Combined intensive chemotherapy and radical surgery for incurable gastric cancer

BACKGROUND

To improve the poor prognosis of patients with advanced incurable gastric cancer, intensive chemotherapy combined with radical surgery was used.

PATIENTS AND METHODS

Thirty patients with incurable gastric cancer were treated with a combination of 5-fluorouracil (370 mg/m2) and leucovorin (30 mg/person), given intravenously for five consecutive days, followed by cisplatinum (70 mg/m2) and etoposide (70 mg/m2) on days 6 and 20, delivered through a catheter placed either in the aorta with its tip at the level of the ninth thoracic vertebra or in the celiac artery. This treatment (FLEP therapy) was repeated twice every 5 weeks. Radical or palliative surgery followed chemotherapy.

RESULTS

The overall response rate to the chemotherapy was 50.0% (15 of 30 patients, 95% confidence limit 0.305-0.671). Nineteen patients (15 with a partial response, three showing no change, and one with progressive disease) underwent surgery. Of these, nine underwent curative surgery and 10 palliative surgery. The median survival time was 6.5 months overall, 12.7 months for responders, and 4.7 months for nonresponders. Long-term survivors were exclusively found among patients with distant lymph node metastasis treated by curative surgery (55.6% at 5 years).

CONCLUSIONS

Favorable results of this small phase II study justify a phase III trial.

Prospective and randomized trial of lipiodol-transcatheter arterial chemoembolization for treatment of hepatocellular carcinoma: a comparison of epirubicin and doxorubicin (second cooperative study). The Cooperative Study Group for Liver Cancer Treatment of Japan

A randomized, controlled clinical trial was conducted to compare the use of epirubicin (EPI) and doxorubicin (DOX) in Lipiodol (Laboratoire Guerbet, Roissy-Charles-de-Gaulle Cedex, France)-transcatheter arterial chemoembolization as a treatment of hepatocellular carcinoma. One hundred ninety-two hospitals participated, and 415 patients were enrolled in the study during the period between October 1989 and December 1990. The patients were randomly allocated to group A (EPI) or group B (DOX) by a centralized telephone registration. The actual doses of EPI and DOX were 72 mg/body and 48 mg/body, respectively. The 1-, 2-, and 3-year survival rates were, respectively, 69%, 44%, and 33% for group A and 73%, 54%, and 37% for group B. There were no statistically significant differences (P = .2296, log-rank test). When each group of patients was classified retrospectively into high-risk and low-risk subgroups based on the severity index calculated by the Cox regression model from the significant prognostic factors (the pretreatment tumor size, the pretreatment serum alpha-fetoprotein level, tumor encroachment, and Child's classification), the survival curve of the low-risk DOX subgroup was significantly superior to that of the low-risk EPI subgroup (P = .0182). However, there was no significant difference between the high-risk subgroups (P = .4606). The change in the serum alpha-fetoprotein level, the extent of Lipiodol accumulation in the tumor, and the extent of tumor reduction after the treatment did not show any significant differences between the groups. The white blood cell count in group B showed a tendency to decrease slightly more than in group A at 3 weeks after Lipiodol-transcatheter arterial chemoembolization. In conclusion, there was no statistically significant difference between the survival curves of the EPI and DOX groups in Lipiodol-transcatheter arterial embolization treatment of hepatocellular carcinoma.

Natural course of serum-specific immunoglobulin E and immunoglobulin G4 for a span of eight years in untreated patients with perennial allergic rhinitis

During the past two decades, considerable attention has been devoted to the clinical role of serum-specific IgE and IgG4 following immunotherapy. To definitely discuss the clinical role of serum-specific IgG4, we should know the natural course of serum-specific IgG4 in the untreated patient with allergic rhinitis. To our knowledge, however, no such kind of study can be found in the literature. Our present study focused on the long-term follow-up of serum-specific IgE and IgG4 in patients who were not treated with immunotherapy for perennial allergic rhinitis. They were scheduled to take no medication for their perennial nasal symptoms for 8 years. Serum-specific IgE and IgG4 in untreated patients with perennial allergic rhinitis never significantly change during the observation period. These data will be of great value for studies in serologic changes following active treatment for atopic diseases. Additionally, our study suggests that a reduction in serum-specific IgE and an increase in serum-specific IgG4 following immunotherapy are not the result of an immunotherapy-independent and age-related phenomenon but the result of active immunologic modulation by immunotherapy.

