Delayed Diagnosis and Prognostic Impact of Breast Cancer During the COVID-19 Pandemic

BACKGROUND

Breast screening services were suspended for several months owing to the coronavirus disease 2019 (COVID-19) pandemic. We estimated the potential impact on breast cancer mortality using long-term global observations. However, the magnitude of the impact may vary across countries; therefore, we conducted an analysis and modeling study of this impact in Japan.

PATIENTS AND METHODS

We compared the clinicopathological features of breast cancers between the nonpandemicgroup (April 1, 2019 to October 31, 2019) and the pandemic group (April 1, 2020 to October 31, 2020). We also compared the estimated 10-year survival rates between the two groups based on the weighted average of the 10-year survival rate by clinical stage and site (2004-2007).

RESULTS

Results...Pandemic-related disruption decreased the number of breast cancer cases from296 to 249 during both 7-month periods. The percentage of patients with stage IIB or higher disease was significantly higher in the pandemic group than in the non-pandemic group (22.0% vs. 31.3%, P = 0.0133). The percentage of cases with a Ki-67 labeling index higher than 20% tended to be higher in the pandemic group than in the non-pandemic group (62.2% vs. 54.4%). The estimated 10-year survival rate was lower in the pandemic group than in the non-pandemic group (83.9% vs. 87.9%, 95% confidence interval of the difference: 0.87-8.8, P > 0.05).

CONCLUSION

We found more aggressive and advanced disease afterthe suspension of breast cancer screening services owing to the COVID-19 pandemic. This may have affected the long-term clinical outcomes of patients with breast cancer.

Prospective Cohort Study of Combination Therapy With Abemaciclib and Hormonal Therapy for Chemotherapy-Treated Patients With Hormone Receptor-Positive Metastatic Breast Cancer

Background

Combination therapy with cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors and hormonal therapy as the first-line and second-line treatments has already been shown to be effective in patients with hormone receptor-positive (HR+) human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (MBC) in clinical trials. On the other hand, in clinical practice, CDK4/6 inhibitors are used not only as first-/second-line but also as later-line hormonal therapies, or for patients receiving prior chemotherapy in metastatic setting. However, the efficacy and safety of combination therapy in these patients remain unclear. In this study, we evaluate the clinical efficacy and safety of combination therapy with abemaciclib and hormonal therapy for chemotherapy-treated patients with HR+ HER2- MBC.

Methods

This multi-institutional prospective cohort study will involve a total of 300 chemotherapy-treated patients with HR+ HER2- MBC. The primary endpoint is progression-free survival (PFS). Secondary endpoints include overall survival, time to treatment failure, response rate, clinical benefit rate, and adverse events. The preplanned subpopulation analysis is the number of chemotherapy regimens for HR+ HER2- MBC (two or less vs. three or more), prior treatment history with CDK4/6 inhibitors other than abemaciclib (presence vs. absence) and menopausal status (pre vs. post). We also planned to determine PFS of the subpopulation treated with abemaciclib as maintenance therapy after chemotherapy.

Discussion

In this multi-institutional prospective cohort study, we evaluate the clinical efficacy and safety of combination therapy with abemaciclib and hormonal therapy for chemotherapy-treated patients with HR+ HER2- MBC. We also evaluate this combination therapy as maintenance therapy in patients who respond to early-line chemotherapy.

Community pharmacists' measurement of health-related quality of life in outpatients taking high-risk drugs

Patients experiencing severe side effects when taking high-risk drugs may have a significantly reduced health-related quality of life (QOL); therefore, it is important to identify changes in the health-related QOL in these patients. This study aimed to determine the health-related QOL in community pharmacy outpatients taking high-risk drugs. This prospective observational study was conducted in 29 community pharmacies with 71 pharmacists in 12 regions and cities in Japan from October to December 2020 and 760 patients were enrolled. Using descriptive questionnaires of EuroQOL-5-dimensions-5-levels (EQ-5D-5L), community pharmacists obtained health-related QOL data from outpatients taking high-risk drugs. The mean health-related QOL of all outpatients was 0.869. The health-related QOL decreased with increasing age. The outpatient health-related QOL was 0.700, 0.763, 0.785, and 0.817 when taking antiepileptic, antidepressant, digitalis, and antiarrhythmic drugs, respectively, which was lower than the average health-related QOL of all outpatients. Mobility and pain/ discomfort accounted for a large proportion of the decline in the health-related QOL with increasing age. There were no significant differences in personal care with increasing age; however, the number of outpatients with mobility, normal activity, and pain challenges decreased with age. In contrast, outpatients aged <65 years with anxiety/depression showed a lower than overall average health-related QOL. To the best of our knowledge, this is the first study in Japan to report an investigation by community pharmacists regarding health-related QOL assessment in outpatients taking high-risk drugs.

Absolute Lymphocyte Count, Platelet-to-Lymphocyte Ratio, and Overall Survival in Eribulin-treated HER2-negative Metastatic Breast Cancer Patients

BACKGROUND/AIM

To investigate the utility of peripheral blood biomarkers - absolute lymphocyte count (ALC), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) - for predicting outcomes in eribulin-treated patients with metastatic human epidermal growth factor receptor type 2 (HER2)-negative breast cancer.

PATIENTS AND METHODS

ALC, NLR, and PLR were retrospectively obtained from pre-treatment blood sampling results of 120 patients and stratified according to means. Univariate and multivariate analyses were performed to investigate the association of clinicopathological factors, including these values, with overall survival (OS) and progression-free survival (PFS).

RESULTS

The ALC, NLR, and PLR cut-off points were 1,285/μl, 3.3, and 235, respectively. No biomarkers were associated with PFS. However, univariate analysis showed ALC (p=0.044) and PLR (p=0.044) to be significantly associated with OS.

CONCLUSION

ALC and PLR can predict eribulin efficacy in terms of OS, reflecting the antitumour immune response in the microenvironment and indicating eribulin's effectiveness.

A case of hereditary metachronous bilateral triple-negative breast cancer that was highly sensitive to carboplatin

A 52-year-old woman with a strong family history of breast cancer was diagnosed as having triple-negative breast cancer (TNBC) in her right breast. Neoadjuvant chemotherapy (NAC; four cycles of epirubicin/cyclophosphamide/5-fluorouracil) was performed, followed by breast-conserving surgery and axillary lymph node dissection. Histopathological analysis of the surgical specimens demonstrated a few focal tumor cells remaining in the stroma, but not a pathological complete response (pCR). Weekly paclitaxel was subsequently added to the treatment regimen. A total of 17 months after the adjuvant treatments, TNBC recurred in her left breast with massive lymph node metastasis. Because of the early recurrence after standard treatment, NAC was administered together with carboplatin and paclitaxel. Histopathological analysis of the partially resected breast and axillary lymph nodes demonstrated a pCR. No recurrent disease was found 2 years after the second TNBC treatment. This case underlines the importance of platinum-based chemotherapy and prophylactic mastectomy for patients with BRCA dysfunction.

