Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy

BACKGROUND

Percutaneous coronary interventions (PCI) in calcified coronary artery lesions are associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using calcium modifying techniques such as Rotational Atherectomy (RA) or Intravascular Lithotripsy (IVL) has been advocated. Studies comparing these technologies are lacking. We aimed to compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either RA or IVL.

METHODS

Patients undergoing either RA- or IVL-assisted PCI from two European centers were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post- PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥ 0.90.

RESULTS

From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0,65 ± 0,13 RA and 0,67 ± 0,11 IVL). After PCI, in-stent pressure gradients were significantly lower in the IVL group (0.032 ± 0.026 vs 0.043 ± 0.026 in the RA group, p = 0.024). The proportions of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; p = 0.669).

CONCLUSIONS

Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL.

Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy

Background

Percutaneous coronary interventions (PCI) in calcified coronary artery lesions is associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using dedicated calcium modifying techniques such as RA or IVL has been advocated. Studies comparing these technologies are lacking.

Objectives

To compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either rotational atherectomy (RA) or intravascular lithotripsy (IVL).

Methods

Patients undergoing either RA- or IVL-assisted PCI from two European centers were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post- PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad, calculated as the difference between the vFFR at the proximal minus distal edge of the stent). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥0.90.

Results

From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0,65±0,13 RA and 0,67±0,11 IVL). After PCI, in-stent pressure gradient was significantly lower in the IVL group (0.032±0.026 vs 0.043±0.026 in the RA group, p=0.024). The proportion of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; p=0.669)

Conclusions

Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL.

Funding Acknowledgement

Type of funding sources: None. In stent gradients after RA and IVL

Acute change in left atrial performance in patients with atrial fibrillation undergoing catheter ablation using AutoStrain

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): International PhD Program in Cardiovascular Pathophysiology and Therapeutics CardioPaTh

Background

Radio-frequency catheter ablation (CA) is associated with changes of left atrial (LA) structure and function. However, the data on the accuracy of automated analysis of LA strain (LAS) are unavailable. Therefore, the aim of the present study was to compare automated with manual LAS analysis in patients with atrial fibrillation (AF) undergoing CA during sinus rhythm.

Methods

We prospectively enrolled 36 consecutive patients (age: 62 ± 22 years, 33% female) with symptomatic AF and preserved  left ventricular (LV) ejection fraction (≥50%) undergoing the CA during sinus rhythm. All patients underwent comprehensive echocardiography at 1-day pre-CA and at 1-day post-CA. Reservoir and contractile LAS were assessed using both the automated and the manual technique as average of segmental values in apical four-chamber (4CH) view using the onset of QRS as a reference point.

Results

Radio-frequency CA was associated with significant decrease in magnitude of reservoir and contractile LAS in all patients, and increase in LA end-systolic (max) and end-diastolic (min) volume index (all p < 0.001) (figure 1). The correlation between (semi-) automated and manual LAS assessment was excellent in all measurements (figure 2). The manual correction was needed in 7 out of 36 patients (19%). Despite this, the time needed to perform AutoStrain-derived analysis was significantly lower than the time needed for the manual LAS analysis (12 ± 3 ms vs. 40 ± 5 ms, p < 0.01). Moreover, in 10 randomly selected patients, the AutoStrain showed significantly lower interobserver variability than the manual LAS analysis (3.1% vs. 6.7%, p < 0.01). 

Conclusion

The AutoStrain-derived LAS analysis showed a high correlation with manual LAS analysis. Moreover, the AutoStrain technique was associated with significantly shorter analysis time and lower interobserver variability compared with the manual technique.

Abstract Figure.

Atrial strain performance in patients with paroxysmal atrial fibrillation undergoing successful radio-frequency catheter ablation

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): International PhD Program in Cardiovascular Pathophysiology and Therapeutics CardioPaTh

Background

Radio-frequency catheter ablation (CA) is associated with changes of left atrial (LA) structure and function. However, there is limited knowledge regarding the long-term impact of successful CA on atrial morphology and mechanics.

Purpose

To compare the time course of LA and right atrial (RA) performance in patients with paroxysmal atrial fibrillation (AF) undergoing the first CA.

Methods

This prospective study included 89 consecutive patients (age:62 ± 21 years; 66% male) with a history of symptomatic AF who underwent successful CA. All patients maintained SR during follow-up. A comprehensive echocardiographic examination was performed 1- day before and 1-day, 3-month and 12-month after CA. The reservoir and contractile strain for both LA and RA (LAS, RAS), and left intra-atrial mechanical dispersion (LAMD) were assessed using 2D speckle tracking echocardiography in all three apical views (only 4CH view for RAS and LAMD).

