11C-methionine- and 18F-FDG-PET double-negative metastatic brain tumor from lung adenocarcinoma with paradoxical high 18F-FDG uptake: A case report

Background:

Imaging with 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) and 11C-methionine (MET)-PET can delineate primary and metastatic brain tumors. Lesion size affects the sensitivity of both scans and histopathological features can also influence FDG-PET, but the effects on MET-PET have not been elucidated.

Case Description:

We report an unusual case of metastatic brain tumors without accumulation of FDG or MET, contrasting with high FDG uptake in the primary lung lesion. The brain lesions were identified as adenocarcinoma with a more mucus-rich background, contributing to the indistinct accumulation of both FDG and MET.

Conclusion:

Histopathological characteristics can affect both MET and FDG accumulation, leading to findings contradicting those of the primary lesion.

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

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

Simultaneous multiple craniotomies in the management of multifocal malignant brain lesions: case reports

The appropriate strategy for treating multiple malignant brain tumors has not been well established. We discuss the indications and surgical considerations of multiple craniotomies in the same surgical session, and present three such cases. A 41-year-old woman (case 1) and a 65-year-old man (case 2), both presented with two metastatic brain lesions, one in each hemisphere. The third case was a 65-year-old woman with multiple recurrent atypical meningiomas, who underwent surgical removal in two stages. In the first surgery, only the superior sagittal sinus lesion was excised. Then in the second surgery, multiple disseminated bilateral convexity tumors were excised through a craniotomy on each side. All cases had a remarkable neurological improvement immediately after surgery. We suggest that the indications for surgical removal of multiple brain tumors with two or more craniotomies in the same surgical session are: 1) progressing neurological symptoms, 2) tumors with a maximum diameter more than 2 cm, 3) resistance to radiation and/or chemotherapy, 4) ability to tolerate the scheduled surgical time, 5) vital prognosis anticipated to be more than 3 months, 6) expectation of significant neurological improvement, and 7) single-session surgery not carrying more risk than multiple surgeries.

Predictive Factors Associated with Pain Relief of Spinal Cord Stimulation for Central Post-stroke Pain

The efficacy and predictive factors associated with successful spinal cord stimulation (SCS) for central post-stroke pain (CPSP) have yet to be definitively established. Thus, this study evaluated the rates of pain relief found after more than 12 months and the predictive factors associated with the success of SCS for CPSP. The degree of pain after SCS in 18 patients with CPSP was assessed using the Visual Analog Scale preoperatively, at 1, 6 and 12 months after surgery, and at the time of the last follow-up. After calculating the percentage of pain relief (PPR), patients were separated into two groups. The first group exhibited continuing PPR ≥30% at more than 12 months (effect group) while the second group exhibited successful/unsuccessful trials followed by decreasing PPR <30% within 12 months (no effect group). Pain relief for more than 12 months was achieved in eight out of 18 (44.4%) patients during the 67.3 ± 35.5 month follow-up period. Statistically significant differences were found for both the age and stroke location during comparisons of the preoperative characteristics between the two groups. There was a significantly younger mean age for the effect versus the no effect group. Patients with stoke in non-thalamus were significantly enriched in effect group compared with those with stoke in thalamus. Multivariable analysis using these two factors found no statistical differences, suggesting that these two factors might possibly exhibit the same behaviors for the SCS effect. These results suggest that SCS may be able to provide pain relief in young, non-thalamus stroke patients with CPSP.

Long-term Effect and Predictive Factors of Motor Cortex and Spinal Cord Stimulation for Chronic Neuropathic Pain

The long-term effects of motor cortex stimulation (MCS) and spinal cord stimulation (SCS) remain unknown. To identify the long-term effects after MCS or SCS and determine any associated predictive factors for the outcomes. Fifty patients underwent MCS (n = 15) or SCS (n = 35) for chronic neuropathic pain. The degree of pain was assessed preoperatively, at 1, 6, and 12 months after surgery, and during the time of the last follow-up using Visual Analog Scale (VAS). Percentage of pain relief (PPR) was calculated, with “long-term effect” defined as PPR ≥ 30% and the presence of continued pain relief over 12 months. Outcomes were classified into excellent (PPR ≥ 70%) and good (PPR 30–69%) sub-categories. Long-term effects of MCS and SCS were observed in 53.3% and 57.1% of the patients, respectively. There were no predictive factors of long-term effects identified for any of the various preoperative conditions. However, the VAS at 1 month after surgery was significantly associated with the long-term effects in both MCS and SCS. All patients with an excellent outcome at 1 month after the surgery continued to exhibit these effects. In contrast, patients with the good outcome at 1 month exhibited a significant decrease in the effects at 6 months after surgery. The long-term effects of MCS and SCS were approximately 50% during the more than 8.5 and 3.5 years of follow-up, respectively. The VAS at 1 month after surgery may be a postoperative predictor of the long-term effects for both MCS and SCS.

