Correlation between postoperative treatment selection and prognosis determined using the Oncotype DX® test data: a retrospective multicenter study in Japan

PURPOSE

Oncotype DX® is a frequently used multigene assay for hormone receptor-positive breast cancers. However, limited evidence is available regarding its application in Japan owing to the lack of insurance coverage. Therefore, we conducted this large-scale, retrospective study by collecting data from nine Japanese institutes and assessed postoperative treatment choice and prognosis by using Oncotype DX®.

METHODS

Six hundred thirty-two patients who underwent breast surgery and whose recurrence score (RS) data were available were included. They were divided into RS 0-25 and RS ≥ 26 groups. The groups were compared in terms of clinicopathological factors, treatment options, and prognosis.

RESULTS

After the median follow-up period of 10.1 years, the disease-free survival (DFS) rates were significantly better in the RS 0-25 group (p = 0.02). Per the recurrent event type, there was no significant intergroup difference in locoregional recurrence (p = 0.139). However, a trend toward better distant DFS was observed in the RS 0-25 group (p = 0.08). Overall survival was also significantly better in this group (p = 0.027). Considering chemotherapy use, DFS worsened among chemotherapy-treated patients with an RS of 0-25 and those with an RS ≥ 26 who did not receive chemotherapy (p < 0.001). Seven (1.35%) chemotherapy-treated patients with an RS of 0-25 showed disease recurrence.

CONCLUSIONS

This study presents the largest database-derived prognostic data in Japanese patients, utilizing the Oncotype DX® treatment selection. Further studies are needed to determine the impact on treatment choice, considering the clinical risk, and the need for additional postoperative treatment.

Sarcoidosis or sarcoid-like reaction with mediastinal lymphadenopathy in patients after breast cancer surgery

BACKGROUND

Patients with breast cancer present with lymphadenopathy involving non-caseating epithelioid cell granulomas in the mediastinum or axilla, referred to as sarcoidosis or sarcoid-like reactions (SLRs). However, sarcoidosis/SLRs prevalence and clinical presentation remain unclear. This study aimed to determine the frequency and clinical presentation of sarcoidosis/SLRs among postoperative patients with breast cancer.

METHODS

Among all patients who underwent surgery for early-stage breast cancer at St. Luke's International Hospital in Japan between 2010 and 2021, those who subsequently developed enlarged mediastinal lymph nodes and underwent bronchoscopy for suspected breast cancer recurrence were included. Patients were classified into sarcoidosis/SLR or metastatic breast cancer groups, and the clinical characteristics were compared.

RESULTS

A total of 9,559 patients underwent breast cancer surgery; bronchoscopy was performed to diagnose enlarged mediastinal lymph nodes in 29 cases. Breast cancer recurrence was observed in 20 patients. Eight women with a median age of 49 years (range 38-75) and a median time from surgery to diagnosis of 4.0 years (range 0.2-10.8) were diagnosed with sarcoidosis/SLRs. Four of the eight patients underwent mammoplasty with silicone breast implants (SBIs), and two experienced postoperative recurrences of breast cancer before or after lymphadenopathy, which was considered inciting factors for SLRs. The remaining two cases could have developed sarcoidosis after breast cancer surgery with no underlying causes for SLR.

CONCLUSIONS

Postoperative sarcoidosis/SLRs rarely occur in patients with breast cancer. An adjuvant action of SBI likely contributed to the progression of SLRs; few cases exhibited a causal relationship with breast cancer recurrence.

Abstract P1-07-05: Clinical utility of twenty-five gene-expression profiling using LAMP method in early stage breast cancer

Background The 21-gene Recurrence Score (RS) (Oncotype DX®) is one of the most frequently used multigene assays to predict prognosis and response to treatment for estrogen receptor-positive breast cancer. Although the result of two prospective randomized trials, TAILORx and RxPONDER trial have increasingly established the clinical utility of Oncotype DX®, the cost and testing period are disadvantages especially in Asian countries. To overcome these disadvantages, we developed a new multi-gene assay using Loop-Mediated Isothermal Amplification (LAMP). We have previously selected a twenty-five genes set through comprehensive gene expression analysis of breast cancer samples from more than 500 cases (patent pending). Although these twenty-five genes are different from those used in conventional assays, their physiological functions are similar to those of Oncotype DX®, and it is expected that the results will be equivalent to Oncotype DX® as a predictor of prognosis and chemotherapeutic efficacy. This new assay can be performed in own institution, and the result can be obtained less than one hour. It can lead to significantly reduce costs and testing time compared to conventional assays. Based on these backgrounds, we constructed the prediction algorithm based on the new gene expression profiles using LAMP and evaluated its performance in this study. Methods Total RNA was extracted using Maxwell® RSC RNA FFPE Kit (Promega) from FFPE tumor samples of postoperative breast cancer tissue which Oncotype DX® have already tested in our institution between January 2009 to January 2021and was quantified by Reverse-transcription LAMP enabling one-step reaction from reverse transcription to amplification under isothermal condition (63°C). Samples were divided into three groups, low-RS (RS 0-10), RS-intermediate (RS 11-25) and RS-high (RS ≥26) based on Oncotype DX®-RS. Using the obtained mRNA amplification detection time as an explanatory variable and Oncotype DX®-RS as an objective variable, a prediction algorithm based on expression profiles based on LAMP method was constructed and evaluated its performance with 4-fold cross-validation. The prediction algorithm was trained using extreme gradient boosting (XGBoost) algorithm that parameters used default of R package “xgboost”. We also performed the quality analysis of mRNA excluded from this analysis due to poor mRNA quality. The percentage of mRNA above 200nt (DV200) was calculated by electrophoresis, and the correlation between the degree of mRNA degradation and the number of years of storage was calculated. Results Of the 221 cases which have tested Oncotype DX® during the study period, 90 samples were used in the analysis, and the remaining samples were excluded from this study due to poor mRNA quality. Of the 90 samples, 19 cases were RS-low, 42 cases were RS-intermediate, and 30 cases were RS-high, respectively. The correlation coefficient between Oncotype DX®-RS and our LAMP method-based predicted RS was r=0.911 (95%CI 0.900−0.921, p-value &lt; 0.001). The overall concordance rate with the predicted risk of recurrence (high/intermediated/low-RS) was 0.9343 (95%CI: 0.9174-0.9486, p-value &lt; 0.001). Regarding the quality analysis of mRNA excluded from this analysis, we found the inverse correlation between the degree of mRNA degradation and the storage periods, namely higher DV200 with shorter periods. In particular, there was less mRNA degradation in specimens that had been stored for less than one year. Conclusion Our new gene expression profiling by the LAMP method suggested to have same discriminately ability with Oncotype DX® to predict the risk of recurrence in early breast cancer patients. The duration of mRNA storage and the fixation time in the FFPE preparation process are suggested to be important for maintaining the quality of mRNA. We are planning to further studies with increase sample size and analyze the correlation with prognosis.

