Prognosis of patients with advanced carcinoma of the esophagus with complete response to chemotherapy and/or radiation therapy: a questionnaire survey in Japan

BACKGROUND

We estimated the survival of patients with advanced carcinoma of the esophagus in Japan who achieved complete response (CR) with chemotherapy and/or radiation therapy.

METHODS

A questionnaire was designed for patients with cancer of the esophagus with pretreatment stage II-IV (excluding organ metastasis [M1]), who were treated with chemotherapy and/or radiation therapy and achieved either a clinical CR continuing for more than 1 year, or a pathological CR in surgical specimens. All patients were treated between January 1, 1990, and December 31, 1997, in Japan.

RESULTS

Of the 169 eligible patients for whom adequate data were available, 106 patients with continuing clinical CR were defined as group A and 63 with pathological CR as group B. The overall survival rates at 5 years were 62.4% in group A and 64.8% in group B. In each of groups A and B, there was no significant difference in overall survival among subgroups of patients classified by initial pretreatment clinical stage. In group A, the survival rate of patients with concurrent chemotherapy and radiation therapy was significantly better than the rates for patients with chemotherapy alone or radiotherapy alone. In group A, the frequency of first failure at the local site of esophageal carcinoma was 7.7%. Of the 12 patients in group B (19%) who died less than 1 year postoperatively, 6 died of postoperative complications.

CONCLUSION

The effect of CR to chemotherapy and/or radiation therapy for carcinoma of the esophagus on survival was marked. In patients with esophageal carcinoma who achieve CR, the prognosis may be independent of the initial pretreatment stage. Local failure in group A patients remains a problem, however.

CYP2C19 genotype related effect of omeprazole on intragastric pH and antimicrobial stability

PURPOSE

A combination of proton pump inhibitors and antimicrobials has been applied as an anti-Helicobacter pylori (H. pylori) therapy. Omeprazole, one of the proton pump inhibitors, is metabolized by CYP2C19. which exhibits genetic polymorphism. It was reported previously that the overall anti-H. pylori efficacy can be related to the CYP2C19 genotype. The main aim of the present study was to obtain a rational explanation for the relationship between the overall anti-H. pylori efficacy and the CYP2C19 genotype.

METHODS

Six healthy volunteers were classified as extensive metabolizers and poor metabolizers, according to their CYP2C19 genotypes. Plasma concentrations and intragastric pH were monitored prior to and until 24 h after the administration of 20 mg omeprazole. The stability of amoxicillin, clarithromycin, and metronidazole was examined using buffer solutions with monitored intragastric pH, and their remaining percentage in the intragastric space was simulated.

RESULTS

The poor metabolizers, classified by the CYP2C19 genotypes, showed the higher effectiveness in anti-H. pylori therapy, via the higher plasma concentration of omeprazole and the higher intragastric pH, and possibly the higher stability of antimicrobials in the higher intragastric pH.

CONCLUSIONS

CYP2C19 genotyping is a very useful method to determine the effective and safe dosage regimen including the selection of the dual and triple therapy in anti-H. pylori therapy.

[Rapid urease test]

The rapid urease test is a simple, sensitive, and highly specific test that enables the endoscopist to diagnose Helicobacter pylori infection in the endoscopy room. Determination of the infection status of Helicobacter pylori by biopsies from the gastric body had a significantly higher sensitivity than antral biopsies. A false-negative reaction by rapid urease test occurred the use of antibiotics (correlates with clearance of the bacteria) and the use of proton pump inhibitor or a part of mucosal protective agents(correlates urease inhibitory effect) and in the case of non-urease producing Helicobacter pylori. The rapid urease test satisfactory overall sensitivity before eradication treatment. However, the sensitivity of these rapid urease tests was lower after eradication than before eradication.

Glut1 expression in T1 and T2 stage colorectal carcinomas: its relationship to clinicopathological features

Glucose uptake is mediated by glucose transporter (Glut) proteins, which exhibit altered expression in a variety of malignant neoplasms. Glut1 expression is thought to be a potential marker for malignant transformation. The aim of the present study was to investigate the expression of Glut1 protein in colorectal adenomas, T1 and T2 stage carcinomas. Immunohistochemical detection of Glut1 protein was examined in 141 formalin-fixed and paraffin-embedded colorectal tumour specimens (57 adenomas, 84 carcinomas). The degree of Glut1 immunostaining of a specimen was graded according to the proportion of Glut1-positive cells in it; absent (positive cells are 0%), weakly positive (less than 10%), moderately positive (10-50%), and strongly positive (more than 50%). Glut1 expression was present in 18% of the adenomas with low-grade dysplasia, and in 63% of the adenomas with high-grade dysplasia. The positivity in such lesions was usually weak, but was moderate in 8% of the adenomas with high grade dysplasia. For the carcinomas, there were significant correlations between Glut1-positivity and depth of invasion (T1 45% versus T2 74%, P<0.01), histological differentiation (well 49% versus moderately to poorly 74%, P< 0.05) and morphological type (polypoid 42% versus depressed 73%, P< 0.05), if the cut-off value was set at 10% of cells. In conclusion, we clarified the relationship between Glut1 expression and clinicopathological features in T1 and T2 stage colorectal carcinomas, and our results suggested a high malignant potential of the depressed-type carcinoma.

