Vegetation as a key driver of the distribution of microbial generalists that in turn shapes the overall microbial community structure in the low Arctic tundra

Understanding the variability of microbial niches and their interaction with abiotic and biotic factors in the Arctic can provide valuable insights into microbial adaptations to extreme environments. This study investigates the structure and diversity of soil bacterial communities obtained from sites with varying vegetation coverage and soil biogeochemical properties in the low Arctic tundra and explores how bacteria interact under different environmental parameters. Our findings reveal differences in bacterial composition and abundance among three bacterial niche breadths (specialists, common taxa, and generalists). Co-occurrence network analysis revealed Rhizobiales and Ktedonobacterales as keystone taxa that connect and support other microbes in the habitat. Low-elevation indicators, such as vascular plants and moisture content, were correlated with two out of three generalist modular hubs and were linked to a large proportion of generalists' distribution (18%). Structural equation modeling revealed that generalists' distribution, which influenced the remaining microbial communities, was mainly regulated by vegetation coverage as well as other abiotic and biotic factors. These results suggest that elevation-dependent environmental factors directly influence microbial community structure and module formation through the regulation of generalists' distribution. Furthermore, the distribution of generalists was mainly affected by macroenvironment filtering, whereas the distribution of specialists was mainly affected by microenvironment filtering (species-engineered microbial niche construction). In summary, our findings highlight the strong top-down control exerted by vegetation on generalists' distribution, which in turn shapes the overall microbial community structure in the low Arctic tundra.

Clinical outcomes following total en bloc spondylectomy for spinal metastases from lung cancer

BACKGROUND

The current guidelines for the treatment of non-small cell lung cancer encourage local curative treatment for selected patients with oligometastases. This study evaluated the surgical results of total en bloc spondylectomy (TES) for isolated spinal metastases originating from lung cancer in carefully selected patients.

METHODS

We retrospectively reviewed 14 patients (7 men and 7 women) who underwent TES for spinal metastases originating from lung cancer between 2000 and 2017. The primary outcome measure was the postoperative overall survival time. The histological types included adenocarcinoma (n = 12), pleomorphic carcinoma (n = 1), and small cell lung carcinoma (SCLC) (n = 1 patient). We assessed postoperative survival using Kaplan-Meier analysis and the log-rank test.

RESULTS

The median postoperative survival time was 83.0 months (6-162 months) in 13 patients with non-small cell lung carcinoma (NSCLC) and 6 months in 1 patient with SCLC. The 3-, 5-, and 10-year overall survival rates in patients with NSCLC were 61.5%, 53.8%, and 15.4%, respectively. Poor postoperative performance status (PS) and Frankel grade, and preoperative irradiation to the vertebrae to be resected were significantly associated with short-term survival after TES in patients with NSCLC (p < 0.05).

CONCLUSIONS

The surgical results of TES for spinal metastases of lung cancer were relatively favorable among carefully selected patients. TES may be indicated for spinal metastases of lung cancer in patients with controlled primary lung cancer, NSCLC histology, prospect of good postoperative PS, and preferably no irradiation to the target vertebrae.

Atlantoaxial Stabilization Using C1 Lateral Mass and C2 Pedicle/Translaminar Screw Fixation by Intraoperative C1- and C2-Direct-Captured Navigation with Preoperative Computed Tomography Images

In C1-C2 posterior fixation, the C1 lateral mass and C2 pedicle/translaminar screw insertion under spine navigation have been used frequently. To avoid the risk of neurovascular damage in atlantoaxial stabilization, we assessed the safety and effectiveness of a preoperative computed tomography (CT) image-based navigation system with intraoperative independent C1 and C2 vertebral registration. It is ideal when a reference frame can be linked directly to the C1 posterior arch for C1-direct-captured navigation, but there is a mechanical challenge. A new spine clamp-tracker system was implemented recently, which allows reliable C1- and C2- direct-captured navigation in nine patients with traumatic C2 fractures. In this way, there was no misalignment of C1-C2 screws. C1 lateral mass screws were used except for one case, and translaminar screws were primarily used as an anchor for C2. The C1 lateral mass screw locations, which are 19 mm laterally from the C1 posterior arch's center, are taken to be constant. However, there is one unusual circumstance in which using a C1 laminar hook instead of a C1 lateral mass screw appears to be a beneficial substitute. The increase of surgical accuracy for posterior C1-C2 screw fixation without cost constraints is significantly facilitated by intraoperative C1- and C2-direct-captured navigation with preoperative computed CT images.

Discrepancies of fungi and plants in the pattern of beta-diversity with environmental gradient imply a comprehensive community assembly rule

Beta-diversity partitioning has shown that the nestedness component is developed with environmental stress in a variety of taxa. However, soil fungal community may maintain its turnover components in contrast to the development of plants' nestedness component, and the potential causes remain unclear. To investigate the process of species turnover of soil fungi along a stress gradient in the Arctic, we divided species turnover component into sub-components: βsim_hete and βsim_homo representing species turnover with and without a change in the guilds, respectively. The results indicate that fungal communities maintain their turnover components, unlike plant communities; however, their βsim_hete increased under stressful conditions. Additionally, GDM analysis showed that βsim_hete was mainly explained by stress gradient and plant nestedness, suggesting that the functionality of soil fungi was ecologically filtered by environmental stress and plant community structure. The discordant trend of beta-diversity values between plant and fungi (i.e. development of plant nestedness and maintenance of fungal turnover) is possibly not caused by different assembly rules working in parallel on the two taxa, but according to an ecological rule that reflects plant-fungal interaction.

Validation and comparison of trunk muscle activities in male participants during exercise using an innovative device and abdominal bracing maneuvers

BACKGROUND

Abdominal bracing is effective in strengthening the trunk muscles; however, assessing performance can be challenging. We created a device for performing abdominal trunk muscle exercises. The effectiveness of this device has not yet been evaluated or comparedOBJECTIVE: We aimed to quantify muscle activity levels during exercise using our innovative device and to compare them with muscle activation during abdominal bracing maneuvers.

METHODS

This study included 10 men who performed abdominal bracing exercises and exercises using our device. We measured surface electromyogram (EMG) activities of the rectus abdominis (RA), external oblique, internal oblique (IO), and erector spinae (ES) muscles in each of the exercises. The EMG data were normalized to those recorded during maximal voluntary contraction (%EMGmax).

RESULTS

During the bracing exercise, the %EMGmax of IO was significantly higher than that of RA and ES (p< 0.05), whereas during the exercises using the device, the %EMGmax of IO was significantly higher than that of ES (p< 0.05). No significant difference was observed in the %EMGmax of any muscle between bracing exercises and the exercises using the device (p= 0.13-0.95).

CONCLUSIONS

The use of our innovative device results in comparable activation to that observed during abdominal bracing.

Functionally explicit partitioning of plant β-diversity reveal soil fungal assembly in the subarctic tundra

Metabarcoding technologies for soil fungal DNA pools have enabled to capture the diversity of fungal community and the agreement of their β-diversity with plant β-diversity. However, processes underlying the synchrony of the aboveground-belowground biodiversity is still unclear. By using partitioning methods for plant β-diversity, this study explored the process driving synchrony in tundra ecosystems, in which drastic vegetation shifts are observed with climate warming. Our methods based on Baselga's partitioning enabled the division of plant β-diversity into two phenomena and three functional components. Correlation of fungal β-diversity with the components of plant β-diversity showed that the spatial replacement of fungi was promoted by plant species turnover, in particular, plant species turnover with functional exchange. In addition, spatial variety of graminoid or forbs species, rather than shrubs, enhanced fungal β-diversity. These results suggest the importance of small-scale factors such as plant-fungal interactions or local environments modified by plants for the fungal community assemblage. The process-based understanding of community dynamics of plants and fungi allows us to predict the ongoing shrub encroachment in the Arctic region, which could weaken the aboveground-belowground synchrony.