Preoperative endocrine therapy for clinical stage A2, B, and C prostate cancer: an interim report on short-term effects. Prostate Cancer Study Group

BACKGROUND

Preoperative endocrine therapy has been suggested to improve surgical radicality and/or patient prognosis in prostate cancer.

METHODS

Patients with clinical stage A2, B, and C prostate cancer were randomized to either group I (n = 113) or group II (n = 111). Group I patients were to receive preoperative endocrine therapy consisting of leuprolide and chlormadinone for 3 months, followed by radical prostatectomy with lymph node dissection. Group II patients were to undergo the surgery before endocrine therapy.

RESULTS

Group I patients showed a remarkable decrease in prostate-specific antigen (PSA) (mean +/- SE: 41.8 +/- 8.6 ng/mL to 2.7 +/- 0.7 ng/mL) and prostate volume (29.8 +/- 1.7 mL to 21.2 +/- 1.6 mL) during the preoperative therapy. Histopathologic analysis showed a significant difference in the rates of down-staging (19.1% in group I versus 3.3% in group II), positive surgical margins (63.8% versus 81.3%) and positive lymph node metastasis (20.7% versus 36.5%). No significant difference was detected in operating features. Subgroup analyses indicated that beneficial effects were correlated positively with degree of histologic differentiation and negatively with the basal PSA level.

CONCLUSIONS

Preoperative endocrine therapy reduced local extension of prostate cancer, and the effects depended on histologic differentiation and PSA level. Long-term follow-up data are needed to determine the effects on the patient prognosis.

Serum level of soluble interleukin-2 receptor in patients with seasonal allergic rhinitis

The rate of release of the soluble form of interleukin-2 receptor (soluble IL-2R) reflects T cell activation in vivo. Since T lymphocytes play a central role in respiratory allergic disorders, the measurement of serum levels of soluble IL-2R may be useful in analysing the disease state of allergic disorders. The study has aimed at investigating the seasonal changes in serum soluble IL-2R in 81 patients with seasonal allergic rhinitis due to Japanese cedar pollens, with special reference to the effect of anti-allergic pharmacotherapy and immunotherapy. Serum samples were obtained twice from each patient, before and during the pollen season, and all the serum samples were simultaneously used for determination of soluble IL-2R and cedar pollen-specific immunoglobin E (IgE). Seasonal elevation in soluble IL-2R was not associated with the good clinical outcome but was associated with the poor clinical outcome, irrespective of pharmacotherapy or immunotherapy. Additionally, successful immunotherapy suppressed seasonal elevation of serum soluble IL-2R more strongly than successful pharmacotherapy, and seasonal increase rates in soluble IL-2R were inversely correlated with the duration of immunotherapy. Seasonal increase rates in soluble IL-2R were significantly correlated with seasonal increase rates in specific IgE in both the medication group and the immunotherapy patients. These results may suggest that seasonal changes in serum soluble IL-2R may serve as an indicator for clinical outcome of seasonal allergic rhinitis, that the magnitude of T cell activation could affect specific IgE production, and that T cell activation could be gradually modulated as immunotherapy proceeds. In conclusion, seasonal changes in serum soluble IL-2R may serve as an objective indicator for clinical outcome of seasonal allergic rhinitis.

Successful treatment of steroid-resistant severe acute GVHD with 24-h continuous infusion of FK506

We report our findings in two cases of steroid-resistant severe acute GVHD after allogeneic BMT successfully treated with FK506 (tacrolimus). An 18-year-old female (patient 1) who underwent BMT from an HLA-identical sibling for ALL in first CR, developed generalized erythema and profuse watery diarrhea, which progressed to acute GVHD of grade III severity, resistant to steroid control. After continuous 24-h administration of FK506, the diarrhea improved within 10 days. Patient 2, a 9-year-old girl with AML who underwent unrelated BMT, had skin, gut and liver lesions of acute GVHD grade IV, which did not respond to high-dose steroid therapy. They were controlled, however, by continuous intravenous infusion of FK506. Both patients are still surviving after more than 1 year without any acute GVHD sequelae or signs of chronic illness. The adverse effects of FK506 were mild and tolerable in both cases. Comparison of our findings with those in the literature suggests that it is important to give FK506 at plasma concentrations as high as 25-35 ng/ml by continuous intravenous infusion for extended periods to control steroid-resistant severe acute GVHD.