Results

At baseline, all patients with paroxysmal AF showed a significant reduction of reservoir and contractile LAS and RAS compared with controls (all p < 0.01). CA was associated with a significant decrease in reservoir and contractile LAS while no significant difference was observed for RAS. At 3-month follow-up, the LAS showed full recovery, whereas the RAS did not show any significant change from 1-day post CA values. At 12-month follow-up, both reservoir and contractile LAS showed further improvement compared to baseline and 3-month values. LAMD derived from the LA strain curve followed a similar trend. Although the RA motion was not affected in the early phase, both reservoir and contractile RAS showed a significant increase between 3-month and 12-month follow-up.

Conclusion

Although the radio-frequency CA affected negatively LA performance in the acute phase, it has a long-term positive impact on both left and right atrial function.

Figure

Time course of reservoir and contractile LAS and RAS at Baseline, 1-day, 3-month and 12-month follow-up.

Abstract Figure.

Hyperemic hemodynamic characteristics of serial coronary lesions assessed by pressure pullbacks gradients (PPG) index

Introduction

The evaluation of functional significance in serial coronary lesions is crucial for achieving optimal clinical outcomes. In this setting, fractional flow reserve (FFR) measurements with pullback pressure recording can be helpful in assessing lesion functional significance.

Purpose

To describe the functional characteristics of angiography-defined serial coronary lesions using FFR-derived motorised pullback tracings, and to describe the Pullback Pressure Gradients (PPG) index - in these lesions.

Methods

Prospective, multicentre study with independent core laboratory analysis. Patients undergoing coronary angiography due to stable angina were enrolled. Serial lesions were defined angiographically as the presence of 2 or more narrowings with visual diameter stenosis >50% separated at least by 3 times the reference vessel diameter in the same coronary vessel. Continuous IV adenosine-FFR measurements were obtained using a motorised device at a speed of 1 mm/s. Pullback curves were assessed to determine the presence of focal step-ups (FFR >0.05 units over 20 mm). In addition, the PPGindex was computed for all vessels. PPGindex values close to 0 define functional diffuse disease whereas values close to 1 define focal disease.

Results

From a total of 159 vessels (117 patients), 25 vessels were adjudicated as presenting serial lesions (mean PPGindex 0.48±0.17, range 0.26–0.87). Two focal pressure step-ups were observed in 40% of the cases (n=10; mean PPGindex 0.59±0.17), whereas 8% of the vessels presented a progressive pressure losses (n=2; mean PPGindex 0.27±0.01). In the remaining 52% of the cases, a single pressure step-up was recorded (n=13; mean PPGindex 0.44±0.12; ANOVA p-value = 0.01). The PPGindex independently predicted the presence of two focal pressure step ups.

Conclusion

Hyperemic FFR curves in tandem stenoses revealed high prevalence of functional diffuse CAD. Two pressure step-ups occurred in less than half of the vessels. High PPG-Index identified vessels with two focal pressure drops. FFR tracings and the PPGindex provide a more objective CAD evaluation, which can lead to changes in the therapeutic approach.

Funding Acknowledgement

Type of funding source: None

Long-term outcome of minimally invasive mitral valve annuloplasty in disproportionate mitral regurgitation

Background

Hypothetical concept of disproportionate secondary mitral regurgitation (SMR) has been recently introduced to facilitate patient's selection for mitral valve intervention. However, real world data validating this concept are unavailable.

Purpose

To investigate long-term effects of minimally invasive mitral valve annuloplasty (MVA) in patients with disproportionate (dSMR) versus proportionate SMR.

Methods

The study population consisted of 44 consecutive patients (age 67±9,5 years; 64% males) on guidelines-directed therapy with advanced heart failure (HF), reduced LV ejection fraction (EF) (32±9,7%) and SMR undergoing isolated mini-invasive MVA. Patients with organic mitral regurgitation or concomitant myocardial revascularization were excluded. To assess SMR disproportionality, the PISA-derived effective regurgitant orifice area (EROA) and regurgitant volume (RV) were compared to the estimated EROA and RV by using Gorlin formula and pooled real world data.