Citation Format: Yasue Tsuchida, Takaaki Ueda, Yuka Nagatake, Satoru Michiyuki, Miku Hattori, Masaki Sato, Norihiro Tomita, Naoki Kanomata, Hideko Yamauchi. Clinical utility of twenty-five gene-expression profiling using LAMP method in early stage breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-07-05.

Efficacy and safety of plasma exchange in interstitial lung diseases with anti-melanoma differentiation-associated 5 gene antibody positive clinically amyopathic dermatomyositis

OBJECTIVE

Clinically amyopathic dermatomyositis (CADM) patients frequently develop refractory interstitial lung disease (ILD), with a poor prognosis. We aimed to verify the efficacy and safety of plasma exchange (PE) treatment for ILD in CADM.

METHOD

A retrospective case-control study was conducted to compare clinical outcomes with and without PE treatment in CADM-ILD patients refractory to combination therapy of high-dose glucocorticoids, calcineurin inhibitors, and cyclophosphamide. Among 19 enrolled patients, 11 were further treated with PE. We compared survival rates and other clinical characteristics. PE consisted of either fresh-frozen plasma or albumin as a replacement solution.

RESULTS

Basal clinical characteristics at diagnosis, including age, gender, serum ferritin, Krebs von den Lungen-6 (KL-6), C-reactive protein, and respiratory function tests, did not differ between the two groups. The survival rate for treatment with PE was higher than for treatment without PE (91% and 50%, respectively, p < 0.05). Among PE-treated patients, anti-melanoma differentiation-associated gene-5 (anti-MDA-5) antibody titre, ferritin, and KL-6 as serological activity markers were sustainably reduced only after initiating PE. Therapeutic intervention with PE reduced the frequency of exacerbation of ILD requiring methylprednisolone pulse therapy. The occurrence of bacterial, fungal, and cytomegalovirus infection did not differ between the groups with and without PE, and adverse events associated with PE resolved with appropriate intervention.

CONCLUSION

Combination therapy with PE was associated with an improved survival rate, and may be effective for the management of refractory ILD in CADM patients. A personalized therapeutic strategy including PE could be introduced for fatal rapidly progressive ILD.

A validated model to predict low recurrence risk distinguished by 21-gene recurrence score in hormone receptor-positive invasive breast cancer patients

532

Background: In the prospective TAILORx and RxPONDER trials, the 21-gene Recurrence Score (RS) showed endocrine therapy alone was non-inferior to chemo-endocrine therapy in the analysis of invasive disease-free survival in postmenopausal hormone-receptor (HR)-positive breast cancer patients with RS < = 25. They also indicated chemotherapy was associated with benefit for women 50 years or younger with RS 11 to 25. However, in Japan, the test is not conventionally available because of non-coverage by national insurance. We aimed to develop and validate a model to predict RS using clinicopathological factors that identify patients who would have low risk shown by testing the 21-gene RS and can avoid chemotherapy. Methods: Four hundred patients, including 187 N0/1 postmenopausal, and 213 N0 premenopausal women who underwent surgery and had the RS from St. Luke’s International Hospital, Tokyo, Japan, were included in derivation cohort. Derivation cohort was divided into 2 groups by RS 25; patients with RS of 0 to 25 (n = 321) and with RS over 26 (n = 79). Multivariate logistic regression analysis was performed using candidate factors for all patients and pre- or postmenopausal patients. The prediction model was validated using an external cohort of 70 patients from Showa University School of Medicine, Tokyo, Japan. Results: Nuclear grade (NG) (adjusted OR, 5.28, 95% CI, 2.47–11.30), high Progesterone receptor (PgR) expression (Allred score 7-8) (adjusted OR, 10.62, 95% CI, 5.34–21.13) and low Ki67 level ( < = 20%) (adjusted OR, 5.29, 95% CI, 2.33-12.01) were significant independent predictors of RS of 0 to 25. With these factors could predict RS of 0 to 25 (AUC of 0.848, 95% CI, 0.803-0.893) with the highest probability of low-RS for 100%. The prediction model of the validation cohort had same discriminatory ability having an AUC of 0.812 (95% CI, 0.701-0.923). In postmenopausal patients, NG (adjusted OR, 4.81, 95% CI, 1.72–13.42), high PgR expression (adjusted OR, 10.62, 95% CI, 4.52–37.72), and low Ki67 level (adjusted OR, 4.94, 95%CI, 1.87-13.04) were significantly associated with RS of 0 to 25 in multivariate analysis. A regression model with these 4 factors could predict RS of 0 to 25 (AUC of 0.842, 95%CI, 0.782-0.902). In premenopausal patients, NG (adjusted OR, 8.76, 95% CI, 1.14–67.40), high PgR expression (adjusted OR, 3.22, 95% CI, 1.61–6.43), and low Ki67 level (adjusted OR, 2.87, 95% CI, 1.20–6.87) were significantly associated with RS of 0 to 10 in multivariate analysis. These factors could predict RS of 0 to 10 (AUC of 0.811, 95% CI, 0.731-0.891). However, the highest probability of low-RS provided this model for premenopausal women was 46.8%. Conclusions: Our validated model could provide useful information to distinguish low-RS especially for postmenopausal patients with high reproducibility. However, for premenopausal women, the 21-gene RS is warranted.

Angiotensin receptor blocker vs ACE inhibitor effects on HDL functionality in patients on maintenance hemodialysis

BACKGROUND AND AIMS

Angiotensin receptor blockers (ARB) and angiotensin converting enzyme inhibitors (ACEI) reduce cardiovascular events in the general population. Maintenance hemodialysis (MHD) patients are at high cardiovascular risk but few studies have directly addressed the comparative efficacy of these drugs. MHD disrupts the normally atheroprotective actions of high density lipoprotein (HDL), therefore, we compared ACEI or ARB treatment on HDL functions in MHD.

METHODS AND RESULTS

HDL was isolated at the starting point (pre) and 3-6 months later (post) in 30 MHD randomly assigned to placebo, ramipril or valsartan. Outcomes included cholesterol efflux, inflammatory cytokine response, effects on Toll-like receptors (TLR), superoxide production, methylarginine and serum amyloid A (SAA) levels. HDL from ARB- or ACEI-treated subjects was more effective in maintaining efflux than HDL of placebo. HDL from ARB- or ACEI-treated subjects but not placebo lessened cellular superoxide production. In contrast, neither ARB nor ACEI improved HDL anti-inflammatory effect. Indeed, HDL of ACEI-treated subjects potentiated the cytokine responses in association with activation of TLR but did not alter the HDL content of methylarginines or SAA.

CONCLUSION

Both ACEI and ARB stabilized HDL cholesterol acceptor function and sustained cellular anti-oxidative effects but not anti-inflammatory effects, and ACEI-treatment instead amplified the HDL inflammatory response. The findings reveal possible utility of antagonizing angiotensin actions in MDH and suggest a possible mechanism for superiority of ARB vs ACEI in the setting of advanced kidney disease.