Successful treatment of G-CSF-related aortitis with prednisolone during preoperative chemotherapy for breast cancer: a case report

Background

With the introduction of dose-dense therapy, the use of primary pegfilgrastim (PEG-G) has been increasing in breast cancer treatment. A rare side effect of PEG-G is aortitis. We describe a case of PEG-G-induced aortitis.

Case presentation

The patient was a 43-year-old woman with stage IIA breast cancer. Due to the subtype of triple-negative breast cancer, preoperative dose-dense epirubicin–cyclophosphamide chemotherapy was started. PEG-G was administered on day 3 after the first cycle of epirubicin–cyclophosphamide chemotherapy. On day 11, she had a fever (39.4 °C) and an elevated C-reactive protein level (27.1 mg/dL). Emergency computed tomography revealed diffused wall thickening of the aortic arch without any other signs of infection. Despite administering antibiotics, her general condition and laboratory findings deteriorated until day 18. Based on these observations, she was diagnosed with PEG-G-induced aortitis. Antibiotics were discontinued, and she was treated with prednisolone thereafter. Subsequently, her clinical symptoms and laboratory findings improved around day 39. A second computed tomography scan revealed a decrease in the aortic arch wall thickening, and she was discharged on day 43.

Conclusions

We successfully treated PEG-G-induced aortitis using prednisolone. Although this side effect is rare, cancer patients receiving PEG-G for chemotherapy should be monitored for aortic inflammation.

Differences in drug sensitivity between two-dimensional and three-dimensional culture systems in triple-negative breast cancer cell lines

Three-dimensional (3D) culture reflects tumor biology complexities compared with two-dimensional (2D) culture. Thus, 3D culture has attracted attention in cell biology studies including drug sensitivity tests. Herein, we investigated differences in anticancer drug sensitivities between 2D and 3D culture systems in triple-negative breast cancer (TNBC) cell lines. Thirteen TNBC cell lines were maintained in 2D and 3D cultures for 3 days before drug exposure. Cell morphology in the 3D culture was examined by phase-contrast microscopy. Sensitivities to epirubicin (EPI), cisplatin (CDDP), and docetaxel (DTX) were investigated by cell viability assay in both cultures and compared. The IC50s of all 3 drugs were significantly higher in the 3D culture than in the 2D culture in most cell lines. Those were correlated between the 2D and 3D cultures in EPI (R = 0.555) and CDDP (R = 0.955), but not in DTX (R = 0.221). Round spheroid-forming cells were more resistant to agents than grape-like types. In conclusion, 3D culture was more resistant to all 3 drugs than 2D culture in most TNBC cell lines. Sensitivity to CDDP was highly correlated between the 2D and 3D cultures, but not to DTX. 2D culture may be acceptable for sensitivity test for DNA-damaging agents.

Abstract 326: Differences of drug sensitivities between 2-dimensional and 3-dimensional culture systems in triple negative breast cancer cell lines

[BACKGROUND] In vitro chemosensitivity tests are not always consistent to clinical results (Hutchinston L et al., Nat Rev Clin Oncol. 2011), partly because of lacking extracellular matrix-cell interactions in 2-dimensional (2D) cell culture system (Antoni D et al., Int J Mol Sci. 2015). Three-dimensional cell culture (3D) system maintains cells with a higher degree of structural complexity and homeostasis, analogous to tissues and organs compared with 2D cell culture system. Thus, 3D cell culture system will be expected for alteration of the animal experiment in chemosensitivity test (Bokhari M et al., J Anat. 2007). Cytotoxic agents are crucial for treating triple negative breast cancer (TNBC).[AIM] To clarify differences of drug sensitivities between 2D and 3D culture in TNBC cell lines, we compared IC50s for Cisplatin (CDDP), Docetaxel (DTX), Epirubicin (EPI) and Bromodomain inhibitor (JQ1).

[METHODS] Thirteen TNBC cell lines were examined; HCC1599, HCC1937, HCC38, MDA-MB-468, HCC1806, HCC70, MDA-MB-436, MDA-MB-231, Hs578T, BT549, MDA-MB-453, BT20, and HCC1395. For 2D culture, cells were plated on general 96 well cell culture plate for 24 hours. For 3D culture, cells were plated on the PrimeSurface® 96 well plate (SUMITOMO BAKELITE) for 72 hours. Then, those were incubated in media including CDDP, DTX, EPI or JQ1 for 72 hours. The cell viability was quantified using CellTiter-Glo 2.0 and CellTiter-Glo 3D cell viability Assay (Promega), respectively.

[RESULTS] For CDDP, IC50s were highly correlated between 2D and 3D culture (r=0.928) . The mean of IC50 value showed higher in 3D culture (27.67±8.40μM) than 2D culture (12.86 ± 17.23μM). For EPI, the correlation was r=0.593. The mean value showed higher in 3D culture (1.41±1.30μM) than 2D culture (0.62±0.72μM). For DTX and JQ1, the mean values were 1.78 ± 2.05nM and 4.31 ±4.72μM in 2D culture, respectively. However, IC50 failed to be obtained in several TNBC cell lines (HCC1937, HCC38, HCC1806, Hs578T and HCC1395 for JQ1 and MDA-MB-436, MDA-MB-453 and BT20 for DTX) in 3D culture.

[CONCLUSION] IC50 value was higher in 3D culture than in 2D culture for CDDP and EPI. The correlation of IC50s between 2D and 3D depended on drugs with the highest in CDDP. We are under investigation on reasons why sensitivity tests for DTX and JQ1 failed in 3D culture system.

Citation Format: Masako Muguruma, Saeko Teraoka, Kana Miyahara, Ai Ueda, Takahiko Kawate, Takashi Ishikawa. Differences of drug sensitivities between 2-dimensional and 3-dimensional culture systems in triple negative breast cancer cell lines [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 326.

Abstract 296: BRCA1 degradation in response to mitochondrial damage in breast cancer cells

The tumor suppressor BRCA1 protein has been implicated in hereditary breast and ovarian cancer syndrome when its gene is mutated. Among the many functions of BRCA1 including DNA repair, transcriptional regulation, cell cycle checkpoint, apoptosis, chromatin remodeling, and centrosome replication, DNA double-strand breaks repair by homologous recombination (HR) is one of the most important. BRCA1-associated tumors increase DNA instability and become sensitive to the Poly (ADP-ribose) polymerase (PARP) inhibitor. It is well known that PTEN-induced kinase 1 (PINK1) and Parkin are involved in mitochondrial quality control and a variety of mutations in these genes causes early-onset Parkinson's disease. In the present study, we report a novel degradation mechanism for BRCA1 protein in response to mitochondrial damage.

While investigating the role of BRCA1 in mitophagy using a breast cancer cell line, we found that BRCA1 protein is rapidly degraded by the mitochondrial targeting reagents, which induce mitochondrial depolarization. The degradation was mediated by the ubiquitin-proteasome system through the direct interaction with the E3 ligase Parkin upon PINK1 upregulation in response to the mitochondrial damage. Moreover, BRCA1 knockdown repressed cancer cell growth. Immunostaining the specimens from breast cancer patients revealed higher BRCA1 and lower PINK1/Parkin expression in their mammary glands. This result correlates with the analysis using the mRNA expression data set from TCGA database. Additionally, BRCA1 expression inversely correlated with PINK1/Parkin expression in the case of relapse-free survival in breast cancer patients. Thus, these findings demonstrated the unanticipated physiological functions of BRCA1 for maintaining cancer cell growth.

