tumor was assessed by palpitation, perception and imaging. The cut-off value of the gross tumor volume for local recurrence was determined by receiver-operating curve analysis. A log-rank test and Cox's proportional hazards model were used for univariate and multivariate analyses with adjustment for the clinical T category (cT1-T4a/cT4b), respectively.

Results

In the univariate analysis, patients with the gross tumor volume ≥83.7 ml were significantly associated with shorter local recurrence-free rate (P = 0.0023) and disease-free survival (P = 0.0064) than those with gross tumor volume <83.7 ml. In the multivariate analysis, gross tumor volume ≥83.7 ml were significantly associated with shorter local recurrence-free rate (P = 0.041).

Conclusions

Pretreatment gross tumor volume of primary tumor ≥83.7 ml was significantly associated with local recurrence-free rate in resectable sinonasal tract squamous cell carcinoma.

Treatment package time predicts cancer-specific survival and distant metastasis in laryngeal cancer

We investigated whether treatment package time was significantly associated with survival outcomes of resectable locally-advanced laryngeal squamous cell carcinoma in patients who consecutively underwent various treatments, including surgery alone and salvage surgery for residual tumor. A total of 100 patients with clinical T3-T4 resectable laryngeal squamous cell carcinoma were enrolled in this study. The treatment package time was calculated in days between the start of any treatment and the end of all treatments, including postoperative radiotherapy and salvage surgery for residual tumors. Using a log-rank test, a treatment package time of ≥68 days showed significantly shorter cancer-specific (P=0.0013) and distant metastasis-free survival (P=0.0017), compared with a treatment package time of <68 days. Multivariate survival analyses of two Cox's hazards proportional models was conducted. In both model-1, which adjusted for cT3/cT4, cN0-1/cN2-3 and total laryngectomy/non-total laryngectomy, and model-2, which adjusted for cT3/cT4, cN0-1/cN2-3 and induction therapy/non-induction therapy, the cancer-specific survival and distant metastasis-free survival, according to treatment package time, were significantly longer with <68 days compared with ≥68 days (P<0.01). The present study demonstrated that a prolonged treatment package time is a prognostic factor for shorter cancer-specific and distant metastasis-free survival after various treatments for resectable locally-advanced laryngeal cancer.

Peak of Standardized Uptake Value in Oral Cancer Predicts Survival Adjusting for Pathological Stage

BACKGROUND/AIM

To predict survival outcomes of different patients with the same stage of disease is difficult. The possible correlation between ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) uptake parameters and survival outcomes was investigated in oral squamous cell carcinoma patients by multivariate analysis adjusted for the pathological stage according to the 8th edition of the tumor-node-metastasis (TNM) classification of the Union for International Cancer Contro.

PATIENTS AND METHODS

¹⁸F-FDG-uptake parameters of 28 patients were assessed by positron emission tomography with computed tomography (PET/CT).

RESULTS

A peak of standardized uptake value of primary tumor (p-SUVpeak) of ≥14.1 was significantly correlated with shorter overall survival by univariate and multivariate analyses adjusted for the pathological TNM stage. A p-SUVpeak of ≥14.1 was significantly associated with shorter local recurrence-free survival and disease-free survival.

CONCLUSION

A higher p-SUVpeak on pretreatment ¹⁸F-FDG-PET/CT is a prognostic parameter of identifying lower survival outcomes.

Lymph node density in papillary thyroid carcinoma is a prognostic factor after adjusting for pathological stage

We investigated the possible association between the lymph node density and survival outcomes in differentiated papillary thyroid carcinoma, and examined whether the lymph node density was a predictor in a multivariate analysis adjusted for the pathological stage in the eighth edition of the Union for International Cancer Control Tumor-Node Metastasis Classification of Malignant Tumors. A total of 543 patients with papillary thyroid carcinoma were enrolled. We performed restaging according to the eighth edition. The lymph node density was the ratio between number of positive lymph nodes and total number of excised lymph nodes. A log-rank test and Cox's proportional hazards model were used for univariate and multivariate analysis with adjustment for the pathological stage in the eighth edition, respectively. In both the univariate and multivariate analyses of 150 patients with pN1bM0, the presence of a lymph node density of ≥ 0.3 with pN1b was significantly associated with shorter disease-specific survival. In both the univariate and multivariate analyses of all 543 patients, a lymph node density of ≥ 0.3 with pN1b were also significantly associated with shorter overall and disease-specific survival. In conclusion, these results suggest that the lymph node density can be used as a predictor for the survival outcomes after adjustment for the pathological stage in the eighth edition.