Isolated maxillary bending in CL/FR strain mice: observation of craniofacial deformity and inheritance pattern

OBJECTIVE

The CL/Fr mouse, known as a strain with spontaneous cleft lip and/or palate (CL/P), has been used as an animal model to investigate etiology in CL/P.

METHOD

We examined a facial asymmetry mutant discovered in a CL/Fr mouse colony that was not associated with CL/P and was shown to be inheritable in subsequent generations. Facial asymmetry became apparent with postnatal growth, whereas it was not detectable at birth, and was termed "maxillary bending" (MB) based on the characteristic bending of the maxilla.

RESULTS

As a result of selective breeding, an 'MB line', In which MB was observed in 21.68% (67/309) in addition to CL/P in 17.80% (55/309) of the offspring, was developed in the CL/Fr colony. In mating experiments between the MB line and C57BL/6J, all F1 progeny showed the normal phenotype. MB was observed in 0.72% (1/139) of the F2 generation, and the backcross generation showed segregation of MB in 6.25% (22/352) and CL/P in 1.42% (5/352). These instances suggested the occurrence of an additional mutation in the CL/Fr mouse genome controlled by an autosomal recessive gene with low penetrance. However, since the CL/Fr mouse primarily has a developmental deficiency in the maxilla, the possibility that CL/P and MB share common etiologic factors cannot be completely ruled out.

CONCLUSION

The maxillary bending retains significance, as this mutant can serve as an animal model of abnormal facial growth. Elucidation of the etiologic relationship between MB and CL/P may provide clues to clarifying the deficiency in first branchial arch in the mouse.

[Diabetic keratopathy]

A variety of corneal complications which occur in diabetics were briefly reviewed and the importance of the recognition of diabetic keratopathy was emphasized. This particular disease emerges and persists following the undue stress including intraocular surgery or photocoagulation. A varied degree of epithelial disturbance such as superficial punctate keratopathy, persistent epithelial defect, or recurrent corneal erosion can take place based on suppressed cell division, deturgence of barrier function, deterioration of basal cell adhesion, or decreased corneal sensitivity. Corneal endothelium also exhibits abnormalities in cell morphology including coefficient variation or percentages of hexagonal cells so that corneal edema tends to persist postoperatively. The involvement of the polyol pathway has been implicated in the pathogenesis of these disorders.

ACTH-independent macronodular adrenocortical hyperplasia (AIMAH): report of two cases and the analysis of steroidogenic activity in adrenal nodules

We report clinical findings and steroidogenic activities in adrenal tissues in 2 cases of AIMAH. Endocrine studies revealed an undetectable level of plasma ACTH and a diminished circadian rhythm of plasma cortisol. A significant increase in plasma cortisol levels in response to ACTH stimulation was observed in both cases. After the administration of metyrapone in one case, urinary excretion of 17-hydroxycorticosteroid (17-OHCS) significantly increased, although the plasma ACTH level did not respond. Computed tomography showed large masses in both adrenal glands, and bilateral uptake was identified on adrenal scintigraphy. The totals for the bilateral adrenal glands were 98 g and 105 g, respectively, and the left adrenal was larger than the right in both cases. Steroid content in the nodules measured by high performance liquid chromatography (HPLC) showed that the cortisol content was definitely lower than that in cortisol-producing adenoma (CPA) and even in normal adrenals. The activities of cytochrome P450c17, P450c21 and P450c11 were evaluated in one case, and all of them were reduced in the nodules. Especially that of P450c17 was remarkably reduced. These data suggest that cortisol production in AIMAH is inefficient, and that the cause of Cushing's syndrome may be related to the marked increase in the number of cells or bulk of the tumor.

