Severe obstruction of the superior vena cava caused by tumor invasion. Recanalization using a PTFE-covered Z stent

Bare stents are commonly used for the treatment of malignant vena cava stenoses. However, the therapeutic effect of treatment using bare stents for cases with intraluminal tumor invasion is not satisfactory. We report a case with severe obstruction of the superior vena cava caused by tumor invasion of mediastinal lymph node metastases from colon cancer, which was successfully treated by the recanalization of superior vena cava using a polytetrafluoroethylene-covered Z stent. The covered stent could not be fully expanded at first, and re-obstruction developed at the stented site due to thrombus formation soon after stenting. So, the additional balloon dilatation made the stent expend fully on another day of stenting. After the balloon dilatation blood flow improved immediately and the clinical symptoms associated with the superior vena cava obstruction resolved. Thereafter no symptomatic recurrence has been observed in 12 months of follow-up period.

Continuous selective intraarterial chemotherapy in combination with irradiation for locally advanced cancer of the tongue and tongue base

We retrospectively evaluated the results of the concurrent combination therapy of selective continuous intraarterial chemotherapy and radiotherapy in 39 patients with locally advanced cancer of the tongue and tongue base between September 1992 and January 2000. Thirty patients were fresh cases (stage II, 10 patients; stage III, 15; stage IV, five) and nine were recurrent cases. The primary lesion was present in the mobile tongue in 33 patients and the tongue base in six. External irradiation (median dose, 48.6 Gy) was performed in all patients, and interstitial brachytherapy using an Au grain or Cs needle (median dose, 50 Gy) in 21. In intraarterial chemotherapy, a catheter was selectively inserted into the lingual artery via the superficial temporal artery, and carboplatin (CBDCA) was continuously infused (median dose, 460 mg/m(2)) concurrently with radiotherapy. In 13 patients with cervical lymph node metastasis, two courses of systemic chemotherapy with 5-FU (700 mg/m(2) x 5 days) and cisplatin (40-50 mg/m(2)x2 days) or its analog was also performed. In 37 (94.9%) of the 39 patients in whom this combination therapy was completed, the response rate was 94.6%. The 3-year local control rate, progression-free survival rate, and overall survival rate by Kaplan-Meier's method were 79.2, 53.2, and 58.9%, respectively. This combination therapy was effective for locally advanced cancer of the tongue and tongue base without causing severe adverse side effects, and a local control rate comparable to that by surgery can be expected.

Therapeutic results of alternating chemoradiotherapy for nasopharyngeal cancer using cisplatin and 5-fluorouracil: its usefulness and controversial points

BACKGROUND

The present study was conducted to evaluate the therapeutic results of alternating chemoradiotherapy for locally advanced nasopharyngeal cancer (NPC).

METHODS

The subjects consisted of six patients with stage III nasopharyngeal cancer and 26 patients with stage IV nasopharyngeal cancer. Using 6 MV photons, radiotherapy was performed at an exposure of 1.8-2.0 Gy five times per week. That is, a total absorbed dose of 36-40 Gy was irradiated between the base of the skull and supraclavicular fossa. After decreasing the irradiation field, an absorbed dose of 26-30 Gy was additionally given thereafter. One course of chemotherapy consisted of the administration of 5-fluorouracil (5-FU) at a dose of 700 mg/m2/24 h for 5 days (days 1-5) and cisplatin (CDDP) at a dose of 50 mg/m2/24 h for 2 days (days 6-7) and a total of 2-3 courses of chemotherapy were performed. During the alternating chemoradiotherapy, chemotherapy was performed initially and 3-5 days after completing the chemotherapy, radiotherapy was performed for 3-4 weeks. Thereafter, chemotherapy and radiotherapy were performed alternately.

RESULTS

The scheduled courses of alternating chemoradiotherapy were completed in 30 (94%) of 32 patients. Although one patient developed shock induced by metal allergy to CDDP, no severe adverse effects were noted in any other patients. In these 32 patients, the overall 5-year survival rate was 75% (95% confidence interval: 60-90%) and the progression-free survival rate was 63% (95% CI: 46-89%).