Results

According to EROA, a total of 20 (46%) and 24 (54%) patients, respectively, had dSMR and proportionate SMR (pSMR). According to RV, a total of 17 (39%) had dSMR and 27 (61%) had pSMR. Patients with dSMR showed significantly lower prevalence of male gender and higher prevalence of diabetes mellitus than patients with pSMR (p<0,001). Moreover, we observed smaller LV end-diastolic volume, larger EROA and RV (both p<0,01) and higher LV EF (p=0,02) in the dSMR versus the pSMR group. Other baseline characteristics were similar. During median follow up of 4.39 y (IQR 2,2–9,96y), a total of 25 (56%) patients died from any cause while 21 (47%) individuals were readmitted for worsening HF. Patients with dSMR versus pSMR according to both EROA and RV showed significantly lower rate of HF readmissions (both p<0.05) (Figure 1, 2). In Cox regression analysis combining clinical and imaging parameters, dSMR was the only independent predictor of HF readmissions (HR 0.20, 95% CI 0.07–0.60, p=0.004). In contrast, mortality was similar between dSMR and pSMR (NS) with age as the only independent predictor (HR 1,10; 95% CI 1,03–1,18, p=0,003).

Conclusions

Minimally invasive MVA is associated with significant reduction of HF readmissions in patients with dSMR versus pSMR while the mortality is similar. This suggests the importance of other parameters, i.e. age and degree of LV remodeling, to guide clinical management in SMR.

Funding Acknowledgement

Type of funding source: None

Quantification of calcium volume by coronary CT compared to OCT

Background

Coronary artery calcifications are frequently observed in patients referred for cardiac catheterization. Using OCT, the calcified volume can be determined. CT is a sensitive non-invasive tool to detect coronary artery calcifications and may be useful to guide percutaneous coronary intervention.

Purpose

The aim of the study was to investigate the accuracy of CT-derived calcium volume with OCT as a reference in patients undergoing PCI.

Methods

66 calcified plaques (32 vessels) from 31 patients undergoing OCT-guided PCI with coronary CT angiography acquired as a standard of care were included. Coronary CT angiography and OCT images were matched using fiduciary points. Calcified plaques were reconstructed in three dimensions to calculate calcium volume. A Passing-Bablok regression analysis and the Bland-Altman method were used to assess agreement between imaging modalities.

Results

27 left anterior descending arteries and 5 right coronary arteries were analyzed. Median calcium volume by CT angiography and OCT were 18.23 mm 3 [IQR 8.09, 36.48] and 10.03 mm 3 [IQR 3.6, 22.88]. The Passing-Bablok analysis showed a proportional difference without a systematic difference (Coefficient A 0.08, 95% CI: −1.37 to 1.21, Coefficient B 1.61, 95% CI: 1.45 to 1.84); with a mean difference of 9.69 mm3 (LOA −10.2 mm 3 to 29.6 mm 3). No significant differences were observed for MLA: median value for CT 2.84 mm2 [IQR 2.03, 3.74] and for OCT 2.55 mm2 [IQR 1.91, 4.43].

Conclusions

Coronary CT angiography volumetric calcium evaluation overestimates calcium volume by 60% compared to OCT. Accounting for CT overestimation may allow for appropriate interpretation of calcific burden in the non-invasive setting. Coronary CT angiography may emerge as a tool to quantify calcium burden for invasive procedural planning.

Calcium burden comparison CT vs OCT

Funding Acknowledgement

Type of funding source: None

P2445Prognostic values of left ventricular reservoir functional indices measured by three dimensional speckle tracking analysis

Background

Left atrial functional indices measured by two dimensional echocardiography (2DE) have prognostic significance for major cardiovascular events (MACE). Retrospective analysis using propensity score matching to assess the prognostic values of left atrial reservoir function measured by three dimensional speckle tracking analysis (3DSTA) was performed.

Methods

Two hundred sixty-four patients (Male 60%, 65±15yo) who underwent both clinically indicated 2DE and 3DSTA for various underlying heart diseases from January 4, 2013 to February 28, 2016 were followed to record MACE. Patients with significant mitral valve disease, history of pulmonary vein isolation and persistent atrial fibrillation were excluded. Maximum and minimum left atrial volume (LAVImax and LAVImin), left atrial emptying fraction (LAEmpF), peak global LA area ratio (LAAC), circumferential strain (LACS) and longitudinal strain (LALS) were measured using 3DSTA. Standard indices including peak global LVLS (2DLVLS) and left ventricular ejection fraction (LVEF) and LA volume index were also assessed by 2DE. Cutoff line for LA reservoir functional indices and 2DLVLS was determined using ROC analysis. Average treatment effect for the treated (ATT), Average treatment effect (ATE) for each index were calculated after propensity score matching for clinical indices (age, sex, coronary artery disease, hypertension, diabetes, eGFR <45 ml/min/1.73m2, LVEF <40%)