Overall, our study shows that: 1) Degradation of BRCA1 due to PINK1-Parkin activity through the ubiquitin-proteasome system occurs in response to mitochondrial damage. 2) BRCA1 promotes the growth of breast cancer cells. 3) Immunostaining of patient specimens and cancer genome data set analysis revealed higher BRCA1 expression with lower PINK1/Parkin expression was observed in the cancerous mammary glands. Moreover, recent reports have suggested that BRCA1 is involved in the pathogenesis of Alzheimer's disease. Thus, transmission of mitochondrial damage to the nucleus causing nuclear DNA double-strand breaks via the PINK1-Parkin-BRCA1 axis may not only be seen in the field of oncology, but also in various other fields including neurodegenerative diseases.

Citation Format: Kana Miyahara, Naoharu Takano, Yumiko Yamada, Hiromi Kazama, Mayumi Tokuhisa, Hirotsugu Hino, Koji Fujita, Edward Barroga, Masaki Hiramoto, Hiroshi Handa, Masahiko Kuroda, Takashi Ishikawa, Keisuke Miyazawa. BRCA1 degradation in response to mitochondrial damage in breast cancer cells [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 296.

Clinical and pathological predictors of recurrence in breast cancer patients achieving pathological complete response to neoadjuvant chemotherapy

INTRODUCTION

Despite the excellent prognosis associated with pathological complete response (pCR) to neoadjuvant chemotherapy (NAC), some patients still develop recurrence. Here, we investigated the outcomes of breast cancer patients with pCR, as well as the clinical and pathological predictors of cancer recurrence in these patients.

MATERIALS AND METHODS

Of the 1599 breast cancer patients treated with NAC, we evaluated 394 patients who achieved pCR between January 2007 and December 2016. pCR was defined as no evidence of invasive cancer in breast. Residual in situ ductal and axillary lymph node diseases were not considered. We analyzed the outcomes using the Kaplan-Meier method. We assessed the association of clinical and pathological predictors with cancer recurrence using the cox proportional hazards regression model.

RESULTS

The median follow-up time was 63 months. The 5-year disease-free survival rate was 92.3%. Cancer recurrence was observed in 28 patients (7.1%): local recurrence 8 patients (2.0%), visceral metastasis 10 patients (2.5%), and brain metastasis 10 patients (2.5%). Brain metastases were found in patients with HER2 type breast cancer. The significant predictors of cancer recurrence were HER2 positivity (p = 0.04), clinical tumor size (p < 0.01), and lymph node metastasis (p < 0.01) before NAC on univariate analysis and only lymph node metastasis on multivariate analysis.

CONCLUSION

Patients achieving pCR to NAC showed excellent outcomes. Advanced clinical stage, large tumor size, presence of lymph node metastasis, and HER2 positivity before NAC were identified as significant predictors of cancer recurrence. Residual in situ ductal and lymph node diseases after NAC were not significant predictors.

A genome-wide association study identifies three novel genetic markers for response to tamoxifen: A prospective multicenter study

Purpose

Although association studies of genetic variations with the clinical outcomes of breast cancer patients treated with tamoxifen have been reported, genetic factors which could determine individual response to tamoxifen are not fully clarified. We performed a genome-wide association study (GWAS) to identify novel genetic markers for response to tamoxifen.

Experimental design

We prospectively collected 347 blood samples from patients with hormone receptor-positive and human epidermal growth factor receptor 2-negative, invasive breast cancer receiving preoperative tamoxifen monotherapy for 14 to 28 days. We used Ki-67 response in breast cancer tissues after preoperative short-term tamoxifen therapy as a surrogate marker for response to tamoxifen. We performed GWAS and genotype imputation using 275 patients, and an independent set of 72 patients was used for replication study.

Results

The combined result of GWAS and the replication study, and subsequent imputation analysis indicated possible association of three loci with Ki-67 response after tamoxifen therapy (rs17198973 on chromosome 4q34.3, rs4577773 on 6q12, and rs7087428 on 10p13, P_combined = 5.69 x 10⁻⁶, 1.64 x 10⁻⁵, and 9.77 x 10⁻⁶, respectively). When patients were classified into three groups by the scoring system based on the genotypes of the three SNPs, patients with higher scores showed significantly higher after/before ratio of Ki-67 compared to those with lower scores (P = 1.8 x 10⁻¹²), suggesting the cumulative effect of the three SNPs.

Conclusion

We identified three novel loci, which could be associated with clinical response to tamoxifen. These findings provide new insights into personalized hormonal therapy for the patients with breast cancer.

Abstract 1601: Clinical studies to treat without surgery for breast cancer cases who achieved clinical complete response by neoadjuvant chemotherapy

Introduction: The pathological complete response (pCR) rate is approaching to 50% particularly in patients with hormone-receptor negative disease by neoadjuvant chemotherapy (NAC). If the disease is not recurred locally in cases with pCR and pCR could be accurately diagnosed preoperatively, it is possible to treat some population of patients without surgery after NAC. We conducted two studies to examine: 1) outcomes of patients who had achieved pCR by NAC with a special attention to local recurrence. 2) diagnostic accuracy of pCR with core needle biopsy (CNB) for cases obtained clinical complete response (cCR) by NAC.

Methods: 1) Clinical outcomes were retrospectively investigated in 395 patients who achieved pCR from 1599 patients with primary operable breast cancer treated by NAC (overall pCR rate of 24.7%: 395/1599). The association of clinic-pathological factors with recurrence was investigated. 2) Ultrasound-guided CNB was performed prospectively for 86 cases who achieved cCR by MRI after NAC. The concordance of pathological results between CNB and surgical specimens was examined. The pathological diagnosis was categorized as no carcinoma (pCR), carcinoma in situ (CIS) and invasive carcinoma (INV).

Results: 1) 395 pCR cases consisted of 50 Luminal type (pCR rate: 7.2%), 98 Luminal-HER2 type (32.1%), 116 HER2 type (52.5%), and 131 triple negative (TN) type (34.2%). The median follow-up was 41 months. Recurrent diseases including local recurrence or distant metastasis were found in 5.80% (23/395). According to subtypes, these were 2.00% (1/50) for Luminal type, 4.08% (4/98) for Luminal-HER2 type, 10.3% (12/116) for HER2 type, and 4.58% (6/131) for TN type. Local recurrence was found in 1.2% of cases (5/395). Risk factors of recurrence were clinical stage before NAC and nodal status after NAC in the univariate analysis, and only clinical stage remained statistically significant in the multivariate analysis. 2) Pathology of surgical specimen revealed pCR in 41 cases (48%), CIS in 17 cases (20%) and INV in 28 cases (32%). Discordant cases: pCR in CNB, but CIS and INV in surgical specimens were found in 24 cases (14 CIS and 10 INV). The false negative rate (FNR) and accuracy of CNB to predict INV were 22.2% and 88.4%, respectively.