[Supratentorial-infraoccipital approach supported by navigation and intraoperative magnetic resonance imaging for glioma located at the medial posterior temporal lobe: two case reports]

Resection of posteromedial temporal lobe lesions is challenging because surgical access through standard approaches requires excessive retraction or resection of temporal cortex. The utility of the supratentorial-infraoccipital approach for posteromedial temporal lobe lesions was first reported in 1995. Here, we report two cases of glioma located at the medial posterior temporal lobe. In both, total tumor removal was achieved by a supratentorial-infraoccipital approach using neuronavigation and intraoperative magnetic resonance imaging. Both patients presented with postoperative quadrantanopia because of optic radiation damage, but did not have worsening language, memory, or cognitive functions.

[Severe rhabdomyolysis and intracranial hemorrhage associated with synthetic cannabinoid: a case report]

A 28-year-old male presented with language and behavior disorders a few days prior to examination. Magnetic resonance images and cerebral angiography revealed an arteriovenous malformation (AVM) in the right frontal lobe. The size of the nidus was 2.0 cm, and it was fed by the middle cerebral arteries and drained by the superior sagittal and transverse sinuses. The AVM was completely surgically resected without any complications. Ten months after the surgery, the patient presented with behavior disorders again and general convulsion. Computed tomography showed a small intracranial hemorrhage at the right frontal lobe, where the AVM was located. Blood examination revealed severe rhabdomyolysis (CK:536,620U/L)and acute kidney injury (Cr:5.20mg/dL). After admission, it became clear that the patient had used synthetic cannabinoid (SC). SC refers to a variety of herbal/chemical mixtures, which mimic the effects of marijuana. Little data is available on the psychopathological and physical effects of SC. This is the first report of severe rhabdomyolysis and intracranial hemorrhage associated with SC use in Japan.

[Biopsy of brain parenchymal lesions: procedure selection and ingenuity of accurate and safety biopsy]

INTRODUCTION

Biopsy procedures of intra-parenchymal lesions are divided into needle biopsy (stereotactic or frameless) or navigation-guided endoscopic biopsy.

METHODS

We retrospectively reviewed 36 consecutive patients with intra-parenchymal lesions who underwent biopsy at our institution. Fourteen patients underwent navigation-guided endoscopic biopsy (endoscopic group) and 22 patients underwent needle biopsy (needle group). Rates of pathological diagnosis and postoperative hemorrhage were compared between groups and analyzed using Fisher's exact test. Probability values of <0.05 were considered statistically significant.

RESULTS

Pathological diagnostic rates were 100% (14/14) for the endoscopic group and 96% (21/22) for the needle group, showing no significant difference. The postoperative hemorrhage rate was 7.1% (1/14) in the endoscopic group and 27.3% (6/22) in the needle group (p=0.21). Symptomatic postoperative hemorrhage was seen in 0% (0/14) of the endoscopic group and 18.2% (4/22) in the needle group (p=0.14).

CONCLUSION

Both needle and endoscopic biopsies are accurate procedures with high rates of pathological diagnosis. Postoperative hemorrhage tended to be less frequent with endoscopic biopsy than with needle biopsy. Here, we described procedure selection and ingenuity of accurate and safe biopsy at our institution.

Use of high-field intraoperative magnetic resonance imaging during endoscopic transsphenoidal surgery for functioning pituitary microadenomas and small adenomas located in the intrasellar region

The usefulness of 1.5-T high-field intraoperative magnetic resonance (iMR) imaging during transsphenoidal surgery for functioning pituitary adenomas was retrospectively evaluated based on long-term endocrine remission from the records of 14 patients who underwent transsphenoidal surgery with iMR imaging for functioning pituitary microadenomas and small adenomas located in the intrasellar region. The maximum tumor diameter was 9.3 ± 2.6 mm. Patients were diagnosed with acromegaly (n = 7), prolactinoma (n = 4), and Cushing's disease (n = 3). If iMR imaging detected tumor remnants after resection, the resection cavity was reexamined and further resection was performed. Postoperative endocrine follow-up period was mean 33.7 ± 13.3 months. Tumor remnants were detected after the first resection in seven patients. Further resection was performed in five of these patients, and three achieved long-term endocrine remission. As a result, the overall long-term endocrine remission rate was 78.5% (11/14), instead of the 57.1% (8/14) that would be expected if iMR imaging had not been performed. Long-term endocrine remission had a tendency to be associated with the absence of tumor remnants on the final iMR images, but this was not significant (p = 0.09). Long-term endocrine remission was associated with presence of tumor remnants in the cavernous sinus on the final iMR images (p = 0.03). High-field iMR imaging is useful for depicting tumor remnants after resection, and increased the long-term endocrine remission rate for patients with functioning pituitary microadenomas and small adenomas.

[Efficacy of tramadol/acetaminophen medication for central post-stroke pain]

OBJECTIVE

Central post-stroke pain(CPSP)is the most difficult type of central neuropathic pain to control with medical treatment. Opioids are commonly used for chronic neuropathic pain, but their efficacy in treating central neuropathic pain, particularly CPSP, is not clear. Tramadol is an opioid analgesic that, in combination with acetaminophen, has been approved since 2011 for the treatment of non-cancer pain in Japan. In this study we evaluated the efficacy of tramadol/acetaminophen medication for CPSP.