Treatment of Acute Myocardial Infarction with Cardiogenic Shock using Left Ventricular Assist Device

We have treated ten cardiogenic shock patients after acute myocardial infarction (AMI) with a left ventricular assist device (LVAD). These patients were later divided into three groups: the first group with ventricular septal perforation, the second with aorto-coronary bypass grafting (ACBG) before LVAD implantation and the third group without ACBG. LVAD maintained the systemic circulation in each group, and cardiac function recovered enough to remove LVAD in 70% of the total patients. Two of three patients in the first group were discharged from hospital. Two weaned cases in the second group died of multiple organ failure and one was discharged, and hemorrhagic necrosis was seen in the bypassed area of the myocardium. One patient of the third group could not be weaned from LVAD because of respiratory failure though his heart function began to recover. Another case in the third group underwent bypass grafting after removal of LVAD. However ACBG surgery should be done very carefully because a patient in shock is occasionally intolerant to major surgery. In all groups, the major cause of death was multiple organ failure which was probably caused by the prolonged low output condition prior to LVAD application. In the light of this experience, it appears that LVAD should be applied before irreversible damage occurs to major organs, including the heart itself. To ensure the timely application of LVAD, some way must be found to introduce systematic application of LVAD into the normal course of AMI treatment.

Impact of hematological inflammatory markers on clinical outcome in patients with salivary duct carcinoma: a multi-institutional study in Japan

The prognostic role of modified Glasgow Prognostic Score (mGPS), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in patients with salivary duct carcinoma (SDC) remains unclear. We conducted a multi-institutional retrospective cohort study of 140 SDC patients. The survival impact of these hematological markers was evaluated using multivariate proportional hazard models.High mGPS (≥1) was significantly associated with worse survival (3-year overall survival (OS): 16.7% vs 66.1%, p-value=0.003; 3-year progression-free survival (PFS): 0.0% vs 27.9%, p-value<0.001). Additionally, high C-reactive protein (CRP) (≥0.39 mg/dl) was significantly associated with worse survival (3-year OS: 32.1% vs 68.2%, p-value=0.001; 3-year PFS: 7.1% vs 31.1%, p-value<0.001). These associations were consistent with multivariate analysis adjusted for established prognostic factors. Although we also found significant association of high NLR (≥2.5) with OS (HR 1.80; 95% confidence interval, 1.05-3.08) in multivariate analysis, this association were inconsistent with the results of PFS. In addition, we found no significant associations of PLR with survival. In conclusion, we found that mGPS, CRP and NLR were identified as prognostic factors associated with survival in SDC patients.

The Impact of Skeletal Muscle Depletion on Head and Neck Squamous Cell Carcinoma

BACKGROUND

Skeletal muscle depletion and sarcopenia have been reported as poor prognostic factors for several types of cancer. The aim of this study was to investigate the prognostic impact of skeletal muscle depletion and sarcopenia on the outcomes in head and neck cancer patients.

METHODS

Patients with head and neck squamous cell carcinoma (HNSCC) treated from January 2013 to June 2014 were included in this study. The pretreatment cross-sectional area of skeletal muscle at the third lumbar vertebra (L3) was measured by computed tomography image analysis using the ImageJ software. L3 skeletal muscle index (SMI) and fat-free mass (FFM) were calculated.

RESULTS

Eighty-five patients with HNSCC were included. The cut-off value of sarcopenia was set at SMI <46.7 cm2/m2 (males) and 30.3 cm2/m2 (females). The cut-off value of FFM was set at 42.3 kg (males) and 30.6 kg (females). Patients with a low SMI (sarcopenia) and low FFM had a significantly poorer prognosis than others, especially those who received definitive radiotherapy. Sarcopenia and low FFM are independent factors for poor prognosis in patients with HNSCC.

CONCLUSION

The skeletal muscle area at L3 should be calculated when considering treatment options for head and neck cancer.

Chemo-selection with docetaxel, cisplatin and 5-fluorouracil (TPF) regimen followed by radiation therapy or surgery for pharyngeal and laryngeal carcinoma

Background

Induction chemotherapy for patients with head and neck cancer is widely performed, and several advantages of induction chemotherapy have been reported. However, there is currently insufficient evidence to strongly recommend induction chemotherapy. In this study, we analyzed the outcomes for patients treated with induction chemotherapy and subsequent definitive treatments.