Flat-elevated and depressed, subtypes of flat early colorectal cancers, should be distinguished by their pathological features

Flat-type colorectal tumors have are being detected with increasing frequency. It has become clear that these flat lesions contain two subtypes; flat-elevated and depressed lesions. However, their clinicopathological features and roles in colorectal carcinogenesis remain obscure. We classified colorectal adenomas and submucosal invasive cancers into three types: polypoid, flat-elevated, and depressed types. A clinicopathological study of 2505 colorectal tumors (2407 adenomas, 98 submucosal invasive cancers) was then performed. Furthermore, 64 tumors (25 adenomas with high-grade dysplasia, 39 submucosal invasive cancers) from which DNA was extracted were examined for K-ras gene mutation. The percentages of each configuration in the resected materials were 62.0%, 36.4%, and 1.6% of the polypoid, flat-elevated, and depressed types, respectively. The rate of submucosal invasive cancer in the depressed type was always high regardless of size. In the polypoid and flat-elevated types, lesions of larger size showed higher rates of invasion. Analysis of submucosal invasive cancers revealed no adenomatous components in any of the depressed-type lesions; in the polypoid and flat-elevated types the frequencies of cancer with adenomatous components were 83.6% and 77.8%, respectively. The flat-elevated type was more frequently located (77.8%) in the proximal colon than the other types (polypoid type 16.4%, depressed type 25.0%). The incidence of K-ras gene mutation was 47.2%, 18.2%, and 0% in the polypoid, flat-elevated, and depressed types, respectively. These findings suggest that the flat-elevated and depressed types are similar in that they are both morphologically flat and have infrequent incidences of K-ras gene mutation, but these two lesions differ in their pathological features. Especially, depressed type lesions have a tendency to invade the submucosal layer even when they are small. Therefore one should always be aware of this type of lesion during colonoscopic examination.

Myocardial infarction with acute insulin poisoning--a case report

A 36-year-old woman without overt coronary risk factors was admitted to hospital with coma about 9 hours after mass self-injection of insulin (1,500 units). Laboratory investigation revealed severe hypoglycemia and hyperinsulinemia. During the treatment of her hypoglycemia, circulatory collapse occurred. The ECG, echocardiogram, and elevation in troponin T suggested a diagnosis of myocardial infarction. Although the patient became apallic and developed systemic spasticity due to hypoglycemic brain damage, her hemodynamics improved with supportive care alone. Coronary angiography and myocardial scintigraphy performed later demonstrated a broad area of myocardial damage despite intact coronary artery circulation. The authors hypothesize that temporary coronary arterial narrowing or coronary arterial vasospasm induced by severe hyperinsulinemia contributed to the pathogenesis of the myocardial infarction. The possibility of myocardial infarction should be considered in patients with acute insulin poisoning.

Helicobacter pylori-negative peptic ulcer in Japan: which contributes most to peptic ulcer development, Helicobacter pylori, NSAIDS or stress?

Of 302 patients with peptic ulcer, 11 (3.6%) proved negative for Helicobacter pylori: 9 with gastric ulcer (GU) and 2 with duodenal ulcer (DU). Among these 11 H. pylori-negative patients with ulcers, two with GU were using non-steroidal anti-inflammatory drugs (NSAIDs) and one with GU was using a corticosteroid. The Hanshin-Awaji earthquake induced life-event stress that not only triggered but exacerbated GU, particularly in the elderly, resulting in a higher GU/DU ratio than the corresponding period of the previous year (3.07 vs. 1.88) in the devastated area. Furthermore, the seroprevalence of the infection and the odds ratio from the case-control study were similar to or even higher than that reported previously in patients with GUs unrelated to the earthquake. H. pylori and the use of NSAIDs are the major independent risk factors for peptic ulcers, although, H. pylori infection plays some role in the development of peptic ulcers under stressful conditions.

Prognostic significance of the carcinoma area in the thickest part of the lymph node

BACKGROUND/AIMS

The carcinoma volume in each metastatic lymph node varies widely. Our aim was to define the meaning of carcinoma volume in lymph nodes as a prognostic factor.

METHODOLOGY

One hundred and five patients with preoperatively untreated esophageal carcinoma who underwent surgery were enrolled as subjects. In the present study, the carcinoma area within lymph nodes at their thickest level was substituted for carcinoma volume in lymph nodes for measurement and analysis. A total of 3,703 lymph nodes were isolated and the area of the carcinoma in the thickest part of the lymph node (CALN) was measured. Univariate and multivariate analysis of prognostic significance were made for the factors age, sex, cancer location, cell differentiation, pT, conventional classification of lymph nodes for surgical dissection (n), number of metastatic lymph nodes (MLN number), and CALN.

RESULTS

In all 105 cases, n was the best prognostic factor and CALN was more useful than MLN number. In the cases in which absolute curative resection was successful, CALN was the best prognostic factor.

CONCLUSIONS

The carcinoma area in the thickest part of the lymph node is a meaningful prognostic factor.

Analysis of Helicobacter pylori vacA gene and serum antibodies to VacA in Japan

Vacuolating cytotoxin, VacA, is one of the most important pathogenetic factors produced by Helicobacter pylori. However, it is not clear whether the diversity in disease outcome may be ascribed to variations in strain and/or to the host responses to virulence factors. In this study, we analyzed the vacA middle region sequence among 65 Japanese isolates to clarify the variation in strain and assayed antibody titer to VacA by ELISA using purified VacA to evaluate the host response to cytotoxin. The nucleotide sequence identities compared among Japanese isolates were 92.8 +/- 3.56%, and compared to 88.3 +/- 2.89% in tox+ strains reported in GenBank. Positive correlation was found between the antibody titers and the severity of atrophic change of the stomach. In Japan the nucleotide sequences of the vacA middle region were highly homologous and genetically closer to tox+ strains. Antibody titers and host response to cytotoxin may be associated with atrophy of the stomach.