Abstract P2-05-36: Clinicopathological predictors for low risk recurrence distinguished by 21-gene recurrence score in estrogen receptor-positive invasive breast cancer patients

Background: The 21-gene Recurrence Score (RS) (Oncotype DX®; Genomic Health, Redwood City, CA) is the most valid and reliable multigene assay to predict prognosis or response to treatment in hormone receptor-positive invasive breast cancer patients. However, in Japan, the test is expensive (about 4,000 US dollars) and one of the problems is that about 30% of patients will be categorized as having moderate recurrence risk. If clinicopathologic factors can be used to predict patients with low recurrence, many patients can avoid postoperative chemotherapy without testing the RS. Such predictors shall have a substantial impact on medical economics too. The aim of this study was to determine significant clinicopathological predictors for low recurrence risk by RS in patients with estrogen receptor-positive primary breast cancer.

Methods: Retrospective cross-sectional study was conducted in tertiary referral hospital in Tokyo, Japan. Two hundreds twenty patients with estrogen receptor-positive invasive breast cancer underwent surgery for breast cancer and tested for RS from November 2009 to March 2016. RS £18 was defined as low recurrence risk. The patients were divided into 2 groups, patients with low recurrence risk (n=143) and with a moderate/high recurrence risk (n=77). Age, menopausal status, histologic type (invasive ductal vs. lobular carcinoma), nuclear grade, progesterone receptor (PR) expression, Ki67 index, tumor size, lymph node status, and lymphovascular invasion were considered as candidate predictors. Student's t test or Wilcoxon-Rank Sum test and Fisher's exact test was used for continuous variables and proportion, respectively. Simple and multiple logistic regression model were used to determine significant predictors. Classification and regression tree analysis (CART) was also conducted.

Results: Mean age (SD) of low and moderate/high recurrence patients was 53 years-old (9.4) and 55 years (10.2), respectively. Univariate analyses revealed that the invasive lobular carcinoma, the high PR expression, Ki67 &lt; 24, and the absence of lymphovascular invasion were significantly associated with low recurrence risk. According to multiple logistic regression, The odds ratio (OR) [95%CI] of histological type (invasive lobular), high PR expression, Ki67 &lt; 24, and the absence of lymphovascular invasion was 0.43 [0.08-1.8], 10 [5.4-23.6], 0.95 [0.93-0.97], and 0.57 [0.23-1.18], respectively. The area under the receiver operating characteristic curve was 0.83. CART showed that the probability of low recurrence risk was 79% if with high PR expression, and 92% if with high PR expression and Ki67 &lt; 24.

Conclusions: High PR expression and Ki67 &lt; 24 were significant predictors for low recurrence risk by RS in estrogen receptor-positive invasive breast cancer patients. More than 90% of patients with high PR expression and Ki67 &lt; 24 could be classified as low recurrence risk by RS.

Citation Format: Tsuchida Y, Hayashi N, Omata F, Yamauchi H. Clinicopathological predictors for low risk recurrence distinguished by 21-gene recurrence score in estrogen receptor-positive invasive breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-36.

Serial magnetic resonance imaging study of posterior cruciate ligament reconstruction or augmentation using hamstring tendons

PURPOSE

The purpose of this study was to analyze serial changes in the magnetic resonance imaging (MRI) signals of autograft hamstrings single bundle posterior cruciate ligament (PCL) reconstruction and the effects of remnant preservation (augmentation).

MATERIAL AND METHODS

Twenty-two isolated PCL injuries were arthroscopically reconstructed or augmented with hamstring tendons. MRI scans were obtained at 3, 6, and 12 months, and prior to the second-look arthroscopy (average 20.7 months). The patients were divided into 2 groups by remnant preservation: five PCL reconstructions after PCL remnant resection (Group Rec) (23%), and 17 reconstructions preserving the remnant (Group Aug) (77%). The 22 patients were also divided in two groups depending on the location of the PCL tear. There were 9 knees with proximal tear (Type P) (41%) and 13 knees with distal tear (Type D) (59%). The signal intensity and fiber continuity of 4 zones (proximal, middle, distal intra-articular and tibial tunnel zones) were evaluated by the Mariani score.

RESULTS

The average MRI evaluation score gradually increased from 6 months through the final MRI. The intra-articular part of the graft exhibited slower maturation (12 months - final scan) as compared with the tibial tunnel (6-12 months). The distal zone underwent better maturation than the proximal or middle zones at all points. In the proximal zone, the score for Group Aug was significantly higher than Group Rec. In the proximal zone, the Type D score with a proximally-preserved remnant was significantly higher than Type P without a proximal remnant.

CONCLUSIONS

The hamstring tendons require more than 1 year to achieve low-signal intensity. PCL remnant has a beneficial effect on the maturation of the hamstring graft.

LEVEL OF EVIDENCE IV

therapeutic case series.

First demonstration of MC-EDFA-repeatered SDM transmission of 40 x 128-Gbit/s PDM-QPSK signals per core over 6,160-km 7-core MCF

We demonstrate the first 7-core multicore erbium-doped fiber amplified (MC-EDFA) transmission of 40 x 128-Gbit/s PDM-QPSK signals over 6,160-km 7-core multicore fiber (MCF). The crosstalk (XT) from all of the other 6 cores of a MC-EDFA and a 55-km length MCF are about -46.5 dB and -45.6 dB at center core, respectively. The core-to-core rotation approach at every amplified span is used to average the XT of all cores. The averaged optical signal-to-noise ratio (OSNR) after 6,160-km transmission is 15.6 dB with 0.1 nm resolution bandwidth. The Q-factor of all 40 channels surpasses the threshold of the forward-error-correction of 6.4 dB with 1 dB margin after 6,160 km. The total net capacity is 28.8 Tbit/s per fiber and achieved capacity-distance product is 177 Pbit/s.km per fiber. We confirmed the feasibility of MC-EDFA repeatered systems for trans-oceanic transmission.

Strategies for realizing photonic crystal fiber bandpass filters

Numerical design strategies are presented to achieve efficient broad or narrow band-pass filters based on index-guiding, solid-core, and single-mode photonic crystal fibers (PCFs). The filtering characteristics have been verified through BPM solver. By scaling the pitch constant, the bandpass window can be shifted accordingly. The fiber design constitutes a fluorine-doped central core, enlarged air-holes surrounding the down-doped core, and small air-holes in the cladding. The proposed bandpass filter is based on controlling the leakage losses, so one can tune filter characteristics simply by changing its length. From numerical simulations we show that for large values of air-hole diameter in the first ring, the bandpass window is narrow, while for low doping concentration and small sized air-holes in the first ring, bandpass window is very broad. We also simulate how the hole-size and number of rings in the PCF cladding affects the device characteristics. We find that a 5-cm long PCF with down-doped core and eleven rings of air-holes can result in approximately 440 nm 3-dB bandwidth with more than 90% of transmission. The longer device has reduced transmission and smaller 3-dB bandwidth. Tolerance analysis has also been performed to check the impact of fiber tolerances on the performance of the PCF bandpass filter. It has been observed that the decrement in cladding hole-diameter by 1% reduces the transmission to 21% from its peak value of 93%, however +/-1% tolerance in the inner hole-diameter degrades the transmission to 75% from its peak.