Results

During a mean follow-up of 547±435 days, MACE developed in 30 patients (7 cardiac death 6 stroke, 1 nonfatal MI, 22 admission for heart failure). Age, coronary artery disease (CAD), diabetes mellitus (DM), chronic kidney disease (CKD: eGFR< 45ml/min/1.73m2), LVEF, 2DLVLS, LAVImax and LAVImin by 2DE and all LA indices by 3DSTA had significant prognostic value by univariate analysis. LAEmpF and LALS by 3DSTA had higher ATT, ATE and Log rank χ2 than other LA indices and 2DLVLS. The model added LALS or LAEmpF by 3DSTA had higher prognostic value (LALS <10.6%: AUC; 0.82, HR; 5.57 CI: 2.32–14.06, LAEmpF <33.0%: AUC; 0.82, HR; 6.59 CI; 2.60–20.18) than LA volume indices by 2DE and also tended to be better than 2DLVLS (LVLS <6.04%: AUC; 0.77, HR; 5.37 CI; 2.06–13.73).

propensity score matching

Conclusion

LALS and LAEmpF by 3DSTA showed additive prognostic value for MACE.

Identification and characterization of the human serotonin-4 receptor gene promoter

The human serotonin-4 (5-HT(4)) receptor gene expression is highly regulated in various tissues. We isolated the human 5-HT(4) receptor gene containing the 5'-flanking region and characterized its promoter. By 5'-RACE (5'-rapid amplification of the cDNA ends) and inverse PCR, multiple transcription initiation sites were identified. The most 5' one (assigned to +1) was 5135 bp upstream to the translation start site. The 500-bp 5'-flanking region contained potential binding sites for transcription factor Sp-1, AP-2, AP-4, and GATA. However, this region lacked TATA- and CAAT-boxes. Transient transfection analyses in human choriocarcinoma T3M-3 (5-HT(4) receptor-positive) and HepG2 (5-HT(4) receptor-negative) cells revealed that the region (-210 to -105) is necessary for the basic and cell-type specific 5-HT(4) receptor gene expression. In addition, untranslated exon 1 contained negative (+112 to +182) as well as positive (+1 to +111) modulators, indicating that exon 1 plays a regulatory role in the 5-HT(4) receptor gene expression.

Neural substrates for recognition of familiar voices: a PET study

Identification of familiar people is essential in our social life. We can identify familiar people by hearing their voices as well as by viewing their faces. By measuring regional cerebral blood flow (rCBF) by positron emission tomography (PET), we identified neural substrates for the recognition of familiar voices. The brain activity during discrimination of voices of the subjects' associates and friends from those of unfamiliar people was compared with that during an analogous discrimination of their own voice from unfamiliar voices as well as during vowel discrimination. The left frontal pole, right temporal pole, right entorhinal cortex, and left precuneus were activated to a greater extent during discrimination of familiar voice than during control discriminations, suggesting that these brain regions are involved in the recognition of familiar voices. Furthermore, the adjusted values of rCBF in the left frontal pole and right temporal pole correlated with the number of subjects' correct identification of familiar voices. The present results suggest that these two regions are coactively associated with matching the currently heard voice to familiar voices in one's memory.

Gamma probe and ultrasonographically-guided fine-needle aspiration biopsy of sentinel lymph nodes in breast cancer patients

AIM

The purpose of the present study was to evaluate the usefulness of gamma probe and ultrasonographically-guided fine-needle aspiration biopsy (FNAB) in the pre-operative detection of sentinel node (SN) metastasis in breast cancer patients.

METHODS

Sentinel node biopsy (SNB) was performed in patients with stage I or II breast cancer with clinically negative nodes using dye and radio-isotope. Axillas of 60 patients in whom a hot spot was detected by gamma probe were examined by ultrasonography. Pre-operative diagnosis of SN metastasis by gamma probe and ultrasonographically-guided FNAB was compared with the histological results of SN.

RESULTS

The sensitivity, specificity and overall accuracy of ultrasonography in the diagnosis of SN metastasis were 50.0%, 92.1% and 76.7%, respectively. SNs were visualized by ultrasonography in 29 of 60 patients. Of 14 patients with positive results by ultrasonography, four had positive and two had negative cytology. The combination of ultrasonography and ultrasonographically-guided FNAB for visualized nodes had a sensitivity of 78.5%, specificity of 93.3% and overall accuracy of 86.2%. Blind FNAB in the hot spot was not useful in the detection of SN metastasis in patients whose SNs failed to be detected by ultrasonography.