Resuscitation from fulminant myocarditis associated with refractory ventricular fibrillation

Resuscitation was possible in a case of fulminant myocarditis with refractory ventricular fibrillation (Vf) using a percutaneous cardiopulmonary support system (PCPS). A 46-year old Japanese man suddenly experienced cardiopulmonary dysfunction shortly after the onset of flu symptoms, was promptly diagnosed as having fulminant myocarditis and PCPS was immediately initiated. On the second day in the hospital, refractory Vf occurred, which lasted for approximately 2h despite repeated efforts to terminate it. Finally, a large dose of steroids was administered. From the third day of hospitalization and onwards, the Vf disappeared totally. The patient completely recovered from such a serious state in 6 months. During the following 3 years, he has had no clinical symptoms of worsening. As in this case demonstrates, most myocarditis is curable and invasive measures are very helpful in rescuing patients from the fulminant type with refractory Vf.

Laparoscopic lower anterior resection is equivalent to laparotomy for lower rectal cancer at the distal line of resection

BACKGROUND

Procedures that involve resection of the distal rectum challenge the current limitations of laparoscopic technology, because of lack of compact articulating stapling instruments.

METHOD

We improve the procedure with the aid of a Lap disk, an abdominal wall sealing device that was developed for hand-assisted manipulation. A linear stapler capable of changing its stop angle is inserted through the disk, and the rectum is transected by the disk during a second pneumoperitoneum.

RESULTS

The transection line becomes equivalent to that obtained with laparotomy.

CONCLUSION

This new technique made laparoscopic lower anterior resection possible to transect the lower rectum in the same way as is done with laparotomy.

HLA-DQB1 locus and the development of atrophic gastritis with Helicobacter pylori infection

Helicobacter pylori is known to be involved in digestive diseases such as peptic ulcer, atrophic gastritis, and gastric cancer. It is supposed that the incidence of these digestive diseases associated with H. pylori is influenced by the strain diversity of H. pylori, factors involving the host or environment, and the duration of infection. In this study, we directed our attention to HLA, a host factor, and investigated the relation between HLA-DQB1 genotype of H. pylori-infected patients and the development of atrophic gastritis. HLA-DQB1 genotyping was performed by the polymerase chain reaction-restriction fragment length polymorphism method on 122 H. pylori-infected patients with atrophic gastritis and 28 uninfected Japanese controls. Infected patients with developed atrophic gastritis were classified as the open type and those with undeveloped atrophic gastritis as the closed type. To estimate the grade of atrophic gastritis reliably, histological and serological evaluations were also undertaken. The allele frequency of DQB1*0401 was significantly higher in the open-type group compared to either the closed-type or the uninfected group. These results suggest that immunogenic factors play an important role in the development of atrophic gastritis in H. pylori-infected patients, and that DQB1*0401 is a useful marker for determining susceptibility to this disease.

Sufficient effect of 1-week omeprazole and amoxicillin dual treatment for Helicobacter pylori eradication in cytochrome P450 2C19 poor metabolizers

Omeprazole is widely used for the treatment of Helicobacter pylori infection. It is metabolized by cytochrome P450 2C19 enzyme (CYP2C19) in the liver. Because this enzyme exhibits a genetic polymorphism, patients with low metabolic activity (poor metabolizers) may be exposed to higher concentrations of this drug than are patients who are extensive metabolizers. Eighty-six patients with cultured H. pylori-positive gastritis or peptic ulcers who completed the treatment and assessment of anti-H. pylori therapy were analyzed for CYP2C19 genotyping using a polymerase chain reaction-restriction fragment length polymorphism method [the wild-type or two mutant genes (ml in exon 5 and m2 in exon 4), or both]. Patients were classified into three groups according to the H. pylori eradication regimen: group I (n = 21; omeprazole 40mg/ day and amoxicillin 2000mg/day for 1 week); group II (n = 21; group I regimen plus sucralfate 4000mg/day, for 1 week); group III (n = 44; group I regimen plus clarithromycin 800mg/day, for 1 week). The combination of two mutant alleles (ml/ml, ml/m2, m2/m2-poor metabolizers) was observed in 13 of 86 patients (15%), and all poor metabolizer patients achieved H. pylori eradication regardless of their treatment regimens. In addition, the eradication rates of the poor metabolizers were significantly higher than those of other genotypes who carry homozygous or heterozygous normal allele (extensive metabolizers) in group I or groups I and II combined. CYP2C19 genotyping can provide a new strategy to choose an optimal regimen, and this genotyping is especially useful for Japanese, as the frequency of poor metabolizers is five times greater than that found among Caucasians.

Interaction of docetaxel ("Taxotere") with human P-glycoprotein

The interaction of docetaxel ("Taxotere") with P-glycoprotein (P-gp) was examined using porcine kidney epithelial LLC-PK1 and LLC-GA5-COL150 cells, overexpressing human P-gp selectively on the apical plasma membrane by transfection of human MDR1 cDNA into the LLC-PK1 cells. The basal-to-apical transport of [14C]docetaxel in LLC-GA5-COL150 cells significantly exceeded that in LLC-PK1 cells, but the apical-to-basal transport was decreased in LLC-GA5-COL150 cells. The intracellular accumulation after its basal or apical application to LLC-GA5-COL150 cells was 4- to 20-fold lower than that of LLC-PK1 cells. Multidrug resistance (MDR) modulators, i.e., cyclosporin A and SDZ PSC 833, inhibited the basal-to-apical transport and increased the apical-to-basal transport of [14C]docetaxel in LLC-GA5-COL150 cells, but verapamil affected only apical-to-basal transport. The intracellular accumulation after basal or apical application to LLC-GA5-COL150 cells was also increased by these three MDR modulators. These observations demonstrated that docetaxel is a substrate for human P-gp, suggesting that docetaxel-drug interactions occur via P-gp. The inhibition of [14C]docetaxel transport by the MDR modulators, as well as daunorubicin and vinblastine, was also found in LLC-PK1 cells, which endogenously express P-gp at lower levels, and concentrations showing similar levels of inhibition were lower than those in the case of LLC-GA5-COL150 cells. These observations indicate that it is necessary to consider the pharmacokinetic and pharmacodynamic interactions of docetaxel via P-gp.