CONCLUSIONS

This method of alternating chemoradiotherapy yielded higher or at least similar survival rates and lower toxicities than concurrent chemoradiotherapy and is worth trying in a multi-institutional study.

Alternating chemoradiotherapy for nasopharyngeal cancer using cisplatin and 5-fluorouracil: a preliminary report of phase II study

Alternating chemoradiotherapy was performed in 35 patients with locally advanced nasopharyngeal cancer. The median duration of follow-up was 20 months, and the 2-year progression free and overall survival rates were 83% (95% confidence interval: 66~101%) and 94% (95% CI: 84~105%), respectively. This method may be useful in treating nasopharyngeal cancer.

Aichi Cancer Center 10-year experience with conservative breast treatment of early breast cancer: retrospective analysis regarding failure patterns and factors influencing local control

PURPOSE

We analyzed the clinical results of conservative breast therapy in our institute to determine the risk factors influencing local and distant disease recurrence.

METHODS AND MATERIALS

From 1989 to 1997, 301 breasts of 295 women with early breast cancer were treated with conservative surgery and adjuvant radiotherapy. There were 212 incidences of Stage I breast cancer, and 89 of Stage II. Patients were routinely treated with local resection, axillar dissection, and 46--50 Gy irradiation given in 23--25 fractions. Some also received a radiation boost to the tumor bed.

RESULTS

The 5-/8-year overall survival, disease-free survival, and local control rates were 93.2/91.5%, 86.0/80.6%, and 95.1/92.5%, respectively. Using both univariate and multivariate analyses, tumor volume, estrogen receptor status, and age < 40 years were significant prognostic factors for disease-free survival. Both age < 40 years and surgical method had a strong effect on local control by uni- and multivariate analysis. Surgical margin status was a significant prognostic factor for local control at the univariate level (p < 0.0001), though it had only borderline significance at the multivariate level (p = 0.08). No patient experienced severe morbidity due to radiotherapy.

CONCLUSION

The results obtained are comparable to previously reported data. Although the follow-up period was too short to draw definite conclusions about long-term outcomes, the outcome from conservative breast treatment was acceptable.

External irradiation and intraluminal irradiation using middle-dose-rate iridium in patients with roentgenographically occult lung cancer

PURPOSE

Therapeutic results were analyzed in 39 patients with roentgenographically occult lung cancer (ROLC), and the significance and optimal dose of this therapy were evaluated.

METHODS AND MATERIALS

The subjects were 39 patients who underwent intraluminal irradiation between May 1987 and August 1999. Radiotherapy was performed by combining external irradiation with intraluminal irradiation using middle-dose-rate iridium (four 370-MBq wires) through a catheter with a spacer, which held the source in the center of the bronchus. The doses of radiation were 22-66 Gy (median value 45 Gy) by external irradiation and 10-46 Gy (median value 28 Gy) by intraluminal irradiation.

RESULTS

The therapeutic effect was CR in 38 patients and PR in 1, and local recurrence was observed in a PR case and 3 of the 38 patients who showed CR. The 3-year and 5-year relapse-free survival rates were both 87%. No severe radiation injury was observed.

CONCLUSIONS

Considering that ROLC often occurs as multiple cancers and that many patients with ROLC have reduced lung function, radiation therapy by a combination of intraluminal irradiation and external irradiation is expected to replace surgery as the first choice for the treatment of this disease in the twenty-first century.

[Two cases of squamous cell carcinoma of the anal canal treated with chemoradiotherapy]

We recently treated 2 patients with squamous cell carcinoma in the anal canal with bilateral inguinal nodal metastases using chemoradiotherapy. Chemotherapy (CT) consisted of 5-fluorouracil 700 mg/m2/day (continuous intravenously) on days 1-5 and cisplatin 50 mg/m2/day (continuous intravenously) on days 6-7. Chemotherapy was administered before the beginning of radiotherapy. In one patient, 2 cycles of CT were performed, and in the other patient 1 cycle only. The total radiation dose was 57.6 Gy to the primary lesion in each patient, and 53.6 Gy, 55.8 Gy to the nodal metastases, respectively. As a primary treatment response, CR was obtained in both patients. Acute grade 3-4 hematologic toxicities were observed in one patient. The patients have had 7 and 9 months survival without disease, and excellent function of the anal sphincter after treatment.