Bend-insensitive lasing characteristics of single-mode, large-mode-area ytterbium-doped photonic crystal fiber

The bend-insensitive lasing characteristics of a newly designed ytterbium-doped photonic crystal fiber (YPCF) are evaluated numerically. The designed YPCF remains single-mode and possesses large-mode-area of 1400 microm(2) at 1064 nm wavelength with the beam quality factor (M(2)) of 1.15, suggesting a diffraction-limited and continuous-wave lasing operation. The doped-region size is optimized for maximum conversion efficiency and it is found through numerical simulations that the doped radius should be more than 21 microm. The "mode expansion", which is the self-expansion of the fundamental mode within the doped region with wavelength increments on bending the fiber, is the basic physical mechanism to give the bend-insensitive lasing performances of YPCF. It leads to an unusual variation of overlap factor when the wavelength is increased. A 41 cm long piece of YPCF demonstrates more than 83% of slope efficiency with 75% of conversion efficiency when pumped with a 975 nm laser source delivering an input power of 1 W.

Behavioral context-dependent modulation of descending statocyst pathways during free walking, as revealed by optical telemetry in crayfish

Crustacean posture control is based on a complex interaction between the statocyst input and other sensory inputs as well as the animal's behavioral context. We examined the effects of behavioral condition on the activity of descending statocyst pathways using an optical telemetry system that allowed underwater recording of neuronal signals from freely behaving crayfish. A functionally identified statocyst-driven interneuron that directionally responded to body tilting without a footboard and to tilting of the footboard was found to show complicated responses depending upon the ongoing behavior of the animal when it freely walked around in water on the aquarium floor. The spike firing frequency of the interneuron increased significantly during walking. When the animal stood or walked on the tilted floor, the interneuron activity represented the tilt angle and direction if the abdomen was actively flexed, but not if it was extended. Two other statocyst-driven descending interneurons were found to be affected differently by the animal's behavioral condition: the spike activity of one interneuron increased during walking, but its directional response on the tilted floor was completely absent during abdominal posture movements, whereas that of another interneuron was enhanced during abdominal extension only, representing the tilt angle and direction. The results obtained in this study provide the first experimental demonstration that crustacean postural control under natural conditions is dependent on very fine aspects of the animal's locomotor behavioral context, suggesting far more complex control mechanisms than those expected from the experimental data obtained in isolated and fixed animals.

Measurement of chromatic dispersion and Raman gain efficiency of a hole-assisted fiber: Influence of bend

We have experimentally measured the Raman gain efficiency (RGE) and chromatic dispersion (CD) of a hole-assisted fiber (HAF). The RGE of a HAF was characterized using standard pump on/off technique while the CD of the fiber was measured using optical network analyzer. Theoretical simulations of the modal characteristics and the RGE of HAF were carried out using an accurate full-vectorial finite element method. Further, the bending effects on the CD and the RGE of a HAF with a smallest feasible bending radius are demonstrated. It was found that the CD increases while the RGE is decreased by bending HAF in a smallest bending radius of 5 mm. Numerical predictions from the theory are shown to be in good agreement with the experimental results.

Retroperitoneal hemorrhage due to bilateral adrenal metastases from lung adenocarcinoma

A 56-yr-old man was admitted to our university hospital for severe back pain one month after a resection for lung adenocarcinoma (stage IIIA) without evidence of the adrenal mass. Computed tomography (CT) of the abdomen showed bilateral bleeding of adrenal tumors. Endocrinological laboratory studies showed high plasma ACTH and normal serum cortisol levels with the loss of circadian rhythm. Although plasma ACTH levels increased, there was no cortisol response to administration of human corticotropichormone (hCRH). Core-needle biopsy was performed on the right adrenal tumor and revealed adenocarcinoma cells mimicking a primary lung tumor previously examined. We diagnosed retroperitoneal hemorrhage due to bilateral adrenal gland metastasis from lung adenocarcinoma with adrenal insufficiency. Adrenal metastases most commonly originate from a primary lung tumor, followed by stomach, esophagus and liver/bile ducts. Bilateral adrenal metastases were noted in approximately half of all adrenal metastases patients. Clinically significant adrenal hemorrhage by metastasis is exceedingly rare and non-specific symptoms, such as abdominal, chest or back pain, nausea and vomiting, confusion, weakness, hypotension, shock and high fever, are often observed in these patients. We present a case of massive retroperitoneal hemorrhage and adrenal insufficiency due to adrenal gland metastasis from adenocarcinoma of lung.

Intranasal administration of ACTH(1-24) stimulates catecholamine secretion

Previously, we reported that intranasal (IN) ACTH(1-24) administration stimulates adrenocortical steroid secretion in normal subjects. To determine the efficiency of transmucosal absorption of ACTH into the adrenal medulla, we measured serum cortisol, aldosterone, epinephrine, norepinephrine and dopamine levels after IN vs. intravenous (IV) administration of 250 microg ACTH(1-24) in 7 healthy adult men (mean age 21.7 +/- 1.2 yr; range, 21 - 24 yr). Blood was collected at 0, 30, 60 and 120 min after administration of ACTH(1-24), and the levels of adrenocortical steroids and catecholamines were measured by specific RIA and HPLC methods, respectively. There were no side effects associated with IN or IV ACTH administration. Consistent with the previous study, serum cortisol and aldosterone increased after IN administration of ACTH(1-24), peaking 30 min after administration. Sixty minutes after IN and IV administration of ACTH, epinephrine levels increased by 41.9 +/- 13.1 % and 63.3 +/- 11.8 %, respectively, and remained elevated throughout the sampling period. Thirty minutes after IN or IV administration of ACTH(1-24), plasma norepinephrine levels increased by 55.9 +/- 13.4 % and 73.7 +/- 15.0 %, respectively, peaking 30 min after ACTH(1-24) administration, and decreasing to basal levels within 60 min. Plasma dopamine levels did not change after IN administration of ACTH(1-24). Adrenocortical steroid and catecholamine levels did not increase after IN administration of saline. These results demonstrate that IN administration of ACTH(1-24) not only stimulates adrenocortical steroids, but also epinephrine and norepinephrine.

Emergency endovascular stent-grafting for infected pseudoaneurysm of brachial artery

The use of covered stents in an infected field is controversial. It is generally recommended that infected aneurysms be treated using autografts or allografts. We report a case of infected brachial pseudoaneurysms that developed after medical debridement of a methicillin-resistant Staphylococcus aureus (MRSA)-infected wound of the right arm and emergency brachial artery bypass-grafting using the saphenous vein, which was successfully treated by endovascular stent-grafting followed by antibiotic administration. The present case suggests that endovascular stent-grafting prevents rupture and occlusion of infected aneurysms and enables the continued administration of antibiotics.

