Recurrent pulmonary adenoid cystic carcinoma presenting as a cardiac tumor

A 58-year-old patient is presented who had a pulmonary adenoid cystic carcinoma which recurred 10 years after sleeve left pneumonectomy. The patient developed acute heart failure because the lesion obstructed blood flow by compressing the left atrium. Transesophageal echocardiography and magnetic resonance imaging demonstrated a solid mass arising from the pericardium which displaced the posterior wall of the left atrium. The mass was resected. Postoperative radiation was not performed.

Strong association of SYT-SSX fusion type and morphologic epithelial differentiation in synovial sarcoma

Synovial sarcoma is characterized by a specific recurrent translocation t(X; 18), resulting in either the SYT-SSX1 or SYT-SSX2 gene fusion. Because this is the primary genetic alteration in these tumors, we sought to identify the impact of molecular heterogeneity of the t(X;18) on cell proliferation, apoptosis, and epithelial differentiation in synovial sarcoma. Seventy-three patients with synovial sarcoma (18 biphasic, 55 monophasic) were selected on the basis of availability of tumor material for molecular and immunohistochemical analysis. Tumors were classified as biphasic on the basis of morphologic glandular differentiation. SYT-SSX fusion transcripts were examined by reverse transcriptase polymerase chain reaction using tumor RNA extracted from frozen or paraffin-embedded tissue. Cell proliferation was assessed immunohistochemically by the Ki-67 labeling index. Apoptosis was analyzed immunohistochemically with BAX and BCL2 antibodies and by the TUNEL method. Immunohistochemical evidence of epithelial differentiation was assessed using antibodies to cytokeratins and epithelial membrane antigen. Approximately two thirds of the tumors had an SYT-SSX1 and one third had an SYT-SSX2 fusion transcript. There was a strong association between SYT-SSX fusion type and histologic subtype. All biphasic synovial sarcomas had the SYT-SSX1 fusion, whereas all tumors with SYT-SSX2 were of monophasic morphology. There was, however, no association between SYT-SSX fusion type and expression of cytokeratins and epithelial membrane antigen among monophasic tumors. Tumors with SYT-SSX2 had a significantly higher mean and median Ki-67 labeling index than those with SYT-SSX1, but a comparison of Ki-67 according to fusion type, histologic type, and sample source suggested that the main determinants of proliferation rate were the latter two factors. Specifically, monophasic tumors and metastatic tumors showed significantly higher Ki-67 scores. Apoptosis (by TUNEL) was rarely observed, consistent with prominent expression of the anti-apoptotic protein BCL2 in almost all cases. TUNEL, BCL2, and BAX results did not correlate with SYT-SSX fusion type. These data confirm the strong association of SYT-SSX fusion transcript type with morphologic but not immunophenotypic epithelial differentiation in synovial sarcoma.

Inhibitory effect of TMK-688 on late asthmatic responses as well as T-cell and eosinophilic infiltration in guinea pigs with asthmatic reactions

The effects of an oral anti-allergic agent, TMK-688, which inhibits 5-lipoxygenase, at doses of 3.2 and 10 mg/kg were studied in guinea pigs with dual-phase asthmatic response. We previously observed that pretreatment with TMK-688 inhibited the late asthmatic response (LAR) induced by ovalbumin inhalation exposure. The present study focused on the effect of TMK-688 on infiltration by T-cells and eosinophils. TMK-688 inhibited both T-cell and eosinophilic infiltration. These findings suggest that TMK-688 is effective in inhibiting infiltration of T-cells and eosinophilic chemotaxis, and thereby suppresses LAR.

Mapping of epitopes and structural analysis of antigenic sites in the nucleoprotein of rabies virus

Linear epitopes on the rabies virus nucleoprotein (N) recognized by six MAbs raised against antigenic sites I (MAbs 6-4, 12-2 and 13-27) and IV (MAbs 6-9, 7-12 and 8-1) were investigated. Based on our previous studies on sites I and IV, 24 consecutively overlapping octapeptides and N- and C-terminal-deleted mutant N proteins were prepared. Results showed that all three site I epitopes studied and two site IV epitopes (for MAbs 8-1 and 6-9) mapped to aa 358-367, and that the other site IV epitope of MAb 7-12 mapped to aa 375-383. Tests using chimeric and truncated proteins showed that MAb 8-1 also requires the N-terminal sequence of the N protein to recognize its binding region more efficiently. Immunofluorescence studies demonstrated that all three site I-specific MAbs and one site IV-specific MAb (7-12) stained the N antigen that was diffusely distributed in the whole cytoplasm; the other two site IV-specific MAbs (6-9 and 8-1) detected only the N antigen in the cytoplasmic inclusion bodies (CIB). An antigenic site II-specific MAb (6-17) also detected CIB-associated N antigen alone. Furthermore, the level of diffuse N antigens decreased after treatment of infected cells with cycloheximide. These results suggest that epitopes at site I are expressed on the immature form of the N protein, but epitope structures of site IV MAbs 6-9 and 8-1 are created and/or exposed only after maturation of the N protein.

Electrophoretic and serologic characterization of 56 kDa antigen (M56) with autologous serum derived from a chondrosarcoma patient: a shared antigen of immunoresponses in cancer and autoimmune diseases

We investigated whether antibodies specific to autologous cancer cells are produced in the peripheral blood of patients with chondrosarcoma. There have been few reports on the investigation of the immune responses, such as autologous antibody production, to chondrosarcoma. Here, tumor-associated antigens were separated by sodium dodecyl sulfate (SDS)-polyacrylamide gel electrophoresis and detected by immunoenzymatic amplification. A 56 kDa molecule (M56) was detected in the serum from patients' peripheral blood. M56 is ubiquitously expressed in various kinds of tissue-derived cells. However, the molecule seemed to be retained mostly in the cytosolic compartment of lymphoid cells, while it was expressed on the cell surface of nonlymphoid cancer cells. Furthermore, the antibodies reactive to the 56 kDa molecule were frequently observed in sera derived from patients with other cancers and autoimmune diseases as compared to the sera from healthy control donors, suggesting that M56 is a common target molecule of immune responses in patients with various cancers and autoimmune diseases.

Native heart complications after heterotopic heart transplantation: insight into the potential risk of left ventricular assist device

BACKGROUND

In heterotopic heart transplantation, the donor heart is connected parallel to the recipient's diseased heart. Recipients continue to have risks, such as arrhythmia, thromboembolism, valvular heart disease, and ischemic heart disease which can develop in the native heart. It may serve as a clinical model to study long-term pathophysiologic processes in the native heart of patients with a left ventricular assist device.

METHOD

We analyzed the prevalence of long-term complications related to the native heart in the heterotopic heart transplant and attempted to gain insight into the potential risk to a native heart after receiving a left ventricular assist device.

RESULTS

Between December 1984 and December 1994, 16 patients (13 men, 3 women, ranging in age from 37 to 60 years) underwent heterotopic heart transplant at the University of Pittsburgh. The 1- and 5-year survival rate after the transplant was 81% and 44%, respectively. Actuarial freedom from complications related to the native heart after 1 year and 4 years was ventricular arrhythmia: 85%, 75%; ischemic disease: 85%, 64%; valvular disease: 100%, 88%; and thromboembolism: 85%, 58%. Of these complications, thromboembolism was not considered in determining actuarial freedom from complications because thromboembolism should be regarded as a device-related complication rather than as a native-heart-related complication for left ventricular assist device recipients. Consequently, actuarial freedom from all complications excluding thromboembolism was 70% after 1 year and 50% after 4 years. In addition, the hazard function curve remains constant up to 80 months after the operation without significant differences among the yearly ratios.

CONCLUSIONS

This analysis suggests that cautious observation of the native heart's long-term performance is necessary for the left ventricular assist device recipient.

