Experience with intradermal injection and intradermal-plus-deep injection in the radioguided sentinel node biopsy of early breast cancer patients

AIMS

Methods of administering (99m)Tc-phytate during sentinel node biopsy of early breast cancer patients were compared to improve the sensitivity of the technique.

METHODS

Two injection methods, intradermal vs. intradermal-plus-deep injection, were compared in 648 early breast cancer patients. Intradermal injection was done in 323 consecutive patients (325 breasts), and intradermal-plus-deep injection was done in 325 consecutive patients (329 breasts). The following items were compared: (1) The number of axillary nodes detected scintigraphically and removed surgically, and the breast number of micrometastasis to axillary nodes; (2) The number of internal mammary nodes detected scintigraphically and removed surgically; and (3) The sensitivity of axillary SNB.

RESULTS

The number of axillary nodes scintigraphically detected was 1.63+/-0.80 (mean+/-SD) in patients given intradermal injection, and was 1.82+/-0.94 in patients given intradermal-plus-deep injection. The number of axillary nodes surgically removed was 1.78+/-0.93 in patients given intradermal injection, and was 1.95+/-0.99 in patients given intradermal-plus-deep injection. The visualization of internal mammary nodes was superior with intradermal-plus-deep injection (5/325 for intradermal, and 51/329 for intradermal-plus-deep). The putative sensitivity was 71/72 (98.6%) for the intradermal-plus-deep method and 56/62 (90.3%) for the intradermal method. The frequency of detection of micrometastasis was 24 in 71 true positive (38.8%) for the intradermal-plus-deep method and 13 in 56 true positive (23.2%) for the intradermal method.

CONCLUSIONS

The SNB procedure with the intradermal-plus-deep injection method detected more axillary and internal mammary nodes, more (not statistically significant) micrometastasis and improved the putative sensitivity more than the SNB procedure with the intradermal injection method.

Radioactivity thresholds for sentinel node biopsy in breast cancer

AIMS

The aim of the present study is to clarify the level of radioactive lymph node should be biopsied after the most radioactive SN is removed.

METHODS

SNB using radionuclide was performed in our hospital for 1179 primary breast cancers between April 2000 and October 2005; most (1177/1179) were performed successfully. Our criterion for harvesting SNs is to remove tissue until no radioactive site is present. The level of radioactivity and the order of removal of each lymph node were compared with pathologic results.

RESULTS

More than 2 (overall average 1.9) radioactive SNs were biopsied in 686 of 1177 breasts. Cancer positive results were recorded for 142 breasts with multiple SNs. In 142 breasts, 64 showed metastasis to the most radioactive node only, 39 showed metastasis other than the most radioactive node only, and 39 showed the most radioactive node and other radioactive nodes. Moreover, if several other criteria were applied, false-positive cases were increased significantly.

CONCLUSIONS

It is necessary to harvest radioactive lymph nodes other than the most radioactive. Moreover, efforts to remove every radioactive lymph node will minimize false-negative results.

Increased intensity of acute graft-versus-host disease after reduced-intensity bone marrow transplantation compared to conventional transplantation from an HLA-matched sibling in children

Eight children underwent reduced-intensity stem cell transplantation (RIST) from an HLA-matched sibling. They received a fludarabine-melphalan based preparative regimen. Stem cell source was bone marrow, and GVHD prophylaxis consisted of cyclosporine A alone. Acute GVHD grade II-IV and grade III-IV were observed in four (50%) and three (37.5%), respectively, out of these eight patients. This incidence was significantly higher than that after conventional bone marrow transplantation, without severe tissue damage, in the same setting of stem cell source and GVHD prophylaxis. Although the number of patients is small, our results suggest that incidence of acute GVHD after RIST for children is significant. It should be remembered that RIST for children does not seem to be an easy transplant procedure from the viewpoint of acute GVHD, although RIST is less toxic.

Pantothenate kinase-associated neurodegeneration with increased lentiform nuclei cerebral blood flow

We report a case of pantothenate kinase-associated neurodegeneration with increased regional cerebral blood flow (rCBF) in bilateral lentiform nuclei on technetium Tc-99m ethyl cysteinate dimer single-photon emission CT (ECD-SPECT). A 6-year-old boy presented with opisthotonus. T2*-weighted MR images revealed areas of marked hypointensity with a hyperintense focus in bilateral globus pallidus, creating the characteristic eye-of-the-tiger appearance. ECD-SPECT showed increased rCBF in bilateral lentiform nuclei.