[Alternating chemoradiotherapy for oropharyngeal cancer]

To evaluate the usefulness of chemoradiotherapy for oropharyngeal cancer, we retrospectively analyzed disease-free survival (DFS) and acute toxicities of the patients treated with this therapy. Between 1990 and 1998, 15 patients were treated with alternating chemoradiotherapy (CRT). Chemotherapy (CT) mainly consisted of 5-fluorouracil 700 mg/m2 (i.v.) on days 1-5 and nedaplatin 100-140 mg/m2 (i.v.) on day 6. Chemotherapy was administered before the beginning of radiotherapy. One cycle of this treatment consisted of CT and a subsequent 27 to 36 Gy of radiotherapy, as a general rule, two cycles were performed. Radiotherapy was delivered in single daily fractions of 1.8 to 2 Gy, to a total dose of 54 to 75 Gy for local lesions and 45 to 86.3 Gy for nodal metastases in the neck. As a historical control, 52 patients treated with curative radiotherapy between 1971 and 1990 were analyzed and compared with the CRT group in terms of DFS. The complete response rate with CRT was 100%. The three-year DFS were 87% and 38% with CRT and RT, respectively. There was a significant difference between the two groups (p = 0.0081). The most frequent and severe acute toxicity was mucositis, with grade 3-4 occurring in 47%. Acute hematologic toxicities were mild. Therefore, this CRT is considered to be an effective and tolerable treatment, and is expected to improve survival for oropharyngeal cancer patients.

A combination therapy of continuous superselective intraarterial carboplatin infusion and radiation therapy for locally advanced head and neck carcinoma. Phase I study

BACKGROUND

To improve the treatment result for locally advanced head and neck carcinoma, the authors used a combination of radiotherapy with superselective continuous intraarterial therapy using carboplatin. The dose limiting toxicity (DLT), maximum tolerated dose (MTD), and treatment effectiveness were tested in Phase I and II protocols. PATIENTS AND METHODS. Thirty-five patients were entered into the study from August 1992 to May 1997. The target arteries were the lingual artery in 18 cases, facial artery in 5 cases, maxillary artery in 11 cases, and external carotid artery initially changing to lingual artery in 1 case. Escalating daily carboplatin doses were tested, starting from 10 mg/m(2) (total dose, 360 or 400 mg/m(2)) to 15 mg/m(2) (total dose, 405 or 450 mg/m(2)) and then 20 mg/m(2) (total dose, 460 or 500 mg/m(2)). Radiotherapy was administered using a 6-megavolt linear accelerator to a total dose of 50-60 grays. Interstitial radiotherapy boost also was used for carcinoma of the tongue.

RESULTS

Excluding 3 patients who discontinued treatment, the treatment results of 32 patients were complete response in 21 cases, partial response in 10 cases, and no change in 1 case. Neutropenia was the DLT, and the MTD was 500 mg/m(2). The local control rate was 64%.

CONCLUSIONS

Superselective continuous intraarterial carboplatin and concurrent radiation therapy can be delivered safely with good efficacy for locally advanced carcinomas of the tongue and base of the tongue. Surgical treatment of these diseases usually incurs severe functional loss. This current approach may be a breakthrough in these cancers.

Urinary orotic acid levels in normal pregnancy and pregnancy-induced hypertension

Our objective was to study the urinary levels of orotic acid in normal pregnancy and in pregnancy-induced hypertension. Such levels were measured using high-performance liquid chromatography with column-switching. The levels of urinary orotic acid (micromol/g creatinine) in normal pregnancy (n = 14) were 6.9 +/- 2.3 (first trimester), 10.1 +/- 2.4 (20 weeks) and 12.0 +/- 3.7 (30 weeks). In pregnancy-induced hypertension (n = 14), the corresponding levels were 6.5 +/- 1.7, 7.8 +/- 2.7 and 7.6 +/- 2.3, respectively. Normal pregnant subjects individually showed a significant elevation at 20 and 30 weeks of gestation as compared with those in the first trimester (p < 0.01). A high consumption of arginine in nitric oxide production during normal pregnancy may cause a physiological elevation of urinary orotic acid. The absence of an elevation in pregnancy-induced hypertension may be associated with a decrease in nitric oxide production.