Expression of CD44 variants in osteosarcoma

The standard form of CD44 (CD44H) is a transmembranous glycoprotein, widely distributed on a variety of human lymphoid cells, epithelial cells and tumours. CD44 has many variant forms, which are generated by alternative splicing. In recent years, CD44 has been reported to be related to the degree of tumour differentiation, tumour cell invasion, and metastasis. We investigated 44 tumour specimens in 39 patients with osteosarcoma immunochemically to analyse the expression of CD44 standard (CD44H) and variant exon-encoded gene products (CD44v3, v4, v5, v6, v7, v9, and v10). Furthermore, the relationship between CD44 expression and the clinical outcome of patients with osteosarcoma was analysed. Membrane accentuation and exclusive cytoplasmic reactivity were analysed as separate staining patterns. Tumour cells and some multinucleated giant cells were markedly stained. CD44H, v3, v4, v5, v6, v7, v9, and v10 were expressed in 85%, 49%, 54%, 59%, 46%, 5%, 28%, and 10% of the specimens respectively. The cumulative 5-year metastasis-free survival was 58% in CD44v6-negative cases and 24% in CD44v6-positive cases (P=0.046). However, the cumulative 5-year metastasis-free survival was not significantly different between cases positive and negative for other variants of CD44. Multivariate analysis (Cox proportional-hazard model) with CD44v6 expression (positive or negative), chemotherapy (intensive or non-intensive), tumour site (proximal or distal), and age (at least 30 years or less than 30 years) showed that expression of CD44v6 and chemotherapy were important prognostic factors in patients with osteosarcoma. Overexpression of CD44 isoforms containing variant v6 is correlated with poor prognosis in patients with osteosarcoma.

Nucleocapsid formation and/or subsequent conformational change of rabies virus nucleoprotein (N) is a prerequisite step for acquiring the phosphatase-sensitive epitope of monoclonal antibody 5-2-26

We investigated the antigenic maturation of rabies virus N protein, for which we used some conformational epitope-specific monoclonal antibodies (MAbs) and an MAb (5-2-26) against a phosphorylation-dependent linear epitope. Infected cells were lysed with a deoxycholate-free lysis buffer and separated by ultracentrifugation into the soluble top and the nucleocapsid fractions. None of the study MAbs recognized N proteins in the top fraction, whereas nucleocapsid-associated N proteins were recognized by all of the MAbs. Immunoprecipitation with polyclonal anti-N antibodies coprecipitated the P proteins from the top fraction, indicating that soluble N proteins are mostly associated with the P protein. The N proteins dissociated from both the N-P complex and nucleocapsids were recognized by none of the study MAbs, whereas the MAb 5-2-6 recognized the SDS-denatured N proteins of the nucleocapsid but not of the top fraction. In addition, the phosphorylation-deficient mutant N proteins were shown to be similarly accumulated as the wild-type N proteins into the viral inclusion bodies, defined as the virus-specific structures composed of viral nucleocapsids, that are produced in the cytoplasm of the infected cells. Based on these results, we believe that newly synthesized N proteins are not immediately phosphorylated at serine-389 (a common phosphorylation site) but are first associated with the P protein. After being used for encapsidation of the viral RNA, the N proteins undergo conformational changes, whereby epitopes for the conformation-specific MAbs are formed and become phosphorylated at serine-389.

Double-layered membrane vesicles released from mammalian cells infected with Sendai virus expressing the matrix protein of vesicular stomatitis virus

The matrix (M) protein of vesicular stomatitis virus (VSV) was reported to form vesicles on the cell surface and subsequently to be released into the cultured medium when expressed from cDNA by virus vectors. To further investigate VSV M activity, we generated a recombinant Sendai virus (SeV) expressing the VSV M protein (SeV-M(VSV)). When cells were infected with SeV-M(VSV), VSV M was found abundantly in the culture medium. Electron microscopy demonstrated the budding of two-membraned vesicles (>/= 0.8 microm in diameter) from the infected cells. The outer membrane of the vesicle was derived from the plasma membrane and the inner one possibly derived from the membrane of an intracellular vesicle. Immuno-gold labeling showed that VSV M was exclusively located in a double-layered region. The released membranes were divided into three parts: the VSV M vesicles with SeV F and HN glycoproteins, SeV particles, and vesicles associated with the cytosolic components. The last abundantly contained phosphorylated SeV matrix (M) protein, which is not released in a usual SeV infection. Furthermore the VSV M protein expressed without using a virus vector was efficiently released into the culture medium. These results suggest that the VSV M protein has a budding activity per se and that SeV proteins are passively involved in the release of VSV M.

[A case report of total aortic reconstruction and choice of staged operation in Marfan syndrome]

A 37-year-old man with Marfan syndrome underwent four operations for extensive cardiovascular disease. He was diagnosed as having AAE, AR and DeBakey type I aortic dissection. First, Bentall operation using Piehler procedure and total aortic arch replacement using retrograde cerebral perfusion and profound hypothermia at 18 degrees C were performed on May 11, 1994. Second, repair of leakage of the right coronary artery anastomosis and grafting for the descending thoracic aortic aneurysm were performed on December 3, 1994. Y-type grafting for the AAA was performed on December 21, 1996. Last, grafting for TAAA was performed under hypothermia at a rectal temperature of 20 degrees C on November 17, 1997. This surgical strategy of staged operation for extensive cardiovascular disease in Marfan syndrome is an effective method. Regular follow-up by CT is necessary for deciding the time and method of reoperation.

Insertion of the patella tendon after prosthetic replacement of the proximal tibia

We describe the technique and the results of a method to reconstruct the patellar tendon insertion to a tumor prosthesis by wrapping an artificial mesh around the prosthesis, followed by suturing the patellar tendon and a gastrocnemius flap to the mesh.

Imaging assessment of the responses of osteosarcoma patients to preoperative chemotherapy: angiography compared with thallium-201 scintigraphy

BACKGROUND

Assessment of the responses of osteosarcoma patients to preoperative chemotherapy is of clinical importance. The purpose of this study was to estimate the accuracy of angiography and thallium-201 scintigraphy, compared with histology, in assessing the responses of patients with osteosarcoma to preoperative chemotherapy.

METHODS

Nineteen patients with osteosarcoma who were diagnosed between 1992 and 1997 were studied. The findings of angiography and thallium-201 scintigraphy before and after preoperative chemotherapy were compared with the percentage of necrosis of tumor cells and the response grade as determined histologically. Quantitative analysis of the isotopic uptake by thallium-201 scintigraphy before and after chemotherapy, defined as the alteration ratio, was correlated with the percentage of tumor necrosis.

RESULTS

Angiography yielded a sensitivity of 88%, a specificity of 73%, and a predictive accuracy of positive test of 70%, whereas thallium-201 scintigraphy achieved 88%, 100%, and 100%, respectively. Both angiographic and scintigraphic assessment showed a significant correlation with response grade as determined histologically (P < 0.05 and P < 0.0003, respectively). The alteration ratio of thallium-201 scintigraphy showed a strong, highly significant correlation with the percentage of tumor necrosis (P < 0.0001).

CONCLUSIONS

A change in the tumor uptake of thallium-201 scintigraphy after preoperative chemotherapy can predict the tumor necrosis in osteosarcoma precisely. Thallium scintigraphy is a noninvasive technique and seems to be more useful than angiography in assessing the response of osteosarcoma to preoperative chemotherapy.

Reconstruction of the hip abductors after resection of the proximal femur

Three patients with malignant bone tumors of the proximal femur underwent implantation of an endoprosthesis with reconstruction of the joint capsule and hip abductors using artificial mesh.