CYP2C19 genotype-related efficacy of omeprazole for the treatment of infection caused by Helicobacter pylori

OBJECTIVES

Omeprazole is used for the treatment of infection caused by Helicobacter pylori, and it is metabolized by the polymorphic cytochrome P4502C19 (CYP2C19). We have found that the anti-H pylori efficacy by the combination of omeprazole and antibiotics is related to the CYP2C19 genotype.

METHODS

One hundred eight patients with cultured H pylori-positive gastritis or peptic ulcer were treated with three regimens: quadruple treatment without proton pump inhibitors (n = 25), dual treatment with omeprazole and amoxicillin (INN, amoxicilline) (n = 26), and triple treatment with omeprazole, amoxicillin, and clarithromycin (n = 57). The CYP2C19 genotype was determined by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method and the assessment of the eradication of H pylori was based on all negative examinations, including culture, histology, and 13C-urea breath test.

RESULTS

The eradication rates for the extensive metabolizers were 50% and 86% for the dual and triple treatments, respectively. In contrast, all of the poor metabolizers treated with omeprazole and antibiotics (n = 15) showed an eradication of H pylori.

CONCLUSION

The anti-H pylori effect of dual treatment is highly efficient for CYP2C19 poor metabolizers, which suggests that clarithromycin is not necessary as a first line of therapy for this type of patients. Genotyping can provide a choice for the optimal regimen based on individual CYP2C19 genotype.

Postoperative complications in patients of esophageal cancer after neoadjuvant chemotherapy

We examined the effects of neoadjuvant chemotherapy on surgery by evaluating postoperative complications in 50 patients who had undergone neoadjuvant chemotherapy (Group A) and in 108 patients who had undergone surgery without neoadjuvant chemotherapy (Group B). Toxicity of grade 3 by chemotherapy were WBC in 3 patients (6%), alopecia in 3 patients (6%), and anorexia in 22 patients (44%). There were 4 patients with anastomotic leakage (8%) (all in minor), 5 patients with infection of wound (10%), 6 patients with arrhythmia (12%), no patients with postoperative bleeding, 2 patients with respiratory complications (4%), and no patients who died due to complications in Group A. In Group B, there were 13 patients with anastomotic leakage (13%) (all in minor), 12 patients with infection of the wound (11%), 11 patients with arrhythmia (10%), 2 patients with postoperative bleeding (2%), 8 patients with respiratory complications (7%), and 2 patients who died due to complications (2%). There was no significant difference in the incidence of postoperative complications between the patients who had undergone surgery after neoadjuvant chemotherapy, such as CDDP + 5FU therapy and FAP therapy, and the patients who had undergone surgery without neoadjuvant chemotherapy, in patients who had been diagnosed as being able to undergo relative non-curative resection or better, who had Ccr 60 ml/min or more and no severe complication, and whose stomach could be used for reconstruction of the esophagus, on the condition that surgery would be performed on NC patients at the end of first-course treatment.

In vitro effect of amezinium on the rabbit urinary bladder: muscle strip and whole bladder evaluation

Dose-response studies for norepinephrine and amezinium were obtained for isolated muscle strips and in vitro whole bladder preparations to investigate the effect of amezinium on the bladder. Specimens (strips from the bladder base and body, and the whole bladder) were obtained from mature female rabbits. By the muscle strip study, amezinium showed a weak contractile effect (up to 40% of spontaneous contraction) on strips from the bladder base. Muscle strips from the bladder body presented no response to amezinium. In the whole bladder preparation, administration of norepinephrine showed an increase in intravesical pressure in 4 out of 7 rabbits, whereas administration of amezinium had negligible effect on intravesical pressure. Administration of amezinium showed no influence on strips from the bladder body and the whole bladder preparation. Direct contractile response in muscle strips from the bladder base by amezinium appeared to be a favourable effect considering urinary storage.

Effect of charcoal hemoperfusion on clearance of cibenzoline succinate (cifenline) poisoning

BACKGROUND

Management of cibenzoline succinate (cifenline) poisoning by symptomatic treatment is recommended because it has been reported cibenzoline succinate is not effectively removed by hemodialysis. The use of charcoal hemoperfusion for patients with cibenzoline succinate poisoning has not been reported previously.

CASE REPORT

An 80-year-old woman with permanent right ventricular pacing was admitted to our hospital with general fatigue and clouding of consciousness. She had been receiving cibenzoline succinate for 1 month. The patient was clearly in shock on admission. Electrocardiogram showed a prolonged QRS and QTc interval and pacing failure. Hemodynamic failure, electrocardiographic abnormalities including pacing failure, and liver and renal dysfunction were compatible with cibenzoline succinate poisoning. Symptomatic treatment was provided. On day 4, charcoal hemoperfusion was initiated because of the development of hypoglycemia accompanied by liver and renal dysfunction. After charcoal hemoperfusion, the hypoglycemia, liver and renal dysfunction, prolonged QRS and QTc interval, and pacing threshold resolved. She was discharged on digoxin. We present a case of cibenzoline succinate poisoning treated with charcoal hemoperfusion which resulted in a rapid reduction of cibenzoline plasma concentrations with a significant clinical improvement.