Estimated daily intake of plasticizers in 1-week duplicate diet samples following regulation of DEHP-containing PVC gloves in Japan

Duplicate hospital diet samples obtained over 1 week in 2001 were analysed to estimate the daily intake of plasticizers and the results were compared with those obtained in 1999. The plasticizers quantified in this study were: dibutyl phthalate, butylbenzyl phthalate (BBP), di(2-ethylhexyl) phthalate (DEHP), diisononyl phthalate (DINP), di(2-ethylhexyl) adipate (DEHA), diisononyl adipate (DINA) and O-acetyl tributyl citrate (ATBC). Dipropyl, dipentyl, dihexyl and dicyclohexyl phthalate were also analysed but not detected. The analytical procedure for this follow-up study was essentially the same as in the previous one. Detection limits were 0.1-15.6 ng g(-1) for each plasticizer. One-week duplicate diet samples provided by three hospitals in three remote prefectures of Japan were analysed as individual meals. DEHP was detected at 6-675 ng g(-1) in 62 of 63 meals, significantly lower levels compared with those detected in 1999. Levels of DEHA and DINP also decreased. The mean intake of plasticizers estimated from all samples was 160 microg DEHP day(-1), 12.5 microg DEHA day(-1), 4.7 microg DINP day(-1) and 3.4 microg BBP day(-1). Levels of DINA were relatively high in meals from one hospital: in those meals, the average daily intake was 1338 microg day(-1). Those of ATBC were also higher in meals from another hospital: the average daily intake was 1228 microg day(-1). The sources of DINA and ATBC can be cling-film or sausage packaging.

Outcome of hepatoblastoma treated with the JPLT-1 (Japanese Study Group for Pediatric Liver Tumor) Protocol-1: A report from the Japanese Study Group for Pediatric Liver Tumor

PURPOSE

Hepatoblastoma is the most common malignant liver tumor in childhood. Multicenter studies elucidate the optimal pre- or postoperative chemotherapeutic regimens. This report reviews the results of the Japanese Study Group for Pediatric Liver Tumor Protocol-1 (JPLT-1) and compares its outcomes with published reports of other studies.

METHODS

From March 1991 to December 1999, 154 patients with malignant liver tumor including 145 cases of hepatoblastomas were enrolled in the JPLT study. Data from 134 cases were analyzed in this study. JPLT-1 protocol 91A was used for patients with stage I or II hepatoblastoma. The chemotherapy regimen consisted of repeated courses of cisplatin (CDDP), 40 mg/m(2), and tetrahydropyranyl (THP)-Adriamycin, 30 mg/m(2). JPLT-1 protocol 91B was administered to patients with stage IIIA, IIIB, or IV hepatoblastoma. The chemotherapy regimen consisted of repeated courses of CDDP, 80 mg/m(2), and THP-Adriamycin, 30 mg/m(2)/day for 2 days. Courses were repeated every 4 weeks as tolerated.

RESULTS

Seven patients died of chemotherapy-related side effects. Six of them died of sepsis caused by leukopenia and 1 case of liver failure. Overall survival rate (3-year/6-year) was 100%/100% for stage I (n = 9), 100%/95.7% for stage II (n = 32), 76.6%/73.8% for stage IIIA (n = 48), 50.3%/50.3% for stage IIIB (n = 25), 64.8%/38.9% for stage IV (n = 20), and 77.8%/73.4% overall. For stage IIIA and B disease, intravenous chemotherapy was better than intraarterial chemotherapy (66.4% v 38.1% for event-free survival and 69.3% v. 57.1% for overall survival). Patients less than 1 year of age had a better prognosis than older patients, but age was not a significant prognostic factor by multivariate analysis.

CONCLUSIONS

The overall and event-free survival rates of the JPLT-1 study of hepatoblastoma were comparable with the results of other multicenter studies in Europe and the United States. The event-free survival rate at 3 years for stage IIIB and IV disease was under 50%. New treatment strategies are needed for patients with advanced hepatoblastoma.

Experience with International Neuroblastoma Staging System and Pathology Classification

The International Neuroblastoma Staging System and Pathology Classification were proposed in 1988 and in 1999, respectively, but their clinical value has not yet been fully studied in new patients. Six hundred and forty-four patients with neuroblastoma treated between January 1995 and December 1999 were analysed by these classifications. The 4-year overall survival rate of patients <12 months of age with INSS stages 1, 2A, 2B, 3 and 4S disease was 98.5%, which was significantly higher than the 73.1% rate in stage 4 patients <12 months (P<0.0001). When patients were > or = 12 months, the 4-year overall survival rate of patients with neuroblastoma at 1, 2A, 2B and 3 stages was 100% and that of patients at stage 4 was 48.5% (P<0.0001). As to the International Neuroblastoma Pathology Classification histology, the 4-year overall survival rate was 98.8% in patients with favourable histology and 60.7% in those with unfavourable histology in the <12 months group (P<0.0001). In the > or = 12 months group, the 4-year oral survival of patients with favourable histology was 95.3% and that of patients with unfavourable histology was 50.6% (P<0.0001). Among biological factors, MYCN amplification, DNA diploidy and 1p deletions were significantly associated with poor prognosis in patients <12 months, as were MYCN amplification and DNA diploidy in patients > or = 12 months of age. Multivariate analysis showed that the INSS stage (stage 4 vs other stages) and International Neuroblastoma Pathology Classification histology (unfavourable vs favourable) were significantly and independently associated with the survival of patients undergoing treatment, stratified by age, stage and MYCN amplification (P=0.0002 and P=0.0051, respectively).

Results of bowel plication in addition to primary anastomosis in patients with jejunal atresia

BACKGROUND/PURPOSE

Disturbed intestinal transit (DIT) associated with bowel dilation occurs in some postoperative patients with jejunal atresia. Bowel plication (BP) has been introduced to prevent the DIT, but the long-term results of BP are unclear.

METHODS

The authors reviewed the preoperative and operative records and postoperative clinical courses (for 2.3 to 7.0 years; mean period, 3.7 years) of 19 jejunal atresia patients, 4 of whom had undergone additional BP with primary anastomosis after dilated bowel resection or tapering jejunoplasty at neonatal surgery. The degree of DIT was evaluated by the clinical symptoms, weight gain, whether reoperation was performed, and duration from the operation to receiving an oral feeding volume of at least 130 mL/kg/d. The patients then were assigned 4 grades (0 to 3). To determine the presence or absence of bowel dilation at the BP site, the plain abdominal x-rays were reviewed.

RESULTS

(1) Within 2 months after surgery, 4 patients without BP underwent operation because of severe DIT. The degree of postoperative DIT in patients who had received additional BP at neonatal surgery was less than that in patients without BP (mean grade, 0.50 v. 2.08). (2) The preoperative clinical features, operative method, and postoperative weight gain were almost similar in patients with and without BP. (3) On abdominal x-ray the bowel dilation remained 6 to 12 months after the operation, but was not observed over 1 year after the operation.

CONCLUSIONS

In this preliminary study, the addition of BP after tapering jejunoplasty or resection of dilated bowel may be effective in preventing early postoperative DIT. Further study is necessary to evaluate the long-term results of additional BP at neonatal surgery. J Pediatr Surg 36:1752-1756.