Prolonged preservation of the blood-perfused canine heart with glycolysis-promoting solution

BACKGROUND

Prolonged ischemia and inadequate myocardial preservation remain significant perioperative risk factors in cardiac transplantation. Long-term preservation techniques that have been effective in small rodent hearts have not been as effective in larger animal models or in clinical studies. We developed a cardioplegia solution formulated to promote high-energy phosphate production from glycolysis and determined its efficacy in a blood perfused canine heart model subjected to 24 hours of ischemia.

METHODS

Hearts harvested from adult dogs (n = 6 per group) were flushed with a histidine-buffered cardioplegia solution containing glucose or University of Wisconsin solution. The hearts were maintained at 4 degrees C for 24 hours then reperfused with autologous blood. After reperfusion, left ventricular pressures were measured with an intracavitary balloon at varying balloon volumes and compared with control nonischemic hearts. Predicted stroke volume and ejection fraction were calculated at an end-systolic pressure of 70 mm Hg and end-diastolic pressure of 15 mm Hg.

RESULTS

Developed pressure was better preserved in the hearts that received histidine-buffered solution (93+/-9 versus 38+/-7 mm Hg, p<0.05), along with a higher end-diastolic volume at 15 mm Hg (31+/-3 versus 22+/-2 mL histidine-buffered versus University of Wisconsin solutions, respectively, p<0.05). Stroke volume and ejection fraction were also higher in the histidine group (17+/-2.5 versus 2.3+/-1.2 mL and 50%+/-3.5% versus 9% +/-4.5%, respectively) in the presence of dobutamine.

CONCLUSIONS

The highly buffered glycolysis-promoting cardioplegia solution provided effective preservation of the blood perfused canine heart with superior recovery of pump performance after 24 hours of hypothermic ischemia compared with University of Wisconsin solution in this model.

Association of a cellular 21-kDa transmembrane protein (VAP21) with enveloped viruses

We reported previously that the rabies virions contained a 21-kDa cellular transmembrane protein (referred to as VAP21) as a minor component (Sagara, J. et al, Microbiol. Immunol. 41(12): 947-955, 1997). In this study, we further examined the possible interactions of VAP21 with other enveloped viruses, including the vesicular stomatitis virus (VSV; negative-stranded RNA virus), Sindbis virus (positive-stranded RNA virus) and herpes simplex virus type 1 (HSV-1; double-stranded DNA virus). An immunoblot analysis demonstrated that all of these enveloped viruses contained VAP21 in the virion as a minor component. Immunoprecipitation studies suggested that VAP21 was associated with certain viral proteins in the cell, such as the matrix (M) protein of VSV, a capsid protein of Sindbis virus, and at least a capsid protein (VP5) of HSV-1. The association was disrupted by treatment with 0.5% sodium dodecyl sulfate, but resistant to the treatment with 1% NP-40 plus 1% deoxycholate. These results suggest that: 1) VAP21 is not primarily associated with the viral transmembrane glycoprotein but rather with the internal viral protein, and, 2) this association would cause the efficient incorporation of VAP21 into the virion.

Evaluation of release surgery for idiopathic carpal tunnel syndrome: endoscopic versus open method

To evaluate the usefulness of endoscopic carpal tunnel release (ECTR) on patients with idiopathic carpal tunnel syndrome, multiple aspects of the results of 44 hands (42 patients) treated by ECTR and 40 hands (40 patients) treated by open carpal tunnel release (OCTR) were compared. Results of ECTR were compared with those of OCTR to study not only recovery rate and surgical safety but also cost-effectiveness. Although ECTR was much less invasive than OCTR, recovery of median nerve palsy in the ECTR group was not as good as that in the OCTR group one month after the surgery. Three months after surgery, the palsy of patients treated by ECTR had improved to almost the same extent as in those treated by OCTR. There were no major surgical complications in both ECTR and OCTR groups. The cost and time needed for ECTR treatment was 1/3 of those needed for OCTR. ECTR reduced both cost and treatment time, which is beneficial for both doctors and patients.

A case of bilateral eosinophilic granuloma in the temporal bone

We present a case of bilateral eosinophilic granuloma in the temporal bone in a 47-year-old woman, who visited our hospital with a headache and a feeling of occlusion in her left ear. Her left tympanic membrane was slightly turbid and pure tone audiometry revealed mild left sensorineural deafness. CT disclosed a shadow of soft tissue in the left mastoid antrum and mastoid cells, which was indicative of marked destruction of the bone. Because MRI findings led us to suspect otitis media cholesteatoma, a mastoidectomy was performed. The mastoid antrum and mastoid cells were filled with easily bleeding granulation, and there was a wide range of bone deficit in the posterior cranial fossa. Histopathologically, the granulation tissue was an eosinophilic granuloma. Her postoperative clinical progress was good and she was discharged. However 2 months after discharge, she had a feeling of occlusion in the right ear and CT revealed a shadow in the right mastoid antrum and cells. Therefore, right tympanoplasty was performed and the same findings as in the left ear were obtained. A histopathological diagnosis of eosinophilic granuloma was made again. To date, there has been no recurrence.

Intracellular behavior of rabies virus matrix protein (M) is determined by the viral glycoprotein (G)

To investigate the nature and intracellular behavior of the matrix (M) protein of an avirulent strain (HEP-Flury) of rabies virus, we cloned and sequenced the cDNA of the protein. Using expression vectors pZIP-NeoSV(X)1 and pCDM8, the cDNA was transfected to animal cells (BHK-21 and COS-7) with or without coexpression of viral glycoprotein (G). When M protein alone was expressed in the cells, it displayed homogeneous distribution in the whole cell including the nucleus. In contrast, coexpression with G protein resulted in the abolishment of nuclear distribution of M antigen, and both of the antigens displayed a colocalized distribution in the cell, especially at the cellular membrane as seen in the virus-infected cells, while the distribution of G antigen was not affected by coexpressed M antigen. Immunoprecipitation studies revealed that M protein was coprecipitated with G protein by anti-G antibody, and vice versa, although cross-linking with dithiobis(succinimidyl propionate) was necessary for coprecipitation because of their easier dissociation in the presence of sodium deoxycholate. These results suggest that M protein intimately associates with G protein, which may affect or regulate the behavior (e.g., intracellular localization) of M protein. Studies with deletion mutants of M protein indicate that an internal region around the amino acids from 115 to 151 is essential for the M protein to preserve its binding ability to G protein.

Newly identified Chinese hamster ovary cell mutants defective in peroxisome assembly represent complementation group A of human peroxisome biogenesis disorders and one novel group in mammals

We isolated peroxisome biogenesis-defective mutants from rat PEX2-transformed Chinese hamster ovary (CHO) cells, using the 9-(1'-pyrene)nonanol/ultraviolet method. A total of 18 mutant cell clones showing cytosolic localization of catalase were isolated. By complementation group (CG) analysis by means of PEX cDNA transfection and cell fusion, cell mutants, ZP124 and ZP126, were found to belong to two novel CGs of CHO mutants. Mutants, ZP135 and ZP167, were also classified to the same CG as ZP124. Further cell fusion analysis using 12 CGs fibroblasts from patients with peroxisome deficiency disorders such as Zellweger syndrome revealed that ZP124 belonged to human CG-A, the same group as CG-VIII in the United States. ZP126 could not be classified to any of human and CHO CGs. These mutants also showed typical peroxisome assembly-defective phenotypes such as severe loss of catalase latency and impaired biogenesis of peroxisomal enzymes. Collectively, ZP124 represents CG-A, and ZP126 is in a newly identified CG distinct from the 14 mammalian CGs previously characterized.