Cytotoxic Chemotherapy Successfully Induces Durable Complete Remission in 2 Patients with Mosquito Allergy Resulting from Epstein-Barr Virus-Associated T-/Natural Killer Cell Lymphoproliferative Disease

Recent findings indicate that Epstein-Barr virus (EBV)-infected T-/natural killer (NK) cells play an important role in the pathogenesis of mosquito allergy, and most patients with mosquito allergy die early in life if not properly treated. Over the last 7 years, we have been using combination chemotherapy and allogeneic stem cell transplantation for the treatment of EBV-associated T-/NK cell lymphoproliferative disease (LPD) in which chronic active EBV infection and mosquito allergy were included. As of this writing, we have successfully treated 2 patients with mosquito allergy with chemotherapy in which EBV-infected T-/NK cells were eradicated. The findings suggest the possible role of chemotherapy in the treatment of EBV-associated T-/NK cell LPD.

A heteroplasmic mitochondrial DNA 3310 mutation in the ND1 gene in a patient with type 2 diabetes, hypertrophic cardiomyopathy, and mental retardation

A mentally retarded 57-year-old Japanese man with maternally-inherited type 2 diabetes was found to have hypertrophic cardiomyopathy (HCM) that was associated with pathological changes in the myocardial mitochondria. The mitochondrial DNA (mtDNA) of this patient was examined and a C3310 T mutation was found in the ND1 gene, which resulted in the substitution of serine for proline. The normal 3310 mtDNA band could not be detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) in mtDNA from his myocardium, pancreas, cerebral tissue, skeletal muscle, and lymphocytes. However two clones sequenced from his pancreatic tissue did not show this C3310 T mutation while forty-eight did. Mitochondria isolated from the lymphocytes of his two sisters also had this mutation. mtDNA point mutations in the ND1 gene region reported thus far have been mostly homoplasmic. However, the C3310 T point mutation that was found in this patient was heteroplasmic, which is a high level of mutation and may represent the pathogenic gene that was responsible for causing mitochondrial disease.

Pulmonary alveolar microlithiasis: CT and pathologic findings in 10 patients

BACKGROUND AND AIM

To evaluate CT findings of pulmonary alveolar microlithiasis and correlate the CT with the pathologic findings.

METHODS

The study included 10 patients with pathologically proven microlithiasis. Two independent observers evaluated the presence, extent and distribution of the CT findings. CT findings were compared with those at autopsy in two patients and with transbronchial biopsy in eight patients.

RESULTS

All patients had a myriad of calcified nodules measuring approximately 1 mm in diameter. Close apposition of the nodules resulted in areas of ground-glass attenuation and consolidation, which were the predominant abnormality on CT in all 10 patients, involving 41% +/- 16.3 (mean +/- SD) and 30% +/- 4.8 of the lung parenchyma, respectively. Calcifications were also seen along interlobular septa, bronchovascular bundles and pleura. Other findings included interlobular septal thickening, thickening of bronchovascular bundles, nodules, and subpleural cysts. There was a solid agreement between the observers for the presence (kappa value; 0.77) and extent (Spearman rank correlation; r = 0.81 to 1.0 p < 0.01) of abnormalities. Autopsy specimens demonstrated microliths in alveolar airspaces and along interlobular septa, bronchovascular bundles and pleura. Subpleural small cysts were shown to represent dilated alveolar ducts.

CONCLUSION

Pulmonary microlithiasis is characterised by the presence of numerous small, calcified nodules, calcifications along interlobular septa, bronchovascular bundles and pleura, ground-glass opacities, consolidation, and subpleural cysts. The cysts represent dilated alveolar ducts.

Exploitation of colinear relationships between the genomes of Lotus japonicus, Pisum sativum and Arabidopsis thaliana, for positional cloning of a legume symbiosis gene

The Lotus japonicus LjSYM2 gene, and the Pisum sativum orthologue PsSYM19, are required for the formation of nitrogen-fixing root nodules and arbuscular mycorrhiza. Here we describe the map-based cloning procedure leading to the isolation of both genes. Marker information from a classical AFLP marker-screen in Lotus was integrated with a comparative genomics approach, utilizing Arabidopsis genome sequence information and the pea genetic map. A network of gene-based markers linked in all three species was identified, suggesting local colinearity in the region around LjSYM2/PsSYM19. The closest AFLP marker was located just over 200 kb from the LjSYM2 gene, the marker SHMT, which was converted from a marker on the pea map, was only 7.9 kb away. The LjSYM2/PsSYM19 region corresponds to two duplicated segments of the Arabidopsis chromosomes AtII and AtIV. Lotus homologues of Arabidopsis genes within these segments were mapped to three clusters on LjI, LjII and LjVI, suggesting that during evolution the genomic segment surrounding LjSYM2 has been subjected to duplication events. However, one marker, AUX-1, was identified based on colinearity between Lotus and Arabidopsis that mapped in physical proximity of the LjSym2 gene.