The antigen-bearing eye and the spleen are indispensable in maintaining anterior chamber-associated immune deviation

PURPOSE

To investigate the role of the eye and the spleen in maintaining suppression of delayed-type hypersensitivity (DTH) after anterior chamber (AC) inoculation of allogeneic splenocytes.

METHODS

Suppression of DTH response was tested in BALB/c mice after AC inoculation of allogeneic B10.D2 splenocytes. Seven days after AC injection, the antigen-inoculated eyes were enucleated or the spleens were removed. After enculeation or splenectomy at different time intervals, DTH responses in groups of the BALB/c mice were examined. Spleen components obtained from BALB/c mice that had been primed by B10.D2 splenocytes in the AC 7 days earlier were transferred intravenously to groups of naive syngeneic acceptors. At various intervals after adoptive transfer, variations of DTH responses were tested.

RESULTS

Inoculation of B10.D2 splenocytes to the AC of BALB/c mice induced antigen-specific suppression of DTH. Either enucleation of the antigen-inoculated eyes or splenectomy weakened the DTH-suppressive effect within 5 weeks and abolished it within 9 weeks, whereas the mice retaining both antigen-inoculated eyes and spleens maintained longstanding DTH suppression. Adoptive transfer of spleen components to syngeneic acceptors demonstrated DTH suppression for only 3 weeks.

CONCLUSIONS

The antigen-inoculated eye and spleen are required for long-standing suppression of DTH after AC inoculation of allogeneic splenocytes.

Correlation of anterior chamber-associated immune deviation with suppression of corneal epithelial rejection in mice

PURPOSE

The authors investigated the effect of anterior chamber corneal (AC) inoculation of genetically graft-identical antigen on T-cell immunity and the suppression of alloepithelial rejection in mice.

METHODS

Antigen-specific suppression of delayed-type hypersensitivity (DTH) and suppression transferability were tested in BALB/c mice injected with irradiated allogeneic B10.D2 splenocytes into AC. Other groups of BALB/c mice received irradiated B10.D2, BALB/c, or C3H/He splenocytes in the AC of the right eye. Seven days later, B10.D2 or C3H/He corneal lenticules were grafted at the limbus of the left eye (keratoepithelioplasty). Alloepithelial rejection of each grafted eye was evaluated according to clinical findings. The DTH response of the keratoepithelioplasty recipients against B10.D2 minor antigen was tested at the end of clinical observation (4 months after grafting). Also examined was spleen component transfer from BALB/c mice with AC inoculation of B10.D2 splenocytes to syngeneic acceptors and its effect on suppression of epithelial rejection against B10.D2 antigen.

RESULTS

Inoculation of B10.D2 splenocytes into BALB/c AC induced antigen-specific DTH suppression, which suppression was transferable. During the 4-month observation period, AC inoculation of B10.D2 minor antigen significantly enhanced the survival of B10.D2-derived epithelium, but not of C3H/He-derived epithelium, in BALB/c mice. However, AC inoculation of BALB/c or C3H/ He splenocytes did not enhance B10.D2 epithelial survival in BALB/c mice. Incapability of antigen-specific DTH response generation was observed in the BALB/c mice with B10.D2 splenocytes in the right AC and B10.D2-derived epithelium in the left eye. Single transfer of spleen components from BALB/c mice with AC inoculation of B10.D2 splenocytes to syngeneic acceptors only delayed B10.D2 minor antigen-stimulated epithelial rejection, whereas supplementary transfers of the identical spleen components at different time intervals showed more significant effect in rejection delay.

CONCLUSIONS

The results showed that AC inoculation of B10.D2 splenocytes in BALB/c mice induced antigen-specific suppression of DTH response, in a phenomenon termed anterior chamber-associated immune deviation (ACAID). It also was shown definitely that ACAID can suppress alloepithelial rejection in a murine keratoepithelioplasty model. Adoptive transfer of splenocytes from ACAID-induced mice merely affords short-term suppression of epithelial rejection, suggesting that an additional mechanism may be involved in ACAID maintenance.

Reopening of macular holes in highly myopic eyes with retinal detachments

BACKGROUND

Gas tamponade with or without vitrectomy is commonly used to treat retinal detachment resulting from a macular hole in a highly myopic eye. Redetachment of the retina occurs frequently, however, and the pathogenesis of redetachment is unclear. One possible mechanism leading to redetachment is tangential traction caused by an epiretinal membrane of the posterior retina.