Isolation and characterization of novel peroxisome biogenesis-defective Chinese hamster ovary cell mutants using green fluorescent protein

We developed an improved method for isolation of peroxisome biogenesis-defective somatic animal cell mutants, using a combination of green fluorescent protein (GFP) expression and the 9-(1'-pyrene)nonanol/ultraviolet (P9OH/UV) selection method. We used TKaG1 and TKaG2 cells, the wild-type Chinese hamster ovary (CHO) cells, CHO-K1, that had been stably transfected with cDNAs each encoding rat Pex2p as well as GFP tagged at the C-terminus with peroxisome targeting signal type 1 (PTS1) or N-terminally PTS2-tagged GFP. P9OH/UV-resistant cell colonies were examined for intracellular location of GFP on unfixed cells, by fluorescence microscopy. Seven each of the mutant cell clones isolated from TKaG1 and TKaG2 showed cytosolic GFP-PTS1 and PTS2-GFP, respectively, indicating the defect in peroxisome assembly. By transfection of PEX2, PEX5, PEX6, and PEX12 cDNAs and cell fusion analysis between the CHO cell mutants, five different complementation groups (CGs) were identified. Two mutant clones, ZPG207 and ZPG208, belonged to novel CGs. Further CG analysis using fibroblasts from patients with peroxisome biogenesis disorders, including rhizomelic chondrodysplasia punctata (RCDP), revealed that ZPG208 belonged to none of human CGs. ZPG207 was classified into the same CG as RCDP. Taken together, ZPG208 is in a newly identified, the 12th, CG in peroxisome-deficient CHO mutants reported to date and represents a novel mammalian CG.

Angiography for assessment of preoperative chemotherapy in musculoskeletal sarcomas

Eleven abnormal findings of digital subtraction angiography were analyzed in 25 patients with bone sarcoma and in 23 patients with soft tissue sarcoma. The relation between digital subtraction angiographic findings and the histologic effect of chemotherapy was evaluated. Digital subtraction angiography was performed with the patient under local anesthesia with the Seldinger technique, using an ADVANT X unit. Contrast medium was injected at a rate of 4 to 6 ml per second, with the usual single bolus dose of approximately 6 to 8 ml. Eleven abnormal findings included tumor stain, hypervascularity, arterial distortion, vascular stretch, arterial dilatation, arteriovenous shunt, arterial encasement, occlusion, blood pool, caliber with irregular wall, and dilatation of draining vein. Each finding after preoperative chemotherapy was compared with that before chemotherapy and divided into three grades; Grade 1, not effective; Grade 2, effective; and Grade 3, very effective. Angiographic Grades 2 and 3 were defined as responders. The histologic effect was examined and scored according to the modified classification proposed by Huvos. Histologic Grades 1 and 2 were classified as nonresponders and Grades 3 and 4 as good responders. In bone sarcomas, hypervascularity and tumor stain were seen in all patients. In soft tissue sarcomas, tumor stain was shown in all 23 patients and hypervascularity was seen in 21 patients. Tumor stain, hypervascularity, vascular stretch, and arterial encasement were correlated closely with histologic findings and showed an accuracy equal to or greater than 70%. When these four findings changed to angiographic Grade 3 after preoperative chemotherapy, 90% of patients had good histologic outcome.

Clinical experience of left ventricular assist systems at the Heart Institute of Japan

The main indications for left ventricular assist system (LVAS) support are postcardiotomy ventricular failure as temporary circulatory support and end-stage cardiomyopathy as chronic circulatory support. To clarify the efficacy of LVAS support, we assessed the clinical outcome of a pneumatic LVAS and an electromagnetic LVAS for patients with severe ventricular failure. As of March 1998, 5 patients with postcardiotomy ventricular failure had received the pneumatic LVAS support, and 2 other patients with end-stage idiopathic cardiomyopathy had undergone implantation of the electromagnetic LVAS. The drive control of the LVAS was mainly counterpulsation in the diastole of the native heart. In the 5 postcardiotomy patients, the duration of pneumatic LVAS support ranged from 30 to 312 h (mean, 109.2). All 3 patients with more than 72 h support were successfully weaned, and 2 of them survived. The other 2 patients with cardiogenic shock and less than 36 h support could not be weaned from the LVAS. In the 2 cardiomyopathy patients, 1 patient was well maintained by the electromagnetic LVAS support and underwent successful heart transplantation 7 months later. The other patient has been chronically supported by the LVAS for 2 months and is doing well so far. These results suggest that selective application of the pneumatic LVAS as a temporary support and the electromagnetic LVAS as a chronic support might be appropriate for maximizing the effectiveness of LVAS treatment for profound cardiac failure.

High complication rate of reconstruction using Ilizarov bone transport method in patients with bone sarcomas

We performed five reconstructions by bone transport in patients with bone sarcoma: three osteosarcomas, one Ewing's sarcoma and one chondrosarcoma. Four sarcomas were in the distal femur and one in the shaft of the tibia. Four patients received multidrug chemotherapy. The average length of the skeletal defect after tumour resection was 17 (range 10-25) cm. All patients underwent double elongation from both proximal and distal sites of the bone defect. The average follow-up period was 48 (range 40-66) months, and the average duration of external fixation was 32 months (range 579-1340 days). In one case, bone formation was satisfactory, but in the other cases, it was poor and slow. The average treatment index was 95 (range 53-191) days per 1 cm of elongation. In one case, the bone fragment disappeared during the bone transport. In one case, the end of the bone protruded from the skin, and osteomyelitis set in. This patient underwent above-knee amputation due to failure of infection control. Three patients suffered talipes equinus. One patient died of pulmonary metastasis. Two patients had fair and three had poor function. This method is not recommended for patients with bone sarcoma who may have a poor prognosis, as it has an unacceptably high complication rate.

A rotating-hinge knee replacement for malignant tumors of the femur and tibia

We evaluated the 2- to 7-year results of a rotating-hinge knee replacement after excision of malignant tumors of the knee joint. There were 25 distal femoral and 7 proximal tibial replacements. The 5-year prosthetic survival for distal femoral replacements was 88%, compared with 58% for proximal tibial replacements. Seven patients underwent prosthetic exchange: 1 for aseptic loosening, 2 for wound slough and perioperative infection, and 4 for articulating component failure. One patient underwent above-knee amputation owing to skin necrosis. The median functional scores at the latest follow-up were 27 by the International Society of Limb Salvage evaluation system and 80 by the Hospital for Special Surgery Knee Score system. This implant is a promising choice for joint reconstruction after excision of tumors at the knee joint.

Relationship between magnitude of resection, complication, and prosthetic survival after prosthetic knee reconstructions for distal femoral tumors

BACKGROUND AND OBJECTIVES

Limb-sparing surgery has become the preferred surgical treatment of malignant bone tumors. The objective of this study was to evaluate factors that influence the morbidity and outcome of prosthetic knee replacement after resection of malignant tumors of the distal femur.

METHODS

Eighty-two patients who had a resection of malignant tumor of the distal femur and implantation of a segmental knee prosthesis (minimum follow-up, 2 years) were retrospectively reviewed.

RESULTS

Twenty-nine patients (35%) underwent 32 prosthetic revisions, 6 from perioperative wound complications, 13 from aseptic loosening, and 13 from other complications. The 3-, 5-, and 10-year Kaplan-Meier prosthetic survival rates were 82%, 71%, and 50%, respectively. On univariate analysis, patients who had more than 40% resection of the distal femur (P = 0.010) and those who had all their vasti muscles resected (P = 0.011) had significantly worse prosthetic survivals than the others. On multivariate analysis, resection of more than 40% of the distal femur was a significant negative prognostic factor for prosthetic survival (P = 0.017). Aseptic loosening was the primary cause of late prosthetic failure. Differences in the magnitude of resection influenced prosthetic survivorship more than prosthetic design.

CONCLUSIONS

In the distal femoral endoprosthetic replacement, higher short- and long-term complications were found after extensive resections. Aseptic loosening was the primary cause of prosthetic failure.