Immobilizing Bactericides on Dental Resins via Electron Beam Irradiation

Polymerizable bactericides, such as quaternary ammonium compound-based monomers, have been intensively studied as candidates for immobilizing antibacterial components on dental resin. However, they predominantly exhibit a bacteriostatic behavior, rather than bactericidal, as the immobilized components are left with insufficient molecular movement to disrupt the bacterial surface structure through contact-mediated action. In this study, we developed a novel strategy to increase the density of the immobilized bactericide and enhance its antibacterial/antibiofilm properties by combining a surface-grafting technique with electron beam irradiation. A solution of the quaternary ammonium compound-based monomer, 12-methacryloyloxydodecylpyridinium bromide (MDPB), was coated on polymethyl methacrylate (PMMA) resin specimens at the concentrations of 30, 50, and 80 wt%. The coated resins were subsequently exposed to 10 MeV of electron beam irradiation at 50 and 100 kGy, followed by thermal stabilization at 60 °C. The antibacterial effect was evaluated by inoculating a Streptococcus mutans suspension on the coated PMMA resin samples, which exhibited bactericidal effects even after 28 d of aging (P < 0.05, Tukey's honestly significant difference test). Transmission electron microscopy and bacteriolytic activity evaluation revealed that the S. mutans cells had sustained membrane depolarization. Furthermore, the antibiofilm effects against S. mutans and bacteria collected from human saliva were assessed. The thickness and the percentage of membrane-intact cells of the S. mutans and multispecies biofilms formed on the MDPB-immobilized surfaces were significantly lower than the uncoated PMMA specimens, even after 28-d aging (P < 0.05, Tukey's honestly significant difference test). Thus, the immobilization of antibacterial MDPB via electron beam irradiation induced rapid membrane depolarization, increasing membrane permeability and eventually causing cell death. Our strategy substantially enhances the antibacterial properties of the resinous materials and inhibits biofilm formation, therefore demonstrating significant potential for preventing infectious diseases in the oral environment.

Interspecific variation in mortality and growth and changes in their relationship with size class in an old-growth temperate forest

Understanding trade-offs between demographic parameters is crucial when investigating community assembly rules in high-diversity forests. To this end, we estimated mortality and growth parameters, and correlations among them, across entire size classes for 17 tree species (Betula, Carpinus, Fagus, Quercus, Castanea, Acer, Cerasus, Swida, Kalopanax, and Styrax) using a dataset over 18 years obtained from an old-growth forest in Japan.Size classes were represented by 12 categories determined by age, height, and diameter at breast height (DBH) from new seedlings to stems of DBH >85 cm. We derived the annual mortality and growth for each species and class using estimates of transition probabilities between classes. Trade-offs or synergies in growth and survival among species per size class were analyzed with and without the inclusion of phylogenetic relationships.Annual mortality showed U-shaped patterns across size classes for species that could potentially reach a DBH ≥55 cm: 0.2-0.98 for seedlings, 0.002-0.01 at DBH 35-45 cm, and ca. 0.01 at DBH ≥55 cm. Other species demonstrated monotonically decreasing mortality toward specific maximum size classes. When phylogenetic information was included in analyses, the correlations between survival and growth changed across size classes were significant for some classes: As an overall tendency, synergy was observed in growth and survival for seedling to sapling classes, trade-offs for juvenile to DBH 15-25 cm classes, and synergy again for larger classes. When phylogenetic information was not included, a significant trade-off was observed only at DBH 5-15 cm. Synthesis. Trade-offs at intermediate classes imply differentiation in demographic characteristics related to life history strategies. However, evolutionarily obtained demographic characteristics are not substantial drivers of niche differentiation in the study area. The polylemma of mortality, growth, and other parameters such as the onset of reproduction may also be important factors driving species-specific demographic traits.

A randomized phase II/III trial of conventional paclitaxel and carboplatin with or without bevacizumab versus dose-dense paclitaxel and carboplatin with or without bevacizumab, in stage IVB, recurrent, or persistent cervical carcinoma (JCOG1311): Primary analysis

OBJECTIVE

To assess the efficacy and safety of dose-dense weekly paclitaxel plus carboplatin (ddTC) with or without bevacizumab compared to conventional, tri-weekly paclitaxel plus carboplatin (cTC) with or without bevacizumab, in metastatic or recurrent cervical carcinoma not amenable to curative local therapy.

METHODS

Patients were randomly assigned to either the cTC or ddTC arm. The cTC regimen was paclitaxel 175 mg/m² and carboplatin at an area under the curve (AUC) of 5 on day 1. The ddTC regimen was paclitaxel 80 mg/m² on day 1, 8, 15 and carboplatin at AUC of 5 on day 1. Both cTC and ddTC treatments were repeated every 3 weeks for up to 9 cycles. After bevacizumab was approved in Japan, patients in both arms received bevacizumab 15 mg/kg if not contraindicated. The primary endpoint of phase II part was response rate (RR). If the RR of ddTC+bevacizumab was found to be at least 5% better than to cTC + bevacizumab, the study would proceed to phase III part, which had overall survival as its primary endpoint.

CLINICAL TRIAL INFORMATION

jRCTs031180007.

RESULTS

In total, 122 patients were randomly assigned to either the cTC arm (cTC + bevacizumab: 32; cTC:29) or the ddTC arm (ddTC+bevacizumab: 30; ddTC:31). The RR for patients on cTC + bevacizumab was 67.9%, and for patients on ddTC+bevacizumab 60.7%, cTC: 55.2%, and ddTC: 50.0%.

CONCLUSIONS

The study did not meet the primary endpoint of phase II portion. Dose-dense, weekly paclitaxel plus carboplatin is not promising for metastatic or recurrent cervical carcinoma.

Abscopal Effect of Frozen Autograft Reconstruction Combined with an Immune Checkpoint Inhibitor Analyzed Using a Metastatic Bone Tumor Model

We evaluated the abscopal effect of re-implantation of liquid nitrogen-treated tumor-bearing bone grafts and the synergistic effect of anti-PD-1 (programmed death-1) therapy using a bone metastasis model, created by injecting MMT-060562 cells into the bilateral tibiae of 6-8-week-old female C3H mice. After 2 weeks, the lateral tumors were treated by excision, cryotreatment using liquid nitrogen, excision with anti-PD-1 treatment, and cryotreatment with anti-PD-1 treatment. Anti-mouse PD-1 4H2 was injected on days 1, 6, 12, and 18 post-treatment. The mice were euthanized after 3 weeks; the abscopal effect was evaluated by focusing on growth inhibition of the abscopal tumor. The re-implantation of frozen autografts significantly inhibited the growth of the remaining abscopal tumors. However, a more potent abscopal effect was observed in the anti-PD-1 antibody group. The number of CD8+ T cells infiltrating the abscopal tumor and tumor-specific interferon-γ (IFN-γ)-producing spleen cells increased in the liquid nitrogen-treated group compared with those in the excision group, with no significant difference. The number was significantly higher in the anti-PD-1 antibody-treated group than in the non-treated group. Overall, re-implantation of tumor-bearing frozen autograft has an abscopal effect on abscopal tumor growth, although re-implantation of liquid nitrogen-treated bone grafts did not induce a strong T-cell response or tumor-suppressive effect.

Radiation Disrupts the Protective Function of the Spinal Meninges in a Mouse Model of Tumor-induced Spinal Cord Compression

BACKGROUND

Recent advances in multidisciplinary treatments for various cancers have extended the survival period of patients with spinal metastases. Radiotherapy has been widely used to treat spinal metastases; nevertheless, long-term survivors sometimes undergo more surgical intervention after radiotherapy because of local tumor relapse. Generally, intradural invasion of a spinal tumor seldom occurs because the dura mater serves as a tissue barrier against tumor infiltration. However, after radiation exposure, some spinal tumors invade the dura mater, resulting in leptomeningeal dissemination, intraoperative dural injury, or postoperative local recurrence. The mechanisms of how radiation might affect the dura have not been well-studied.