A women's support group for Asian international students

International students underuse counseling services, which are grounded in Western cultural values. The authors describe a support group for Asian international students that they launched at a large midwestern university to help students feel at ease with American university life, address homesickness, language problems, and academic and social stressors. Co-leaders created a safe and culturally sensitive atmosphere where the women could network, socialize, and address their issues. Group treatment offers many advantages over individual counseling and can enhance the health of international students.

Improvement of endocardial border delineation during dobutamine stress echocardiography with Levovist

OBJECTIVES

This study evaluated whether the use of Levovist improves endocardial border delineation during dobutamine stress echocardiography.

METHODS

Thirty patients (20 men and 10 women) were enrolled in this study. Dobutamine was infused intravenously using an incremental regimen of 5, 10, 20, 30, and 40 micrograms/kg/min, each dose for 3 min. Levovist (277 mg/ml), dissolved in 9 ml of 5% dextrose, was infused intravenously. Two ml was infused at rest, 10, and 20 micrograms/kg/min. Three ml was infused at peak dobutamine dosage. Echocardiograms were recorded on videotapes. A endocardial border delineation score index (EDSI) was used for image analysis. The EDSI was obtained from each of 12 segments of the left ventricular wall (30 patients) in the rest and peak stress periods, before and after Levovist. Data from a total of 1,440 segments were analyzed separately.

RESULTS

The mean EDSI at rest was 2.2 +/- 0.6 without contrast medium, and 2.4 +/- 0.7 with contrast medium (p < 0.05). The mean EDSI during peak stress was 2.0 +/- 0.7 without contrast medium, and 2.2 +/- 0.6 with contrast medium (p < 0.05). The wall-by-wall EDSI revealed that the delineation of apical-septal, mid- and apical-lateral, apical-inferior, and apical-anterior segments was improved significantly with Levovist in the rest and peak stress periods.

CONCLUSIONS

Delineation of the apical-septal, mid- and apical-lateral, apical-inferior, and apical-anterior segments was improved significantly with Levovist during dobutamine stress echocardiography.

Molecular regulation of the oxytocin receptor in peripheral organs

The oxytocin receptor belongs to the G-protein-coupled seven transmembrane receptor superfamily. Its main physiological role is regulating the contraction of uterine smooth muscle at parturition and the ejection of milk from the lactating breast. Oxytocin receptor expression is observed not only in the myometrium and mammary gland but also in the endometrium, decidua, ovary, testis, epididymis, vas deferens, thymus, heart and kidney, as well as in the brain. The expression profile shows a tissue-specific as well as a stage-specific pattern. The oxytocin receptor gene is a single-copy gene consisting of four exons and three introns, localized at 3p25-3p26.2 in the human chromosome. In transfection studies using a fusion construct containing the promoter region of the oxytocin receptor gene inserted in a reporter plasmid, neither proinflammatory cytokines nor oestrogen directly activate the gene. The nuclear fractions from up-regulated (term myometrium) and down-regulated (non-pregnant myometrium) tIssues show differential patterns of protein binding to the 5'-flanking region, and a human homologue of chicken MafF has been cloned as a term-myometrium-specific oxytocin receptor modulator. The oxytocin receptor gene appears to be highly methylated. Methylation around intron 1 and in intron 3 might contribute to tIssue-specific suppression of the gene. The oxytocin receptor is also regulated by desensitization, whose mechanism appears to involve loss of ligand-binding activity of the protein as well as suppression of the oxytocin receptor mRNA transcription. These findings taken together indicate that the oxytocin receptor is regulated in a very complicated manner, and the transcriptional regulatory elements critical for this regulation should be investigated further.