METHODS

We retrospectively reviewed nine cases of CPSP that received oral tramadol/acetaminophen medication. All cases received tramadol/acetaminophen medication after first taking pregabalin then antidepressant medication. Pain levels were assessed before tramadol/acetaminophen medication began and one month after a maintenance dose was reached, using a visual analogue scale(VAS)and the McGill pain questionnaire(MPQ).

RESULTS

The mean dose of tramadol was 121±61.6 mg/day. Tramadol/acetaminophen medication was effective in reducing pain in seven of nine cases(77.8%). The VAS improved 32.9±13.8% from pre-to post-medication, and the MPQ improved from 15.4±9.1 pre-medication to 8.1±4.7 post-medication(p<0.05). These effects continued 9.3±4.5 months during follow up periods. Side effects were observed in six cases(one severe, one moderate, two mild, two transient), but medication was continued in eight cases.

CONCLUSION

Oral tramadol/acetaminophen medication was effective at reducing pain levels in patients with CPSP, and is a medication option for the treatment of CPSP.

Endoscopic biopsy for lesions located in the parenchyma of the brain: preoperative planning based on stereotactic methods. Technical note

Endoscope biopsy guided navigation for intra-parenchymal lesions is safe and effective, but determination of the entry point and trajectory of the endoscopic biopsy is less clear. We describe preoperative planning based on stereotactic methods, and achieving the plan using several techniques. The preoperative planning was based on stereotactic methods such as determining target, entry point, and trajectory. A transparent sheath was advanced under guidance of the navigation system and specimens collected under visual endoscopic monitoring. After collecting specimens, intraoperative magnetic resonance imaging was performed for confirming accurate sampling. Correct specimens were obtained in 6 cases as confirmed by intraoperative magnetic resonance imaging. The histological diagnoses were diffuse large B-cell type malignant lymphoma (n = 3), astrocytoma (n = 1), glioblastoma (n = 1), and inflammatory changes without neoplastic cells (n = 1). No postoperative intracranial hemorrhage or other operative complications occurred. Preoperative planning based on stereotactic methods and procedures guided by navigation systems can achieve endoscopic biopsy for intraparenchymal lesions safely and accurately.

[Dual lead spinal cord stimulation using octad lead for central post-stroke pain]

Spinal cord stimulation (SCS) has become the preferred option for neurosurgical management of several intractable pains. To evaluate effects of dual lead SCS using two quad leads for central post-stroke pain (CPSP), we retrospectively reviewed eight consecutive patients with CPSP who underwent SCS. Six (75%) of eight patients obtained more than 50% pain relief during test stimulation, and the efficacies continued for about 12 months in five (83%) of six patients. There were no significant complications. SCS is less invasive neurostimulation treatment and provides pain relief for some cases of CPSP.

Peptide-pulsed dendritic cell vaccination targeting interleukin-13 receptor α2 chain in recurrent malignant glioma patients with HLA-A*24/A*02 allele

BACKGROUND AIMS

Dendritic cell (DC)-based vaccination targeting tumor-associated antigens is an attractive approach to overcoming the limitations of current treatments for malignant gliomas (MG). Interleukin-13 receptor α2 chain (IL-13Rα2) is a promising target because of its abundant and specific expression in MG. We conducted a phase I trial of DC vaccination in patients with recurrent MG using two IL-13Rα2-derived peptides restricted to HLA-A*0201 and -A*2402. The objective was to evaluate the safety and clinical and immunologic responses.

METHODS

Eight recurrent MG patients were enrolled. DC were generated from peripheral blood and pulsed with HLA-matched peptide; 1 × 10(7) DC were administered every 2 weeks for a maximum of six immunizations. The T-cell response in peripheral blood was evaluated by tetramer and ELISPOT assays in HLA-A*2402 patients.

RESULTS

All enrolled patients except one completed at least four DC vaccinations. No severe adverse events were observed. A positive T-cell response was detected in two out of three evaluable HLA-A*2402 patients. One patient achieved stable disease for 16 months and another patient showed a dramatic regression for one lesion for 4 months.

CONCLUSIONS

The regimen was feasible and safe, and the HLA-A*24-restricted peptide exhibited a capacity to induce immune responses. These results warrant further studies to evaluate whether add-on regimens to post-operative chemoradiotherapy delays recurrence in newly diagnosed MG patients.