CONCLUSIONS

Gamma probe and ultrasonographically-guided FNAB is a potentially useful method for pre-operative detection of SN metastasis. In patients with positive SNs, SNB is not indicated and complete axillary lymph-node dissection can be performed as a primary procedure.

Oleanane acid from Myrica cerifera

From the twigs of Myrica cerifera L. (Myricaceae), a new oleanane triterpenic acid named myrica acid was isolated along with myricalactone and several other known constituents. The structure of the acid was determined as 3beta-hydroxy-1-oxoolean-11,13(18)-dien-28-oic acid on the basis of chemical and spectral evidence.

Intraoperative sentinel lymph node examination by imprint cytology and frozen sectioning during breast surgery

BACKGROUND

The purpose of the present study was to evaluate the usefulness of intraoperative imprint cytology and frozen sectioning of sentinel lymph nodes in patients with clinically node-negative breast cancer.

METHODS

Sentinel node biopsy was performed in 101 patients with stage I or II breast cancer with clinically negative nodes using a dye-guided method. Intraoperative evaluation of sentinel node involvement by imprint cytology and frozen sectioning was compared with the final histopathological results of permanent sections. Tumour-negative nodes in paraffin sections stained by haematoxylin and eosin were further studied using an anticytokeratin antibody.

RESULTS

The results of imprint cytology and frozen-section analysis were compared with those of haematoxylin and eosin-stained sections. The sensitivity, specificity and overall accuracy of imprint cytology were 96.0, 90.8 and 92.1 per cent respectively, and those of frozen-section examination were 52.0, 100 and 88.1 per cent. Ten sentinel nodes were tumour positive on imprint cytology and tumour negative on stained paraffin sections. Micrometastasis was found in eight of these nodes on immunohistochemistry. Taking these immunohistological results into consideration, the final sensitivity, specificity and overall accuracy of imprint cytology were 90.9, 98.5 and 96.0 per cent respectively.

CONCLUSION

Intraoperative imprint cytology is a useful method for evaluating the status of sentinel nodes and is more accurate than frozen-section analysis. In addition, imprint cytology can detect micrometastasis more accurately than conventional haematoxylin and eosin-stained sectioning.

Inhibition of lysoPAF acetyltransferase activity by components of licorice root

Licorice root traditionally used as an anti-inflammatory drug exhibited an inhibitory effect on lysoPAF (platelet-activating factor) acetyltransferase in vitro: the ether soluble fraction of the crude drug produced a 27.3% inhibition at a concentration 10 microg/ml. From this fraction, licoricidin (1), 1-methoxyphaseollin (2), 6,8-diprenylgenistein (3) and 1-methoxyphaseollidin (4) were isolated as active components, whose IC50 values were 7.7, 57, 19 and 48 microM, respectively. Licoricidin (1) seems to be one of the most potent compounds of plant origin isolated so far.

Activation of the right inferior frontal cortex during assessment of facial emotion

We measured regional cerebral blood flow (rCBF) using positron emission tomography (PET) to determine which brain regions are involved in the assessment of facial emotion. We asked right-handed normal subjects to assess the signalers' emotional state based on facial gestures and to assess the facial attractiveness, as well as to discriminate the background color of the facial stimuli, and compared the activity produced by each condition. The right inferior frontal cortex showed significant activation during the assessment of facial emotion in comparison with the other two tests. The activated area was located within a triangular area of the inferior frontal cortex in the right cerebral hemisphere. These results, together with those of previous imaging and clinical studies, suggest that the right inferior frontal cortex processes emotional communicative signals that could be visual or auditory and that there is a hemispheric asymmetry in the inferior frontal cortex in relation to the processing of emotional communicative signals.

Malignant seeding of the lumpectomy cavity upon breast-conserving surgery

One of the etiologic factors involved in local recurrence after breast-conserving surgery may be malignant seeding of the wound during the lumpectomy procedure. A total of 340 patients with stage I and II breast cancer were entered into the study. Of these, 270 patients received breast-conserving surgery (BCS group), and the other 70 patients underwent mastectomy (control group). After resection, lavage cytology was performed at the surgical wound. There were 55 patients (20.4%) who showed positive lavage cytology in the BCS group. In the control group, there were only 3 patients (4.3%) with positive cytology. Positivity was significantly higher in the former group (p = 0.00064). Patients with evidence of cutting across cancer lesions showed significantly higher positive rates in lavage cytology (p < 0.00001). Positivity in lavage cytology was significantly higher in patients with positive surgical margins evaluated by frozen sections (p = 0.0017), touch cytology (p < 0.0001) and formalin-fixed, paraffin-embedded sections (lateral or medial margin; p = 0.0036, anterior and posterior margin: p = 0.0210). The positivity was also significantly higher in patients with an extensive intraductal component (p < 0.0001), and less than or equal to 50 (p = 0.0061) years of age. Multivariate analysis revealed that the highest relative risk factor for positive cytology was evidence of cutting across cancer lesions (relative risk = 8. 166; p < 0.00001).