Methods

Operable patients with untreated oropharyngeal, hypopharyngeal and laryngeal squamous cell carcinoma treated with induction chemotherapy were included in this retrospective study. We conducted induction chemotherapy using docetaxel, cisplatin and 5-fluorouracil and performed subsequent surgical treatment or radiotherapy according to the response to induction chemotherapy.

Results

A total of 65 patients were included in this study, and 50 patients (76.9%) had Stage IV tumors. The response to induction chemotherapy was CR in two patients, PR in 55 patients, and SD in eight patients. The subsequent definitive treatment was radiotherapy in 60 patients, and surgery in five patients. The 3-year overall survival rates for patients who received radiotherapy and surgery were 88.4% and 75.0%, respectively (P = 0.30). The 3-year disease-free survival rates for patients who received radiotherapy and surgery were 68.0% and 0%, respectively (P = 0.01). The 3-year laryngeal dysfunction free survival rates for patients who received RT and surgery were 77.8% and 0%, respectively (P < 0.01).

Conclusions

We achieved favorable survival outcomes and high larynx preservation rates. Our results suggest that induction chemotherapy using TPF regimen is one of the optimal treatment strategies when treating head and neck cancers. Further prospective studies with a larger cohort are required to confirm our findings.

Left ventricular cardiac hemangioma in a patient with chronic heart failure

Cardiac hemangiomas are rare benign tumors. Here, we report the case of a man in his 30s who had a cardiac hemangioma with no symptoms. He was being treated with β-blockers for chronic heart failure with hypertensive heart disease at Osaka Minato Central Hospital. Routine echocardiography revealed a mobile spherical mass in the left ventricle that had not been detected on echocardiography performed 4 months previously. Subsequently, the tumor was excised to prevent potential embolic events and was pathologically diagnosed as a cardiac hemangioma. This case demonstrates the relatively rapid progress of a cardiac hemangioma regardless of β-blocker administration, which is occasionally used for the treatment of hemangiomas. The efficacy of β-blockers in treating cardiac hemangiomas may vary according to the type of β-blocker. Echocardiography is useful in screening and follow-up of cardiac hemangiomas; however, additional imaging modalities are needed for differential diagnosis.

Expression of cancer/testis antigens in salivary gland carcinomas with reference to MAGE-A and NY-ESO-1 expression in adenoid cystic carcinoma

AIMS

Cancer/testis antigens (CTAs) are detected in cancer cells but not in healthy normal tissues, with the exception of gametogenic tissues. CTAs are highly immunogenic proteins, and thus represent ideal targets for cytotoxic T-lymphocyte-mediated specific immune therapy. The aim of this study was to screen CTA expression in various types of salivary gland carcinoma and to clarify clinicopathological significance of MAGE-A and NY-ESO-1 expression in adenoid cystic carcinomas (AdCCs) of the salivary gland, which is one of the most common salivary gland carcinomas, and usually has a fatal outcome.

METHODS AND RESULTS

We used immunohistochemistry to examine the expression of four CTAs (MAGE-A, NY-ESO-1, CT7, and GAGE7) in various types of salivary gland carcinoma (n = 95). When carcinoma cases were divided into low-grade and intermediate/high-grade types, NY-ESO-1 and CT7 were expressed more frequently in intermediate/high-grade carcinomas. We then focused on MAGE-A and NY-ESO-1 expression in a large cohort of adenoid cystic carcinomas (AdCCs) (n = 46). MAGE-A and NY-ESO-1 were frequently expressed in AdCC; specifically, MAGE-A was expressed in >60% of the AdCC cases. MAGE-A expression and tumour site (minor salivary gland) were identified as independent risk factors for locoregional tumour recurrence.

CONCLUSIONS

These findings suggest that CTAs may be expressed in a variety of salivary gland carcinomas, especially in those with higher histological grades. In addition, MAGE-A, which is frequently expressed in AdCC cases, may be a useful prognostic factor for poorer locoregional recurrence-free survival.