Isolated adrenocorticotropic hormone deficiency associated with Hashimoto's disease and thyroid crisis triggered by head trauma. Case report

A 47-year-old man presented to our hospital after suffering transient loss of consciousness and falling to the floor. On admission, his Glasgow Coma Scale score was 11 (E3V3M5), and he exhibited restlessness. Blood examination revealed hyperthyroidism. Computed tomography showed slight traumatic subarachnoid hemorrhage. He developed fever and tachycardia, and was diagnosed with thyroid crisis. Magnetic resonance imaging showed a brain contusion in the right frontal lobe, and encephalopathy signs in the right frontal and insular cortex. Immunocytochemical examinations suggested Hashimoto's disease, and hormone examinations revealed plasma levels were undetectably low of adrenocorticotropic hormone (ACTH) and low of cortisol. Pituitary stimulation tests showed inadequate plasma ACTH and cortisol response, consistent with isolated ACTH deficiency (IAD). The final diagnosis was IAD associated with Hashimoto's disease. Hydrocortisone replacement therapy was continued, and the patient was nearly free from neurological deficits after 18 months. The neuroimaging abnormalities gradually improved with time.

Intraoperative tractography and motor evoked potential (MEP) monitoring in surgery for gliomas around the corticospinal tract

BACKGROUND

Our goal is to indicate the importance of combining intraoperative tractography with motor-evoked potential (MEP) monitoring for glioma surgery in motor eloquent areas.

METHODS

Tumor removal was performed in 28 patients with gliomas in and around the corticospinal tract (CST), in an operation theater equipped with an integrated high-field intraoperative magnetic resonance imaging and a neuronavigation system. Diffusion-tensor imaging-based tractography of the CST was implemented preoperatively and intraoperatively. When the surgically manipulated area came close to the corticospinal pathway, MEP responses were elicited by subcortical stimulation. Responsive areas were compared with the locations of fibers traced by preoperative and intraoperative tractography. Imaging and functional outcomes were reviewed.

RESULTS

Intraoperative tractography demonstrated significant inward or outward shift during surgery. MEP responses were observed around the tract at various intensities, and the distance between MEP responsive sites and intraoperative tractography was significantly correlated with the stimulation intensity (P < 0.01). The distance from preoperative tractography was not correlated. A more than subtotal resection was achieved in 24 patients (85.7%). Transient motor deterioration was seen in 12 patients (42.8%), and a permanent deficit was seen in 1 patient (3.5%).

CONCLUSIONS

We found that intraoperative tractography demonstrated the location of the CST more accurately than preoperative tractography. The results of the linear regression between distance and stimulation intensity were informative for guiding approaches to tumor remnants without impinging on the CST. The combination of intraoperative tractography and MEP monitoring can enhance the quality of surgery for gliomas in motor eloquent areas.

[Removal of an arteriovenous malformation near the pyramidal tract using the neuronavigation system: a case report]

A 20-year-old female presented with sudden severe headaches. Computed tomography showed an intraventricular hemorrhage and slightly dilated lateral ventricles. Her neurological examinations revealed no abnormalities. Magnetic resonance (MR) images and cerebral angiography revealed arteriovenous malformation (AVM) in the right parietal lobe. The size of the nidus was 1.8 cm, and it was located in the deep white matter. It was fed by middle cerebral arteries and drained by the vein of Galen. Diffusion tensor tractography (DTT) demonstrated that the right pyramidal tract was situated close to the nidus. The AVM was surgically resected completely, without any complications, using intraoperative neuronavigation image guidance. Neuronavigation images combined with DTT are useful for surgical resection of AVM that is located close to the pyramidal tract.

Clinical indications for high-field 1.5 T intraoperative magnetic resonance imaging and neuro-navigation for neurosurgical procedures. Review of initial 100 cases

Initial experiences are reviewed in an integrated operation theater equipped with an intraoperative high-field (1.5 T) magnetic resonance (MR) imager and neuro-navigation (BrainSUITE), to evaluate the indications and limitations. One hundred consecutive cases were treated, consisting of 38 gliomas, 49 other tumors, 11 cerebrovascular diseases, and 2 functional diseases. The feasibility and usefulness of the integrated theater were evaluated for individual diseases, focusing on whether intraoperative images (including diffusion tensor imaging) affected the surgical strategy. The extent of resection and outcomes in each histological category of brain tumors were examined. Intraoperative high-field MR imaging frequently affected or modified the surgical strategy in the glioma group (27/38 cases, 71.1%), but less in the other tumor group (13/49 cases, 26.5%). The surgical strategy was not modified in cerebrovascular or functional diseases, but the success of procedures and the absence of complications could be confirmed. In glioma surgery, subtotal or greater resection was achieved in 22 of the 31 patients (71%) excluding biopsies, and intraoperative images revealed tumor remnants resulting in the extension of resection in 21 of the 22 patients (95.4%), the highest rate of extension among all types of pathologies. The integrated neuro-navigation improved workflow. The best indication for intraoperative high-field MR imaging and integrated neuro-navigation is brain tumors, especially gliomas, and is supplementary in assuring quality in surgery for cerebrovascular or functional diseases. Immediate quality assurance is provided in several types of neurosurgical procedures.