QUESTIONS/PURPOSES

To investigate how radiation affects the spinal meninges, we asked: (1) What is the effect of irradiation on the meningeal barrier's ability to protect against carcinoma infiltration? (2) What is the effect of irradiation on the meningeal barrier's ability to protect against sarcoma infiltration? (3) What is the effect of irradiation on dural microstructure observed by scanning electron microscopy (SEM)? (4) What is the effect of irradiation on dural microstructure observed by transmission electron microscopy (TEM)?

METHODS

Eighty-four 10-week-old female ddY mice were randomly divided into eight groups: mouse mammary tumor (MMT) implantation 6 weeks after 0-Gy irradiation (nonirradiation) (n = 11), MMT implantation 6 weeks after 20-Gy irradiation (n = 10), MMT implantation 12 weeks after nonirradiation (n = 10), MMT implantation 12 weeks after 20-Gy irradiation (n = 11), mouse osteosarcoma (LM8) implantation 6 weeks after nonirradiation (n = 11), LM8 implantation 6 weeks after 20-Gy irradiation (n = 11), LM8 implantation 12 weeks after nonirradiation (n = 10), and LM8 implantation 12 weeks after 20-Gy irradiation (n = 10); female mice were used for a mammary tumor metastasis model and ddY mice, a closed-colony mice with genetic diversity, were selected to represent interhuman diversity. Mice in each group underwent surgery to generate a tumor-induced spinal cord compression model at either 6 weeks or 12 weeks after irradiation to assess changes in the meningeal barrier's ability to protect against tumor infiltration. During surgery, the mice were implanted with MMT (representative of a carcinoma) or LM8 tumor. When the mice became paraplegic because of spinal cord compression by the growing implanted tumor, they were euthanized and evaluated histologically. Four mice died from anesthesia and 10 mice per group were euthanized (MMT-implanted groups: MMT implantation occurred 6 weeks after nonirradiation [n = 10], 6 weeks after irradiation [n = 10], 12 weeks after nonirradiation [n = 10], and 12 weeks after irradiation [n = 10]; LM8-implanted groups: LM8 implantation performed 6 weeks after nonirradiation [n = 10], 6 weeks after irradiation [n = 10], 12 weeks after nonirradiation [n = 10], and 12 weeks after irradiation [n = 10]); 80 mice were evaluated. The spines of the euthanized mice were harvested; hematoxylin and eosin staining and Masson's trichrome staining slides were prepared for histologic assessment of each specimen. In the histologic assessment, intradural invasion of the implanted tumor was graded in each group by three observers blinded to the type of tumor, presence of irradiation, and the timing of the surgery. Grade 0 was defined as no intradural invasion with intact dura mater, Grade 1 was defined as intradural invasion with linear dural continuity, and Grade 2 was defined as intradural invasion with disruption of the dural continuity. Additionally, we euthanized 12 mice for a microstructural analysis of dura mater changes by two observers blinded to the presence of irradiation. Six mice (three mice in the 12 weeks after nonirradiation group and three mice in the 12 weeks after 20-Gy irradiation group) were quantitatively analyzed for defects on the dural surface with SEM. The other six mice (three mice in the 12 weeks after nonirradiation group and three mice in the 12 weeks after 20-Gy irradiation group) were analyzed for layer structure of collagen fibers constituting dura mater by TEM. In the SEM assessment, the number and size of defects on the dural surface on images (200 μm × 300 μm) at low magnification (× 2680) were evaluated. A total of 12 images (two per mouse) were evaluated for this assessment. The days from surgery to paraplegia were compared between each of the tumor groups using the Kruskal-Wallis test. The scores of intradural tumor invasion grades and the number of defects on dural surface per SEM image were compared between irradiation group and nonirradiation group using the Mann-Whitney U test. Interobserver reliabilities of assessing intradural tumor invasion grades and the number of dural defects on the dural surface were analyzed using Fleiss'κ coefficient. P values < 0.05 were considered statistically significant.

RESULTS

There was no difference in the median (range) time to paraplegia among the MMT implantation 6 weeks after nonirradiation group, the 6 weeks after irradiation group, the 12 weeks after nonirradiation group, and the 12 weeks after irradiation group (16 days [14 to 17] versus 14 days [12 to 18] versus 16 days [14 to 17] versus 14 days [12 to 15]; χ2 = 4.7; p = 0.19). There was also no difference in the intradural invasion score between the MMT implantation 6 weeks after irradiation group and the 6 weeks after nonirradiation group (8 of 10 Grade 0 and 2 of 10 Grade 1 versus 10 of 10 Grade 0; p = 0.17). On the other hand, there was a higher intradural invasion score in the MMT implantation 12 weeks after irradiation group than the 12 weeks after nonirradiation group (5 of 10 Grade 0, 3 of 10 Grade 1 and 2 of 10 Grade 2 versus 10 of 10 Grade 0; p = 0.02). Interobserver reliability of assessing intradural tumor invasion grades in the MMT-implanted group was 0.94. There was no difference in the median (range) time to paraplegia among in the LM8 implantation 6 weeks after nonirradiation group, the 6 weeks after irradiation group, the 12 weeks after nonirradiation group, and the 12 weeks after irradiation group (12 days [9 to 13] versus 10 days [8 to 13] versus 11 days [8 to 13] versus 9 days [6 to 12]; χ2 = 2.4; p = 0.50). There was also no difference in the intradural invasion score between the LM8 implantation 6 weeks after irradiation group and the 6 weeks after nonirradiation group (7 of 10 Grade 0, 1 of 10 Grade 1 and 2 of 10 Grade 2 versus 8 of 10 Grade 0 and 2 of 10 Grade 1; p = 0.51), whereas there was a higher intradural invasion score in the LM8 implantation 12 weeks after irradiation group than the 12 weeks after nonirradiation group (3 of 10 Grade 0, 3 of 10 Grade 1 and 4 of 10 Grade 2 versus 8 of 10 Grade 0 and 2 of 10 Grade 1; p = 0.04). Interobserver reliability of assessing intradural tumor invasion grades in the LM8-implanted group was 0.93. In the microstructural analysis of the dura mater using SEM, irradiated mice had small defects on the dural surface at low magnification and degeneration of collagen fibers at high magnification. The median (range) number of defects on the dural surface per image in the irradiated mice was larger than that of nonirradiated mice (2 [1 to 3] versus 0; difference of medians, 2/image; p = 0.002) and the median size of defects was 60 μm (30 to 80). Interobserver reliability of assessing number of defects on the dural surface was 1.00. TEM revealed that nonirradiated mice demonstrated well-organized, multilayer structures, while irradiated mice demonstrated irregularly layered structures at low magnification. At high magnification, well-ordered cross-sections of collagen fibers were observed in the nonirradiated mice. However, disordered alignment of collagen fibers was observed in irradiated mice.

CONCLUSION

Intradural tumor invasion and disruptions of the dural microstructure were observed in the meninges of mice after irradiation, indicating radiation-induced disruption of the meningeal barrier.

CLINICAL RELEVANCE

We conclude that in this form of delivery, radiation is associated with disruption of the dural meningeal barrier, indicating a need to consider methods to avoid or limit Postradiation tumor relapse and spinal cord compression when treating spinal metastases so that patients do not experience intradural tumor invasion. Surgeons should be aware of the potential for intradural tumor invasion when they perform post-irradiation spinal surgery to minimize the risks for intraoperative dural injury and spinal cord injury. Further research in patients with irradiated spinal metastases is necessary to confirm that the same findings are observed in humans and to seek irradiation methods that prevent or minimize the disruption of meningeal barrier function.

Propensity score-matched analysis of systemic chemotherapy versus salvage hysterectomy for persistent cervical cancer after definitive radiotherapy/concurrent chemoradiotherapy

BACKGROUND

The aim of the current study was to evaluate oncologic outcomes of patients who were treated with salvage hysterectomy (HT), compared to systemic chemotherapy (CT) for persistent cervical cancer after definitive radiotherapy (RT)/ concurrent chemoradiotherapy (CCRT).

