Non-sentinel lymph node status and prognosis of the breast cancer patients with micrometastatic sentinel lymph nodes

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Background: Sentinel lymph node biopsy (SLNB) has become a standard therapy for clinically node-negative breast cancer patients and improvements of histopathological and molecular analysis of sentinel lymph node (SLN) have increased the rate of micrometastases identified. However it remains controversial whether to perform axillary lymph node dissection (ALND) for patients with micrometastases in SLNs and their prognostic significance is also a matter of debate. The purpose of this study is to determine the non- sentinel lymph node (NSLN) status and prognosis of the patients with micrometastatic SLNs. Methods: A prospective database of 666 breast cancer patients with the tumor size less than 3cm and clinical negative node, who underwent SLNB from January 2002 to July 2007 at Keio University Hospital was analyzed. SLNs were detected using a combined method of isosulfun blue dye and small-sized technetium-99m-labeled tin colloid. SLNs were diagnosed with standard hematoxylin and eosin (HE) staining and immunohistochemical (IHC) analysis. Results: Micrometastases in SLNs were found in 50 (7.5%) of 666 patients. Twenty nine (58.0%) of 50 patients with micrometastatic SLNs underwent ALND and revealed no NSLN metastasis. Among 21 (42.0%) patients with micrometastatic SLNs who skipped ALND, no axillary lymph node recurrence has been observed in the median follow-up time of 43 months, although 20 patients (95.2%) in 21 patients received adjuvant systemic therapy. There is no significant difference in recurrence free survival between the patients with micrometastatic and negative SLNs (98.0% vs. 95.7%, respectively). Conclusions: These date suggested that it may not be necessary to perform ALND for the patients with micrometastases in SLNs and the presence of micrometastases in SLNs may not be associated with prognosis.

No significant financial relationships to disclose.

Long-term treatment with intravenous bisphosphonates in metastatic breast cancer (MBC)

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Background: Intravenous bisphosphonates (IV BPs) are safe and effective in reducing skeletal related events in MBC. The effects of IV BPs after 24 months of therapy are unknown. The incidence of osteonecrosis of the jaw (ONJ) and renal insufficiency (RI) among women with MBC receiving >= 24 months of IV BPs is also poorly defined. We studied the long term effect of IV BPs in a cohort of women with MBC. Methods: We maintain an ongoing prospective database of >600 women with MBC diagnosed and treated at our institution from January 1999. A long-term cohort (LTC) of 159 women with metastatic breast cancer to bone treated for >= 24 months with pamidronate (n = 9), zoledronic acid (n = 110), or both (n = 40) was identified. A control cohort (CC) of 62 women with MBC to bone treated with IV BPs for 12–23 months was also identified. RI was defined as an increase in serum creatinine (scr) of > 0.5 mg/dl or an absolute level of scr >1.5mg/dl; ONJ was diagnosed by dental consultation. Results: Median follow-up of the LTC was 39 months (range 24–99) months. Median overall survival in this cohort was 43 months (range 24–114). The vast majority of women in the LTC (140/159, 88.1%) continued to receive IV BPs at standard dose every 3–4 weeks. The incidence of ONJ in the LTC was 6/159 (3.8%), after a mean 42.2 treatment cycles, with a median time to ONJ of 44 months. Three of six patients with ONJ (50%) underwent surgical resection, and 3/6 (50%) were managed conservatively, and 3/6 (50%) resumed IV BPs after a mean 12 month hold. The incidence of RI (all pts had baseline scr < 1.4 mg/dl) in the LTC was 19/159 (11.9%), occurring after a mean 43.4 treatment cycles, with a median time to RI of 43 months. Eleven of 19 patients (57.9%) recovered to baseline scr and 7/19 (36.7%) patients showed partial recovery. Seventeen of 19 patients (89.4%) were able to resume therapy after temporary discontinuation, decreasing the dose, or increasing the interval of the IV BP. Incidence of ONJ in the CC was 1/62 (1.6%) and RI in the CC was 6/62 (9.7%). Conclusions: Long term (>=24 month) IV BP use in MBC is well tolerated and safe, with relatively low incidence of ONJ and RI. Most patients were able to resume IV BP therapy after a therapy hold without further complication.