Sentinel Node Biopsy in Breast Cancer Patients with Clinically Negative Lymph-Nodes

BACKGROUND: The purpose of the present study is to evaluate the usefulness ofdye-guided sentinel node biopsy in breast cancer patients with clinically negative nodes and to clarify the anatomic distribution of sentinel nodes in the axilla. METHODS: Sentinel node biopsy was performed in patients with T1 or T2 breast cancer who had clinically negative nodes, using an indocyanin green dye-guided method. Thereafter, complete axillary dissection was performed. Sentinel node andcomplete axillary lymph-node dissection specimens were examined separately, andthe incidence of metastases was compared. RESULTS: We identified sentinel nodes in 115 (76.7%) of 150 patients with clinically negative nodes. The mean number of sentinel nodes was 1.7 (range, one toeight nodes). The mean size of sentinel nodes was 9.0 mm (range, 2.0 to 28.0 mm). Of the 31 patients who had a tumor-positive sentinel node, 14 (45.2%) patients had only the sentinel node involved. There was concordance on histological examination between sentinel node and axillary node status in 111 (96.5%) of 115 cases. Of the sentinel nodes 89.1% were located cranially to the intercostobrachial nerve and within 2 cm of the lateral edge of the pectoralis minor muscle. CONCLUSIONS: Sentinel node biopsy guided by indocyanin green dye is an easy technique with an acceptable detection rate of sentinel nodes for breast cancer patients with clinically negative nodes. Most of the sentinel nodes were locatednear the lateral edge of the pectoralis minor muscle and cranial to the intercostobrachial nerve.

Further characterization of the 5'-flanking promoter region of the human beta1-adrenergic receptor gene

Further characterization of the 5'-flanking promoter region of the human beta1-adrenergic receptor (AR) gene was attempted. The transcription initiation sites, determined by the primer extension and the rapid amplification of the 5'-cDNA end, are multiple in a spanning about 30 nucleotides (-289 to -261 relative to the translation start site). There exist inverted CCAAT boxes, multiple binding sites for transcription factor Sp1 and AP-2 nearby transcription initiation sites, however, this region lacks a typical TATA box. In order to localize the regulatory region for the basal transcription of the human beta1-AR gene, a variety of 5'-flanking sequence/chloramphenicol acetyltransferase reporter gene fusion constructs was prepared and transiently expressed in HeLa cells. Functional analyses reveal negatively (-3813 to -2925 and -1772 to -796) as well as positively (-2925 to -1772) regulatory regions, in addition to the region (-796 to -87) being necessary for the basic expression of the human beta1-AR gene.

Neuroanatomical correlates of the assessment of facial attractiveness

Frontal cortical damage can lead to changes in affective aspects of personality. However, the difficulty of dissociating such abnormalities from cognitive disorders has overshadowed most previous findings. Regional cerebral blood flow (rCBF) was measured with positron emission tomography (PET) while normal subjects were assessing facial attractiveness. Two left frontal regions showed a significant increase in rCBF while assessing facial attractiveness. The increased rCBF in the left anterior frontal cortex correlated with the overall percentage of assessments of a face as unattractive, while that in the left fronto-temporal junction correlated with the percentage of assessments of a face as attractive. These findings provide direct evidence that the left frontal regions are engaged in the assessment of facial attractiveness.

Pleural lavage cytology immediately after thoracotomy and before closure of the thoracic cavity for lung cancer without pleural effusion and dissemination: clinicopathologic and prognostic analysis

BACKGROUND

The significance of intraoperative pleural lavage cytology (PLC) in lung cancer patients without malignant effusion remains undetermined in terms of staging, prognosis, and local management.

METHODS

PLC was performed both after thoractomy and before closure of the thoracic cavity in 325 patients with lung cancer without malignant pleurisy.

RESULTS

According to the PLC results (positive [+] or negative [-] after thoracotomy/before closure), the patients were classified as follows: group A (-/-), 262 patients; group B (+/-), 19; group C (-/+), 22; and group D (+/+), 22. In comparison with group A, group C showed more advanced stage with aggressive nodal involvement, and group D showed more advanced lung cancer related to pleural and nodal involvement, whereas group B showed characteristics similar to those of group A. The rate of pleural recurrence in group D was the highest (26%). In particular, pleural recurrence was seen in the patients with a relatively large number of adenocarcinoma cells in PLC after thoractomy. The patients in groups C and D, especially those with adenocarcinoma, showed poorer prognosis, but in a multivariate analysis, PLC status was not an independent prognostic factor.