METHODS

Eleven consecutive highly myopic eyes with retinal detachment resulting from a macular hole were treated by vitrectomy, gas or silicone oil tamponade, and removal of an epiretinal membrane. Surgical outcomes and clinical characteristics of these patients were reviewed.

RESULTS

An epiretinal membrane was found to be present in all eyes. Of 11 eyes, removal of an epiretinal membrane was complete in six eyes, and macular holes remained closed in all 6 eyes. In five of the 11 eyes, removal of the epiretinal membrane was incomplete. In four of these five eyes, the macular hole reopened.

CONCLUSION

Reopening of the macular holes most likely were caused by tangential traction of the remaining epiretinal membranes. It seems that it is important to remove epiretinal membranes as completely as possible during vitrectomy for retinal detachment resulting from a macular hole in a highly myopic eye.

Flow characteristics and required control algorithm of an implantable centrifugal left ventricular assist device

As the clinical application of LVADs has increased, attempts have been made to develop smaller, less expensive, more durable and efficient implantable devices using rotary blood pumps. Since chronic circulatory support with implantable continuous-flow LVADs will be established in the near future, we need to determine the flow characteristics through an implantable continuous-flow LVAD. This study describes the flow characteristics through an implantable centrifugal blood pump as a left ventricular assist device (LVAD) to obtain a simple non-invasive algorithm to control its assist flow rate adequately. A prototype of the completely seal-less and pivot bearing-supported centrifugal blood pump was implanted into two calves, bypassing from the left ventricle to the descending aorta. Device motor speed, voltage, current, flow rate, and aortic blood pressure were monitored continuously. The flow patterns revealed forward flow in ventricular systole and backward flow in diastole. As the pump speed increased, an end-diastolic notch became evident in the flow profile. Although the flow rate (Q [l/min]) and rotational speed (R [rpm]) had a linear correlation (Q = 0.0042R - 5.159; r = 0.96), this linearity was altered after the end-diastolic notch was evident. The end-diastolic notch is considered to be a sign of the sucking phenomenon of the centrifugal pump. Also, although the consumed current (I [A]) and flow rate had a linear correlation (I = 0.212Q + 0.29; r = 0.97), this linearity also changed after the end-diastolic notch was evident. Based upon the above findings, we propose a simple algorithm to maintain submaximal flow without inducing sucking. To maintain the submaximal flow rate without measuring flow rate, the sucking point is determined by monitoring consumed current according to gradual increases in voltage.

[Reliability and validity of a self-administered questionnaire of patient health care behavior and satisfaction]

The reliability of a self-administered questionnaire of health care behavior and patient satisfaction, and also the validity of measuring patient satisfaction by a single question, were investigated on 754 outpatients and 204 inpatients. In order to assess the reliability and the validity, the questionnaire was administrated twice. Subjects for reliability tests were 194 outpatients and 91 inpatients and validity tests were performed with 280 outpatients and 84 inpatients. To assess the validity of patient satisfaction, supplementary questions about satisfaction (outpatients 22 items, inpatients 14 items) were included in the questionnaire. Reliability was assessed using kappa coefficient and proportion of agreement. To assess validity, principal component analysis was performed, and the correlation between principal-components and the score of patient satisfaction was analyzed. With the exception of patient understanding of the doctor's explanation and patient satisfaction, kappa coefficient and proportion of agreement were high (kappa: 0.4 approximately 0.82), indicating that question contents were objective and easily understood. By making the question categories simple, a higher kappa coefficient and proportion of agreement in patient understanding about doctor's explanation and patient satisfaction were achieved. This suggests that in questionnaire, similar question category must be made simple or similar categories should be put together in analysis. Spearman's correlation coefficient between the question about patient satisfaction and the first principal component (which summarizes all of the questions about patient satisfaction) was high (outpatients: 0.63, inpatients: 0.67). Therefore the validity of measuring general information about patient satisfaction by using a single question is suggested.