Identification of a human leukocyte antigen-A24-restricted T-cell epitope derived from interleukin-13 receptor alpha2 chain, a glioma-associated antigen

OBJECT

The human leukocyte antigen-A24 (HLA-A24) allele is highly expressed in Asians. This allele is expressed in 60% of the Japanese population and in a significant number of people of other ethnicities. The interleukin-13 type alpha2 receptor (IL-13Ralpha2) has been shown to be a glioma-specific antigen, and is abundantly expressed in a majority of high-grade astrocytomas. In this study, the authors first investigated the suitability of IL-13Ralpha2 as a target antigen of malignant glioma cells, and then identified a potential HLA-A24-restricted peptide derived from IL-13Ralpha2.

METHODS

The expression of IL-13Ralpha2 in glioma tissues was examined by reverse transcription-polymerase chain reaction analysis. To identify the desired epitope, the authors selected 5 candidate peptides from IL-13Ralpha2 that were predicted to bind to HLA-A24. The lytic activity of cytotoxic T lymphocytes (CTLs) induced by peptide-pulsed dendritic cells was analyzed against various glioma cell lines and freshly isolated human glioma cells.

RESULTS

In a series of glioma tissues obtained in 29 patients, the authors found that > 50% of high-grade gliomas expressed IL-13Ralpha2. Of the 5 peptides tested, P174 (WYEGLDHAL) was found to be the most useful for the induction of HLA-A24-restricted and IL-13Ralpha2-specific CTLs. A CTL line induced by P174 also showed antigen-specific cytotoxicity to surgically removed glioma cells depending on their level of expression of IL-13Ralpha2 and HLA-A24.

CONCLUSIONS

Interleukin-13Ralpha2 is a glioma-specific antigen, and the immunogenic peptide P174 may contribute to a peptide-based immunotherapy against malignant glioma cells expressing HLA-A24.

Inhibition of Aurora-B function increases formation of multinucleated cells in p53 gene deficient cells and enhances anti-tumor effect of temozolomide in human glioma cells

Cell division is an elemental process, and mainly consists of chromosome segregation and subsequent cytokinesis. Some errors in this process have the possibility of leading to carcinogenesis. Aurora-B is known as a chromosomal passenger protein that regulates cell division. In our previous studies of giant cell glioblastoma, we reported that multinucleated giant cells resulted from aberrations in cytokinesis with intact nuclear division occurring in the early mitotic phase, probably due to Aurora-B dysfunction. In this study, as we determined p53 gene mutation occurring in multinucleated giant cell glioblastoma, we investigated the role of Aurora-B in formation of multinucleated cells in human neoplasm cells with various p53 statuses as well as cytotoxity of glioma cells to temozolomide (TMZ), a common oral alkylating agent used in the treatment of gliomas. The inhibition of Aurora-B function by small-interfering (si)RNA led to an increase in the number of multinucleated cells and the ratios of G2/M phase in p53-mutant and p53-null cells, but not in p53-wild cells or the cells transduced adenovirally with wild-p53. The combination of TMZ and Aurora-B-siRNA remarkably inhibited the cell viability of TMZ-resistant glioma cells. Accordingly, our results suggested that Aurora-B dysfunction increases in the appearance of multinucleated cells in p53 gene deficient cells, and TMZ treatment in combination with the inhibition of Aurora-B function may become a potential therapy against p53 gene deficient and chemotherapeutic-resistant human gliomas.

EGFR mutations in patients with brain metastases from lung cancer: association with the efficacy of gefitinib

Gefitinib--a specific inhibitor of epidermal growth factor receptor (EGFR)-associated tyrosine kinase--has demonstrated efficacy in a subgroup of patients with non-small-cell lung carcinoma (NSCLC) who fail conventional chemotherapy. It is also reported to have an antitumor effect in brain metastases from NSCLC. Additionally, EGFR mutations have shown a strong association with gefitinib sensitivity for NSCLC. Here, we assessed the efficacy of gefitinib in brain metastases from NSCLC and evaluated the association of this efficacy with EGFR mutations. We retrospectively reviewed eight cases in which patients were suffering from brain metastases before the initiation of gefitinib treatment. Brain tumor response could be evaluated by MRI in these patients; EGFR gene analyses were also available. We evaluated whether objective tumor response was observed after gefitinib treatment and assessed the efficacy of gefitinib as effective, noneffective, or not assessable in consideration of the influence of previous radiotherapy. Of the eight patients, the efficacy of gefitinib was assessed as effective in three and as noneffective in three. All three patients demonstrating effective efficacy had EGFR mutations in the tyrosine kinase domain (deletion mutation in two patients and point mutation in one patients), whereas none of the three patients demonstrating noneffective efficacy had EGFR mutations. Gefitinib appears to be effective in treating brain metastases in a subgroup of patients. Our data suggested a possible association between the efficacy of gefitinib in the treatment of brain metastases and EGFR mutations.