CONCLUSIONS

PLC status after thoractomy provides useful information in the detection of high-risk subgroup for pleural recurrence. Although PLC status is closely associated with survival, its prognostic value is not independent.

Catalytic properties of carbonyl reductase from rabbit liver for analogs of acetohexamide and 4-acetylpyridine

A correlation was observed between the values of specificity constant (kcat/Km) of carbonyl reductase from rabbit liver for acetohexamide analogs and their partition coefficients. This result indicates that the hydrophobicity in straight-chain alkyl groups of acetohexamide analogs plays an important role in the catalytic activity and substrate-binding capacity of the enzyme. Furthermore, the double logarithmic plots of kcat/Km values of the enzyme for 4-acetylpyridine analogs with a straight-chain alkyl group up to five carbon atoms against their partition coefficients gave a straight line. On the other hand, the plots for 4-acetylpyridine analogs with a straight-chain alkyl group over five carbon atoms and with a branched-chain alkyl group were away from the straight line. It is reasonable to postulate that a hydrophobic pocket is located in the substrate-binding domain of the enzyme.

Pitfalls in fine needle aspiration cytology of breast tumors. A report of two cases

Two cases of fibroadenoma that were cytologically misdiagnosed as mucous carcinoma are reported. The reason for this misdiagnosis was the presence of mucus in the background of the smears. Cytologically, even if plenty of mucus is present in a smear, careful observation of the content of the mucus is necessary. A group of stromal cells in mucus or of epithelial cells dissociated from mucus suggests fibroadenoma with a mucous change in the fibromatous tissue.

[Urinary cytology for carcinoma of the urinary bladder]

Cytologic examinations of voided urine were reviewed for 82 cases of invasive or noninvasive papillary carcinoma and 25 cases of carcinoma in situ of the urinary bladder. Five of the 82 cases of invasive or noninvasive papillary carcinoma and 3 of the 25 cases of carcinoma in situ were asymptomatic, and malignancy was detected only by urinary cytology. Urinary cytology was positive in 18.5% of the Grade 1, 33.3% of the Grade 2, 75% of the Grade 3 noninvasive carcinomas and in 77.8% of the invasive carcinomas. However, all 25 cases of carcinoma in situ gave positive cytologic results. Malignant cells found in Grade 1 noninvasive papillary carcinoma were slightly atypic in shape. Their nuclei were small but showed mild to moderate hyperchromasia. These malignant cells appeared in small clusters but the number of clusters were few. In Grade 2 or 3 noninvasive papillary carcinoma, malignant cells appeared in small clusters or isolated single cells. Their nuclei were irregular in shape and showed moderate to marked hyperchromasia. In invasive carcinoma and carcinoma in situ, many malignant cells with marked atypia were observed, but in carcinoma in situ, the background of the specimens was clean.

A new method of intraoperative cytodiagnosis for more precisely locating the occult neoplasms of the pancreas

We have done endoscopic retrograde pancreatography-aspiration cytology for 81 consecutive patients in whom there had been neither pancreatic mass nor duct stenosis; cancer cells were detected in four cases (5%). This report reviews a new method of intraoperative cytodiagnosis, which was done for these four cases, to locate the original lesion of the cancer cells. This method involved dividing the pancreatic neck at a right angle to the main pancreatic duct. A catheter was then inserted in both the caudal and cranial ducts of Wirsung. With the aid of an intravenous injection of secretin, pure pancreatic secretions were collected separately and used for intraoperative cytodiagnosis. With this method, all four occult neoplasms of the pancreas were correctly identified as to whether they were located in the cranial, caudal, or both portions. In one case in which carcinoma in situ extended throughout the entire pancreas, total pancreatectomy had been indicated by the positive results obtained from both portions. Likewise, in the other three cases in which, the occult neoplasms were limited to the cranial or caudal pancreas, either a Whipple procedure (one case) or a caudal pancreatectomy (two cases) had been quite correctly indicated. Since this method is simple, safe, and reliable, it is beneficial to the patient with occult neoplasm, because it prevents blind resection of the entire pancreas without any fear of leaving the neoplastic lesion behind.