Malignant epithelial tumor of unknown origin of the broad ligament

Malignant epithelial tumor of the broad ligament is rare and to our knowledge only 17 cases have been reported. We report a 54-year-old Japanese woman in whom transvaginal sonography (TVS) and magnetic resonance imaging (MRI) showed a left adnexal tumor. Serum CA125 was elevated to 10,000 U/ml. Preoperatively, we diagnosed this tumor was a left ovarian malignant tumor though, it was confirmed a the 47x57 mm tumor in the left broad ligament at laparotomy. Histologically most of the tumor showed serous papillary adenocarcinoma with changes similar to poorly differentiated carcinoma and as seen in transitional cell carcinoma on hematoxylin-eosin staining. After three courses of platinum based adjuvant chemotherapy, the patient is alive with no recurrence at 18 months postoperatively.

Personal dimensions of identity and empirical research in APA journals

This study reviewed 402 empirical research papers published during 1999 in 9 American Psychological Association journals from the perspective of the Personal Dimensions of Identity (PDI) model. Descriptions of participants were reviewed to determine whether researchers reported information concerning Dimensions A, B, and C of the PDI model. PDI A and B Dimensions of age, gender, education, and geographic location were reported with the highest frequency: 88.56%, 89.30%, 78.50%, and 73.88%, respectively, whereas race/ethnicity was reported with moderate frequency, 60.70%. The remaining PDI A Dimensions of language, physical disability, sexual orientation, and social class, and the remaining B Dimensions of citizenship status, employment status, income, marital status, military experience, occupation, and religion, were reported in relatively low percentages of studies.

Combined spinal and epidural anesthesia for abdominal aortic aneurysm surgery in patients with severe chronic pulmonary obstructive disease

BACKGROUND

The presence of chronic obstructive pulmonary disease (COPD) should not be considered a contraindication to operation but should rather identify those patients that require special preoperative and postoperative pulmonary care. The purpose of this paper is to report our experience in the use of combined spinal and epidural anesthesia (CSEA) for open AAA repair in such patients.

METHODS

From April 1997 to November 1998, three patients with severe COPD underwent elective open infrarenal AAA repair under CSEA. All the patients satisfied one or more of the following criteria: a room air PaO2 =or<60 mmHg, PaCO2 =or>45 mmHg, FEV1 =or<50% of predicted, and/or FVC =or<75% of predicted, and one of them was on home oxygen preoperatively. Preoperative preparation of the patients consisted of breathing exercises with incentive espirometry, elimination of underlaying pulmonary infections and usage of bronchodilator therapy.

RESULTS

All the patients tolerated surgery safely. None of them developed postoperative complications, including pneumonia and other respiratory conditions. No significant changes in room air arterial blood gas or pulmonary function was recognized before and after surgery.

CONCLUSIONS

CSE anesthesia is a viable anesthetic option for conventional AAA surgery in patients with severe COPD since it can preserve spontaneous breathing and provide additional respiratory benefits over general anesthesia.

Application of synchrotron X-ray imaging to phase objects in orthopedics

Novel imaging of the fine structures of the ribs of a pig and a specimen of human osteosarcoma utilizing the spatial coherence of X-rays was successfully performed with an incident X-ray energy of 30 keV at SPring-8, Japan. The image contrast appearing at the periphery of trabecular bone, small calcifications and small fractures is caused by the phase shift of the X-rays at the boundary of these objects that have different X-ray refractive indices. The image is recorded on mammography film without an intensifying screen. Comparison of the image contrast using different sample-to-film distances, Z, such as Z = 5 m and Z approximately 0 m, showed that the former images were always more informative, i.e. better in resolution and/or image contrast when imaging trabecular bone, bone marrow and small fractures in compact bone, and for imaging cartilage. Radiography using synchrotron X-rays for phase objects should be a powerful tool for diagnosis in orthopedics, especially for bone disease.

Granulomatous and cytokine responses to pulmonary Cryptococcus neoformans in two strains of rats

The present study was undertaken to elucidate the participation of Th1 and Th2 responses in granulomatous inflammation induced by Cryptococcus neoformans using Lewis and Brown Norway rats which have Th1-polarized and Th2-polarized innate immunity, respectively. Both strains demonstrated granulomatous inflammation in the lung, and the lesions were composed mainly of mononuclear phagocytes and surrounded by lymphocytes. Lewis rats demonstrated tuberculoid epithelioid cell granulomas with a central necrosis resembling caseation, and increased transcription of Th1 relevant cytokines. On the other hand, Brown Norway rats showed mature granulomas including eosinophils with increased transcription of IL-12 without increased transcription of not only IFN-gamma and IL-2 but also Th2 cytokines such as IL-4, IL-5, and IL-10, unexpectedly. The colony-forming unit of the lung was decreased exponentially in both strains, and that of Brown Norway rats was significantly lower than that of Lewis rats 10 days after the inoculation. This indicated that Brown Norway rats demonstrated more fungicidal activity than Lewis rats in the early stage of the infection. The role of eosinophils with humoral immunity may be considered to be resistant in Brown Norway rats in addition of the function of macrophages.