Activation of JAK/STAT signalling in neurons following spinal cord injury in mice

The Janus kinase (JAK)/signal transducer and activator of transcription (STAT) signalling pathway is one of the most important in transducing signals from the cell surface to the nucleus in response to cytokines. In the present study, we investigated chronological alteration and cellular location of JAK1, STAT3, phosphorylated (p)-Tyr1022/1023-JAK1, p-Tyr705-STAT3, and interleukin-6 (IL-6) following spinal cord injury (SCI) in mice. Western blot analysis showed JAK1 to be significantly phosphorylated at Tyr1022/1023 from 6 h after SCI, peaking at 12 h and gradually decreasing thereafter, accompanied by phosphorylation of STAT3 at Tyr705 with a similar time course. ELISA analysis showed the concentration of IL-6 in injured spinal cord to also significantly increase from 3 h after SCI, peaking at 12 h, then gradually decreasing. Immunohistochemistry revealed p-Tyr1022/1023-JAK1, p-Tyr705-STAT3, and IL-6 to be mainly expressed in neurons of the anterior horns at 12 h after SCI. Pretreatment with a JAK inhibitor, AG-490, suppressed phosphorylation of JAK1 and STAT3 at 12 h after SCI, reducing recovery of motor functions. These findings suggest that SCI at the acute stage produces IL-6 mainly in neurons of the injured spinal cord, which activates the JAK/STAT pathway, and that this pathway may be involved with neuronal response to SCI.

Susceptibility to exogenously added interferon-beta protein depends on intracellular interferon-beta mRNA level in human glioma cells

Exogenously added human interferon-beta (HuIFN-beta) protein possesses a remarkable antiproliferative activity in human glioma and melanoma. Endogenous HuIFN-beta protein, which is produced by its gene transfer using cationic liposomes, has much more effective antiproliferative activity against these tumors, even in cells resistant to exogenously added HuIFN-beta protein. As the first step to elucidate the possible difference in antiproliferative mechanisms between exogenous and endogenous HuIFN-beta protein, we here investigated the relationship between the intracellular level of its mRNA and susceptibility to exogenously added HuIFN-beta protein. In this study, we used seven human glioma cell lines (SK-MG-1, SK-MG-4, SK-AO2, U87MG, U251SP, U251MG and T98) and one human melanoma cell line (MMAN). At first, we examined the relationship between spontaneous expression of HuIFN-beta mRNA and susceptibility to exogenously added HuIFN-beta protein (50 IU/ml) in human glioma cells and then confirmed a significant correlation between them. Next, we confirmed that administration of 0-100 IU/ml exogenously added HuIFN-beta protein upregulated the HuIFN-beta mRNA in a dose-dependent manner using the RT-PCR technique and that the HuIFN-beta mRNA was suppressed by siRNA for HuIFN-beta in SK-MG-1 and MMAN cells. Furthermore, we confirmed that the siRNA for HuIFN-beta significantly suppressed the antiproliferative effect of SK-MG-1 cells treated with 10-100 IU/ml HuIFN-beta protein and MMAN cells with 25 and 50 IU/ml HuIFN-beta protein. We found this phenomenon in another human glioma cell line, U87MG cells, as well. This finding would suggest that susceptibility to exogenously added HuIFN-beta protein is related to the amount of intracellular HuIFN-beta mRNA in human glioma and melanoma cells.

Brain metastases from apocrine carcinoma of the scalp: case report

Apocrine carcinoma is an extremely rare malignant neoplasm that occurs most frequently in the axilla. Although it usually shows an indolent clinical course, it often metastasizes to regional lymph nodes and sometimes to lungs or bones. However, a literature search did not reveal any report describing the detailed clinical course of brain metastases from apocrine carcinoma. We report a case of a 54-year-old male who suffered from multiple brain metastases from apocrine carcinoma that had originated in the scalp 6 years before. The brain metastases appeared in spite of several regimens of chemotherapy for lung metastases for two years. The tumor in the right frontal lobe was successfully operated. However, the small tumor in the right occipital lobe was not cured by gamma knife surgery, and eventually required second operation. The operation had contributed to his neurologically independent life for about one year until he died for gradual progression of lung metastases. To our knowledge this is the first reported case of metastatic brain tumor from apocrine carcinoma.

Nursing care for dialysis patients in Japan

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

Multicentric atypical teratoid/rhabdoid tumors occurring in the eye and fourth ventricle of an infant: case report

Atypical teratoid/rhabdoid tumors (AT/RTs) are aggressive malignant tumors found in infants and young children. The tumor is characterized by the presence of a rhabdoid cell component in all cases, but the histological origin is still unclear. Recently, germline mutation of the hSNF5/INI1 gene has been reported in association with AT/RTs. The authors report a rare case of an intraocular AT/RT followed by a fourth ventricular tumor. The results of immunohistochemical studies of the surgical specimens revealed the presence of an AT/RT and from this finding the neural origin was inferred. A novel missense mutation of the hSNF5/INI1 gene was demonstrated by DNA analysis. High-dose chemotherapy with stem cell rescue was effective in treating this patient. The immunohistochemical relationship between rhabdoid cells and the neurogenic zone, which has not been described in AT/RTs, is of great interest in view of the nature of rhabdoid cells.