Gastric ulcer formation after the Hanshin-Awaji earthquake: a case study of Helicobacter pylori infection and stress-induced gastric ulcers

BACKGROUND

Both Helicobacter pylori (H. pylori) infection and various stresses are known to induce peptic ulcer disease of the upper gastrointestinal tract. However, the pathogenetic relationship between the two factors has not yet been clarified. We conducted a case-control study to examine whether H. pylori infection played a role in the development of gastric ulcer (GU) induced by life-event stresses that were experienced after the Hanshin-Awaji earthquake.

MATERIALS AND METHODS

Serum samples from patients in the devastated area who developed GUs during the 2 months following the Hanshin-Awaji earthquake and those from GU patients in the same area during the corresponding period of the previous year, and from gender-, age- and institute-matched ulcer-free controls were tested for the presence of the H. pylori IgG antibody.

RESULTS

A significant association between H. pylori infection and the development of GU in uninjured patients was observed in all sets [matched odds ratio (OR) = 3.23, 95% confidence interval: 1.95-5.35]. Moreover, the prevalence of H. pylori infection in patients who developed GUs after the earthquake was not different from that for GU patients in the previous year. In contrast, there was no association between H. pylori infection and the development of GU in the physically injured patients after the earthquake.

CONCLUSIONS

H. pylori infection may play an important role in the development of GUs that are induced by emotional life-event stresses.

Optical tunneling effect calculation of a solid immersion lens for use in optical disk memory

A solid immersion lens (SIL) has the advantage of easily decreasing the spot size for high data density in optical recording. To accurately obtain the optical tunneling effect for a high-N.A. SIL, we calculated the optical tunneling beam characteristics, using electromagnetic theory. Tunneling beam spot-size dependence on polarization direction and energy-transfer efficiency are also clearly shown.

Possibility of pre-operative diagnosis of lymph node metastasis based on morphology

BACKGROUND/AIMS

The accuracy of pre-operative diagnosis of lymph node metastasis is insufficient. Our aim was to define the possibility of diagnosing metastatic lymph nodes based on morphology.

METHODOLOGY

One hundred and fifty-seven patients with pre-operatively untreated esophageal squamous cell carcinoma underwent resection, 5334 lymph nodes were isolated, and the short and long diameters were measured. We tried to construct a linear regression line for metastasis rate versus lymph node size (long diameter classified at intervals of 1 mm) by each location. The ratio of short diameter to long diameter (SL ratio) of metastasis-positive lymph nodes was compared with that of negative ones at each location.

RESULTS

Gradient and intercept of overall regression line was 0.0213 and 0.0101, respectively, and the long diameter producing a metastasis rate of 80% (LD80) was 37.1 mm. Metastasis-positive lymph nodes larger than calculated LD80 represented no more than 9.5% of all the corresponding metastasis-positive nodes. The locations with significant difference of SL ratio between metastasis-positive and negative ones were limited to right cardiac, left gastric artery, thoracic paratracheal, bifurcation, and the highest mediastinal nodes.

CONCLUSIONS

There is a low possibility that lymph node metastasis can be exactly diagnosed pre-operatively based on the size and morphology.

Hypokalemia with syncope caused by habitual drinking of oolong tea

A 61-year-old woman developed hypokalemia, atrioventricular block and ventricular tachycardia with syncope after habitual drinking 2 to 3 liters of oolong tea per day. She had been suffering from rheumatoid arthritis and Sjögren's syndrome and her serum albumin was decreased (2.9 g/dl). Oolong tea contains caffeine at approximately 20 mg/dl. Great quantities of caffeine can induce hypokalemia. The serum protein binding caffeine is albumin. Accordingly, in patients with hypoalbuminemia, caffeine is apt to induce hypokalemia. This case suggested that great quantities of oolong tea, one of the so-called "healthy" drinks, result in serious symptoms for patients with hypoalbuminemia.

Application of Bead-ELISA method to detect Helicobacter pylori VacA

Helicobacter pylori is an etiological agent of gastritis, gastric ulcer and gastric cancer. In order to clarify the significance of vacuolating cytotoxin (VacA) for the pathogenesis of Helicobacter pylori infection, we established and applied the sandwich bead enzyme-linked immunosorbent assay (Bead-ELISA) for quantitative determination of VacA in the culture mediums of H. pylori and other species of Helicobacter. The minimum concentration of VacA in culture medium detected by Bead-ELISA was 25 pg VacA/ml and its sensitivity was found to be quite high compared to vacuolation assay and Western blot analysis, e.g. the minimum concentrations of VacA in culture medium required for detection by vacuolation assay and Western blotting were 11 ng/ml and 38 ng/ml, respectively. All the H. pylori strains used were found to produce VacA in the culture medium by Bead ELISA, even though some strains were negative by Western blot and vacuolation assay. The results obtained by Bead-ELISA was consistent with those by PCR amplification of a 785 bp vacA fragments. A toxin immunologically similar to VacA produced by other strains of Helicobacter such as H. muridarum (ATCC49282), H. mustelae (F10) and H. felis (ATCC49179) could not be detected by Bead-ELISA as well as Western Blot.

Genetic variations in recurrent astrocytic tumors detected by restriction landmark genomic scanning

The genetic mechanisms associated with recurrence of advanced astrocytic tumors are poorly understood. We therefore analyzed 24 biopsy specimens from 12 patients with a recurrent astrocytic tumor by a two-dimensional gel electrophoresis method, termed restriction landmark genomic scanning (RLGS). Four spot changes were commonly present in the primary astrocytomas, indicating that the corresponding gene alterations were early events in the development of this tumor type. Altered spots were more frequent and of different distribution in recurrent tumors than in the primary astrocytomas. In particular, specifically increased intensity for spots on chromosomes 9-12 and 18 were observed in the secondary tumors, suggesting a relation with recurrence. The same spot changes observed in primary tumors were also found in the respective secondary lesions but with strikingly different densities in some cases, suggesting increased genetic instability. The altered segments provide important candidate regions for the search for genes involved in events leading to progression and more malignant recurrent tumors.