The influence of the maternal heart rate on the uterine artery pulsatility index in the pregnant ewe

We investigated the influence of the maternal heart rate on the uterine artery pulsatility index in pregnant ewes. We used an external pacemaker to alter the heart rate of 5 pregnant ewes at 16-17 weeks of pregnancy and examined the effect of changes in the maternal heart rate on the uterine artery flow velocity waveforms and the pulsatility index, as determined by Doppler velocimetry. The uterine artery pulsatility index showed a significant negative correlation with the maternal heart rate. There were no significant changes in other hemodynamic parameters. The maternal heart rate had a significant influence on the uterine artery pulsatility index.

Substance P- and antigen-induced release of leukotriene B4, prostaglandin D2 and histamine from guinea pig skin by different mechanisms in vitro

Substance P (SP) induces increased vascular permeability, vasodilatation and granulocyte infiltration upon intradermal injection. Studies with antagonists and mast cell-deficient mice have suggested that granulocyte infiltration in response SP is mediated by leukotriene (LT) B4 derived from mast cells. However, the release of LTB4 has not been detected using mast cells isolated from human skin. Here we report the release of LTB4, prostaglandin (PG) D2 and histamine from guinea pig skin tissue in response to SP. The release of these agents occurred in a dose-dependent manner over a concentration range of SP from 1 x 10(-6) to 3 x 10(-4) M. No detectable PGE2 was released at any concentration up to 3 x 10(-4) M SP. The kinetics of histamine release induced in response to SP was more rapid than that induced by antigen. By comparison, SP-induced and antigen-induced release of LTB4 and PGD2 were similar, but slower than the histamine release. In the absence of extracellular Ca2+, release of histamine and PGD2 in response to SP was partially impaired, but to a lesser extent than that induced by antigen. On the other hand, LTB4 release in response to both SP and antigen was abolished under the same conditions. These results indicate that SP induces the release of LTB4, as well as histamine and PGD2, in the skin most likely from mast cells by a mechanism which may be different from that of mediator release in response to antigen.

Fetal compromise assessed by Doppler ultrasound of venous flow in pregnancy-induced hypertension

The purpose of this study was to determine the change of venous flow patterns in the inferior vena cava of fetuses in pregnancy-induced hypertension (PIH). We studied 80 normal pregnant women and 46 pregnant women with PIH and their fetuses. We determined the pulsatility index (PI) for arterial vessels, the ratio of peak flow velocities in early diastole and late diastole (E/A) in atrioventricular valves, and the preload index for the inferior vena cava. Twelve of the 46 PIH women showed an umbilical artery PI higher than the 95th percentile in normal pregnant women. Five of them demonstrated a decreased middle cerebral artery PI. Three of the 5 had an increased mitral E/A. Two of them had a decreased tricuspid E/A, an increased preload index, and a poor prognosis. An increased preload index suggests severe compromise in fetuses with a redistribution of arterial and intracardiac blood flow.

Chemical mediators in atopic dermatitis: involvement of leukotriene B4 released by a type I allergic reaction in the pathogenesis of atopic dermatitis

BACKGROUND

The mediators produced from a type I allergic reaction have not yet been able to explain the pathogenesis of atopic dermatitis (AD).

OBJECTIVE

The purpose of this study was to elucidate the involvement of leukotriene (LT) B4 produced from a type I allergic reaction in the pathogenesis of AD.

METHOD

The release of LTB4 was measured both in vitro, in passively sensitized and antigen-challenged human skin slices, as well as in vivo, in skin chambers on patients with AD.

RESULTS

LTB4 was released from in vitro human skin by stimulation of the antigen (54.9 +/- 14.6 pg/g wet weight of skin by antigen challenge and 28.0 +/- 11.1 pg/g in control skin, P <.002). Antigen-specific release of LTB4 and histamine was also observed in vivo in nonlesional skin from the patients with AD by using the skin chamber technique.