Intraventricular chordoid meningioma presenting with Castleman disease due to overproduction of interleukin-6

✓ A rare case of chordoid meningioma in the lateral ventricle observed in an adult is reported. The first clinical manifestation of the disease was a prolonged fever of unknown origin. Abnormalities in the patient's blood chemistry, principally polyclonal hypergammaglobulinemia (immunoglobulin [Ig]G, IgA, and markedly IgE) and an elevated serum level of C-reactive protein, were associated with the disease. The tumor was histologically confirmed to be a chordoid meningioma, and its surgical removal resulted in complete resolution of the patient's symptoms. By combining reverse transcription—polymerase chain reaction and immunohistochemical analysis, it may be shown that cytokine production, including that of interleukin (IL)-6, IL-1β, and vascular endothelial growth factor, plays a role in the pathogenesis of chordoid meningioma associated with Castleman syndrome.

[Gene therapy for brain tumors--present conditions and prospects]

Malignant brain tumors, particularly malignant gliomas, are one of the most difficult diseases to cure. Gene therapy for malignant gliomas has been clinically applied since 1992 as an advanced therapeutic strategy for a breakthrough. Suicide gene therapy with retroviral or adenoviral vectors was the mainstream at first. Now protocols of immune gene therapy and oncolytic therapy with replication competent virus only within tumor cells are increasing in number. So far, it would be difficult to hold that gene therapy for malignant brain tumors has shown a remarkable therapeutic effect. However, gene therapy would be a more powerful tool for exploration of therapeutic genes on the basis of molecule antitumor mechanisms, improvement of gene expression systems and amelioration of gene delivery methods. Besides in addition, cooperation among industry, administration and university is necessary for promotion of basic and clinical research as well as the development of gene therapy to overcome malignant brain tumors.

Growth inhibition of human pancreatic cancer cells by human interferon-beta gene combined with gemcitabine

We examined the anti-tumor effect of cationic multilamellar liposome containing human IFN-beta (huIFN-beta) gene against cultured human pancreatic cancer cells. We also evaluated the combined effect of huIFN-beta gene entrapped in liposomes and gemcitabine. Furthermore, we examined the anti-tumor mechanisms of the therapy, with emphasis on the Ras-related signal pathway. Three human pancreatic cancer cell lines (AsPc-1, MIAPaCa-2, and PANC-1) were used in this study. The growth inhibition together with the therapy were evaluated by WST-1 assay; the production of huIFN-beta protein was measured by ELISA; the cell cycle and apoptosis were analyzed using a FACScan flow cytometer; the protein levels of Son of sevenless (SOS-1) and Ras-GAP were measured by Western blotting; and the activation of Ras-GTP was evaluated by the immunoprecipitation method. As a result, we found that huIFN-beta gene entrapped in liposomes demonstrated a strong anti-tumor effect against human pancreatic cancer cells. The treatment that combined huIFN-beta gene entrapped in liposomes and gemcitabine was more effective than each treatment alone. Although gemcitabine remarkably reduced the level of SOS-1, the above combined therapy reduced the level of SOS-1 even more significantly. Both huIFN-beta gene entrapped in liposomes and the com-bination of huIFN-beta gene entrapped in liposomes and gemcitabine increased the level of Ras-GAP, and decreased the activity of Ras-GTP. These results suggest that this combination therapy can induce strong anti-tumor activity against human pancreatic cancer cells through the regulation of the Ras-related signal pathway.

Human gene therapy for malignant gliomas (glioblastoma multiforme and anaplastic astrocytoma) by in vivo transduction with human interferon beta gene using cationic liposomes

Transfer of interferon beta gene via cationic liposomes has been found to induce regression of experimental glioma. We performed a pilot clinical trial of safety and effectiveness of this interferon beta gene therapy in five patients with malignant glioma (glioblastoma multiforme or anaplastic astrocytoma). Transgene expression and antitumor activity were detected in four patients. Two patients showed a partial response (>50% tumor reduction) and two others had stable disease 10 weeks after beginning therapy. One patient could not be evaluated because of previous treatment with gamma-knife therapy. This study suggests the feasibility and safety of interferon beta gene therapy, which may become an important treatment option for patients with malignant glioma.

Vaccination with tumor cell lysate-pulsed dendritic cells augments the effect ofIFN-? gene therapy for malignant glioma in an experimental mouse intracranial glioma

Interferon-beta (IFN-beta) has been used as an antitumor drug against human glioma, melanoma and medulloblastoma since the 1980s. Recently, we developed a new gene therapy using the IFN-beta gene against malignant gliomas and then began clinical trials in 2000. Since stimulation of immune system was one mechanism of antitumor effect induced by IFN-beta gene therapy, we hypothesized that combination of IFN-beta gene therapy with immunotherapy might increase its effectiveness. In the present study, we tested whether combination therapy with IFN-beta gene therapy and immunotherapy using tumor cell lysate-pulsed dendritic cells (DCs) would increase the efficacy of IFN-beta gene therapy. In an experimental mouse intracranial glioma (GL261), which cannot be cured by either IFN-beta gene therapy or DC immunotherapy alone, IFN-beta gene therapy following DC immunotherapy resulted in a significant prolongation in survival of the mice. Moreover, when this combination was performed twice, 50% of treated mice survived longer than 100 days. Considering these results, this combination therapy may be one promising candidate for glioma therapy in the near future.