Studies on the structures and antigenic properties of rabies virus glycoprotein analogues produced in yeast cells

We investigated two forms (designated as yGI and yGII) of rabies virus glycoprotein (G) analogues produced in the G cDNA-transfected yeast cells. Molecular weights of yGI and yGII were estimated as 66 and 56 kDa, respectively, according to their relative mobility in SDS-PAGE. Although being produced in large amounts, yGI was present mostly in insoluble forms and hardly extractable with non-ionic detergents. The yGI reacted with polyclonal anti-G antibodies, but did not react with our conformational epitope-specific anti-G monoclonal antibodies (G-MAbs). No protective immunity was induced by yGI in guinea pigs nor in mice. On the other hand, yGII was Triton-soluble, but was only small in amount (at most 1% of total G proteins) and was shown to lack the cytoplasmic domain. The yGII, however, reacted with the G-MAbs and induced protective immunity in guinea pigs as well. When the G-cDNA was expressed in animal cells in culture, a single form (about 66 kDa) of G protein was produced, which displayed similar behaviors as seen in its reactivity with the MAbs and intracellular distribution as seen in the virus-infected cells. These results suggest that most G protein molecules were not processed normally in yeast cells, resulting in abnormal folding and multimer formation, while only a small fraction were occasionally folded normally to have conformational epitopes but were mostly deprived of the C-terminal portion.

Studies on the rabies virus RNA polymerase: 2. Possible relationships between the two forms of the non-catalytic subunit (P protein)

We investigated the relationship between the two forms of rabies virus P protein, a non-catalytic subunit of rabies virus RNA polymerase. The two displayed different electrophoretic mobilities as 37- and 40-kDa polypeptides, hence termed as p37 and p40, respectively. Double labeling experiments with [3H]leucine and [32P]orthophosphate demonstrated that p40 was much more phosphorylated than p37. Treatment of the virion proteins with alkaline phosphatase eliminated only p40, and not 37-kDa polypeptide. The p37 was a major product of the P gene, and was accumulated in the infected cell and incorporated into the virion. On the other hand, p40 was apparently detected only in the virion, and little detected in the cells. Treatment of infected cells with okadaic acid, however, resulted in significant accumulation of p40 in the cell, suggesting that p40 was continuously produced in the cell but dephosphorylated quickly. We detected both 37- and 40-kDa products in P cDNA-transfected animal cells, while only a 37-kDa product was produced in Escherichia coli. Incubation of 37-kDa products from E. coli with the lysates of animal cells in vitro resulted in the production of a 40-kDa product, which was also shown to be suppressed by the heparin. From these results, it is suggested that p40 is produced by the hyperphosphorylation of a 37-kDa polypeptide, which depends on certain heparin-sensitive cellular enzyme(s) and occurs even in the absence of the other viral gene products, and that p40 is reverted quickly to p37 in the infected cells, probably being dependent on some virus-induced factor(s).

Algorithm for the surgical treatment of malignant lesions of the proximal tibia

Complications are common among patients treated for malignant lesions of the proximal tibia and can be difficult to manage. This investigation was a retrospective review of 40 patients treated with total knee replacements after proximal tibial resections. Various reconstructive methods were used to fix the prosthetic stems, reestablish the extensor mechanism, and provide soft tissue coverage. Thirty-one patients had adequate followup to allow for review of prosthetic outcome (means, 78 months; range, 25-193 months). Seven patients died with less than 2 years followup, and two patients had postoperative acute infections treated by early amputation to allow chemotherapy to resume promptly. The overall 5-, 8-, and 12-year event free prostheses survival rates were 62%, 33%, and 16%, respectively. Prognostic factors for prosthetic survival were analyzed (age, gender, type of excision, type of prosthesis, type of fixation, and percent of bone resected). None were statistically significant. Patients with less than 40% of the tibia resected had better prosthetic survival at 5 years. The durability of uncemented stem fixation exceeded that of cemented stems. Expected survival of prostheses after revision was 52% at 8 years. The major cause of limb loss was infection. Failure to reconstruct soft tissues satisfactorily caused most failures. Aggressive multistage management of infection is needed. Prosthetic knee replacement is most suitable for patients with cancers that require chemotherapy and for those patients who have short potential survival.

Evaluation of the effect of preoperative chemotherapy in bone sarcomas. 99mTc-HMDP scintigraphy in 34 cases

We quantitatively analyzed images of 99mTc-HMDP bone scintigraphy in 34 bone sarcomas before and after preoperative chemotherapy. The isotopic uptake was calculated as tumor-to-background ratio (TBR), and the changes in TBR before and after chemotherapy were calculated as the alteration ratio. The histological effect of preoperative chemotherapy was classified in 4 grades, according to Huvos. We defined good scintigraphic responders as cases having decreased uptake after chemotherapy, with an alteration ratio > or = 60%. There was a positive correlation (Rho = 0.76, p < 0.001) between the histological effect and the alteration ratio. Of the 17 good histological responders, 13 showed a good scintigraphic response. The average alteration ratio in 17 cases with good response (68%) was higher than that in 17 cases showing poor response (-9.9%) (p < 0.001). 3 patients with pathologic fractures and 1 with primarily normal uptake showed false negative findings. The sensitivity of this method was 100% and the specificity was 81%.

[Postoperative therapy using human atrial natriuretic peptide in cases of valve replacement]

The effect of hANP (atrial natriuretic peptide) was investigated clinically in 40 patients who underwent isolated valve replacement. Patients were divided into four groups: aortic regurgitation (AR), aortic stenosis (AS), mitral regurgitation (MR) and mitral stenosis (MS). Each group was divided into two subgroups: one was administered hANP after the operation until leaving ICU, and the other was not administered hANP. We measured the levels of hANP and c-GMP and blood pressure, pulmonary artery pressure, central venous pressure and levels of Na, K of urine and blood prcoperatively, immediately postoperatively and 1, 2, 4, 6 hours after operation. First, to examine the relationship between preoperative level of hANP and cardiac function, the relationship between preoperative level of hANP and history of cardiac failure and pulmonary artery wedge pressure (PAWP) were evaluated. Also, we evaluated the relationship between preoperative level of hANP and each dimension on echocardiography. There was a weak statistical relationship between hANP and PAWP (row = 0.39 (p = 0.04) Pearson correlation method) and there was no statistical relationship between hANP and duration of cardiac failure (row = 0.00445 (p = 0.98) Pearson correlation method). Preoperatively Left atrial diameter (LAD) showed a statistical relationship with level of hANP in every group using Spearman correlation method. Other dimensions such as left ventricular diastolic diameter (LVDd) and left ventricular systolic diameter (LVDs) and also fractional shortening (FS) did not show a strong correlation with preoperative level of hANP. Especially, in AS group there was a strong relationship between every dimension and preoperative level of hANP. Only in MS group LAD and the level of hANP were negatively related. This finding suggests that atrial dilatation results in reduction of secretion of hANP in cases of MS on long term follow up. Finally, hNAP therapy was shown to have a continuous diuretic effect, with stable hemodynamics.

Value of thallium-201 scintigraphy in bone and soft tissue tumors

The potential role of thallium-201 (201Tl) scintigraphy in the imaging of various musculoskeletal tumors was investigated in 80 patients. Uptake of 201Tl was observed in 17 (100%) malignant bone tumors, 6 (100%) giant cell tumors, and 2 of 8 (25%) benign bone tumors. Nineteen of 30 malignant soft tissue tumors (63%) were positive for 201Tl scintigraphy, while 2 of 14 benign soft tissue tumors (14%) yielded positive results. None of 6 liposarcomas were visualized by 201Tl scintigraphy. There was no 201Tl uptake in the tissues of 5 non-tumorous conditions. Ten patients with osteosarcoma were evaluated by 201Tl scintigraphy both pre- and post-chemotherapy. There was a significant correlation between changes in tumor-to-normal count ratio and percent necrosis of the resected tumor. The mean decrease in tumor-to-normal count ratio was 71% for patients with >/=90% tumor necrosis and 26% for those with <90% tumor necrosis. Serial 201Tl scintigraphy, with quantitative analysis of alterations in 201Tl uptake, may provide a quantitative and objective measure of the effect of preoperative chemotherapy in patients with malignant bone tumors.