METHODS

Patients with persistent cervical cancer treated with definitive RT/CCRT at 35 institutions from 2005 to 2014 were reviewed retrospectively (n = 317). Those who underwent a HT for persistent cervical cancer after definitive RT/CCRT were matched with propensity scores for patients who underwent systemic CT. Oncologic outcomes between the two groups using a propensity score matched-cohort analysis were compared.

RESULTS

A total of 142 patients with persistent cervical cancer after definitive RT/CCRT were included after matching (HT: 71, systemic CT: 71). All background factors between HT and CT groups were well balanced. Median overall survival was 3.8 and 1.5 years in the HT and CT groups, respectively (p = 0.00193, hazards ratio [HR] 0.41, 95% confidence interval [CI] 0.23-0.73), Increasing residual tumor size was significantly associated with a high incomplete resection rate (p = 0.016, Odds Ratio 1.11, 95%CI 1.02-1.22). Severe late adverse events occurred in 7 patients (9.9%) in the HT cohort.

CONCLUSION

The current study demonstrated that, when compared to systemic CT, the adoption of salvage HT for patients with persistent cervical cancer after definitive RT/CCRT reduced mortality rate by about 60%. This indicates that salvage HT could be curative treatment for those patients. Further prospective clinical trials with regard to salvage HT after RT/CCRT are warranted.

Efficacy and Safety of Abdominal Trunk Muscle Strengthening Using an Innovative Device in Elderly Patients With Chronic Low Back Pain: A Pilot Study

Objective

To examine the efficacy and safety of an innovative, device-driven abdominal trunk muscle strengthening program, with the ability to measure muscle strength, to treat chronic low back pain (LBP) in elderly participants.

Methods

Seven women with non-specific chronic LBP, lasting at least 3 months, were enrolled and treated with the prescribed exercise regimen. Patients participated in a 12-week device-driven exercise program which included abdominal trunk muscle strengthening and 4 types of stretches for the trunk and lower extremities. Primary outcomes were adverse events associated with the exercise program, improvement in abdominal trunk muscle strength, as measured by the device, and improvement in the numerical rating scale (NRS) scores of LBP with the exercise. Secondary outcomes were improvement in the Roland-Morris Disability Questionnaire (RDQ) score and the results of the locomotive syndrome risk test, including the stand-up and two-step tests.

Results

There were no reports of increased back pain or new-onset abdominal pain or discomfort during or after the device-driven exercise program. The mean abdominal trunk muscle strength, NRS, RDQ scores, and the stand-up and two-step test scores were significantly improved at the end of the trial compared to baseline.

Conclusion

No participants experienced adverse events during the 12-week strengthening program, which involved the use of our device and stretching, indicating the program was safe. Further, the program significantly improved various measures of LBP and physical function in elderly participants.

A randomized phase II/III trial of conventional paclitaxel and carboplatin with/without bevacizumab versus dose-dense paclitaxel and carboplatin with/without bevacizumab, in stage IVB, recurrent, or persistent cervical carcinoma (JCOG1311): Results of the phase II part

6027

Background: A randomized controlled trial was conducted to assess the efficacy and safety of dose-dense, weekly paclitaxel plus carboplatin (ddTC) with or without bevacizumab (Bmab) compared to conventional, tri-weekly paclitaxel plus carboplatin (cTC) with or without Bmab, in metastatic or recurrent cervical carcinoma not amenable to curative treatments with local therapy. Methods: Patients were randomly assigned to either a cTC or a ddTC regimen. After Bmab was approved in Japan (in May 2016) the protocol was amended, and patients on both arms received Bmab if not contraindicated. The cTC was paclitaxel 175 mg/m2 intravenously (IV) for 3 h on day 1 followed by carboplatin at an area under the curve of five IV for 1 h on day 1. The ddTC was paclitaxel 80 mg/m2 IV for 1 h on day 1 followed by carboplatin at an area under the curve of five IV for 1 h on day 1 and paclitaxel 80 mg/m2 IV for 1 h on day 8 and day 15. Both cTC and ddTC treatments were repeated every three weeks, for up to nine cycles. Bmab 15 mg/kg IV was repeated until progression or unacceptable toxicity. The primary endpoint of phase II was the response rate (RR) in patients with measurable lesion, who had received Bmab. If the RR of the ddTC + Bmab arm was greater than that of the cTC + Bmab arm for more than 5%, the study would proceed to phase III, which had overall survival (OS) as its primary endpoint. The planned sample size in the phase II part was 56 to select the ddTC arm with a probability of at least 75% if the difference of RR was 15% or more (45% vs. 60%). Results: Patient accrual started in October 2015. It was suspended in May 2019 because the number of Bmab-treated patients with measurable lesions reached 56. In total, 122 patients were enrolled and randomly assigned to either the cTC arm (cTC: 29 patients; cTC + Bmab: 32 patients) or the ddTC arm (ddTC: 30 patients; ddTC + Bmab: 31 patients). The primary analysis of the phase II part was conducted in November 2019. The RRs of each regimen were 67.9% [95% CI, 47.7-84.1] (19/28, cTC + Bmab), 60.7% [40.6-78.5] (17/28, ddTC + Bmab), 55.2% [35.7-73.6] (16/29, cTC), and 50.0% [29.9-70.1] (13/26, ddTC). Conclusions: The study did not meet the primary endpoint of phase II. Dose-dense, weekly paclitaxel plus carboplatin is not promising for metastatic or recurrent cervical carcinoma. Clinical trial information: jRCTs031180007.

[A Case of Bilateral Trigeminal Neuralgia and the Possible Onset Mechanisms Based on the Operative Findings]

Several cases of bilateral trigeminal neuralgia(TN)have been reported;however, the possible onset mechanism has rarely been discussed. We encountered a case of bilateral TN occurring in two stages. A 64-year-old woman presented with left TN. Magnetic resonance imaging showed the transverse pontine vein adhering to the left trigeminal root and superior cerebellar artery adhering to the right trigeminal root;however, no symptoms were noted. Immediately after microvascular decompression(MVD)on the left side, TN disappeared completely. However, 2 years postoperatively, the patient presented with right TN. The second MVD surgery revealed that the right cerebellar surface severely adhered to the dura mater, particularly under the surface of the tentorium. The arachnoid membrane at the cerebellopontine angle was slightly adhered. The patient was completely free from pain after the second MVD. The intraoperative findings suggested that the brain stem may have shifted and the cerebellopontine cistern may have narrowed because of cerebellar adhesion to the surrounding structures and arachnoid adhesion. We speculate that such structural changes in the posterior fossa after the first operation may have caused the asymptomatic vascular adhesion to change into the symptomatic offending adhesion over time.

Correlation between osteoporotic vertebral fracture and abdominal trunk muscle strength in middle-aged and older women

We investigated the correlation between abdominal trunk muscle strength and spinal deformities in middle-aged and older women. The results indicated that abdominal trunk muscle weakness, older age, and low lumbar bone mineral density were significant risk factors associated with the presence of OVFs in the lower thoracic and lumbar spine.

PURPOSE

We developed an innovative exercise device for the abdominal trunk muscles that also measures muscle strength. We investigated the correlation between the strength and thoracolumbar spinal deformity in middle-aged and older women.

METHODS

This study included 206 consecutive female patients who were 50 years or older and scheduled to undergo surgery for degenerative diseases of the lower extremities. Patients with a history of symptomatic osteoporotic vertebral fractures (OVFs) requiring treatments were excluded. Before surgery, patients underwent physical measurements including abdominal trunk muscle strength using our device, full-spine standing radiography, and bone mineral density measurement of the lumbar spine (L-BMD). According to radiographic findings of the radiogram, patients were divided into four groups: control group (n = 134), listhesis group (n = 29), scoliosis group (n = 19), and fracture group (n = 24). The Tukey-Kramer honestly significant difference test was used to compare all measurements among the four groups. To identify factors associated with the presence of OVFs, a multivariate logistic regression analysis was performed.