Striated duct adenoma presenting with intra-tumoral hematoma and papillary thyroid carcinoma-like histology

Striated duct adenoma of the salivary gland is a rare benign tumor characterized by unilayered duct epithelium and striations of the tumor cell membranes. To the best of our knowledge, only six cases have been reported in the literature. Here we report an additional case, which was complicated by an intra-tumoral hematoma on clinical presentation and by papillary thyroid carcinoma-like histology on intra-operative frozen section diagnosis. An asymptomatic 78-year-old male presented with a two-year-history of a painless tumor of the left parotid. An intra-tumoral hematoma, which is unusual for a salivary gland tumor, was suspected from results of pre-operative radiology. The patient then underwent a left parotidectomy. The intra-operative frozen section diagnosis indicated a benign tumor, although ectopic papillary thyroid carcinoma was raised as a differential diagnosis since the eosinophilic tumor cells occasionally possessed nuclear grooves and nuclear pseudo-inclusions. By precise histopathological examination using paraffin sections, the tumor was finally diagnosed as striated duct adenoma. This type of tumor has unique features of hypervascular stroma and papillary thyroid carcinoma-like nuclei. In our case, the former feature was associated with the intra-tumoral hematoma and the latter feature, with difficulty in frozen section tumor diagnosis.

A fundamental study for quantitative measurement of ultrasound contrast concentration by low mechanical index contrast ultrasonography

PURPOSE

In high mechanical index (MI) contrast ultrasonography it has been shown that the power of contrast signal intensity (CI) has a strong linear correlation with the concentration of the ultrasound contrast agent under conditions of constant applied acoustic pressure. However, it is unclear whether the linearity is preserved in low-MI contrast ultrasonography. Thus, we investigated the relationship between ultrasound contrast concentration and CI in vitro.

METHODS

Solutions of the ultrasound contrast agents Definity and Imagent were prepared at concentrations of 0.5, 2, 8, 32, and 128 μl/l. Placing a jelly block between the transducer and the solution, the solutions were transmitted using pulse subtraction imaging with an MI of 0.05, 0.1, and 0.5. CI was measured in dB in a region of interest 3 mm in height placed just below the border between the jelly and the solution. Data were plotted using double logarithm scales, where the concentration was expressed in dB as 10 × log (concentration).

RESULTS

CI in dB had a strong linear correlation with concentration in dB for both agents with any MI. Best fitted slopes were close to 1, indicating that the power of CI is proportional to the concentration.

CONCLUSIONS

In low-MI contrast ultrasonography, the power of CI is proportional to contrast concentration, and CI in dB is logarithmic to the concentration. Thus, the microbubble concentration can be quantitatively measured even in low-MI contrast ultrasonography.

Lymph node density predicts lung metastases in oral squamous cell carcinoma

The association between lymph node density and survival free of lung metastases in oral squamous cell carcinoma (SCC), has not been investigated so far to our knowledge. Lymph node density ≧ 0.07 has been reported by a multicentre international study to be a significant predictor of shorter survival in patients with oral SCC who have invaded nodes. We investigated whether a lymph node density of ≧ 0.07 correlates with shorter overall survival, survival free of distant metastases, and survival free of lung metastases, in patients with oral SCC and invaded lymph nodes. Thirty-five patients with histologically-confirmed invaded lymph nodes werestudied. Their density was calculated as the ratio of the number of invaded lymph nodes:total number of nodes. A density of ≧ 0.07 correlated significantly with shorter overall survival (p<0.02), survival free of distant metastases (p<0.01), and survival free of lung metastases (p<0.01) on log rank testing. On testing by Cox's proportional hazards model of multivariate survival analysis with adjustment for the pathological stage (pstage IV/pstage III), and invaded surgical margins or extracapsular spread, or both, we found that lymph node density ≧ 0.07 was associated with significantly shorter survival (p<0.02). We conclude that lymph node density predicts lung metastases in patients with oral SCC.

Androgen receptor-positive mucoepidermoid carcinoma: case report and literature review

Androgen receptor (AR) is usually expressed in salivary duct carcinoma (SDC), but only infrequently in other carcinoma types including mucoepidermoid carcinoma (MEC). The clinicopathological characteristics of AR-positive MEC remain to be clarified. Here we report a case of AR-positive MEC. A 76-year-old man presented with a growing painless tumor of the right parotid. The resected tumor was a high-grade tumor with necroses. Since the tumor was positive for AR, GCDFP-15, and HER2, SDC was first suspected, but it was also positive for CK5/6 and P63, and negative for S-100 protein and α-smooth muscle actin. In addition, scattered mucous secreting tumor cells were found in the tumor nests, and they were positive for Alcian blue. A diagnosis of AR-positive MEC was finally made. The patient died of the tumor 5 years after the surgery. The present case may expand the histopathological spectrum of high-grade MEC.