Detection of hepatic oxidative DNA damage in patients with hepatoblastoma and children with non-neoplastic disease

BACKGROUND

The authors have revealed a significant association between hepatoblastoma and low birth weight. This study was done to explore the evidence that liver cells were oxidatively damaged, based on the hypothesis that oxidative damage to DNA is involved in the development of hepatoblastoma in children of low birth weight.

PROCEDURE

Oxidative DNA damage in the liver was examined by immunohistochemically detecting the presence of a DNA repair product, 8-hydroxy-2'-deoxyguanosine (8-OHdG), in five patients with hepatoblastoma and 14 children with non-neoplastic disease.

RESULTS

Positive staining for 8-OHdG was observed in all five patients with hepatoblastoma. Distribution of 8-OHdG positivity was diffuse in the intralobular area in one patient and was restricted to the periportal area of the lobules in four patients. There was no apparent correlation between birth weight of the patients, histological findings in the liver, and the distribution of 8-OHdG positivity. In children with non-neoplastic disease, 8-OHdG was detected in nine of 14 patients, and 8-OHdG was positive in the intralobular area of the liver parenchyma except in one patient.

CONCLUSIONS

These results suggest that the cause of oxidative DNA damage in patients with hepatoblastoma may be different from the cause, extensive parenchymal damage to the liver, in children with non-neoplastic disease, but the 8-OHdG formation is not specific to hepatoblastoma patients of low birth weight. Further studies to elucidate the true reason for the high incidence of hepatoblastoma in children of low birth weight are necessary.

Phosphoenolpyruvate carboxylase kinase involved in C(4) photosynthesis in Flaveria trinervia: cDNA cloning and characterization

In C(4) plants, phosphoenolpyruvate carboxylase (PEPC; EC 4.1.1.31), a key enzyme in C(4) photosynthesis, is controlled by reversible phosphorylation of a conserved Ser residue near the N-terminus. We now report the first cloning of a cDNA from a C(4) plant, Flaveria trinervia, which encodes the specific protein kinase (FtPEPC-PK) involved in the phosphorylation of C(4)-form PEPC. Several lines of supportive evidence are: strict substrate specificity of the recombinant enzyme, prominent light/dark response of the transcript level and abundant expression in leaves of C(4) plant (F. trinervia) but very low expression in a C(3) plant of the same genus (Flaveria pringlei). We also discuss the possibility that the FtPEPC-PK gene has co-evolved with the PEPC gene to participate in C(4) photosynthesis.

Effects of recombinant human endostatin on a human neuroblastoma xenograft

New antitumor agents must be added to the current neuroblastoma treatment regimens to improve the clinical results. We investigated whether recombinant human endostatin (rhEndostatin), an antiangiogenic agent, is effective against human neuroblastoma in the human neuroblastoma xenograft model designated TNB9. When tumors on the back of nude mice grew to a weight of 90-95 mg, rhEndostatin 10 mg/kg/day was administered subcutaneously every day for 10 consecutive days. Mean relative tumor weight in mice administered rhEndostatin (n=5) was significantly less than that in controls (n=12) on days 2, 4, and 6 after the start of administration (p<0.01 on day 2, p<0.05 on days 4 and 6), and regression of tumor growth (TRW<1.0) was marked on day 2. The maximum inhibition rate (MIR) by rhEndostatin was 46.4%, indicating inefficacy, but it may not be appropriate to apply Battelle Columbus Laboratories criteria to this experimental model because rhEndostatin is a protein. After day 8, tumors in the experimental group increased in weight and were not statistically significantly different from those in controls. Recombinant human endostatin was used in tumors in the arterial system of the mouse in this experiment because eventually rhEndostatin, not recombinant mouse endostatin, may be used to treat advanced neuroblastoma in the clinical setting. The results show that there is little cross-reactivity of rhEndostatin with the human and mouse models and indicate that rhEndostatin could become an effective agent for the treatment of human neuroblastoma.

Effects of p53 mutations on cellular sensitivity to ionizing radiation

Mutations in the p53 tumor suppressor gene have been found in more than 50% of human tumors including those in breast, colon, lung, and oral cavity. However, the significance of p53 mutation in radiation sensitivity and its underlying mechanisms still remains unclear. In this study, we have measured the effects of p53 mutation on cell cycle delay, apoptosis, and radiation sensitivity using mouse cells transfected with different forms of p53 mutations. Wild-type p53 and p53-Null mouse embryo fibroblast cells were used as positive and negative controls, respectively. Exponentially growing cells were irradiated with 0- to 9-Gy gamma rays and then assayed for cell survival, p53 expression, cell cycle checkpoint, and apoptosis. Cell survivals determined by clonogenic assay show that p53 mutant cells are generally more sensitive to ionizing radiation than cells with wild-type p53. Western blot analysis indicates that exposure to 6-Gy gamma rays increases the p53 expression levels by two- to threefold in wild-type p53 cells. However, the p53 level remains unchanged in cells with mutant p53 during the same postirradiation period. Irradiation with 6-Gy gamma rays produces G2/M arrest in all cell lines, indicating that p53 is probably not involved in the G2/M checkpoint. However, all mutant cells fail to show any significant G1/S arrest after irradiation, suggesting that G1/S arrest may be implicated in radiation sensitivity. Finally, there is very little apoptosis (<3% by Tat-mediated dUTP nick-end labeling [TUNNEL] and morphologic assays) detected in wild-type and p53 mutant cell lines after 6-Gy gamma rays. Our results suggest that mutant forms of p53 represent a phenotype that affects the radiation sensitivity and is not dependent on the apoptotic pathway.

Intestinal motility in an in vivo rat model of intestinal ischemia-reperfusion with special reference to the effects of nitric oxide on the motility changes

BACKGROUND

To clarify the relation between intestinal ischemia-reperfusion (IR) and dysmotility, the authors investigated changes in the motility pattern in the duodenum and jejunum in an in vivo rat model of IR when artery- (and vein-) fed jejunum was clamped transiently. The authors also studied the effect of nitric oxide on the motility changes in this model by means of the administration of L-NAME (N(G)-nitro-L-arginine methyl ester) or S-methylisothiourea sulfate (SMT).

MATERIALS AND METHODS

A force transducer was sutured onto the serosal side of the duodenum or jejunum. After a 3-to 4-day recovery period, contractions were recorded during periods of preischemia, ischemia (60 minutes), and reperfusion (90 minutes). An intestinal IR was produced by clamping and releasing the mesenteric artery and vein with artery forceps.

RESULTS

In the jejunum, there was a prolongation in the duration of contraction and there were decreases in the number of contractions (NC) during the IR. When treated with L-NAME, no decrease in the NC was observed during the 45 to 90 minutes after reperfusion. S-methylisothiourea sulfate did not affect the IR-induced motility changes significantly. In the duodenum, there was a prolongation in the duration of contraction and a decrease in the NC and AC only during the reperfusion. L-NAME or S-methylisothiourea sulfate inhibited the decreases in the NC during the reperfusion.

CONCLUSIONS

Intestinal IR causes motility changes in the ischemic site during the IR and in the nonischemic site during the reperfusion. The IR-induced motility changes partly depend on nitric oxide production.