RESULTS

The average abdominal trunk muscle strength in the fracture group was significantly lower than that of the control group. The multivariate analysis revealed that abdominal trunk muscle weakness, older age, and a low L-BMD were associated with OVF findings.

CONCLUSIONS

Abdominal trunk muscle weakness in middle-aged and older women was associated with OVF. The strength measurement can be a risk assessment of OVF.

Determination of eligibility criteria for salvage hysterectomy after definitive radiotherapy/concurrent chemoradiotherapy for residual cervical disease

5524

Background: Patients with persistent cervical cancer after definitive radiotherapy/concurrent chemoradiotherapy (RT/CCRT) have a poor prognosis. Salvage hysterectomy (HT) is potentially curative, but eligibility criteria therefor have not been determined. Methods: Part 1) Retrospective review of patients with persistent cervical cancer treated with definitive RT/CCRT at 35 institutions of the Japanese Clinical Oncology Group (JCOG) from 2005–2014. Differences between a salvage HT group and a systemic chemotherapy (CT) group after definitive RT/CCRT for residual tumor were evaluated. Clinical variables influencing a salvage HT treatment decision were evaluated using logistic regression analysis. Part 2) Questionnaire-based survey conducted by JCOG gynecologic oncologists assessing treatment choice for patients with residual cervical disease after definitive RT/CCRT. Patients with residual cervical tumor before, during and after definitive RT/CCRT were surveyed for 86 conditions and appropriate candidates for salvage HT were evaluated using heat map analysis. Results: Part 1) We identified 298 patients who underwent salvage HT or systemic CT. Median overall survival was 3.8 and 0.9 year in the HT and CT groups, respectively (HR 0.4341, 95% CI 0.336-0.559, p < 0.01). FIGO stage and lymph node metastasis at initial treatment, performance status (PS) at diagnosis of residual cervical tumor and parametrial invasion of residual cervical tumor significantly influenced a salvage HT treatment decision. Part 2) Heat map analysis showed that surveyed variables segregated into 3 groups: i) in favor of salvage HT, ii) in favor of systemic CT, and iii) either. Conditions such as FIGO stage IB-IIB, PS of 0-1, residual tumor < 4 cm, no parametrial invasion and no residual lymph node metastasis were included in group i, in favor of salvage HT. Conclusions: Eligibility criteria could be determined based on the results of the current study, and a prospective clinical trial evaluating the survival benefit of salvage HT for residual cervical tumor after definitive RT/CCRT is being planned by JCOG.

Fluoroscopy-assisted posterior percutaneous reduction for the management of unilateral cervical facet dislocations after unsuccessful closed reduction: A case report

•

Open reduction of cervical facet dislocation is needed when closed reduction fails.

•

Anterior cervical discectomy and fusion after posterior percutaneous reduction was performed.

•

Posterior percutaneous reduction can be useful for cervical facet dislocations.

Introduction

In some cases of cervical facet dislocations, open reduction becomes imperative when closed reduction fails. In these cases, posterior open reduction with subsequent posterior fixation has been favored in previous reports as reduction using the posterior approach is less challenging than that using the anterior approach. However, it invades the posterior cervical muscles, is associated with a high risk of postoperative axial neck pain, and is less likely to restore cervical lordosis than anterior surgery. In this report, we describe a novel reduction technique, posterior percutaneous reduction, which can address this dilemma.

Presentation of case

An attempt to perform closed reduction in a 19-year-old adolescent with a unilateral facet dislocation at the C4-C5 level was unsuccessful. To preserve the posterior cervical muscles and obtain good cervical alignment, we opted for posterior percutaneous reduction and subsequent anterior cervical discectomy and fusion instead of posterior open reduction and fixation. An elevator was inserted into the locked facet percutaneously with fluoroscopic assistance, and reduction was achieved by lever action. Seven days after the percutaneous reduction, anterior cervical discectomy and iliac bone grafting with plate fixation were performed. There were no complications or neurological deficits postoperatively.

Discussion

This report describes the case of a patient who underwent anterior cervical discectomy and fusion after posterior percutaneous reduction with preservation of the posterior cervical muscles for unilateral facet dislocation when closed reduction was unsuccessful.

conclusion

Posterior percutaneous reduction could be a useful option for the management of cervical facet dislocations.

Profile of treatment-related complications in women with clinical stage IB-IIB cervical cancer: A nationwide cohort study in Japan

OBJECTIVE

To examine clinico-pathological factors associated with surgical complications and postoperative therapy for clinical stage IB-IIB cervical cancer.

METHODS

This nationwide multicenter retrospective study examined women with clinical stage IB-IIB cervical cancer who underwent radical hysterectomy plus pelvic and/or para-aortic lymphadenectomy between 2008-2009 at 87 institutions of the Japanese Gynecologic Oncology Group (n = 693). Multivariate models were used to identify independent predictors of perioperative grade 3-4 complications and bladder dysfunction.

RESULTS

The overall intraoperative and postoperative complication rates were 3.3% and 9.8%, respectively. Clinical stage was not associated with perioperative complications (P = 0.15). Radiotherapy-based adjuvant therapy was significantly associated with an increased risk of postoperative complications (radiotherapy alone: adjusted-odds ratio [OR] 3.19, 95% confidence interval [CI] 1.46-6.99, P = 0.004; radiotherapy plus chemotherapy: adjusted-OR 3.26, 95%CI 1.66-6.41, P = 0.001), whereas chemotherapy was not (P = 0.45). Nerve-sparing surgery significantly reduced the risk of postoperative bladder dysfunction (adjusted-OR 0.57, 95%CI 0.37-0.90, P = 0.02) whereas adjuvant chemotherapy increased the risk of bladder dysfunction (adjusted-OR 2.06, 95%CI 1.16-3.67, P = 0.01). Among women receiving adjuvant chemotherapy, nerve-sparing radical hysterectomy significantly reduced the risk of bladder dysfunction (15.0% versus 32.9%, OR 0.31, 95%CI 0.14-0.68, P = 0.004). After propensity score matching, survival outcomes were similar with both types of adjuvant therapy (radiotherapy-based versus chemotherapy, P>0.05).

CONCLUSION

Our study highlighted two distinct complication profiles of adjuvant therapy after radical hysterectomy for clinical stage IB-IIB cervical cancer, with radiotherapy increasing grade 3-4 adverse events and chemotherapy increasing bladder dysfunction. In this setting, nerve-sparing surgery may be useful if chemotherapy is being considered for adjuvant therapy.

A randomized phase II/III trial of conventional paclitaxel and carboplatin with or without bevacizumab vs dose-dense paclitaxel and carboplatin with or without bevacizumab, in stage IVB, recurrent or persistent cervical carcinoma: Japan Clinical Oncology Group Study (JCOG1311)

A randomized controlled trial has been initiated to compare chemotherapy containing dose-dense paclitaxel plus carboplatin with or without bevacizumab to a conventional regimen containing tri-weekly paclitaxel plus carboplatin with or without bevacizumab. Eligible patients are those with stage IVB, recurrent or persistent cervical carcinoma not amenable to curative treatment with local therapy. Patients are randomly assigned to either the conventional or dose-dense regimen. However, patients who are at increased risk of adverse events following bevacizumab administration will not receive this drug. The primary endpoint of phase II part is response rate. If the response rate of the dose-dense regimen is better than that of conventional regimen, this study will proceed to phase III, where the primary endpoint is overall survival. Secondary endpoints in phase III part are progression-free survival, response rates, adverse events, serious adverse events and the proportion of non-hospitalization periods compared with planned treatment periods.