[Saponins of anemarrhenae rhizoma]

Three steroidal saponins 3, 4 and 5a were newly isolated from Anemarrhenae Rhizoma. Compounds 3 and 4 were identical with desgalactotigonin and F-gitonin, respectively. Compound 5a was established as (25S)-26-O-beta-D-glucopyranosyl-22-hydroxy-5 beta-furostane-3 beta,26-diol 3-O-beta-D-glucopyranosyl-(1----2)-O-beta-D-galactopyranoside on the basis of chemical and spectroscopic evidence.

Occult thyroid cancer discovered by fine-needle aspiration cytology of cervical lymph node: a report of three cases

Three cases of occult thyroid cancer measuring 10, 6, and 3 mm in diameter were discovered by fine-needle aspiration cytology of cervical lymph nodes. In these three cases, thyroid tumors were not palpable, and scintigraphic, echographic, and soft-tissue radiologic examinations demonstrated no abnormalities of the thyroid glands. Cytologically, the presence of intranuclear cytoplasmic inclusions, nuclear grooves, and colloid was characteristic in aspirated materials. Histologically, all three cases were diagnosed as papillary carcinoma. Fine-needle aspiration cytology of cervical lymph node was very useful to find occult carcinoma of the thyroid gland.

Cytologic diagnosis of laryngeal and hypopharyngeal squamous cell carcinoma in sputum

A prospective study of the value of sputum cytology in the diagnosis of squamous cell carcinoma of the larynx and hypopharynx is reported. Sputum cytology established the diagnosis in 63.5% of the patients with laryngeal lesions and in 77.4% of the patients with hypopharyngeal lesions. In laryngeal cancer, a positive diagnosis by sputum cytology was related to clinical T factors (according to the TNM classification): while only 29.4% of T1 lesions were positively detected by sputum cytology, 63.3% of T2 lesions, 69.7% of T3 lesions and 79.2% of T4 lesions were so detected. In hypopharyngeal cancer, there was no discernible relationship between sputum cytodiagnosis and clinical T factors. Generally, there was only a small number of cancer cells present in the sputum in these cases. Some of the squamous cancer cells were not very conspicuous and would require careful screening of the sputum specimens to be detected.

Fine needle aspiration cytology of "minimal" breast cancer

The value of fine needle aspiration (FNA) cytology in the diagnosis of "minimal" breast cancer was studied. Sixteen (76.2%) of 21 cases of invasive breast cancer less than 1.0 cm in diameter and 14 (73.3%) of 19 cases of noninvasive breast carcinoma were given a positive diagnosis by FNA cytology. One "suspicious" and the five false-negative diagnoses occurred in cases of invasive carcinoma; the reasons were considered to be either a faulty technique of needling the tumor or the presence of prominent fibrosis in the tumor. In noninvasive carcinoma, atypical cells were misdiagnosed in two of the five smears that had been originally reported as negative. The results of the retrospective analysis showed that FNA cytology had a higher accuracy in the diagnosis of small lesions than did radiologic and echographic criteria, and FNA cytology was thus used as the main criterion for deciding on the necessity for preoperative surgical biopsies.

Alteration in RNA synthesis in the dorsal root ganglia of methylmercury-treated rats

The effect of methylmercury in vivo on the incorporation of 3H-uridine in vitro into RNA of dorsal root ganglia of the rat was examined. Modified methods for the incubation of the tissue and extraction of RNA were applied to adequately determine the rate of RNA synthesis. Methylmercury significantly decreased the RNA content and RNA synthetic activity only in the symptomatic period, while uptake of the precursor into the acid-soluble pool remained unchanged. These results indicate that the previously reported inhibition of protein synthesis in dorsal root ganglia at an early phase of methylmercury intoxication was not due to impairment RNA synthesis in this tissue.

[Evaluation of aspiration cytology in the diagnosis of mammary tumors]

Aspiration cytology was performed in 1603 patients with breast lesions. Of 298 histologically confirmed malignant tumors, 234 (78.5%) had a concordant cytologic diagnosis. In 75% of 24 patients infiltrating cancer of 1.0 cm or less in greatest dimension, a correct diagnosis was obtained. The ratio of true-positive cases was higher and that of suspicious and false-positive cases lower, in aspiration cytology compared to mammography or echography. Cytologic diagnosis showed 4.7% false-positive results in this series. Atypical cells from intraductal proliferation and low malignant cancer cells were sometimes difficult to distinguish. In patients with such atypical cells, surgical biopsy was required. No difference in the 5-year survival was found between breast cancer patients who had aspiration cytology and their matched controls. Therefore, this method is very safe and is considered to be the most valuable in the correct diagnosis of breast cancer.