Conclusion: Except HER2 type, recurrence was not frequent particularly in cases with an early clinical stage. Local recurrence was rarely observed in any subtype. However, ultrasound-guided CNB for cCR cases diagnosed by MRI was not reliable enough to predict pCR. Thus, imaging diagnosis and biopsy methods need to be improved to achieve 10% of FNR and 90% of accuracy for predicting pCR and to proceed to an observational study without performing surgery.

Citation Format: Takashi Ishikawa, Mariko Asaoka, Kazutaka Narui, Akimitsu Yamada, Nobuyasu Suganuma, Takashi Chishima, Takahiko Kawate, Kana Miyahara, Kazuaki Takabe, Yasushi Ichikawa, Eiichi Sato. Clinical studies to treat without surgery for breast cancer cases who achieved clinical complete response by neoadjuvant chemotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1601.

Amino acid starvation culture condition sensitizes EGFR-expressing cancer cell lines to gefitinib-mediated cytotoxicity by inducing atypical necroptosis

The maintenance of the intracellular level of amino acids is crucial for cellular homeostasis. This is carried out via the regulation of both the influx from the extracellular environment and the recycling of intracellular resources. Since epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors, including gefitinib (GEF) have been reported to induce the apoptosis of several cancer cell lines, in the present study, we examined whether the cytotoxic effects of GEF are further enhanced under amino acid starvation (AAS) culture conditions. Under AAS culture conditions, the cell killing effect of GEF was synergistically pronounced in the EGFR-expressing cell lines, namely, CAL 27, Detroit 562, A549 and PANC-1 cells compared with those treated with either GEF or AAS alone. The addition of essential amino acids, but not non-essential amino acids to the cell culture medium resulted in the cancellation of this pronounced cytotoxicity. The knockdown of L-type amino acid transporter 1 (LAT-1) by siRNA also enhanced GEF-induced cytotoxicity. Therefore, the shortage of the intracellular amino acid pool appears to determine the sensitivity to GEF. Notably, this enhanced cytotoxicity is not mediated by the induction of apoptosis, but is accompanied by the pronounced induction of autophagy. The presence of necrostatin-1, an inhibitor of receptor-interacting serine/threonine-protein kinase 1 (RIPK‑1), but not that of Z-VAD-fmk, attenuated the cytotoxic effects of GEF under AAS culture conditions. Electron microscopy demonstrated that the CAL 27 cells treated with GEF under AAS culture conditions exhibited swelling of the cytosol and organelles with an increased number of autophagosomes and autolysosomes, but without chromatin condensation and nuclear fragmentation. Autophagic cell death was excluded as the inhibition of autophagy did not attenuate the cytotoxicity. These results strongly suggest the induction of necroptosis in response to GEF under AAS culture conditions. However, we could not detect any phosphorylation of RIPK-1 and mixed lineage kinase domain like pseudokinase (MLKL), as well as any necrosome formation. Therefore, the enhanced cytotoxic effect of GEF under AAS culture conditions is thought to be mediated by atypical necroptosis.

Macrolide Antibiotics Exhibit Cytotoxic Effect under Amino Acid-Depleted Culture Condition by Blocking Autophagy Flux in Head and Neck Squamous Cell Carcinoma Cell Lines

Autophagy, a self-digestive system for cytoplasmic components, is required to maintain the amino acid pool for cellular homeostasis. We previously reported that the macrolide antibiotics azithromycin (AZM) and clarithromycin (CAM) have an inhibitory effect on autophagy flux, and they potently enhance the cytocidal effect of various anticancer reagents in vitro. This suggests that macrolide antibiotics can be used as an adjuvant for cancer chemotherapy. Since cancer cells require a larger metabolic demand than normal cells because of their exuberant growth, upregulated autophagy in tumor cells has now become the target for cancer therapy. In the present study, we examined whether macrolides exhibit cytotoxic effect under an amino acid-starving condition in head and neck squamous cancer cell lines such as CAL 27 and Detroit 562 as models of solid tumors with an upregulated autophagy in the central region owing to hypovascularity. AZM and CAM induced cell death under the amino acid-depleted (AAD) culture condition in these cell lines along with CHOP upregulation, although they showed no cytotoxicity under the complete culture medium. CHOP knockdown by siRNA in the CAL 27 cells significantly suppressed macrolide-induced cell death under the AAD culture condition. CHOP-/- murine embryonic fibroblast (MEF) cell lines also attenuated AZM-induced cell death compared with CHOP+/+ MEF cell lines. Using a tet-off atg5 MEF cell line, knockout of atg5, an essential gene for autophagy, also induced cell death and CHOP in the AAD culture medium but not in the complete culture medium. This suggest that macrolide-induced cell death via CHOP induction is dependent on autophagy inhibition. The cytotoxicity of macrolide with CHOP induction was completely cancelled by the addition of amino acids in the culture medium, indicating that the cytotoxicity is due to the insufficient amino acid pool. These data suggest the possibility of using macrolides for "tumor-starving therapy".

Targeting bortezomib-induced aggresome formation using vinorelbine enhances the cytotoxic effect along with ER stress loading in breast cancer cell lines

The ubiquitin-proteasome and autophagy-lysosome pathways are two major self-digestive systems for cellular proteins. Ubiquitinated misfolded proteins are degraded mostly by proteasome. However, when ubiquitinated proteins accumulate beyond the capacity of proteasome clearance, they are transported to the microtubule-organizing center (MTOC) along the microtubules to form aggresomes, and subsequently some of them are degraded by the autophagy-lysosome system. We previously reported that macrolide antibiotics such as azithromycin and clarithromycin block autophagy flux, and that concomitant treatment with the proteasome inhibitor bortezomib (BZ) and macrolide enhances endoplasmic reticulum (ER) stress-mediated apoptosis in breast cancer cells. As ubiquitinated proteins are concentrated at the aggresome upon proteasome failure, we focused on the microtubule as the scaffold of this transport pathway for aggresome formation. Treatment of metastatic breast cancer cell lines (e.g., MDA-MB‑231 cells) with BZ resulted in induction of aggresomes, which immunocytochemistry detected as a distinctive eyeball-shaped vimentin-positive inclusion body that formed in a perinuclear lesion, and that electron microscopy detected as a sphere of fibrous structure with some dense amorphous deposit. Vinorelbine (VNR), which inhibits microtubule polymerization, more effectively suppressed BZ-induced aggresome formation than paclitaxel (PTX), which stabilizes microtubules. Combined treatment using BZ and VNR, but not PTX, enhanced the cytotoxic effect and apoptosis induction along with pronounced ER stress loading such as upregulation of GRP78 and CHOP/GADD153. The addition of azithromycin to block autophagy flux in the BZ plus VNR-containing cell culture further enhanced the cytotoxicity. These data suggest that suppression of BZ-induced aggresome formation using an inhibitory drug such as VNR for microtubule polymerization is a novel strategy for metastatic breast cancer therapy.