Positron emission tomographic imaging of head and neck lesions

Positron emission tomography (PET) produces images that reflect the rate and distribution of biochemical and physiological processes in tissue in vivo. This has been observed with many types of neoplasm not evident when using such anatomical imaging techniques as computed tomography or magnetic resonance imaging. We evaluated the feasibility of 2-18F-2-deoxy-D-glucose (FDG) PET studies in diagnosing and assessing the effects of treatment on lesions of the tongue, maxillary sinus and nasopharynx. FDG-PET imaging was performed 45 times in 17 patients with tumors before treatment. Ten patients with malignant lesions also underwent imaging after treatment. The differential absorption ratio (DAR) of the isotope was calculated at 55 min and the time activity curve (TAC) was obtained by dynamic emission scans for 0-55 min following injection of FDG. FDG-PET images, DAR and TAC were evaluated in all lesions. Findings showed that FDG-PET images could be used to diagnose malignant tumors and evaluate treatment when the DAR was > 4.0 and TAC was steep upward. Images suggestive of benign lesions had low DAR values (< 4.0) and mildly upward or flat TACs.

Treatment of herpetic keratitis with acyclovir: benefits and problems

Since the introduction of acyclovir in the last decade, the visual prognosis of herpetic keratitis has improved dramatically. Benefits with this superb agent include rapid resolution of epithelial keratitis, reduction of disturbances in ocular surface epithelia, and a decreased incidence of necrotizing keratitis or subsequent corneal melting. On the other hand, persistent superficial punctate keratopathy associated with topical usage, emergence of an acyclovir-resistant strain of herpes simplex virus, and a gradual increase in progressive corneal endotheliitis comprise the problems to be resolved.

A World Wide Web-based user interface for a data management system for use in multi-institutional clinical trials--development and experimental operation of an automated patient registration and random allocation system

We have employed the Hypertext Transfer Protocol (HTTP) and Hypertext Markup Language (HTML) to develop an automated patient registration and random allocation system for use in a multi-institutional clinical trial. We made it available on-line to World Wide Web clients in each hospital through a user friendly graphical user interface. During experimental operation, the physicians found it satisfactory from the viewpoint of both ease of operation and response time. For the development of a graphical user interface in network-based information system for use in multi-institutional clinical trials, HTTP/HTML has several advantages over an ordinary client-server model. Therefore, we concluded that we would adopt HTP/HTML for the construction of user interfaces for physicians in each spital and for data managers in our coordinating center.

Combination phase I/II study of irinotecan hydrochloride (CPT-11) and carboplatin in relapsed or refractory non-Hodgkin's lymphoma. CPT-11/Lymphoma Study Group

Irinotecan hydrochloride (CPT-11) is a new derivative of camptothecin which inhibits topoisomerase I. Phase II studies have demonstrated that CPT-11 is active against a broad spectrum of neoplasms including intractable non-Hodgkin's lymphoma. An early phase II study in lymphoma suggested that a schedule of daily infusions of 40 mg/m2/day for three or five consecutive days is more effective than a single infusion of 200 mg/m2 every three to four weeks. Carboplatin is also an active agent against lymphoma, and preclinical studies have shown that CPT-11 and its active metabolite have a synergistic effect with platinum compounds. To evaluate the maximal tolerated dose (MTD) and the therapeutic efficacy of CPT-11 in combination with carboplatin in relapsed or refractory non-Hodgkin's lymphoma, we conducted a combination phase I/II study. The starting dose of CPT-11 was 20 mg/m2/day (days 1 through 3 and 8 through 10), and dose escalations of 5 mg/m2/day increments were planned, with a fixed dose of carboplatin (300 mg/m2, day 1). Six of the eight patients receiving both agents at the starting dose level developed critical toxicities such as grade 4 hematologic (neutropenia 6/8, thrombocytopenia 1/8) and grade 3 non-hematologic toxicities (diarrhea 2/8, transaminase elevation 1/8). Further dose escalation of CPT-11 was halted, and the starting doses were judged to be the MTDs. The response rate (25%, 2/8) to the combination of the MTDs was not superior to that of CPT-11 alone in a previous phase II study (38%, 26/69), and the MTD of CPT-11 in combination with carboplatin was less than half the single-agent dose. We conclude that carboplatin is not recommendable for combination with CPT-11 in lymphoma patients. Other suitable agents for such a combination should be sought.