A new human chondrosarcoma cell line (OUMS-27) that maintains chondrocytic differentiation

A new human chondrosarcoma cell line, OUMS-27, was established. Monolayer cultures consisted of elongated polygonal cells with a doubling time of 41 hr and a plating efficiency of 2.1%. After reaching confluence, the cells continued to slowly proliferate and formed nodule-like structures, which showed metachromasia when stained with toluidine blue, indicating the presence of proteoglycan. The cells in the nodules were round to polygonal in shape, multilayered and surrounded by abundant extracellular matrix. Types I, II and III collagens were identified by Northern blotting and immunostaining. The cells formed colonies (0.1%) in 0.3% soft-agar medium 3 weeks after inoculation. Inoculation of cells into athymic mice resulted in the formation of tumors at the injection site, resembling the original chondrosarcoma. These results demonstrated that OUMS-27 cells expressed a differentiated chondrocytic phenotype. Moreover, OUMS-27 cells had p53-gene mutation. Thus, the OUMS-27 cell line can provide a useful model not only for studies on human chondrocyte but also for basic studies on the diagnosis, treatment and etiology of human chondrosarcoma.

Minimally invasive cardiac surgery in the adult: surgical instruments, equipment, and techniques

To clarify the special instruments and equipment used for minimally invasive cardiac surgery (MICS), we examined the initial experiences with MICS operations with ministernotomy or minithoracotomy at our institution. Fifty adult patients with congenital, valvular, and/or ischemic heart diseases underwent MICS operations, and all surgical procedures were completed without conversion to full sternotomy. The length of the skin incision was about 10 cm or less in all patients. Postoperative recovery was favorable, and the majority of the patients were discharged from the hospital around the end of the second postoperative week. In this series of patients, an oscillating bone saw, lifting type retractor, 2 blade spreader, cannula with a balloon, and right-angled aortic clamp among other items, were very useful for successfully performing various operations with MICS approaches and techniques. The associated results suggest that MICS with ministernotomy or minithoracotomy was feasible using special instruments and equipment and could be encouraged for adult patients with various cardiovascular diseases.

Studies on rabies virus RNA polymerase: 1. cDNA cloning of the catalytic subunit (L protein) of avirulent HEP-flury strain and its expression in animal cells

To investigate the RNA polymerase of rabies virus, we cloned a cDNA of the catalytic subunit (called L protein because of its large molecular size) of the HEP-Flury strain, an avirulent strain obtained by high frequencies of serial embryonated hen egg passages. Nucleotide sequencing showed that the cDNA encodes a long polypeptide of 2,127 amino acids (Mr. 242,938). A comparison of the deduced amino acid sequence with that of other strains (PV and SAD B19) indicated that the sequence was highly conserved, except for several amino acid substitutions which were accumulated in some limited regions. A fragment of the cDNA was used for expression in Escherichia coli (E. coli) to prepare the L antigen for raising the antibodies in rabbits. Immunoprecipitation studies with the rabbit antiserum showed that the polypeptides produced in the L cDNA-transfected COS-7 cells displayed almost the same electrophoretic mobility as that of authentic L protein. Immunofluorescence studies indicated that both L and P (another subunit of RNA polymerase) proteins displayed colocalized distribution with the nucleocapsid antigen (N) in the cytoplasmic inclusion bodies, where envelope proteins (G and M) were absent. On the other hand, expression of the L protein alone did not cause inclusion body-like granular distribution, suggesting that the inclusion body-like accumulation depends on certain interaction(s) with other viral gene products, probably with the ribonucleoproteins comprising the inclusion bodies.

PEX12, the pathogenic gene of group III Zellweger syndrome: cDNA cloning by functional complementation on a CHO cell mutant, patient analysis, and characterization of PEX12p

Rat PEX12 cDNA was isolated by functional complementation of peroxisome deficiency of a mutant CHO cell line, ZP109 (K. Okumoto, A. Bogaki, K. Tateishi, T. Tsukamoto, T. Osumi, N. Shimozawa, Y. Suzuki, T. Orii, and Y. Fujiki, Exp. Cell Res. 233:11-20, 1997), using a transient transfection assay and an ectopic, readily visible marker, green fluorescent protein. This cDNA encodes a 359-amino-acid membrane protein of peroxisomes with two transmembrane segments and a cysteine-rich zinc finger, the RING motif. A stable transformant of ZP109 with the PEX12 was morphologically and biochemically restored for peroxisome biogenesis. Pex12p was shown by expression of bona fide as well as epitope-tagged Pex12p to expose both N- and C-terminal regions to the cytosol. Fibroblasts derived from patients with the peroxisome deficiency Zellweger syndrome of complementation group III (CG-III) were also complemented for peroxisome biogenesis with PEX12. Two unrelated patients of this group manifesting peroxisome deficiency disorders possessed homozygous, inactivating PEX12 mutations: in one, Arg180Thr by one point mutation, and in the other, deletion of two nucleotides in codons for 291Asn and 292Ser, creating an apparently unchanged codon for Asn and a codon 292 for termination. These results indicate that the gene encoding peroxisome assembly factor Pex12p is a pathogenic gene of CG-III peroxisome deficiency. Moreover, truncation and site mutation studies, including patient PEX12 analysis, demonstrated that the cytoplasmically oriented N- and C-terminal parts of Pex12p are essential for biological function.

Preparation and evaluation of micro-porous ethylcellulose capsule as oral sustained-release preparation of theophylline

Micro-porous ethylcellulose (EC) membrane capsules were prepared by dissolving polyvinylalcohol (PVA) particles from membranes which were made of a mixture of EC (a water-insoluble polymer). The pore size was approximately 400 microns. Since the dissolution rate of theophylline from the micro-porous EC membrane capsules was fast, gel-forming polymer, poly(acyclic) acid (Carbomer), was incorporated inside the capsule at 10, 20 or 30 mg. Using test capsules containing 100 microns of theophylline, in vitro dissolution studies were performed. By including Carbomer in capsule formulations, the dissolution rate of theophylline was decreased. However, there were not significant differences in dissolution rates between preparations containing the three different amounts of Carbomer. In vivo evaluation studies using beagle dogs showed that AUC, Cmax and Tmax were inversely proportional to the formulated amount of Carbomer. The capsule containing 20 mg of Carbomer gave plasma theophylline concentrations between 5 and 15 micrograms mL-1, which reflect levels within the therapeutic window. The effect of food intake on the pharmacokinetics of theophylline was also studied with the same capsule. Food increased AUC, Cmax and Tmax, although plasma theophylline levels were maintained within the therapeutic range.

The 21-kDa polypeptide (VAP21) in the rabies virion is a CD99-related host cell protein

In our monoclonal antibody (MAb) stocks prepared against the BHK-21 cell antigens, two (#11875 and 28276) recognized a 21-kDa polypeptide (referred to as VAP21) which is efficiently incorporated into the rabies virion. By using these MAbs, we isolated the cDNA clones that encoded a polypeptide of 144 amino acids from our BHK-21 cell cDNA library. Based on the following evidence, the cDNA was assumed to encode a full-length sequence of VAP21 antigen: i) expression of the cDNA in animal cells resulted in the production of a polypeptide recognized by the two MAbs, and its electrophoretic mobility was the same as that of authentic VAP21 antigen; and ii) immunization with the products from the cDNA-transformed E. coli cells raised specific antibodies in rabbits that recognized a 21-kDa polypeptide in the virion. From the deduced amino acid sequence, it is suggested that the VAP21 antigen has a molecular structure of type-I transmembrane protein containing characteristic proline-rich and glycine-rich regions in its ectodomain. Homology searches resulted in finding homologous sequences (totally about 40% homology) in the human MIC2 gene product (CD99; 32-kDa) of T lymphocytes. These results suggest that the VAP21 antigen in the rabies virion is a cellular CD99-related transmembrane protein.