CONCLUSION

LTB4 release during type I allergic reaction in human skin has been determined in vitro. The released LTB4 possibly contributes to cellular response at the acute inflammatory lesion of AD.

[A case report of Erdheim-Chester disease]

Erdheim-Chester disease is a rare and distinctive lipid granulomatosis with characteristic pattern of radiographic changes in bone. The characteristic radiographic finding is an unusual symmetrical sclerosis at the diametaphyseal portions of many long bones. This study demonstrates a case of Erdheim-Chester disease and mainly documents radiographic findings.

[Clinical reliability of a new IgE detection system using chemiluminescent enzyme immunoassay named LUMIWARD immunoassay system]

The measurement of allergen-specific IgE antibodies and total IgE was performed with LUMIWARD immunoassay system (chemiluminescent enzyme immunoassay) using 406 serum samples obtained from patients with various allergic diseases and 81 serum samples from normal donors. These were collected by departments of internal medicine, pediatrics, dermatology and otorynolaryngology at eleven institutes in Japan. In addition to a comparative study with CAP RAST, skin tests were also performed to establish a clinical diagnosis. Simultaneous measurements were performed and an excellent correlation with CAP RAST was observed with a concordance rate of 92.6% and correlation coefficient of 0.922. The specificity determined by the normal serum samples was 96.4% for CAP RAST and 96.2% for LUMIWARD. The sensitivity determined by the samples, of which etiological allergens were identified clinically, was 84.8% for CAP RAST and 85.5% for LUMIWARD. Among them, the sensitivity of skin test was 91.8%. The concordance rate with clinical diagnosis was as high as 90.6% and 90.8% for CAP RAST and LUMIWARD. The normal upper limit of total IgE by cumulative 95% value was calculated to be 170 IU/ml for adult subjects. These results indicate the clinical usefulness of the LUMIWARD immunoassay system in evaluating IgE antibodies and total IgE.

[Surgical repair of infarct-related ventricular septal perforation using Teflon felt patch]

Eight patients with infarct-related ventricular septal perforation underwent surgical repair using Teflon felt patch. The overall early operative mortality rate was 12% (1/8). One of three patients (33%) with cardiogenic shock preoperatively, one of five patients (20%) operated within 7 days after the onset of infarction died within 30 days after operation. A patient with inferior infarction died early after operation. In 5 of 8 patients (63%), IABP was removed within 24 hours after operation. A patient died due to the recurrence of gastric cancer in late postoperative phase. None of patients was found to have a recurrence of the ventricular septal perforation after the operation. Five of 6 patients (83%) surviving the operation are in NYHA class I or II.

[Assessment of the relation between bone mineral metabolism and mitral annular calcification or aortic valve sclerosis in elderly patients]

We assessed the effect of bone mineral metabolism on mitral annular calcification (MAC) and aortic valve sclerosis (AVS) in elderly patients. Both MAC and AVS were derived by 2-D echocardiography and bone mineral content (BMC) of vertebral body was obtained by quantitative computed tomography using a calibrated phantom system. The 162 patients were classified according to the echocardiographic finding into three groups; CNT group consisted of the 79 control patients (31 males, 48 females) without MAC or AVS. MAC group: 42 patients (11 males, 31 females) with MAC, and AVS group: 41 patients (19 males, 22 females) with AVS. The results were as follows: 1) The incidence of MAC and AVS in both males and females were increased in proportion to aging. 2) The incidence of MAC in females (31%) was higher than that of males (18%). 3) The AVS in males (31%) was more frequent than that in females (22%). 4) In females of eighth and ninth decades, the BMC in MAC group was significantly decreased than that in CNT group, but not different in males. 5) In both males and females, the BMC in AVS group was not significantly different from that in CNT group. These results suggest that the MAC may be attributed to the ectopic deposit, probably related to the de-calcification from the spinal bone. On the other hand, the AVS may be caused by the other factors, mainly prolonged and sustained pressure or stress loading.