Evaluation of left ventricular rotation by two-dimensional speckle tracking method and real-time three-dimensional echocardiography: comparison with MRI tagging method

BACKGROUND

Recently, it has become possible to evaluate left ventricular (LV) torsion by two-dimensional (2D) speckle tracking images. However, LV torsion is a three-dimensional (3D) performance, which per se cannot be assessed by the 2D speckle tracking method. The present study investigated the accuracy of the 2D speckle tracking method and real-time 3D echocardiography in measuring LV rotation, comparing with the MRI tagging method.

METHODS

We assessed LV apical rotation using the 2D speckle tracking method, real-time 3D echocardiography, and MRI tagging method in 26 normal subjects, and compared the results of these three methods. LV apical rotation was measured just before the level in which the posterior papillary muscle was absorbed into the free wall.

RESULTS

The degree of LV apical rotation evaluated by the 2D speckle tracking method (Δθ 2D) was significantly smaller than that evaluated by 3D echocardiography (Δθ 3D) and the MRI tagging method (Δθ MRI) (Δθ 2D 7.3 ± 2.8°; Δθ 3D 8.8 ± 3.4°; Δθ MRI 9.0 ± 3.4°; Δθ 2D vs. Δθ 3D, p = 0.0001; Δθ 2D vs. Δθ MRI, p < 0.0001). There were good correlations among Δθ 2D, Δθ 3D, and Δθ MRI, but agreement between Δθ 3D and Δθ MRI (mean difference 0.14 ± 1.43°) was better than that between Δθ 2D and Δθ MRI (mean difference 1.68 ± 1.89°).

CONCLUSION

The degree of LV apical rotation was underestimated with the 2D speckle tracking method compared with the MRI tagging method, whereas it could be precisely measured by 3D echocardiography.

Effect of sildenafil citrate (Viagra) on coronary flow in normal subjects

BACKGROUND

The purpose of this study was to evaluate the effect of sildenafil citrate (Viagra) on coronary function in normal subjects.

METHODS

The study assessed mean blood pressure, left anterior descending coronary artery (LAD) flow, and echocardiographic variables before and 30 and 60 minutes after taking 50 mg of sildenafil citrate. The mean velocity of LAD flow was assessed with Doppler flow imaging. The study subjects were 6 healthy male volunteers (mean age 37 years).

RESULTS

The mean velocity of LAD flow increased 60 minutes after taking sildenafil citrate, but there were no other changes. Two volunteers felt mild flashing and one had mild headache during the study.

CONCLUSION

Sildenafil citrate caused vasodilatation in a normal coronary artery without systemic pressure drops. These results suggest that the agent itself did not have negative effects on the heart in normal subjects.

Low testosterone levels in patients with mild hypertension recovered after antidepressant therapy in a male climacterium clinic

Recently, middle-aged men who have begun frequently complaining of erectile dysfunction and nonspecific symptoms similar to those of postmenopausal women, visited a male climacterium clinic in Japan. Some patients, who were already taking antihypertensive medication, discontinued or reduced their dosages of antihypertensive medication after anti-depressant therapy. Forty-nine males over the age of 40 years were studied to evaluate the relationships between blood pressure, mental stress, and testosterone levels. The systemic blood pressure (sBP) of 24 patients was higher than the criteria for mild hypertension: 140/90 mmHg (HT group) at first visit. The sBP of the other 25 patients was normal (N group). The international index of erectile function (IIEF5) score (normal >21), self-rating depression scale (SDS) score (normal <40), and plasma testosterone levels were also evaluated before and after anti-depressant therapy without androgen replacement therapy. There were no significant differences between the groups in IIEF5 or SDS scores. The plasma testosterone levels in the HT group at first visit were significantly lower than those in the N group (230+/-77 vs. 343+/-92 ng/dL, p<0.001). After treatment, the IIEF5 scores were unchanged, whereas SDS scores were lower in both groups. Mean systemic blood pressure (mBP) in the HT group significantly decreased from 112+/-7 to 94+/-7 mmHg after treatment, concomitant with the disappearance of nonspecific complaints and the increase of testosterone levels. In the N group, however, neither mBP nor testosterone levels changed. Psychotherapy can ameliorate mild systemic hypertension in climacteric men with low testosterone levels. Mental stress might suppress the hypothalamic-pituitary-gonadal axis to decrease testosterone levels.