[Characteristics of anti-microbial agents and its clinical choice for H. pylori treatment]

Eradication of Helicobacter pylori (H. pylori) is now established as main treatment of upper-gastrointestinal diseases. Resistance to H. pylori and acid condition in the stomach were important factors which influenced H. pylori eradication. Recolonized H. pylori strains will be easily resistant to metronidazole and clarithromycin, whereas almost all of H. pylori strains are sensitive to amoxicillin. On the other hand, amoxicillin targets cell wall biosynthesis and clarithromycin inhibits protein synthesis of Helicobacter pylori mainly in the growth phase which induced high intragastric pH condition, however, metronidazole targets DNA and, therefore, is independent of the stationary or growth phase distribution. To established a optimal regimen for Helicobacter pylori treatment, several factors included them should be account according to the parmacokinetical standings.

Urokinase type plasminogen activator receptor expression in colorectal neoplasms

BACKGROUND

The urokinase type plasminogen activator receptor (uPAR) may play a critical role in cancer invasion and metastasis.

AIMS

To study the involvement of uPAR in colorectal carcinogenesis.

METHODS

The cellular expression and localisation of uPAR were investigated in colorectal adenomas and invasive carcinomas by in situ hybridisation, immunohistochemistry, and northern and western blot analyses.

RESULTS

uPAR mRNA expression was found mainly in the cytoplasm of dysplastic epithelial cells of 30% of adenomas with mild (19%), moderate (21%), and severe (47%) dysplasia, and in that of carcinomatous cells of 85% of invasive carcinomas: Dukes' stages A (72%), B (93%), and C (91%). Some stromal cells in the adjacent neoplastic epithelium were faintly positive. Immunoreactivity for uPAR was detected in dysplastic epithelial cells of 14% of adenomas and in carcinomatous cells of 49% of invasive carcinomas. uPAR mRNA and protein concentrations were significantly higher in severe than in mild or moderate dysplasia (p<0.05); they were notably higher in Dukes' stage A than in severe dysplasia (p<0.05), and significantly higher in Dukes' stage B than in stage A (p<0.05), but those in stage B were not different from those in stage C or in metastatic colorectal carcinomas of the liver.

CONCLUSIONS

Colorectal adenoma uPAR, expressed essentially in dysplastic epithelial cells, was upregulated with increasing severity of atypia, and increased notably during the critical transition from severe dysplasic adenoma to invasive carcinoma. These findings implicate uPAR expression in the invasive and metastatic processes of colorectal cancer.

Successful removal of large adrenal pheochromocytoma on the right side with liver mobilization

We report a case of a large adrenal pheochromocytoma on the right side successfully removed with liver mobilization. Bilateral anterior subcostal incision with a ventral midline incision extending from the xiphoid and subsequent use of self-retraction system provided satisfactory exposure of liver and diaphragm. This incision is useful for easy mobilization of the liver and manipulation of the inferior caval vein in patients with large adrenal tumour on the right side.

Antioxidant, OPC-14117, attenuates edema formation, and subsequent tissue damage following cortical contusion in rats

Oxygen free radicals contribute to various kinds of tissue injury processes within the central nervous system. It has been suggested that inhibition of free radical formation has the potential to attenuate secondary neural tissue damage involving ischemia or trauma, and antioxidant therapy may offer a promising approach. In the present study, employing a cortical contusion model in the rat, contusion-induced neural damage, was evaluated by investigating edema formation, behavioral activities and histological changes. The effects of the superoxide radical scavenger, OPC-14117, were also tested to determine how free radicals may contribute to such neural damage. The results demonstrated that cerebral contusion induces a progressive decrease in tissue specific gravity representing edema formation, and behavioral deficits in the Morris water maze test and habituation of exploratory activity. Histological examinations revealed necrotic cavity formation in the cortex and selective neuronal death of the hippocampal CA3 region. These changes were significantly attenuated by OPC-14117, which was administered as a single dose immediately following trauma induction. The above results indicate that oxygen free radicals are involved in contusion-induced edema formation, subsequent tissue damage and cognitive deficits. The superoxide radical scavenger, OPC-14117, has a powerful therapeutic potential for preventing secondary cell damage following traumatic brain injury.

[Telomerase activity in esophageal carcinoma and lesions unstained with Lugol's solution]

Telomerase is a specific enzyme required for the replication of telomeres. Its activity is detected in almost human cancers. We examined in esophageal carcinoma and lesions unstained with Lugol's solution telomerase activity by using telomeric repeat amplification protocol (TRAP) assay. Telomerase activity was detected in all 22 esophageal carcinomas, regardless of histopathological findings. In unstained lesions, telomerase activity was detected in 15 of 22; 10 squamous cell carcinomas, four dysplasia, one regenerative epithelium, no telomerase activity was found in seven; four normal esophageal epithelia, two Barrett's esophagi, one regenerative epithelium. These results suggest that telomerase activity may be a useful molecular marker for the diagnosis of esophageal carcinoma and of the early esophageal carcinoma in area unstained with Lugol's solution.

Correlations between urethral elastance and histological architecture in patients with benign prostatic hyperplasia

To investigate whether the properties of the flow-controlling zone (FCZ) in obstructive benign prostatic hyperplasia (BPH) would be affected by differences in the histological architecture of the prostate, we evaluated relationships between morphometric and urodynamic data. BPH specimens from 14 patients undergoing transurethral surgery were analysed by quantitative morphometry. The cross-sectional area and mean elastance of FCZ, together with other parameters, were calculated on a preoperative pressure-flow study. Correlations between these parameters and tissue composition were determined. Our study group comprised men with clinical and urodynamic evidence of infravesical obstruction secondary to BPH. No correlations were found between the area density or total volume of each histological element and the cross-sectional area of FCZ at peak flow rate. Neither area density nor total volume of each element correlated with the mean urethral elastance. Our results indicate that the histological architecture of the prostate in patients with obstructive BPH cannot predict the urethral elastance.