Effective induction of antiglioma cytotoxic T cells by coadministration of interferon-beta gene vector and dendritic cells

As type I interferons (IFNs) enhance the stimulatory activity of dendritic cells (DCs), we hypothesized that transfection of glioma cells with the IFN-beta gene in the presence of DCs would provide particularly effective antitumor activity by both facilitating apoptosis of glioma cells and presenting the resulting glioma antigens to T cell by DCs, thereby inducing specific T-cell responses against glioma cells. A mouse glioma cell line 203G was first transfected with cDNA encoding IFN-beta using cationic liposomes, then cocultured with syngeneic bone marrow-derived DCs and naïve splenic T cells. The 203G cells were almost completely killed following 96-hour coculture with DCs and T cells, and strong tumor-specific cytotoxic T-lymphocyte (CTL) activity accompanied by high level interleukin (IL)-12 and IFN-gamma production was observed in culture. In addition, omission of either IFN-beta gene delivery, DCs or T cells from the coculture completely abrogated the induction of the CTL activity, suggesting that the combination of these components was required to elicit an optimal effect. On the basis of these in vitro data, syngeneic animals bearing subcutaneous 203G tumors received intratumoral injections of IFN-beta gene and DCs. Suppression of the tumor growth by this combinational therapy was superior to treatment with DC or IFN-beta gene solely. This combination may constitute a new therapeutic strategy to induce potent antiglioma immune responses.

Radioimmunoscintigraphy of intracranial glioma xenograft with a technetium-99m-labeled mouse monoclonal antibody specifically recognizing type III mutant epidermal growth factor receptor

The type III mutant epidermal growth factor receptor (EGFR) is expressed on the cell surface of a subset of glioma, but not of normal tissues. In this study, we investigated the in vivo kinetics of 3C10 mouse monoclonal antibody (mAb), specifically recognizing the type III mutant EGFR (EGFRvIII), using athymic nude mice bearing the intracranial glioma xenograft overexpressing the EGFRvIII. Human glioma cell line, U87MG, expressing the wild type EGFR and the transfectant, named U87MG x deltaEGFR, expressing the EGFRvIII, were transplanted subcutaneously or intracranially to nude mice. 3C10 mAb labeled with a technetium-99m (99mTc) was intravenously injected into these nude mice and then the mice were sacrificed at 24 h later, and the 99mTc-uptake by xenografts and major normal organs was measured to determine the biodistribution of mAb. Furthermore, at 3, 6 and 24 h after injection of 99mTc-labeled 3C10 mAb, whole-body scintigraphy was obtained with a gamma camera to localize the tumor site. 3C10 mAb significantly accumulated to U87MG x deltaEGFR xenografts transplanted subcutaneously or intracranially in nude mice, showing high tumor-to-blood ratio of 10.30 and 4.01, respectively. In contrast, uptake of control antibody in the intracranial tumor was as low as 0.43. In scintigrams, intracranially transplanted U87MG x deltaEGFR xenografts were detectable at 3 h after injection of 99mTc-labeled 3C10 mAb. These results suggest that intravenously injected 3C10 mAb specifically accumulated to the subcutaneous or intracranial glioma xenograft expressing the EGFRvIII and 3C10 mAb is a potential diagnostic and therapeutic agent for patients with gliomas expressing the EGFRvIII.

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

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

Antitumor effect of an adeno-associated virus vector containing the human interferon-beta gene on experimental intracranial human glioma

We constructed an adeno-associated virus (AAV) vector containing the human interferon-beta (HuIFN-b ) gene (AAV-IFN-beta) and investigated its antitumor effect against human glioma cells (U251-SP) inoculated into the brain of nude mice. Prior to this, we examined human glioma cells transduced with AAV-IFN-beta using video-enhanced contrast differential interference contrast (VEC-DIC) microscopy. Infection of AAV-IFN-beta induced apoptosis and secondary necrosis in human glioma cells. In in vivo experiments, we confirmed production of HuIFN-beta and induction of heat-shock protein (HSP) in glioma cells transduced with AAV-IFN-beta. Growth of the experimental gliomas was completely inhibited by six injections of AAV-IFN-beta, starting 7 days after transplantation of glioma cells. In addition, the survival of mice treated with AAV-IFN-beta was remarkably prolonged. These results indicate that AAV-IFN-beta induces apoptosis of glioma cells and has a strong antitumor effect in this experimental glioma model.

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

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

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

OBJECT

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

METHODS

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

CONCLUSIONS

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

Japanese patients not seeking kidney transplants

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

[Intracardiac floating thrombi in patients with acute pulmonary thromboembolism]

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