En bloc corpectomy for late gastrointestinal stromal tumor metastasis: a case report and review of the literature

Background

Spinal metastases of gastrointestinal stromal tumors are rare; however, the incidence has been increasing since the introduction of tyrosine kinase inhibitors, which have improved overall survival. Due to the rarity of cases, there are no treatment guidelines for spinal metastases of gastrointestinal stromal tumors. We describe a patient who underwent spinal metastasectomy for a rectal gastrointestinal stromal tumor; we further provide a review of all cases of gastrointestinal stromal tumors with spinal metastases.

Case presentation

A 51-year-old Japanese man who had undergone resection for a rectal gastrointestinal stromal tumor was diagnosed with L3 vertebral metastasis 10 years after surgery. As there were no metastases to vital organs, an en bloc corpectomy of the L3 vertebral body, using bilateral retroperitoneal approaches, was performed to achieve local cure and to prevent neural compression. A 3-year follow-up showed no local recurrence or new metastases; he had full neurological function.

Conclusions

Spinal metastasectomy can be an effective treatment for solitary spinal metastases of gastrointestinal stromal tumors.

Total spondylectomy for Enneking stage III giant cell tumor of the mobile spine

PURPOSE

We reported the surgical outcomes of total en bloc spondylectomy (TES) with intralesional T-saw transpedicular osteotomy in patients with Enneking stage III spinal giant cell tumors (GCTs).

METHODS

The medical records and imaging and pathological studies of 25 consecutive patients with Enneking stage III spinal GCTs undergoing surgery at our institution who were followed for at least 2 years were retrospectively reviewed.

RESULTS

Eight men and 17 women (mean age: 34.2 years, range 16-51 years, at the time of surgery) were included. Six patients underwent previous tumor excision at another hospital, and one patient had a history of denosumab treatment. The GCTs were at the cervical, thoracic, and lumbar levels in three, nine, and 13 patients, respectively. TES was performed in 13 patients; 12 required intralesional pediculotomy. The remaining patients underwent total piecemeal spondylectomy with further intralesional tumor resection. During a mean follow-up of 99.2 months (range 24-216), two patients who underwent total piecemeal spondylectomy had local tumor recurrence, but no patients who underwent TES with intralesional pediculotomy had recurrence. The 2- and 10-year recurrence-free survival rates of patients treated with total piecemeal spondylectomy were 91.7% and 78.6%, respectively, while those of patients treated with TES were both 100%.

CONCLUSIONS

TES with intralesional pediculotomy had a good surgical outcome even in patients with Enneking stage III spinal GCT, suggesting that minimal intralesional procedures could radically cure spinal GCTs. These slides can be retrieved under Electronic Supplementary Material.

Practice patterns of adjuvant therapy for intermediate/high recurrence risk cervical cancer patients in Japan

Objective

Although radiation therapy (RT) and concurrent chemoradiotherapy (CCRT) are the global standards for adjuvant therapy treatment in cervical cancer, many Japanese institutions choose chemotherapy (CT) because of the low frequency of irreversible adverse events. In this study, we aimed to clarify the trends of adjuvant therapy for intermediate/high-risk cervical cancer after radical surgery in Japan.

Methods

A questionnaire survey was conducted by the Japanese Gynecologic Oncology Group to 186 authorized institutions active in the treatment of gynecologic cancer.

Results

Responses were obtained from 129 facilities. Adjuvant RT/CCRT and intensity-modulated RT were performed in 98 (76%) and 23 (18%) institutions, respectively. On the other hand, CT was chosen as an alternative in 93 institutions (72%). The most common regimen of CT, which was used in 66 institutions (51%), was a combination of cisplatin/carboplatin with paclitaxel. CT was considered an appropriate alternative option to RT/CCRT in patients with risk factors such as bulky tumors, lymph node metastasis, lymphovascular invasion, parametrial invasion, and stromal invasion. The risk of severe adverse events was considered to be lower for CT than for RT/CCRT in 109 institutions (84%).

Conclusion

This survey revealed a variety of policies regarding adjuvant therapy among institutions. A clinical study to assess the efficacy or non-inferiority of adjuvant CT is warranted.

Development of a Cavity Disinfectant Containing Antibacterial Monomer MDPB

An experimental cavity disinfectant (ACC) that is intended to be used for various direct and indirect restorations was prepared by adding an antibacterial monomer 12-methacryloyloxydodecylpyridinum bromide (MDPB) at 5% into 80% ethanol. The antibacterial effectiveness of ACC and its influences on the bonding abilities of resin cements were investigated. To examine the antibacterial activity of unpolymerized MDPB, the minimum inhibitory and bactericidal concentrations (MIC and MBC) were determined for Streptococcus mutans, Lactobacillus casei, Actinomyces naeslundii, Parvimonas micra, Enterococcus faecalis, Fusobacterium nucleatum, and Porphyromonas gingivalis. Antibacterial activities of ACC and the commercial cavity disinfectant containing 2% chlorhexidine and ethanol (CPS) were evaluated by agar disk diffusion tests through 7 bacterial species and by MIC and MBC measurement for S. mutans. The effects of ACC and CPS to kill bacteria in dentinal tubules were compared with an S. mutans–infected dentin model. Shear bond strength tests were used to examine the influences of ACC on the dentin-bonding abilities of a self-adhesive resin cement and a dual-cure resin cement used with a primer. Unpolymerized MDPB showed strong antibacterial activity against 7 oral bacteria. ACC produced inhibition zones against all bacterial species similar to CPS. For ACC and CPS, the MIC value for S. mutans was identical, and the MBC was similar with only a 1-step dilution difference (1:2). Treatment of infected dentin with ACC resulted in significantly greater bactericidal effects than CPS ( P < 0.05, analysis of variance and Tukey’s honest significant difference test). ACC showed no negative influences on the bonding abilities to dentin for both resin cements, while CPS reduced the bond strength of the self-adhesive resin cement ( P < 0.05). This study clarified that the experimental cavity disinfectant containing 5% MDPB is more effective in vitro than the commercially available chlorhexidine solution to eradicate bacteria in dentin, without causing any adverse influences on the bonding abilities of resinous luting cements.

Prognostic factors from a randomized phase III trial of paclitaxel and carboplatin versus paclitaxel and cisplatin in metastatic or recurrent cervical cancer: Japan Clinical Oncology Group (JCOG) trial: JCOG0505-S1

PURPOSE

The Japan Clinical Oncology Group (JCOG) trial JCOG0505 demonstrated the statistically significant non-inferiority of paclitaxel plus carboplatin (TC) to paclitaxel plus cisplatin (TP) in terms of overall survival (OS) in metastatic or recurrent cervical cancer. In that trial, patients were randomly assigned, adjusting for institution and known prognostic factors. The objective of this ancillary study was to evaluate the appropriateness of the adjustment factors used to have randomly assigned treatments and to investigate new potentially useful prognostic factors of paclitaxel plus platinum for future randomized trials in metastatic or recurrent cervical cancer.

METHODS

The study subjects comprised 244 eligible patients in the JCOG0505 who were merged to have received either TC or TP. The effects of the following factors on OS were investigated using a Cox regression model taking into consideration the adjustment factors used in randomization in this trial (e.g., performance status [PS]) and other baseline factors, including platinum-free interval (PFI), pretreatment hemoglobin levels (PHLs), and pretreatment platelet counts (PPCs).

RESULTS

The median follow-up was 17.6 months, and median OS was 18.0 months. The hazard ratio was 1.83 in patients with a PS of 1 or 2 (vs. 0; P = 0.0004; 95 % confidence interval [CI] 1.31-2.55), 2.92 in patients with a PFI of <6 months (vs. PFI of ≥12 months; P < 0.0001; 95 % CI 1.73-4.91), 2.09 in patients with a PFI of <12 months (vs. PFI of ≥12 months; P = 0.0034; 95 % CI 1.28-3.44), and 0.69 in patients with PHL higher than or equal to the median value (vs. less than the median; P = 0.016; 95 % CI 0.51-0.93). No significant differences were obtained for PPC or the other known factors.