Magnetic resonance angiography of portal collateral pathways after hepatic portoenterostomy in biliary atresia: comparisons with endoscopic findings

BACKGROUND/PURPOSE

This study was undertaken to assess the usefulness of magnetic resonance angiography (MRA) in detecting varices and to investigate the possibility of avoiding routine endoscopy after surgery for biliary atresia (BA).

METHODS

The subjects are 21 patients who have undergone periodical MRA since 1996. The esophageal and gastric vessels were investigated as the sites of potential development of collateral vessels. The collateral vessels on MRA were compared with endoscopic findings.

RESULTS

(1) Detection of collateral vessels: of 21 patients examined, 9 patients had 12 varices. MRA depicted collateral vessels in all of the 12 varices (sensitivity, 100%). However, all MRA findings, but one was compatible with endoscopic findings (specificity, 92.9%). Outside of a series of these 21 patients, there were 3 additional patients who had undergone endoscopic treatments previously with success, and in whom esophageal vessels were not depicted on MRA, but endoscopy showed remnant varices. (2) Time-dependent relationship between the appearance of collateral vessels and varices: of 4 varices that appeared after the start of MRA, 3 esophageal varices were found endoscopically simultaneously with or after delineation of collateral vessels on MRA. In the remaining patient, varices were found enodscopically 6 months before the MRA delineation, because a simultaneous MRA was not performed in this case. All these varices were in the early stage.

CONCLUSIONS

MRA was highly sensitive and specific in detecting esophagogastric collateral vessels of the portal venous system. An endoscopic examination is unnecessary until collateral vessels are seen on MRA after surgery for BA.

Inflammatory pseudotumor of the liver: case report and review of the literature

Inflammatory pseudotumor is a rare lesion that generally is considered to be benign in biological behavior, although some may recur or metastasize. The authors report on a patient with inflammatory pseudotumor of the liver whose preoperative radiologic findings resembled those of focal nodular hyperplasia. The biological investigation showed a polyclonality of the cells and diploidy of the DNA content and suggested benign characteristics of the lesion. J Pediatr Surg 36:663-666.

Life-threatening mediastinal teratoma in a neonate

This report describes a newborn with a large mediastinal teratoma (MT) presenting with severe respiratory distress (RD) at birth. At operation, there was no space for dissection because the huge cystic and solid tumor completely occupied the left hemithorax. After evacuation of the cystic component, the tumor was removed successfully. To our knowledge, only 16 newborn infants with MT presenting with RD have been reported. Operative morbidities occurred in one-half of the cases. We have reviewed the literature to discuss the potential risks of this entity.

Usefulness of magnetic resonance imaging for surgical management of extravasation of an antitumor agent: a case report

We report a case of extravasation of an antitumor agent by preoperative magnetic resonance (MR) imaging. MR studies demonstrated a decreased signal intensity on T1- and T2-weighted images and a strong enhancement of contrast media in injured tissue, including subcutaneous adipose tissue and deep fascia, which was cicatrical macroscopically. The MR findings were in good agreement with the macroscopic findings. We believe that MR imaging is useful for estimating deep tissue damage due to extravasation of an antitumor agent.

Hepatic fatty acid-binding proteins of a teleost, Lateolabrax japonicus. The primary structures and location of a disulfide bond

Two fatty acid-binding proteins (FABP), FABP-1 and FABP-2, were purified from the liver cytosol of the teleost, Lateolabrax japonicus (Japan sea bass), and characterized. The complete primary structure of FABP-2 was determined by protein analysis to be the following: MDFSGTWQVY AQENYEEFLR AMELPADVIK MAKDIKPITE IKQSGNDFVV TSKTPGKTVT NSFTIGKEAD ITTMDGKKIR CVVNLEGGKL VCNTGKFCHI QELRGGEMVE TLTMGSTTLI RKSKKM. Partial peptide sequences of FABP-1 were also determined. Phylogenetic analysis indicates that FABP-2 is a homologue of mammalian hepatic FABP, whereas FABP-1 is most similar to the members of mammalian cardiac FABP subfamily. L. japonicus FABP-2 contains three cysteine residues, and a disulfide bond is identified between Cys-81 and Cys-92. A theoretical model of FABP-2 generated by a homology modeling method indicates close proximity of the two cysteine residues in the three-dimensional structure. This is a rather rare case of cytosolic protein having a disulfide bond under the normally reducing conditions of the cytosol, though the presence or absence of disulfide bonds does not seem to affect the ligand-binding ability.

Risk of contralateral manifestation in children with unilateral inguinal hernia: should hernia in children be treated contralaterally?

PURPOSE

This study was done to identify risk factors for metachronous manifestation of contralateral inguinal hernia in patients with unilateral inguinal hernia.

METHODS

Characteristics of 156 patients with metachronous contralateral hernia were compared with those of 156 patients with unilateral hernia who were ascertained not to have presented with contralateral hernia.

RESULTS

There was a tendency for the hernia to be more often on the left side in 88 of 156 patients (56.4%) with contralateral manifestation compared with 70 of 156 patients (44.9%) in the control group (P =.054). The age at hernia repair of the patients with contralateral manifestation, 1 to 120 months (median, 14 months), was significantly younger than the 1 to 149 months (median, 20 months) of the control patients (P =.016). More patients with contralateral manifestation had a family history of inguinal hernia, and the percentage, 24.4%, was significantly higher than the 14.7% in the control group (P =.046). A univariate analysis with the Cox regression models found that hernia on the left side and a positive family history were significantly associated with the metachronous manifestation of contralateral hernia (hazard ratio [HR], 1.40; P =. 037 and HR, 1.59; P =.013, respectively).

CONCLUSION

The risk of metachronous manifestation of contralateral hernia is high in patients with left-side hernia and in those with a family history, and the incidence of contralateral hernia is at most 10% in these patients. The authors think that the incidence is still too low to justify routine exploration and surgery for a patent processus vaginalis. Contralateral exploration should therefore be reserved for high-risk patients in whom second anesthesia and surgery have to be avoided.

Antitumor effects of fotemustine and busulfan against a human neuroblastoma xenograft

We examined whether or not fotemustine, a new nitrosourea derivative, and busulfan, an agent already clinically used, are effective against human neuroblastoma, using a human neuroblastoma xenograft model designated TNB9. The maximum inhibition rate (MIR) of fotemustine against the TNB9 model was 44.6% with a total dose of fotemustine of 75 mg/kg, indicating that fotemustine is not effective against TNB9. The MIR of busulfan against the same model was 26.7% when a total dose of 135 mg/kg was administered orally to nude mice. Busulfan was also suspended in carboxy-methylcellulose, and was administered intraperitoneally. The MIRs were 19.4% and 36. 4% when busulfan was administered intraperitoneally at a total dose of 40 mg/kg and 60 mg/kg, respectively. The total doses of 40 mg/kg and 60 mg/kg did not show any adverse effects on mice, but were found to be ineffective against TNB9, indicating that busulfan might not be an effective chemotherapeutic agent against human neuroblastoma.