Abstract 2031: Association between CYP2D6 genotype and response to tamoxifen in a prospective multicenter study in Japan

Purpose:

CYP2D6 is key enzyme responsible for the generation of the potent active metabolite of tamoxifen, “endoxifen”. We previously reported that reduced- or null-function alleles of CYP2D6 were significantly associated with poor clinical outcome of breast cancer patients treated with tamoxifen. However, there are still discrepant reports questioning the association between CYP2D6 genotype and tamoxifen efficacy. Hence, we carried out prospective multicenter studies to evaluate the value of CYP2D6 genotyping in tamoxifen therapy.

Patients and Methods:

We studied 279 patients with hormone receptor-positive and Her-2 negative, invasive breast cancer receiving preoperative tamoxifen monotherapy for 14 - 28 days. Ki-67 response in breast cancer tissues after tamoxifen therapy was used as a surrogate marker of response to tamoxifen. We investigated the effects of allelic variants of CYP2D6 on Ki-67 change in breast cancer tissues, histological response, breast conservative operation and hot flash.

Results:

Ki-67 labeling index in breast cancer tissues significantly decreased after preoperative tamoxifen monotherapy for 14-28 days (P = 0.00000000024). Moreover, proportion of estrogen receptor positive cells in breast cancer tissues were significantly associated with Ki-67 change after tamoxifen therapy (P = 0.0099). CYP2D6 variants were not significantly associated with histological response, breast conservative operation and hot flash (P = 0.25, P = 0.28 and P = 0.34, respectively). However, CYP2D6 variants were significantly associated with Ki-67 decrease after the preoperative tamoxifen therapy (P = 0.000014; in patients with two variant alleles v patients carrying one or two wild-type alleles).

Conclusion:

Our result suggest that genetic variation in CYP2D6 is a key predictor for the prognosis of patients with breast cancer treated with tamoxifen.

Citation Format: Hitoshi Zembutsu, Seigo Nakamura, Sadako Akashi-Tanaka, Takashi Kuwayama, Chie Watanabe, Tomoko Takamaru, Hiroyuki Takei, Kana Miyahara, Hiroshi Matsumoto, Yoshie Hasegawa, Goro Kutomi, Hiroaki Shima, Fukino Satomi, Hideki Maeda, Minoru Okazaki, Hisamitsu Zaha, Mai Onomura, Ayami Matsukata, Yasuaki Sagara, Shinichi Baba, Akimitsu Yamada, Kazuhiro Shimada, Daisuke Shimizu, Koichiro Tsugawa, Arata Shimo, Tan Ern Yu, Mikael Hartman, Chan Ching Wang, Soo Chin Lee, Yusuke Nakamura. Association between CYP2D6 genotype and response to tamoxifen in a prospective multicenter study in Japan. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2031.

Abstract C216: The safety and efficacy of the concurrent use of radiopharmaceutical strontium-89 (Sr-89) chloride with zoledronic acid in standard anticancer therapy for breast cancer patients with painful multifocal bone metastases

Our aim in this study was to examine the safety and efficacy of the concurrent use of the radiopharmaceutical strontium-89 (Sr-89) chloride with zoledronic acid in standard anticancer therapy for breast cancer patients with painful multifocal bone metastases. The study comprised 33 breast cancer patients with painful multifocal bone metastases detected by bone scintigraphy, computed tomography, or magnetic resonance imaging. All patients were treated with Sr-89 and zoledronic acid concurrently between October 2007 and September 2012 as part of a standard therapeutic regimen comprising chemotherapy, endocrine therapy, molecular targeting therapy, and targeted radiotherapy. Sr-89 was administered intravenously at 2 MBq/kg to a maximum of 141 MBq per person. Safety was evaluated according to myelotoxicity as measured by the Common Terminology Criteria for Adverse Events (v3.0). To assess treatment efficacy, we monitored changes in analgesic drug dosages. Furthermore, bremsstrahlung imaging after the administration of Sr-89 was utilized to examine the relationship between the accumulation of Sr-89 in metastatic sites and treatment efficacy. Based on the results, a total of 25 out of 33 patients (76%) reported bone pain relief, indicating a high efficacy of Sr-89 combined with zoledronic acid. In responsive cases, a strong uptake of Sr-89 was observed on bremsstrahlung imaging at the same sites indicated by 99mTc bone scintigraphy. Moreover, severe white blood cell decreased (&gt; grade 3) was observed in only 1 patient (3%), and severe platelet count degreased (&gt; grade 3) was observed in 2 patients (6%), adverse events were tolerable. In conclusion, the use of Sr-89 with zoledronic acid in breast cancer patients with painful bone metastases was safe and effective when administered concurrently with other standard therapies. In the future, the treatment with Sr-89 at the early stage should be considered, and a large-scale clinical study should be conducted.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):C216.

Citation Format: Kimito Yamada, Hiroshi Kaise, Seiichirou Komatsu, Fuyou Kimura, Mayuko Matsumura, Yukiko Nakamura, Mari Hosonaga, Takahiko Kawate, Kana Miyahara, Yuko Kawai, Ai Ueda, Saeko Teraoka, Mana Yoshimura, Norio Kohno. The safety and efficacy of the concurrent use of radiopharmaceutical strontium-89 (Sr-89) chloride with zoledronic acid in standard anticancer therapy for breast cancer patients with painful multifocal bone metastases. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr C216.

Accuracy and validity of sentinel lymph node biopsy for breast cancer using a photosensitizer: 8-year follow-up

BACKGROUND AND OBJECTIVE

We evaluated an alternative procedure for sentinel lymph node biopsy (SLNB) for breast cancer after approval of the study by the Ethics Committee of Tokyo Medical University Hospital in 2004. We examined the efficacy and safety of SLNB using the photosensitizer talaporfin sodium (Laserphyrin®, Meiji Seika Pharma, Tokoyo, Japan), compared with current methods.

STUDY DESIGN/PATIENTS AND METHODS

The study included 21 breast cancer patients (Japanese women; median age, 54 years; range, 35-75). All patients received a breast cancer operation combined with SLNB between June 2004 and May 2005. Three milliliters of talaporfin solution was locally injected into the subareolar region just before the operation. We attempted to identify a sentinel lymph node (SLN) that exhibited fluorescence and was consistent with a radioisotope (RI) localization technique. Our purpose was to verify the accuracy and validity of the talaporfin fluorescence imaging method after 8 years of application.

RESULTS

There was no consistent correlation between fluorescence and pathological SLN metastasis, although all four cases of pathological SLN metastasis revealed positive fluorescence. In some cases in which we could not identify SLNs by the RI technique, we could identify SLNs using talaporfin. The method using talaporfin did not adversely affect the patients after the operation, even the chronic renal failure patient. After 8 years, all patients are alive, and none had lymph node recurrence. Side effects were not observed.