CONCLUSIONS

In addition to the known prognostic factor of PS, which was used as an adjusting factor, a PFI of <12 months and lower PHL were newly demonstrated to be associated with poor outcomes in patients with metastatic or recurrent cervical cancer. These new prognostic factors should be validated in future prospective trials.

CLINICAL TRIAL INFORMATION

UMIN-CTR[ http://www.umin.ac.jp/ctr/ ] ID: C000000335.

Topographic patterns in the phylogenetic structure of temperate forests on steep mountainous terrain

In rugged terrain subject to active geomorphological processes, the species composition of forest communities changes along topographic gradients over short distances. However, the phylogenetic structure of forests on rugged terrain has rarely been examined. Understanding such structures provides insight into community assembly rules dependent on local environmental conditions. To this end, we tested the topographic trends of measurements of phylogenetic community structure [net relatedness index (NRI) and nearest taxon index] in a catchment covered by temperate forests with complex relief in Japan. We found that phylogenetic structure changed from over-dispersion to clustering with increasing slope inclination, change of slope aspect from south to north and decreasing soil depth. This result suggested that environmental filtering tended to restrict community composition at relatively stressful sites, whereas species interaction functioned more strongly at relatively stress-free sites. Relatively stressful sites were characterized by early-successional species that tended to assemble in certain phylogenetic clades, whereas highly competitive late-successional species associated with lower NRI at relatively stress-free sites. However, despite this significant topographic tendency, phylogenetic community structures were not statistically different from random assumptions in most plots. This obscuration of the phylogenetic structures at the plot level could be interpreted as species adapting to disturbances because they were abundant in this catchment. Accordingly, we suggest that a stochastic process was also important for this community at the plot level, although biotic and abiotic environmental filtering controlled the vegetation structure in the catchment, where disturbances occur frequently because of geomorphological mountain denudation processes owing to active crustal movements and abundant rainfall.

En Bloc Resection and Reconstruction Using a Frozen Tumor-Bearing Bone for Metastases of the Spine and Cranium from Retroperitoneal Paraganglioma

BACKGROUND

Paragangliomas are neuroendocrine tumors that originate from autonomic nervous system-associated paraganglia and are rare tumors accounting for only 0.3% of all neoplasms. Malignant paragangliomas frequently spread to the skeleton. The authors present a case of malignant paraganglioma with bone metastases to the spine and cranium, as well as excellent local control achieved with en bloc tumor resection and reconstruction using frozen tumor-bearing bone for the sites of the metastases.

CASE

The patient was a 61-year-old woman who underwent retroperitoneal paraganglioma resection 12 years previously. Nine years after the primary surgery, she began to experience back pain. Magnetic resonance imaging revealed an isolated metastasis in T6, and the following evaluation detected another metastasis in the left temporal bone. We performed curative surgeries for the metastases, including total en bloc spondylectomy of T6, partial craniectomy for the cranial metastasis, and spinal and cranial reconstruction using frozen tumor-bearing bone for the sites of the metastases. At the 24-month follow-up examination, bone fusion was achieved between the frozen bone and the adjacent healthy bone in the spine and cranium. At 36 months postoperatively, an asymptomatic metastatic lesion was found in the pelvis. Nevertheless, no local recurrences at the surgical sites were detected. Her quality of life and performance in activities of daily living were well preserved. To the author's knowledge, this is the first report to present a case of cranioplasty achieved using a liquid nitrogen frozen, tumor-bearing autologous bone flap in a single-stage operation.

Paclitaxel Plus Carboplatin Versus Paclitaxel Plus Cisplatin in Metastatic or Recurrent Cervical Cancer: The Open-Label Randomized Phase III Trial JCOG0505

PURPOSE

In metastatic or recurrent cervical cancer, cisplatin-based chemotherapy is standard. The JCOG0505 randomized phase III trial evaluated the clinical benefits of carboplatin-based regimen.

PATIENTS AND METHODS

Eligible patients had metastatic or recurrent cervical cancer and had ≤ one platinum-containing treatment and no prior taxane. Patients were randomly assigned either to conventional paclitaxel plus cisplatin (TP; paclitaxel 135 mg/m(2) over 24 hours on day 1 and cisplatin 50 mg/m(2) on day 2, repeated every 3 weeks) or paclitaxel plus carboplatin (TC; paclitaxel 175 mg/m(2) over 3 hours and carboplatin area under curve 5 mg/mL/min on day 1, repeated every 3 weeks). Primary end point was overall survival (OS). Planned sample size was 250 patients to confirm the noninferiority of TC versus TP with the threshold hazard ratio (HR) of 1.29.

RESULTS

Between February 2006 and November 2009, 253 patients were enrolled. The HR of OS was 0.994 (90% CI, 0.79 to 1.25; noninferiority P = .032 by stratified Cox regression). Median OS was 18.3 months with TP versus 17.5 months with TC. Among patients who had not received prior cisplatin, OS was shorter with TC (13.0 v 23.2 months; HR, 1.571; 95% CI, 1.06 to 2.32). One treatment-related death occurred with TC. Proportion of nonhospitalization periods was significantly longer with TC (P < .001).

CONCLUSION

TC was noninferior to TP and should be a standard treatment option for metastatic or recurrent cervical cancer. However, cisplatin is still the key drug for patients who have not received platinum agents.

Development of an antibacterial root canal filling system containing MDPB

An antibacterial monomer 12-methacryloyloxydodecylpyridinum bromide (MDPB)-containing experimental, chemically cured primer was prepared to develop a new resin-based root canal filling system. This study investigated the antibacterial effects of the MDPB-containing primer (experimental primer [EP]) against Enterococcus faecalis and assessed the in vitro bonding and sealing abilities of the filling system, consisting of EP and a Bis-GMA-based sealer resin. Antibacterial effects of EP were evaluated by contact with planktonic or adherent bacteria for 30 or 60 sec, and the viable bacterial number was counted. The antibacterial effects against E. faecalis in dentinal tubules were also assessed, according to a root canal infection model. Bonding and sealing abilities of the experimental filling system were examined by microtensile bond strength tests and leakage tests based on fluid filtration methods. Significantly greater reduction in viable bacteria in planktonic and adherent form was obtained by short-period contact with EP compared with the control primer (without MDPB) or with the proprietary (Epiphany) primer (p < .05). Significantly greater bactericidal effects of the EP inside the dentinal tubule of root, as opposed to the control primer or Epiphany primer, were confirmed according to a root canal infection model (p < .05), and 100% killing of E. faecalis could be obtained by the application of EP after irrigation with a 5% sodium hypochlorite solution. The experimental endodontic filling system demonstrated significantly greater bond strength to root dentin than Epiphany sealer system (Epiphany primer and Epiphany Root Canal Sealant; p < .05), showing formation of resin tags and a hybridized layer. Leakage tests clarified that the experimental system provided excellent sealing. This study confirmed that the MDPB-containing experimental antibacterial primer has the ability to effectively disinfect the root canal. Additionally, the experimental root canal filling system employing this primer and the Bis-GMA-based sealer resin is useful for achieving good sealing, suggesting its possible benefit for successful endodontic treatments.

Recovery of normal hemodynamic activities after long-term medication in a patient with left internal carotid arterial occlusion

BACKGROUND AND OBJECTIVE

Aspirin, clopidogrel, cilostazol, and statins are thought to reduce the risk of cerebral infarction in patients with intracranial arterial stenosis. We present a case of multiple intracranial arterial stenoses in which increased cerebral blood flow (CBF) was demonstrated after long-term medical therapy.