Effect of autotransplantation of microvessel fragments on experimental random-pattern flaps in the rat

We examined whether autotransplantation of microvessel fragments (Mvf) and/or myofibroblasts (Mf) into an in vivo skin flap model might improve the survival of the ischemic flap. If so, this could improve blood perfusion, increase blood flow, and improve the survival of the flap. A skin flap was raised on the back of each rat (n = 15 in each group). In the control group, the flap was sutured to the original bed. In the other groups (1) phosphate-buffered saline; (2) autotransplanted Mvf, Mf, or Mvf plus Mf, and (3) a homogenized mixture of Mvf plus Mf was injected into the distal part of the flap. In a further group, Mvf labeled with DiI-acetylated low-density lipoprotein were autotransplanted with Mf into the distal part of the flap, and India ink was perfused through the abdominal aorta 7 days postoperatively. The transplanted Mvf plus Mf group showed better flap survival after 7 days than the other groups (p < 0.02). Labeling with DiI-acetylated low-density lipoprotein showed that transplanted Mvf sent arborizations into the nearby tissue. India ink was found in the lumina within such arborizations. Thus, autotransplanted Mvf may improve the survival of ischemic skin flaps by promoting the early formation of patent connections between Mvf and the host's microcirculatory system. This apparently requires the presence of Mf.

Reduced or absent expression and codon 201Gly/Arg polymorphism of DCC gene in rhabdomyosarcoma and Ewing's sarcoma/PNET family

Genetic alterations occurring in various chromosomes have been described in many human tumors. The DCC gene was originally identified in colorectal cancer and was reported as a tumor suppressor gene that might be related to tumor metastasis. We investigated 10 cell lines and 15 fresh tumors of childhood rhabdomyosarcoma, 7 cell lines of Ewing's sarcoma, and 4 cell lines of primitive neuroectodermal tumor (PNET) for the expression and mutation of DCC gene by RT-PCR analysis and PCR-single stranded conformation polymorphism (SSCP) analysis. Twenty-five pairs of primers were used for PCR-SSCP. Six of ten (60%) cell lines of rhabdomyosarcoma and 3 of 7 (43%) cell lines of Ewing's sarcoma showed reduced or absent expression of DCC gene. There was no mobility shift within 24 exons by SSCP analysis, although 3 types of polymorphism were found at codon 201 in exon 3. Direct sequencing of different bands showed types I, II, and I/II representative of codon 201Gly, codon 201Arg, and codon 201Gly/Arg, respectively. The proportion of type I between fresh rhabdomyosarcoma and normal controls was not significant. Our results suggested that the inactivation of DCC gene may play a role in the pathogenesis of a subset of rhabdomyosarcoma and Ewing's sarcoma.

Case-control study of perinatal factors and hepatoblastoma in children with an extremely low birthweight

BACKGROUND

There is a significant association between hepatoblastoma and low birthweight. A case-control study was conducted to reveal risk factors for hepatoblastoma in children of extremely low birthweight (< 1,000 g).

METHODS

Prenatal and postnatal histories, including parental histories, of 12 hepatoblastoma cases and 75 birthweight-matched controls were compared.

RESULTS

The gestational age of the hepatoblastoma cases (23-32 weeks: median 25 weeks), tended to be lower than that of the controls (23-36 weeks; median, 27 weeks; P = 0.072). The time for an infant's bodyweight to return to the same level as the birthweight also tended to be longer in hepatoblastoma cases than in controls (P = 0.055). All hepatoblastoma cases received oxygen therapy for a period of 4-508 days (median 114 days), which was significantly longer than the 0-366 days (median 62 days) in the controls (P = 0.022). Furosemide was given to all hepatoblastoma cases and was used for a significantly longer period in these infants (6460 days; median 89 days) than in the controls (0-241 days; median 44 days P = 0.027). A univariate Cox regression demonstrated that the time taken to regain bodyweight at birth and the duration of both oxygen therapy and furosemide treatment were significantly associated with the development of hepatoblastoma (hazard ratio (HR)= 1.044, P= 0.013; HR = 1.006, P= 0.001; and HR = 1.007, P= 0.001, respectively). Although there were significant correlations between the factors, a multivariate Cox regression analysis identified the duration of oxygen therapy as a significant independent risk factor (HR = 1.006, P = 0.001).

CONCLUSIONS

Oxygen therapy and furosemide treatment, along with the rate of growth, are risk factors for the development of hepatoblastoma in children of extremely low birthweight, and the duration of oxygen therapy is the most important factor in predicting the development of hepatoblastoma. Further studies are necessary to determine the real reasons for the development of hepatoblastoma and to protect children of low birthweight from the development of cancer.

Evaluation of leukocyte dynamics in choroidal circulation with indocyanine green-stained leukocytes

PURPOSE

To develop a new method with which to visualize leukocytes moving through the choroidal vessels of pigmented animals and enable the evaluation of leukocyte dynamics in the choroidal microcirculation.

METHODS

Pigmented rabbits and monkeys were used in this study. Leukocytes, collected by centrifugal separation of autologous blood, were stained with indocyanine green (ICG) dye. The ICG-stained leukocyte fluid was injected into the vein, and the fundus image was obtained with a scanning laser ophthalmoscope. The image was recorded on videotapes and analyzed with a personal computer-based image analysis system.

RESULTS

In pigmented rabbits, fluorescent leukocytes moving in the choroidal circulation were clearly visible for more than 1 hour. In monkeys, distinct fluorescent dots were seen moving approximately 50 to 200 microm in the foveal avascular zone for more than 30 minutes after the injection of the ICG-stained leukocyte fluid. Dim fluorescent dots were seen moving in the fundus. Although the movement of these dim dots was difficult to trace, they seemed to be moving in the choroidal vessels. In the rabbits, the mean flow velocity of leukocytes moving without plugging was 0.48 +/- 0.14 mm/sec in the peripheral choriocapillaris. In the monkeys, the mean flow velocity of distinct fluorescent leukocytes without plugging was 2.45 +/- 0. 48 mm/sec in the posterior choroid.

CONCLUSIONS

In pigmented rabbits and monkeys, this method allows visualization of leukocytes passing through the choroidal vessels and provides a new way to investigate, noninvasively and in vivo, leukocyte dynamics in the choroidal microcirculation.

Latissimus dorsi musculocutaneous free flap transplantation to salvage below-elbow amputation in an emergency operation: a case report

We used a free latissimus dorsi musculocutaneous flap (LD m-c flap) to cover a large skin defect at the stump of a forearm in an emergency operation. The patient we discuss is a 52-year-old man. Amputation at the distal one third of the left forearm occurred after catching his hand and wrist in a machine. The amputated left hand was severely damaged and there were wide skin defects. The function of the elbow joint was well preserved. Both the radius and ulna were cut 7 cm distal from the elbow joint. A 20 x 8 cm square of LD m-c flap was transplanted, to the stump of the forearm. The flap survived without incident. The range of motion of the elbow joint was from 20 degrees to 85 degrees. The prosthesis was well fitted to the stump, and the patient returned to his workshop 9 months after injury.