Cloning and chromosomal mapping of a novel ABC transporter gene (hABC7), a candidate for X-linked sideroblastic anemia with spinocerebellar ataxia

We isolated a novel human ATP-binding cassette (ABC) transporter cDNA, determined its nucleotide sequence, and designated it human ABC7 (hABC7). The nucleotide sequence was highly homologous to the ATM1 gene in yeast, which encodes an ABC transporter (yAtm1p) located in the mitochondrial inner membrane. The deduced human product, a putative half-type transporter, consists of 752 amino acids that are 48.9% identical to those of yAtm1p. A computer-assisted protein structural and localization analysis revealed that the mitochondrial targeting signal of yAtm1p is conserved in the N-terminal region of the primary sequence of the hABC7 protein, and therefore this product is also likely to be located in the mitochondrial inner membrane. The evidence strongly suggests that the hABC7 gene is a counterpart of ATM1 and that its product is probably involved in heme transport. We mapped the hABC7 gene to chromosome Xq13.1-q13.3 by fluorescence in-situ hybridization. As band Xq13 has been implicated in X-linked sideroblastic anemia with spinocerebellar ataxia, hABC7 becomes a candidate gene for this heritable disorder.

Interrelationships of clinical outcome, length of resection, and energy cost of walking after prosthetic knee replacement following resection of a malignant tumor of the distal aspect of the femur

The relationships between the functional score according to the system of the International Society of Limb Salvage, the extent of resection, energy cost of walking, and gait characteristics were studied in thirty-six patients who had had segmental knee replacement after resection of a malignant tumor of the distal aspect of the femur. The mean free-walking velocity was 62.3 meters per minute (79 per cent of normal), which was a result of decreases in both cadence and stride length. The mean net energy cost during walking was 35 per cent greater than that of normal controls and correlated with the percentage of the femur that had been resected. All patients had decreased single-limb support time on the affected side compared with the unaffected side. There was a weak correlation between the asymmetry of the single-limb support time and the percentage of the femur that had been resected. The mean extensor torque of the affected knee was 30 per cent that of the unaffected knee when one head of the quadriceps muscle had been excised, 19 per cent when two heads had been excised, 4 per cent when three heads had been excised, and 1 per cent when four heads had been excised. The patients who had had an extra-articular resection had lower mean extensor and flexor torques at the knee compared with those who had had an intra-articular resection. The asymmetry of the single-limb support time was inversely related to the residual extensor and flexor torques. The overall score according to the system of the International Society of Limb Salvage ranged from 17 to 29 points (mean, 24.6 points; 82 per cent of normal). The net energy cost, percentage of maximum aerobic capacity, and asymmetry of the single-limb support time had significant negative correlations with the overall functional score. Multivariate analysis showed that the overall functional score and the percentage of the femur that had been resected were the two most important factors that predicted the net energy cost. To our knowledge, this is the first objective validation of the functional score according to the system of the International Society of Limb Salvage. As the net energy cost can be predicted from universally available, inexpensive measures, investigators can easily use it as a clinical and research tool to evaluate prosthetic performance and to assess operative outcome.

Prosthetic knee replacement after resection of a malignant tumor of the distal part of the femur. Medium to long-term results

We evaluated the medium to long-term results of treatment with a custom prosthetic knee replacement after wide resection of a primary malignant tumor of the distal part of the femur in forty consecutive patients. The duration of follow-up ranged from five to seventeen years (median, eight years). At the time of the latest follow-up, thirty-five (88 per cent) of the forty patients were free of disease and five (13 per cent) were alive with metastatic disease. No local recurrence was observed. Twenty early complications occurred in eighteen patients (45 per cent). Aseptic loosening of the femoral component, which necessitated a revision in eleven patients at an average of fifty-one months, was the most frequent mode of failure. The rate of prosthetic survival, as estimated with use of the Kaplan-Meier method, was 85, 67, and 48 per cent at three, five, and ten years. Univariate analysis demonstrated that the rate of prosthetic survival was significantly worse for male patients, for those in whom at least 40 per cent of the femur had been resected, for those who had had total resection of the quadriceps muscles or subtotal resection (preservation of only the rectus femoris muscle), and for those in whom a straight femoral stem had been used (p < 0.05 for all comparisons). Multivariate analysis showed that the independent adverse prognostic factors for prosthetic survival were male gender, resection of at least 40 per cent of the femur, and fixation of the femoral stem with cement. The rate of limb salvage was calculated, with use of the Kaplan-Meier method, to be 93 per cent at three years and 90 per cent at five and ten years. At the latest follow-up examination, the functional scores according to the classification system of the Musculoskeletal Tumor Society ranged from 14 to 29 points; the mean was 24 points, which represents function that is 80 per cent that of normal. The mean scores in the categories of walking supports and gait were better for the patients in whom the quadriceps muscles had been preserved than for those who had had total or subtotal resection of those muscles. Although advances in imaging and local therapy narrow the indications for an extra-articular resection of a tumor, the implant that was used in the present study continues to be used in approximately 15 per cent of patients who have a fracture or an intra-articular extension of the tumor that necessitates extensive extra-articular resection.

Studies on the antiviral mechanisms of protein kinase inhibitors K-252a and KT5926 against the replication of vesicular stomatitis virus

We investigated the antiviral mechanisms of K-252a, a broad non-specific protein kinase inhibitor which was isolated from Nocardiopsis sp. and its derivative (KT5926), against vesicular stomatitis virus (VSV) replication in BHK-21 cells. Although K-252a (5 microM) and KT5926 (15 microM) similarly suppressed the viral primary and secondary transcriptions and genomic RNA synthesis in vivo, the inhibitory mechanisms did not seem to be the same; phosphorylation of the viral NS protein was suppressed by K-252a, which might account for the decreased viral RNA synthesis caused by K-252a. On the other hand, KT5926, being known to preferentially inhibit myosin light chain kinase (MLCK), had little effect on NS protein phosphorylation. Cellular casein kinase II, which is believed to be involved in the phosphorylation of the N-terminal side (domain I) of NS protein, was not inhibited at all by KT5926 even at 15 microM under in vitro assay conditions, and was only weakly inhibited by K-252a at 1 to 10 microM. Neither inhibitor seemed to directly affect viral protein synthesis, but affected it indirectly as a secondary effect of reduced viral RNA synthesis. These results suggest that both the KT5926-sensitive and the KT5926-resistant but K-252a-sensitive functions are involved in the essential processes of viral RNA synthesis. The KT5926-sensitive function(s) might not be involved in the NS protein phosphorylation, but may participate in some other way in the process of virus replication. On the other hand, the KT5926-resistant, K-252a-sensitive function(s) are probably involved in NS protein phosphorylation. The possible nature of those functions is discussed.

EWS-FLI1 fusion transcript structure is an independent determinant of prognosis in Ewing's sarcoma

PURPOSE

More than 90% of Ewing's sarcomas (ES) contain a fusion of the EWS and FLI1 genes, due to the t(11;22)(q24;q12) translocation. At the molecular level, the EWS-FLI1 rearrangements show great diversity. Specifically, many different combinations of exons from EWS and FLI1 encode in-frame fusion transcripts and result in differences in the length and composition of the chimeric protein, which functions as an oncogenic aberrant transcription factor. In the most common fusion type (type 1), EWS exon 7 is linked in frame with exon 6 of FLI1. As the fundamental pathogenetic lesion in ES, the molecular heterogeneity of these fusion transcripts may have functional and clinical significance.