CONCLUSION

SLNB using the photosensitizer talaporfin sodium in breast cancer patients is considered to be useful as complementary to other current methods. We could evaluate the accuracy and validity of this method 8 years after all of the procedures were performed. In the future, a large-scale clinical study with statistical analyses should be conducted.

Effect of hepatic arterial infusion chemotherapy of 5-fluorouracil and cisplatin for advanced hepatocellular carcinoma in the Nationwide Survey of Primary Liver Cancer in Japan

BACKGROUND

The efficacy of hepatic arterial infusion chemotherapy for the treatment of advanced hepatocellular carcinoma (HCC) remains unclear.

METHODS

The outcome of 476 patients with HCC who underwent hepatic arterial infusion chemotherapy with 5-fluorouracil and cisplatin (HAIC) were compared with 1466 patients who did not receive active therapy.

RESULTS

A survival benefit of the therapy after adjusting for known risk factors was observed (hazard ratio, 0.48; 95% CI, 0.41-0.56; P<0.0001). In propensity score-matched analysis (n=682), median survival time was longer for patients who underwent chemotherapy (14.0 months) than for patients who did not receive active treatment (5.2 months, P<0.0001).

CONCLUSION

For advanced HCC, HAIC is considered to be an effective treatment.

Pro-angiogenic cytokines for prediction of outcomes in patients with advanced hepatocellular carcinoma

Background:

We previously reported that expressions of the pro-angiogenic cytokines angiopoietin-2 (Ang-2), follistatin, granulocyte colony-stimulating factor, hepatocyte growth factor, leptin, platelet-derived growth factor-BB, platelet endothelial cell adhesion molecule-1, and vascular endothelial growth factor were associated with the response to sorafenib in patients with advanced hepatocellular carcinoma (HCC). The aim of the present study is to examine the same relationship in a larger cohort.

Methods:

In the current retrospective cohort study, we measured serum levels of the eightcytokines in 120 consecutive HCC patients who were treated with sorafenib. We evaluated the effects of increased expression of serum cytokines on progression-free survival (PFS) and overall survival (OS).

Results:

Elevated expression of Ang-2 correlated both with significantly shorter PFS (hazard ratio (HR), 1.84; 95% confidence interval (CI), 1.21–2.81), and OS (HR, 1.95; 95% CI, 1.21–3.17). Patients with more than three cytokines expressed above the median similarly had significantly shorter PFS (HR, 1.98; 95% CI, 1.30–3.06) and OS (HR, 1.94; 95% CI, 1.19–3.22). Differences in OS were evident in cases with the evidence of macroscopic vascular invasion or extrahepatic metastasis.

Conclusion:

High expression of Ang-2 or more than cytokines in serum is associated with poor PFS and OS in HCC patients treated with sorafenib.

High-density lipoprotein cholesterol subfractions and lecithin: cholesterol acyltransferase activity in collegiate soccer players

Many of the published data on the lipid profile of athletes is based on studies of endurance athletes. The data on soccer players are rare. The purpose of this study was to examine serum high-density lipoprotein cholesterol subfractions and lecithin:cholesterol acyltransferase activity in collegiate soccer players. 31 well-trained male collegiate soccer players were divided into 2 groups: 16 defenders and 15 offenders. They were compared with 16 sedentary controls. Dietary information was obtained with a food frequency questionnaire. The subjects were all non-smokers and were not taking any drug known to affect the lipid and lipoprotein metabolism. The offenders had significantly higher high-density lipoprotein cholesterol, high-density lipoprotein2 cholesterol, and apolipoprotein A-I than the defenders and controls, whereas the defenders had the significantly higher high-density lipoprotein2 cholesterol than the controls. Both groups of athletes had significantly higher lecithin:cholesterol acyltransferase activity than the controls. The results indicate that favorable lipid and lipoprotein profile could be obtained by vigorous soccer training.

Relationship between epithelial damage or basement membrane thickness and eosinophilic infiltration in nasal polyps with chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) with nasal polyps is characterized by eosinophilic infiltration. This study hypothesized that the aggregation of the mucosal pathology during remodeling is related to infiltrating eosinophils in patients with such nasal polyps.

OBJECT

To clarify the pathogenetic role of eosinophils in patients with CRS with nasal polyps, this study investigated the relationship between epithelial damage or basement membrane (BM) thickening and the epithelial infiltration of eosinophils in these nasal polyps.

METHODS

The number of eosinophils that infiltrated into the epithelial and subepithelial layers of sinonasal tissues was counted. The staging of epithelial damage allowed the quantification of epithelial loss.

RESULTS

Both epithelial damage and BM thickness in CRS, which were correlated with the number of infiltrated eosinophils, were significantly greater than in the control group. Neither parameter showed significant differences between the asthma and non-asthma groups. There was a significantly correlation in the eosinophilic infiltration between the subepithelial and epithelial layers.

CONCLUSION

It is suggested that eosinophils that infiltrate into both the epithelial and subepithelial layers play a part in the process of mucosal remodeling of CRS with nasal polyps.

Role of interleukin-17A in the eosinophil accumulation and mucosal remodeling in chronic rhinosinusitis with nasal polyps associated with asthma

BACKGROUND

Interleukin (IL)-17A is a highly inflammatory cytokine with a robust effect on stromal cells in many tissues. Although IL-17A is known to be associated with inflammatory lung disorders by triggering an accumulation of neutrophils, the effect of IL-17A on the upper airway is still uncertain. The expression of IL-17A and its role were investigated in the nasal polyps of chronic rhinosinusitis associated with asthma.

METHODS

IL-17A was detected by immunohistochemistry and quantitative real-time RT-PCR. The cellular source of IL-17A was examined by double staining with EG2, CD4 and neutrophil elastase. The tissue remodeling of the nasal polyps was evaluated by assessing the epithelial damage and basement membrane thickness.

RESULTS

Both the immunoreactivity and mRNA of IL-17A were significantly detected in the nasal polyps in comparison with control normal sinus mucosa. The localization of IL-17A expression predominantly coincided with eosinophils and CD4-positive lymphocytes. Furthermore, the number of IL-17A-positive cells correlated with tissue eosinophils, but not with neutrophils. The degree of epithelial damage and basement membrane thickness was dependent on the number of infiltrated IL-17A-positive cells.

CONCLUSION

The present study suggests, for the first time, that IL-17A plays an important role in the eosinophil accumulation in the nasal polyps and the remodeling of the nasal polyps of chronic rhinosinusitis associated with asthma.

[New method for preparing proximal anastomotic system]

Heartstring is a useful device. However, the device failure at the time of loading the seal into the delivery device is a troublesome issue. To avoid this problem, we invent a new method using 2 tourniquets made of 5 mm-wide woven Teflon tapes and plastic tubes. Using our method, the loading procedure became easier and more reliable.

Cell-phone based assistance for waterworks/sewage plant maintenance

Cell-phones are now incorporating the functions necessary for them to be used as mobile IT devices. In this paper, we present our results of the evaluation of cell-phones as the mobile IT device to assist workers in industrial plants. We use waterworks and sewage plants as examples. By employing techniques to squeeze the SCADA screen on CRT into a small cell-phone LCD, we have made it easier for a plant's field workers to access the information needed for effective maintenance, regardless of location. An idea to link SCADA information and the plant facility information on the cell-phone is also presented. Should an accident or emergency situation arise, these cell-phone-based IT systems can efficiently deliver the latest plant information, thus the worker out in the field can respond to and resolve the emergency.