Sildenafil citrate (Viagra) enhances vasodilatation by atrial natriuretic peptide in normal dogs

BACKGROUND

Sildenafil citrate (Viagra) is a selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5, which might enhance the vasorelaxant and natriuretic actions of atrial natriuretic peptide (ANP) in patients with heart failure. The objective of this study was to examine the combined effect of Viagra on hemodynamic changes during infusion of exogenous ANP.

METHODS AND RESULTS

Healthy male beagles were used to assess systemic blood pressure, pulmonary artery pressure (PAP), and plasma levels of cGMP. After hemodynamic variables were measured, 0.1 microg.kg(-1).min(-1) of ANP was given during this study. One hour after initiating infusion of ANP, 2 mg/kg of sildenafil citrate or vehicle was given orally via a nasogastric tube. Hemodynamic changes were measured before and 1 h after these administrations. Mean systemic and PAP decreased during infusion of ANP, and further decreased after sildenafil citrate administration, however, mean systemic blood pressure decreased within 10 mmHg. Plasma levels of cGMP also increased after sildenafil citrate administration.

CONCLUSION

In normal dogs, sildenafil citrate enhances the vasodilator effect of ANP by increasing the cGMP level, however, the concomitant use of sildenafil citrate with ANP will not induce severe hypotension.

Effect of systemic blood pressure on microcollateral circulation evaluated by real-time contrast echocardiography

BACKGROUND

In acute myocardial infarction, residual collateral-derived myocardial blood flow (CBF) within the ischemic area is one of the major determinants of infarct size. Management of systemic blood pressure (sBP) related to maintain collateral circulation is still difficult. The aim of this study was to reveal the influence of sBP on the rescue of area at risk by collateral circulation.

METHODS

Real-time myocardial contrast echocardiography just after the onset of complete occlusion of the left circumflex coronary artery was performed in collateral-rich open-chest dogs. The video intensity of the ischemic area was evaluated during the occlusion and the CBF (A x beta) was calculated from a replenishment curve: y = A (1 - e(-beta t)). To analyze the effect of sBP on the collateral circulation, sBP was altered by infusion of nitroglycerin or etilefrine hydrochloride. To evaluate the defect size (%DS), every end-systolic myocardial contrast echocardiography image after left circumflex coronary artery occlusion was converted into binary images using custom offline software.

RESULTS

The %DS increased and CBF slightly decreased at low sBP. The %DS decreased and CBF increased at high sBP. At excessively high sBP, %DS increased and CBF decreased again.

CONCLUSION

Real-time myocardial contrast echocardiography, which is a useful noninvasive method to evaluate the collateral perfusion quantitatively, has a crucial role in the decision of patient treatment and management strategy of acute myocardial infarction.

Brief communications: visualization of coronary arteries in rats by 3-dimensional real-time contrast echocardiography

Angiogenesis is under intense investigation to advance the treatment of various ischemic diseases. Small animals, such as mice and rats, are often used for this purpose. However, evaluating the structure of coronary arteries in small animals in situ is not easy. We succeeded in visualizing the coronary artery in rats on 3-dimensional real-time contrast echocardiography using a high-frequency transducer. These methods will be applied for more convenient assessment in a new study, examining issues such as angiogenesis using rats in situ.

Three-dimensional reconstruction of coronary arteriole plexus image by contrast echocardiography using a high-frequency transducer

OBJECTIVE

This study was established to examine the efficacy of a high-frequency liner probe for visualizing fine anatomy of coronary microcirculation.

METHODS

The vessel size and its velocity-time integral at the anterior wall in dogs by real-time contrast echocardiography with high-frequency liner probe and pulse Doppler methods, and the coronary flow volume, were measured before and after adenosine triphosphate injection. A 3-dimensional (3D) image was reconstructed by the built-in 3D system using intermittent flash echocardiographic images.

RESULTS

The increments of flow volume calculated from vessel sizes and velocity-time integral were well correlated with those of coronary flow volume. Using intermittent flash echocardiographic images, fine dots and lines of contrast echocardiographic-expected arterioles were evident, and easily and quickly reconstructed as coronary plexus by 3D system.

CONCLUSION

A high-frequency liner probe provides the fine-vessel images to evaluate those morphologic changes; a 3D reconstruction image could provide new information about coronary arterioles.