PATIENTS AND METHODS

We performed a clinical and pathologic analysis of 112 patients with ES in which EWS-FLI1 fusion transcripts were identified by reverse-transcriptase polymerase chain reaction (RT-PCR). Adequate treatment and follow-up data were available in 99 patients treated with curative intent. Median follow-up in these 99 patients was 26 months (range, 1 to 140 months). Univariate and multivariate survival analyses were performed that included other prognostic factors, such as age, tumor location, size, and stage.

RESULTS

Among the 99 patients suitable for survival analysis, the tumors in 64 patients contained the type 1 fusion and in 35 patients contained less common fusion types. Stage at presentation was localized in 74 patients and metastatic in 25. Metastases (relative risk [RR] = 2.6; P = .008), and type 1 EWS-FLI1 fusion (RR = 0.37; P = .014) were, respectively, independent negative and positive prognostic factors for overall survival by multivariate analysis. Among 74 patients with localized tumors, the type 1 EWS-FLI1 fusion was also a significant positive predictor of overall survival (RR = 0.32; P = .034) by multivariate analysis.

CONCLUSION

EWS-FLI1 fusion type appears to be prognostically relevant in ES, independent of tumor site, stage, and size. Further studies are needed to clarify the biologic basis of this phenomenon.

Prognostic factors for patients with sarcomas of the pelvic bones

BACKGROUND

Treatment of malignant tumors of the pelvis represents one of the most difficult problems in musculoskeletal oncology. However, factors that influence the local and systemic control of the disease remain ill-defined.

METHODS

One hundred and two patients with localized pelvic sarcomas who underwent a surgical excision of the tumors were analyzed. The tumor diagnosis was chondrosarcoma in 49 patients, osteosarcoma in 26 patients, Ewing's sarcoma in 20 patients, and other tumors in 7 patients. The tumor was located in the ilium in 65 patients, the pubis in 21 patients, the ischium in 8 patients, and the sacrum in 8 patients. Eighty-three patients underwent a limb-sparing surgery and 19 patients underwent hemipelvectomy. Prognostic factors for local recurrence, metastasis, and survival were analyzed.

RESULTS

At last follow-up, 47 patients were disease free, 7 were alive with disease, and 48 had died. The 5-year survival rate was 55% (chondrosarcoma: 65%, osteosarcoma: 47%, and Ewing's sarcoma: 52%). Inadequate surgical margin emerged as the only independent adverse prognostic factor for local recurrence. For distant metastasis, surgical stage remained as an independent prognostic factor. Patients who underwent a hemipelvectomy and those who had an inadequate surgical margin had significantly poorer survivals.

CONCLUSIONS

Pelvic sarcomas remain diseases with a poor prognosis. Independent prognostic factors are few; an adequate surgical margin is critical to prevent local recurrence, and the surgical stage is related to the risk of distant metastasis. Surgical margins and hemipelvectomy were predictors of survival, but the patients who underwent hemipelvectomy also tended to have the largest, most advanced tumors. Hemipelvectomy should be considered when there is sacral involvement.

Immunological studies of a 21 kDa cellular component efficiently incorporated into rabies virion grown in a BHK-21 cell culture

To investigate cellular components incorporated into the rabies virion, monoclonal antibodies (MAbs) were screened based on their reactivity with additional virion components. Two of the MAbs we prepared recognized a virion-associated 21 kDa polypeptide (referred to as VAP21) from a BHK-21 cell. Since the MAbs precipitated the rabies virion and trypsin digestion eliminated the VAP21 antigen from the virion but alkaline treatment (pH 11) did not, VAP21 seems to be anchored into the viral envelope and exposed on the virion surface. Although quantitative immunoblot analyses indicated an apparently increased concentration of VAP21 in the virion, the ratio of the content of VAP21 to that of viral glycoprotein (G) was several times decreased as compared to the ratio of those in the cell. These data suggest that sorting of VAP21 occurs during the viral budding process on the cell but that it might be inefficient, probably due to a more intimate association of VAP21 with the viral envelope proteins. This assumption seems to be consistent with the results of immunofluorescence studies; that is, VAP21 displayed colocalized distribution with viral envelope antigens in the cell. From these results, it is suggested that VAP21 closely associates with the viral envelope proteins in the cell, and this association might cause passive but relatively efficient incorporation of VAP21 into the virion.

Hyperparathyroid crisis in a patient with a giant brown tumor of the iliac bone: a case report

We observed a patient with a giant brown tumor of the iliac bone due to hyperparathyroidism. There was a risk of pathologic fracture due to huge cysts produced by bone absorption. In hyperparathyroid crisis, control of severe hypercalcemia is difficult without resection of the parathyroid gland.

Peripheral primitive neuroectodermal tumors in adults: documentation by molecular analysis

PURPOSE

The Ewing tumor (ET) family of peripheral primitive neuroectodermal tumors (pPNETs) are primitive small round-cell tumors (SRCTs) of the bone and soft tissue that occur predominantly in children and adolescents. However, pPNETs only rarely enter the differential diagnosis of bone and soft tissue SRCTs in adults. Recently, gene fusions between the EWS gene and different members of the ETS transcription factor family have been shown to occur in virtually all pPNETs and thus constitute a pathognomonic marker for this tumor subclass. The aim of the present study was to document EWS/ETS fusion gene expression in suspected pPNETs of adults as objective evidence for the existence of this tumor family in older patients.

PATIENTS AND METHODS

The three contributing molecular diagnostic laboratories retrospectively compiled a cohort of all SRCT cases in which EWS/ETS gene fusions had been shown by molecular analysis. This cohort was surveyed for cases that occurred in patients aged 40 years or older, which were then analyzed for their clinical and pathologic features.

RESULTS

Nine patients between 40 and 65 years of age were found to have tumors positive for EWS/ETS gene fusions. Standard histopathologic and clinical features of these cases, other than age, were similar to those of childhood pPNETs. Patients were initiated on appropriate therapy after molecular analysis confirmed the diagnosis of pPNET.

CONCLUSION

Identification of an EWS/ETS gene fusion is useful in providing objective evidence of the diagnosis of pPNET in patients over the age of 40 years. This diagnosis should be considered in adults who present with bone and soft tissue SRCTs and appropriate biopsy specimens should be collected for molecular analysis at the time of diagnosis.

Osteosarcoma of the pelvis. Oncologic results of 40 patients

The cases of 40 patients with osteosarcoma of the pelvis treated between 1977 and 1994 were reviewed. The location of the tumor was ilium in 30 patients, ischium in four, pubis in one, and sacrum in five. Most (58%) of the tumors were of the chondroblastic subtype. Thirty patients had surgical excision of the tumors: 10 with hemipelvectomies and 20 with limb sparing procedures. A wide margin was achieved in 16 of 30 (53%) patients, including 12 of 14 who had no sacral tumor involvement. Positive margins occurred at the sacrum in 11 patients, lumbar vertebra in one, perirectal space in one, and contralateral pubic body in one. Macroscopic tumor emboli within the regional large vessels were found in seven patients. The incidence of local recurrence was 32%: 13% in wide excisions, 38% in marginal excisions, and 80% in intralesional excisions. The 1- and 5-year overall patient survivals were 73% and 34%, respectively. Patients who had a surgical excision of the primary tumor had a significantly better survival than did those treated without surgery (5-year survival; 41% and 10%, respectively). Tumor size, surgical excision of the primary tumor, surgical margin, and type of surgical procedure were the prognostic factors for patients with Stage IIB tumors.