Peptic ulcers after the Hanshin-Awaji earthquake: increased incidence of bleeding gastric ulcers

OBJECTIVE

Although physical stresses are known to induce peptic ulcers in the upper gastrointestinal tract, it remains controversial whether emotional stress can cause peptic ulcers. Therefore, we examined retrospectively the influence of the Hanshin-Awaji earthquake that occurred in Japan in January 1995 on the occurrence of peptic ulcer disease among noninjured residents.

METHODS

Sixty-one hospitals, covering 70% of all endoscopy examinations performed in this area, joined the study and were divided into three areas according to the severity of the damage. A comparison was made between a group of 10,831 patients who underwent upper gastrointestinal endoscopy within 2 months after the earthquake and 16,100 who did so in the same hospitals during the corresponding period in 1994.

RESULTS

In the most devastated area, in spite of a dramatic decrease in the total number of endoscopies (50.0%), patients with gastric ulcer (GU) were increased in 1995, whereas those with duodenal ulcer were decreased, resulting in a higher ratio of gastric to duodenal ulcers than in 1994 (3.07 vs 1.88). In particular, there was a marked increase in bleeding GU. The mean age of patients with GU was significantly higher in 1995 than in 1994.

CONCLUSION

The Hanshin-Awaji earthquake-induced life event stress not only triggered but also exacerbated GU, particularly in the elderly.

Antioxidant, OPC-14117, attenuates edema formation and behavioral deficits following cortical contusion in rats

Oxygen free radicals may contribute to tissue injury processes in the central nervous system following ischemia or trauma. Recent studies have suggested that inhibition of free radicals improves the outcome in experimental models involving such conditions, and antioxidant therapy appears promising. In the present study, behavioral changes and edema formation in rat cortical contusion model were investigated, and the effects of a superoxide radical scavenger, OPC-14117, were tested. Wistar rats were anesthetized with halothane inhalation. Cortical contusion was induced in the parietal cortex employing a controlled cortical impact device. Immediately following injury induction, OPC-14117 was administered (300 mg/kg, p.o.). Edema formation was assessed in the center and peripheral areas of the contusion by the specific gravity method. Behavioral changes were evaluated by the Morris water maze test and the habituation of exploratory activity. The results revealed that the vehicle-administered control showed progressive edema formation and behavioral deficits following the injury. These changes were significantly attenuated by the OPC-14117 treatment (p < 0.05). Further, OPC-14117 reduced the size of contusional necrosis (p < 0.05). These findings suggest that superoxide free radicals are involved in contusion-induced edema formation, necrosis formation, and behavioral deficits, and that OPC-14117 has a therapeutic potential to prevent secondary cell damage following traumatic brain injury.

Hemodynamic depression and microthrombosis in the peripheral areas of cortical contusion in the rat: role of platelet activating factor

Cerebrovascular damages leading to subsequent reductions in regional cerebral blood flow (rCBF) may play an important role in secondary cell damages following traumatic brain injury (TBI). Recent studies have demonstrated that rCBF markedly decrease in experimental model of TBI (e.g. fluid percussion injury, acute subdural hematoma, contusion). However, precise mechanisms underlying post-traumatic CBF reduction remain unclear. In the present study, the rCBF changes and microthrombosis formation were investigated in a cortical contusional model in rats, and the effects of etizolam (platelet activating factor antagonist) on microthrombosis were tested. The rCBF in the peripheral areas increased transiently, and decreased to ischemic level 3 hours post- injury. The histological examinations revealed microthrombosis formation in the contused area, extending from the center to the peripheral areas within 6 hours post-injury. The rCBF decrease and the contusion necrosis volume were significantly attenuated by etizolam administration. These results indicate that platelet activating factor is involved in microthrombosis formation and hemodynamic depression, and resultant ischemic damages within areas surrounding the contusion.

Codon 201Arg/Gly polymorphism of DCC (deleted in colorectal carcinoma) gene in flat- and polypoid-type colorectal tumors

Recent studies have identified the distinct existence of flat-type colorectal tumors. The low incidence of ras gene mutations in these tumors suggests that their genetic pathways of tumor progression may be different from those of the polypoid type. To elucidate further genetic alterations in flat-type colorectal tumors, codon 201Arg/Gly polymorphism in the DCC (deleted in colorectal carcinoma) gene was analyzed in normal tissue (normal colonic mucosa or peripheral lymphocytes) and in tumor tissue from 191 patients with colorectal tumors (36 patients with flat-type colorectal tumors, 81 patients with polypoid-type colorectal tumors, and 74 patients with advanced carcinomas). For normal controls, 30 samples obtained from patients who had neither colorectal tumors (confirmed by total colonoscopy) nor a family history of colorectal carcinoma were analyzed. DCC gene codon 201Arg/Gly polymorphism was investigated by polymerase chain reaction-based restriction fragment length polymorphism analysis, fluorescence-based dideoxy sequencing, or both. For the flat type, the frequency of codon 201Gly of the DCC gene was 64% and 54% in the normal tissue of patients with adenoma with high-grade dysplasia and submucosal carcinoma, respectively. It was 49%, 52%, and 49% in the normal tissue of patients with polypoid-type adenoma with high-grade dysplasia, submucosal carcinoma, and advanced carcinoma, respectively. In the normal tissue, codon 201Gly of the DCC gene was more frequently observed in patients with flat-type adenoma with low-grade dysplasia (67%) than in those with polypoid-type adenoma with low-grade dysplasia (18%) or in normal controls (17%, P < 0.05, chi2 test). Codon 201Arg/Gly polymorphism in tumor tissues did not differ from that in the corresponding normal tissues, except for 10 cases of carcinoma with loss of heterozygosity (LOH). In carcinomas with LOH, preferential loss of the codon 201Arg allele was noted (9/10 cases). These results suggest that codon 201Gly of the DCC gene is not only associated with flat-type colorectal tumors, but that it may serve as a useful genetic marker for identifying groups at higher risk for colorectal cancer.