DNA methylation of the human oxytocin receptor gene promoter regulates tissue-specific gene suppression

In the human oxytocin receptor (OTR) gene, there is a CpG island from 140 bp upstream to 2338 bp downstream of the transcription start site (TSS). We investigated whether the methylation state of this region affects the transcription of the OTR gene. HepG2 derived from human hepatoblastoma, in which OTR gene transcription was suppressed, was treated with a demethylating agent, 5-azacytidine (Aza-C) for 2 days. Semiquantitative RT-PCR indicated that OTR mRNA was significantly increased by Aza-C treatment in a dose-dependent manner. We estimated the level of methylation within the CpG islands of the OTR gene in peripheral blood leukocytes, nonpregnant uterine myometrium, term uterine myometrium and liver. A 1.5-kb region located 5' upstream of the translation start site was divided into four fragments. Each was amplified by PCR after complete digestion with methylation-sensitive restriction enzyme HpaII. The amount of PCR products was largest in the liver, suggesting that this CpG island in the OTR gene is most highly methylated in liver, where the gene is always inactivated. We compared the effect of in vivo methylation of the CpG island on transcriptional activity of an OTR-reporter plasmid. The reporter gene activity of expression plasmid -2860/+1342-GL3, containing the CpG island, in HepG2 cells was suppressed to 30.6% of the control level after methylation with SssI methylase, while that of -2840/+144-GL3, without the CpG island was suppressed only to 81.4%. The deletion of the segment (MT2) where the level of methylation was most different between liver and uterus (-2860/+1342(del)MT2-GL3) rescued the suppression rate to 68.0%. These results indicate that the methylation of the CpG island in the human OTR gene promoter suppressed its transcription at least in liver and may regulate tissue specific gene expression among organs.

Evaluation of image quality and spatial resolution of low-dose high-pitch multidetector-row helical high-resolution CT in 11 autopsy lungs and a wire phantom

PURPOSE

The aim of this study was to evaluate whether low-dose high-pitch (6:1) multidetector-row helical high-resolution CT is appropriate for the evaluation of various pulmonary abnormalities, including faint opacities.

METHODS

Eleven autopsy lungs were scanned with a multidetector-row CT scanner using 2.5 mm x 4 beam collimation, effective slice thickness 3 mm, 6:1 pitch, 0.8 second gantry rotation speed, 20 cm Display FOV, high spatial frequency (bone) algorithm, and various radiation doses (120 kVp; 160, 80, 40, 24, and 8 mAs). The image quality of each CT set was assessed as adequate or inadequate for diagnosis by two independent observers. In addition, a wire phantom was scanned with the same parameters in order to describe the MTF curves.

RESULTS

There was excellent agreement between the observers for the evaluation of image quality (kappa statistic, 0.84). The ratio of images evaluated as inadequate for 8 mAs and 24 mAs was significantly higher than that for 160, 80, and 40 mAs (p<0.01: chi-square test). MTF curves of both 8 and 24 mAs were significantly inferior to those of 40, 80, and 160 mAs (p<0.0 1, Friedman test), while the MTF curve of 40 mAs was relatively inferior to that of 160 mAs (p<0.05, Friedman test).

CONCLUSION

More than 40 mAs in combination with 120 kVp is preferable for the evaluation of details of lung parenchyma by high-pitch. multidetector-row helical high-resolution CT.

Pulmonary involvement in primary Sjögren's syndrome: spectrum of pulmonary abnormalities and computed tomography findings in 60 patients

The purpose of this study was to describe the high-resolution computed tomography (HRCT) findings of pulmonary involvement in primary Sjögren's syndrome. The study included 60 patients who met the diagnostic criteria for primary Sjögren's syndrome. The authors retrospectively reviewed the presence, extent, and distribution of various HRCT findings. Results showed that the most common HRCT findings were areas with ground-glass attenuation (92%), followed by subpleural small nodules (78%), non-septal linear opacity (75%), interlobular septal thickening (55%), bronchiectasis (38%), and cysts (30%).