[Successful treatment for tachyarrhythmia with ultra short acting beta-blocker during beating coronary artery bypass grafting; report of a case]

A 62-year-old man with supraventricular/ventricular tachycardia associated with myocardial infarction developed tachycardia during beating coronary artery bypass grafting (CABG). Intravenous administration of an ultra short acting beta-blocker, landiolol hydrochloride, controlled heart rate and improved tachyarrhythmia without significant change of blood pressure. Landiolol hydrochloride is effective and useful for the treatment of tachyarrhythmia during beating CABG.

Total aortic arch graft replacement for recurrent aortic aneurysm

We successfully performed a total aortic arch replacement for a recurrent aortic aneurysm following repair of an aortic dissection. A 59-year-old man underwent a patch aortoplasty through median sternotomy for Stanford type B aortic dissection in other hospital. Three years and 6 months later an aneurysm developed. Computed tomography and magnetic resonance imaging angiography demonstrated an enlargement of the aneurysm, resulting in a diagnosis of recurrent distal aortic arch aneurysm. A graft replacement of the total aortic arch with the aid of selective cerebral perfusion was performed through a median resternotomy and left lateral thoracotomy. Additional left lateral thoracotomy offered a sufficiently optimal operating field for distal anastomosis. However, care must be taken not to overlook the bleeding from intercostal arteries. Since aortoplasty may lead to subsequent dilation and aneurysmal formation, initial replacement of the segment of the aorta is recommended, and careful long-term follow-up of the patient is important.

[Repair of tetralogy of Fallot in an adult; the importance of preoperative examination for major aorto-pulmonary collateral arteries]

We report the repair of tetralogy of Fallot in a 51-year-old man. He underwent a left classical Blalock-Taussig (B-T) shunt when he was ten years old. Preoperative angiography showed a patent B-T shunt. Total corrective surgery was performed. Postoperatively, he suffered from left ventricular failure. Re-intubation was required three times. Postoperative catheterization showed excellent correction of the right ventricular system, however, descending aortography revealed a great many aorto-pulmonary collateral arteries, which caused the left ventricular failure. Coil embolization of these 13 collateral arteries was performed and he recovered from the left ventricular failure. We conclude that even in an elderly patient with tetralogy of Fallot, total correction should be performed, since the surgical risk is acceptable and the procedure improves the capacity for physical activity and quality of life. Preoperative examination of collateral arteries is important, especially in elderly patients, and coil embolization should be considered.

[Extraction of bisphenol-A from a cardiopulmonary bypass circuit]

We measured levels of bisphenol-A (BPA) in a priming solution and blood of a cardiopulmonary bypass (CPB) circuit. Eight circuits were used in the study of a priming solution. Blood samples were obtained from 6 patients who underwent open heart surgery after the commencement of CPB and at the termination of CPB. Another 3 samples were collected directly from the saline in a polyethylene container as a control. Then the concentrations of BPA in them were determined by means of gas chromatography. No detectable BPA was found in controls. However, a small amount was detected in the saline from the circuits (0.9 +/- 1.1 micrograms/l). A very small amount was also detected in the blood after the commencement and at the termination of CPB (0.3 +/- 0.2 microgram/l, and 0.4 +/- 0.3 microgram/l, respectively). BPA was considered to be leached from the circuit to the priming solution and the blood because the parts of the reservoir and the oxygenator were made of polycarbonate containing BPA. We suppose the BPA concentration is probably at a safe level. However, the data on the endocrinologically toxic level of blood BPA are insufficient. Therefore, the use of plastic in a circuit may require closer scrutiny to determine whether BPA contributes to exposure to xenoestrogens.

Arteriosclerosis in the influx and intravisceral arteries of the liver, kidney and lung of WHHL rabbits

We performed a histopathological investigation on arteriosclerotic development in the influx and intravisceral arteries of the liver, kidney and lung of male WHHL rabbits. In the influx arteries of these organs, we observed severe atherosclerotic vascular lesions with high-grade luminal stenosis. In the intravisceral arteries of the liver and kidney, no arteriosclerotic lesions were observed. However, in the intrapulmonary arteries, we recognized severe atherosclerotic vascular changes with high-grade stenosis or total obstruction of the lumen in some middle to large sized pulmonary arteries. These observations indicate that the development of arteriosclerosis in parenchymatous organs differs, and that some organs are predisposed to arteriosclerosis formation.

[Surgical reconstruction for radiation-induced extracranial vertebral artery stenosis: a case report]

We report a case of symptomatic extracranial vertebral artery stenosis after radiation therapy. This 49-year-old female received radiation therapy to the neck for nasopharyngeal carcinoma 11 years earlier, was admitted because of continuous dizziness and a floating sensation. Magnetic resonanse imaging showed no abnormalities, but an aortography demonstrated complete occlusion of the right common carotid artery as well as occlusion of the right vertebral artery and severe stenosis of the left vertebral artery at its origin, which was presumed to be the result of previous radiation therapy. Percutaneous transluminal angioplasty (PTA) for the left vertebral artery was performed using conventional balloon treatment, which resulted in wall dissection. Because of this, she underwent end-to-side vertebral artery to subclavian artery transposition, and she has had no further ischemic events science that time. PTA has been successfully performed as the first treatment of choice for vertebral artery stenosis, but surgical reconstruction can be a therapeutic management of choice for cases of failed PTA.

[A case of diffuse alveolar hemorrhage developing after open heart surgery]

A 47-year-old man was receiving anticoagulant therapy after coronary artery bypass grafting and mitral valve plasty. A chest roentgenogram disclosed alveolar infiltrates throughout both lung fields 6 months postoperatively. Lung biopsy specimens showed the presence of hemosiderin-laden macrophages in the alveolar spaces, establishing a diagnosis of diffuse alveolar hemorrhage. Anticoagulant therapy may have caused the hemorrhage, because the patient had no immunologic disorder or renal disease. The shadows completely disappeared after steroid therapy and discontinuation of anticoagulant therapy. Diffuse alveolar hemorrhage should be considered, when extensive infiltrates develop on chest roentgenogram in patients receiving anticoagulant therapy after open heart surgery. Lung biopsy is essential, when a bronchoalveolar lavage fails to diagnose the disease.