CASE PRESENTATION

A 68-year-old man with a history of cerebral infarction showed complete occlusion of the left internal carotid artery with severe stenoses in the A1 segment of the left anterior cerebral artery (ACA) and the left posterior communicating artery resulting in poor visualization of the left middle cerebral artery (MCA) on magnetic resonance angiography (MRA). Administration of aspirin and clopidogrel prevented ischemia from recurring for 1 year; however, the stenoses never improved. Technetium-99m-L, L-ethylcysteinate dimer single-photon emission computed tomography (SPECT) demonstrated a significant decrease in CBF in the territory of the left MCA. Anastomosis between the superficial temporal artery and the MCA was recommended to the patient because no supplementary blood supply was expected through either the left A1 or posterior communicating artery. However, the patient refused surgery because of the associated risks. To enhance vasodilation, clopidogrel was replaced by cilostazol. One year later, the stenoses had partially improved. Further treatment with aspirin, cilostazol, simvastatin, and nateglinide contributed to the significant increase in CBF with normal hemodynamics, as shown with acetazolamide-loading SPECT.

CONCLUSION

The goal of treatment for intracranial arterial stenosis is to supply sufficient blood flow to the brain rather than to completely dilate the stenotic artery. Long-term treatment with aspirin, cilostazol, simvastatin, and nateglinide might help increase CBF in some patients with intracranial arterial stenosis.

Genotype distribution of human papillomaviruses in Japanese women with abnormal cervical cytology

We report the prevalence and genotype distribution of human papillomaviruses (HPVs) among Japanese women with abnormal cervical cytology using the PGMY-CHUV assay, one of PGMY-PCR-based lineblot assays that was validated and shown to be suitable for the detection of multiple HPV types in a specimen with minimum bias. Total DNA was extracted from cervical exfoliated cells collected from 326 outpatients with abnormal Pap smears. Overall, 307 specimens (94%) were HPV-positive, 30% of which contained multiple genotypes. The prevalence of HPV DNA was 83% (49/59 samples) in atypical squamous cells of undetermined significance (ASC-US); 91% (20/22 samples) in atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H); 97% (130/134 samples) in low-grade squamous intraepithelial lesion (LSIL); and 99% (85/86 samples) in high-grade squamous intraepithelial lesion (HSIL). Three most frequent HPV types detected in HSIL were HPV16 (36%), HPV52 (24%), and HPV58 (14%). Our results suggest that multiple HPV infections are more prevalent in Japanese women than previously reported, and confirm that HPV52 and 58 are more dominant in their cervical precancerous lesions when compared to those reported in Western countries.

A randomized, phase III trial of paclitaxel plus carboplatin (TC) versus paclitaxel plus cisplatin (TP) in stage IVb, persistent or recurrent cervical cancer: Japan Clinical Oncology Group study (JCOG0505)

5006

Background: TC is a less toxic regimen in terms of milder nephropathy, neuropathy and no need of hospitalization. This multicenter phase III trial was designed to evaluate the clinical benefits of TC compared with TP which is current standard chemotherapy for stage IVB or recurrent cervical cancer. Methods: Patients (pts) with stage IVB or recurrent cervical cancer; not amenable to curative therapy; 0-1 prior platinum; no prior taxanes; were randomized with minimization method to either TP (T 135 mg/m2 24h d1 + P 50 mg/m2 2h d2) or TC (T 175 mg/m2 3h d1 + C AUC5 1h d1), both for maximum 6 cycles every 21 days. Primary endpoint was overall survival (OS). Secondary endpoints were progression-free survival (PFS), toxicities, and the proportion of non-hospitalization periods (NHP) as a surrogate for QoL. The trial was powered at least 70% to confirm the non-inferiority of TC to TP (threshold hazard ratio [HR] 1.29) in terms of OS, and the planned sample size was 250 pts with one-sided alpha 5%. HR is estimated by a stratified Cox regression. Results: From 2/06 to 11/09, 253 pts were enrolled. 71% pts of TP arm and TC arm each received 6 cycles. Median follow-up is 17.4 mo. Results are as below. As an alpha level for an interim analysis was less than 0.0001, significance level for the final analysis is approximately 5% even after the multiplicity adjustment. Conclusions: This first randomized controlled trial comparing carboplatin doublet with cisplatin doublet showed significant non-inferiority of TC in terms of OS. More feasible and less toxic TC can be recommended as the new standard treatment for stage IVB or recurrent cervical cancer. [Table: see text]

[A case of stage IVb vulvar cancer effectively treated by concurrent chemoradiotherapy with cisplatin]

A 72-year-old woman was hospitalized because of a 10 cm tumor in her right inguinal area. Furthermore, a 6 cm tumor mass was observed in her right vulva. Computed tomography revealed multiple swollen lymph nodes in the para-aortic and pelvic areas. On the basis of these findings, the patient was diagnosed with stage IVb squamous cell carcinoma of the vulva. Radiation therapy of 67.4 Gy/33 Fr was administered to the pelvis, inguinal area and vulva. Four courses of chemotherapy with cisplatin (40 mg/m(2)) were concurrently administered every week during radiation therapy. The response to chemoradiotherapy was assessed to be complete. The patient has been doing well without any recurrence for 24 months.

Dual regulatory pathways of flagellar gene expression by ClpXP protease in enterohaemorrhagic Escherichia coli

In enterobacteria such as Escherichia coli and Salmonella species, flagellar biogenesis is strictly dependent upon the master regulator flhDC. Here, we demonstrate that in enterohaemorrhagic E. coli (EHEC), the flagellar regulon is controlled by ClpXP, a member of the ATP-dependent protease family, through two pathways: (i) post-translational control of the FlhD/FlhC master regulator and (ii) transcriptional control of the flhDC operon. Both FlhD and FlhC proteins accumulated markedly following ClpXP depletion, and their half-lives were significantly longer in the mutant cells, suggesting that ClpXP is responsible for degrading FlhD and FlhC proteins, leading to downregulation of flagellar expression. ClpXP was involved in regulating the transcription of the flhD promoter only when the cells had entered stationary phase in a culture medium that markedly induced expression of the locus of enterocyte effacement (LEE). Comparative analyses of transcription from the flhD promoter in EHEC cells with different genetic backgrounds suggested that the downregulation of flhDC expression by ClpXP is dependent on the LEE-encoded GrlR-GrlA system. We have also shown that the degradation of FlhD and FlhC by ClpXP is responsible for downregulating flagellar expression even when LEE expression is induced.

A phase III trial of paclitaxel plus carboplatin versus paclitaxel plus cisplatin in stage IVB, persistent or recurrent cervical cancer: Gynecologic Cancer Study Group/Japan Clinical Oncology Group Study (JCOG0505)

A randomized controlled trial has been started in Japan to compare the utility of palliative chemotherapy containing paclitaxel and carboplatin (TC) with paclitaxel and cisplatin (TP) as a standard treatment for patients with the newly diagnosed Stage IVB, persistent or recurrent cervical cancer who are not amenable to curative treatment with local therapy. This trial was designed to evaluate the non-inferiority of TC as measured by the number of hospitalized days as an indicator of quality of life (QOL) when compared with TP combination therapy. The primary endpoint is overall survival. Secondary endpoints are progression-free survival, response rates, adverse events, severe adverse events and the proportion of non-hospitalization periods compared with planned treatment periods.

[Pleuroperitoneal communication at the beginning of continuous ambulatory peritoneal dialysis; report of a case]

A 46-years-old woman admitted for induction of continuous ambulatory peritoneal dialysis (CAPD). When peritoneal functional test was performed, dyspnea was occurred. Chest X-ray and chest computed tomography (CT) scan revealed massive right hydrothorax. Technetium-99m macroaggregated albumin scintigraphy showed communication between abdominal cavity and thoracic cavity. The thoracoscopic diaphragmal repair was performed. After CAPD was started, right hydrothorax occurred again. Re-repair of the diaphragm was performed in small thoracotomy and small hole was revealed. The hole was sutured and diaphragm was coverd by fibrin glue and polyglycolacid (PGA) felt all over. Since then, CAPD was continued successfully. Thoracoscopic surgery is less invasive and appropriate therapy for this case. It is important that the diaphragm will be covered all over by fibrin glue and PGA sheet because even pin-hole makes recurrence. For detect of the communicative portion, use of indigocarmin and examination of glucose concentration in the pleural effusion were effective.