Functional property, norepinephrine content and morphometric findings in human hyperplastic prostate

BACKGROUND

Although alpha-adrenergic blockers are widely used as a treatment of benign prostatic hyperplasia (BPH), it is not clear whether contractile property of hyperplastic prostate to alpha-adrenergic agonist depends upon an area of density of smooth muscle within the respective BPH tissue.

METHODS

Functional study and quantitative morphometric analysis were performed on human prostatic specimens obtained by transurethral resection from 22 men with symptomatic BPH. Tissue norepinephrine content was also evaluated.

RESULTS

There was a linear correlation between the area of density of smooth muscle and maximum response to phenylephrine (r = 0.457, P = 0.0362). Although the area of density of smooth muscle showed a positive correlation with norepinephrine content (r = 0.437, P = 0.0471), norepinephrine content was not correlated with maximum phenylephrine response.

CONCLUSIONS

Contractile response to alpha-adrenergic agonist was directly influenced by the area of density of the smooth muscle within an individual prostate.

[Neoadjuvant chemotherapy and concurrent radiochemotherapy for advanced esophageal carcinoma potentially invading adjacent structures]

Advanced esophageal carcinoma invades adjacent structures, and its resection without residual tumor is difficult. Preoperative chemotherapy and combined modality therapy are being tried to improve survival in patients with T4 esophageal carcinoma. For these cases, chemotherapy with 5-fluorouracil and cisplatin (FP) is known to be not so effective. For 17 patients with T4 esophageal carcinoma in 2 institutes, treated primarily with chemotherapy with 5-fluorouracil, cisplatin and adriamycin (FAP), the response rate was 76%. Operation was performed in all of them after 2-3 courses of FAP, and curative resection without resection of adjacent structure was carried out in 14 cases (82%). Treatment with FP concurrent with more than 50Gy of radiation (CRT) was effective for patients with T4 esophageal carcinoma, its response rate was 72.80% in Japanese literature, and resectability rate was 37-48% after treatment. All of our 3 cases had partial response, but resection was not performed because patients refused surgery. Phase II trial of neoadjuvant chemotherapy followed by concurrent chemotherapy plus high-dose radiation therapy was carried out for 45 patients with clinical stage T1-4N0-1M0 in an attempt to improve the result of concurrent chemoradiation in America (RTOG), and the overall median survival was 20 months. But this treatment will not be used, because treatment-related death was seen in 10%. We think that FAP and CRT are the most effective neoadjuvant therapy in patients with T4 esophageal carcinoma. If curative resection is possible after treatment, operation should be done to improve prognosis.

[A case of rheumatoid arthritis (RA) with drug-induced acute pancreatitis due to mizoribine]

A rare case of mizoribine-induced acute pancreatitis is presented. A 39-year-old female with RA was admitted to our hospital because of upper abdominal pain, fever and the elevation of serum amylase concentration. Acute pancreatitis was diagnosed. Mizoribine (MZB) had been administered for 12 days for the treatment of RA before the onset of pancreatitis. Withdrawal of MZB soon resulted in the improvement of the disease. She was asymptomatic for the next few weeks. The pancreatitis recurred 36 hours after she took MZB again on her own judgement for arthralgia. This clinical course strongly suggested that her pancreatitis was due to MZB. Acute pancreatitis due to MZB has never, to our knowledge, been reported. MZB is commonly used for the treatment of RA. Therefore the clinician should take care for the complication of acute pancreatitis even though it is rare.

Effects of enalapril on tissue factor in patients with uncomplicated acute myocardial infarction

In a randomized, double-blind, placebo-controlled study beginning 4 weeks after uncomplicated acute myocardial infarction, it was established that the baseline plasma tissue factor antigen level was significantly higher in patients with myocardial infarction than in control subjects, and enalapril therapy significantly reduced the elevated plasma tissue factor antigen level. This may be associated with the reduction in the risk of coronary thrombosis seen with the use of angiotensin-converting enzyme inhibitors.

[Preoperative management of the aged patients with cancer of the esophagus]

The peak incidence of esophageal cancer is in the sixth decade, but the number of resections in patients older than 70 is increasing. 184 patients who underwent esophageal resections (C > or = 1) were divided into five groups according to age; Group A: under 50, B: 50s, C: 60s, D: 70s E: over 80. Five-year survival for Group D (20.5%) was much lower than other groups. Group E had better 1- and 2-year survival than Group D. Preoperative condition, stage and postoperative course were investigated in 145 patients who underwent subtotal esophagectomy with two-field lymphadenectomy and reconstruction with the stomach. In Group D, more respiratory dysfunction and abnormality of electrocardiogram were seen than Group C (p < 0.05) preoperatively. There was no difference in stage. Group D had higher incidence of postoperative pneumonia, abnormal ECG (p < 0.01) and delirium (p < 0.05). Group D had less cancer deaths and more deaths from other diseases. These results indicate that patients older than 70 should be called aged and it is safe to reduce the lymph node dissection in the upper mediastinum for these patients.