[Successful treatment of a patient with low pressure syndrome associated with gait disturbance]

The authors report an unusual case of low intracranial pressure (ICP) syndrome that was successfully treated by the placement of an anti-siphon device (ASD). This 36-year-old male had suffered suprasellar germinoma with hydrocephalus and had had a V-P shunt following radiotherapy. Sixteen years later he developed gait disturbance and somnolence and MRI demonstrated a small lateral ventricle as well as a diffuse dural enhancement. A lumbar tap revealed a low ICP of 12 mmH2O. Because of this, an ASD was placed in the patient. Postoperatively, his symptoms of gait and consciousness disturbance improved. Typical clinical findings of low ICP syndrome such as headache were not observed in this case. To our knowledge, no symptom of gait disturbance with low ICP has been reported previously. We present an interesting case of low ICP syndrome with gait disturbance and discuss the mechanism of the symptoms. Symptoms of this patient were due at first to brain ischemia. After convulsion and consciousness disturbance due to low intracranial pressure, the symptoms increased in strength until gait disturbance occurred. The possibility is suggested that gait disturbance in this patient was due both to brain ischemia and low intracranial pressure.

Hereditary dilated cardiomyopathy in Holstein-Friesian cattle in Japan: association with hereditary myopathy of the diaphragmatic muscles

This report deals with the pathology and genetic basis of dilated cardiomyopathy in 10 Holstein-Friesian cows aged 3-6 years, a disease similar to that reported in Simmental-Red Holstein and Holstein-Friesian cattle in several other countries. The main clinical signs were associated with systemic circulatory failure, and at necropsy the animals showed cardiomegaly, severe congestion and fibrosis of the liver, and systemic cardiac oedema. Histologically, hypertrophy and vacuolation of the cardiac muscle fibres and severe fibrosis were noted. Electron microscopically, the sarcoplasm of the hypertrophic fibres was seen to be filled with fine structures of low electron-density, together with thin filamentous material, suggesting myofibrillar lysis. The mitochondria showed increased size, an abnormal cristae pattern and vacuolation due to partial loss of cristae. Pedigree analysis of the affected cattle indicated an autosomal recessive mode of inheritance. The family line of this cardiomyopathy overlapped with that of hereditary myopathy of the diaphragmatic muscles in Holstein-Friesian cattle, the pathological aspects and inheritance mode of which were reported previously. The available evidence suggested a genetic association between these two pathologically distinct diseases.

Pyloric stenosis: new histopathologic perspective using confocal laser scanning

BACKGROUND/PURPOSE

Idiopathic hypertrophic pyloric stenosis (IHPS) is a common infantile disorder characterized by enlargement of the pylorus and gastric outlet obstruction. Its complete etiology is still not fully understood, but recent research has focussed on abnormalities of nerve distribution. The authors used confocal laser scanning microscopy to perform 3-dimensional studies of pylorus biopsy specimens taken from cases of IHPS and present their findings.

METHODS

Pylorus biopsy specimens obtained at pyloromyotomy from 6 infants with IHPS were studied using confocal microscopy and compared with 6 control pylorus biopsy specimens from patients without gastrointestinal disease. Biopsy specimens were pretreated to enhance nerve expression by using protein gene product 9.5 (PGP9.5) polyclonal antibody to identify enteric nerve system fibers. Double staining immunofluorescence was used to detect alpha smooth muscle actin (SMA), a smooth muscle marker.

RESULTS

Control pylorus biopsy specimens showed many thin PGP9.5-positive nerve fibers in the circular and longitudinal muscle layers that communicated with each other to create a 3-dimensional meshlike network. Muscle cells stained by alpha SMA antibody were thin. In contrast, muscle cells from IHPS patients were fat and round. The PGP9.5 staining nerve fibers from IHPS patients formed numerous, thick, and contorted bundles that did not communicate.

CONCLUSIONS

By using confocal laser microscopy the authors were able to identify abnormally thick contorted nerve bundles in the pyloric muscle layers of infants with IHPS. These anormal nerve bundles have not been described previously because of the limitations of 2-dimensional microscopy. The authors suspect that the etiology of IHPS may be related to these abnormal fibers.

Intestinal neuronal dysplasia-like pathology in Ncx/Hox11L.1 gene-deficient mice

BACKGROUND/PURPOSE

Ncx/Hox11L.1-deficient (Ncx-/-) mice specifically created by the authors had mega-ileo-ceco-colon (mega-ICC) with a caliber change in the proximal colon. The authors studied the nerve distribution in the bowel of these Ncx-/- mice to determine the cause of their bowel dysmotility.

METHODS

Four-week-old Ncx-/- mice (n = 10; 5 with mega-ICC, 5 without mega-ICC) were killed and the bowel harvested. Half of each specimen was snap frozen for AchE and NADPH-diaphorase histochemistry, and the other half were fixed with 10% formalin for H&E staining and immunohistochemistry using PGP9.5 antibody (a marker for neurons), C-kit antibody (a marker for intestinal pacemaker cells), and stem cell factor antibody (a marker for C-kit ligand). Age-matched wild-type normal mice (n = 5) served as controls.

RESULTS

In the ileum, cecum, and proximal colon from all Ncx-/- mice (irrespective of the association of mega-ICC), typical findings of human intestinal neuronal dysplasia (IND) ie, obvious hyperganglionosis in neuronal plexuses on PGP9.5 immunohistochemistry, ectopic ganglia in the mucosal and muscular layers on AchE histochemistry, and ghostlike ganglia on NADPH-diaphorase histochemistry were found. Likewise, in normal caliber distal colon from these mice, the distribution of ganglion cells, C-kit, and stem cell factor was normal. In control specimens, there was no ectopic ganglia or hyperganglionosis.

CONCLUSIONS

These findings suggest that the Ncx/Hox11L.1 gene is required for the proper innervation of the enteric nervous system in mice, and our deficient strain may be useful as a model for studying IND in humans.

Transplantation of newborn esophagus: an experimental study

PURPOSE

The aim of this study was to see if allogeneic transplantation (Tx) of newborn esophagus can create viable esophageal tissue that may be used for treating long gap esophageal atresia.

METHODS

Specimens of thoracic esophagus from newborn Brown-Norway rats, each were transplanted into a pouch created in the distal omentum of 5-week-old Lewis rats. In group I no immunosuppressant was used. FK-506 was used in group II (0.2 mg/kg), group III (0.6 mg/kg), and group IV (1.2 mg/kg) until a predetermined day of graft harvesting (1, 2, 3, 4, 5, 6, and 8 weeks after Tx). FK-506 was used for only 2 weeks in group V (0.6 mg/kg), and group VI (1.2mg/kg), and transplanted esophageal grafts were harvested 1, 2, 3, and 4 weeks after cessation of 2 weeks course FK-506. Syngeneic esophagus transplants were used as controls. All grafts were examined by H&E staining to assess graft viability and degree of rejection.

RESULTS

Each successfully transplanted esophagus appeared macroscopically as a tube like mass. Each graft could be mobilized to the thoracic cavity, because of the long omental pedicle. Graft survival in the control group was 100%. Rejection was observed in all grafts from groups I, II, V, and VI. In contrast, grafts from groups III and IV showed only minimal or no rejection. There was no evidence of side effects of FK-506 in rats in groups III and IV, except significantly slower weight gain compared with controls (P <.05).

CONCLUSIONS

FK-506 successfully prevented rejection, although immunologic tolerance was not achieved. These observations suggest that the authors' procedure has the potential to produce viable esophageal tissue that could be a new option for treating long gap esophageal atresia.