No significant financial relationships to disclose.

Studies on the conformation and interactions of elastin: nuclear magnetic resonance of the polyhexapeptide

Synthesis, proton magnetic resonance and carbon-13 magnetic resonance characterizations, including complete assignments, are reported for the polyhexapeptide of elastin, HCO-Val(Ala1-Pro2-Gly3-Val4-Gly5-Val6)18-OMe. Temperature dependence of peptide NH chemical shifts and solvent dependence of peptide C-O chemical shifts have been determined in several solvents and have been interpreted in terms of four hydrogen bonded rings for each repeat of the polyhexapeptide. The more stable hydrogen bonded ring is a beta-turn involving Ala1C-O--HN-Val4. More dynamic hydrogen bonds are an 11-atom hydrogen bonded ring Gly3NH--O-C Gly5, a 7-atom hydrogen bonded ring (a gamma-turn) Gly3 C-O--NH-Gly5, and a 23-atom hydrogen bonded ring Val6inH--O-C Val6(i+1). This set of hydrogen bonds results in a right-handed beta-spiral structure with slightly more than two repeats (approximately 2.2) per turn of spiral. The beta-spiral structure is briefly discussed relative to data on the elastic fiber.

An aspergillotic aneurysm of the internal carotid artery following allogeneic bone marrow transplantation: successful management with catheter coil embolization and long-term antifungal agents

We report a case of a mycotic aneurysm of the internal carotid artery and cerebral hemorrhagic infarction resulting from Aspergillus middle ear infection in a patient with severe aplastic anemia who received unrelated bone marrow transplantation. Although a mycotic aneurysm is a rare complication, and most often fatal, the patient was successfully treated with catheter coil embolization of the internal carotid artery and long-term systemic antifungal therapy. This case emphasizes the need for the rapid diagnosis of potential fungal involvement of the vascular system and suggests the necessity for aggressive treatment, such as with the modality illustrated in this case.

Phex mutation causes overexpression of FGF23 in teeth

OBJECTIVE

Hyp mice have a disorder in phosphate homeostasis, and display hypo-mineralization in bones and teeth, while the Phex (phosphate regulating gene homologies to endopeptidase on the X chromosome) gene in Hyp mice has a deletion of the 3' end. We investigated whether a mutation of Phex has an effect on the expression level of fibroblast growth factor 23 (FGF23), one of the key factors of phosphate homeostasis, in developing teeth of Hyp mice.

DESIGN

RT-PCR and in situ hybridisation analyses for FGF23 were performed using developing teeth of WT mice. Quantitative RT-PCR analyses for FGF23 were performed using the tooth germs of WT and Hyp mice in both in vivo and in vitro experiments.

RESULTS

Undifferentiated and early secretory ameloblasts as well as odontoblasts expressed FGF23 mRNA during early tooth development. Further, quantitative RT-PCR analyses revealed that the amount of FGF23 mRNA in Hyp mouse teeth was significantly higher than that in wild type mice.

CONCLUSIONS

These findings suggest that loss of Phex function is related to overexpression of FGF23 in teeth, which is an intrinsic defect of Hyp mouse teeth.

Phex mutation causes the reduction of npt2b mRNA in teeth

Hyp mice (murine homologue of human X-linked hypophosphatemia) have a disorder in phosphate homeostasis, and display hypomineralization in bones and teeth. We investigated whether a mutation of Phex (phosphate regulating gene homologies to endopeptidase on the X chromosome) has an effect on the expression level of type II sodium-dependent phosphate co-transporter (Npt2) in the developing teeth of the Hyp mouse. Quantitative RT-PCR analyses revealed that the amount of Npt2b mRNA, an isoform of Npt2, in Hyp mouse tooth germs was significantly lower than that in wild-type mice, in both in vivo and in vitro experiments. In addition, tooth germs from wild-type mice cultured in medium supplemented with antisense oligo-deoxynucleotide for Phex also showed a reduction of Npt2b mRNA expression. These findings suggest that the loss of Phex function is related to the defect of Npt2b expression in teeth, and Npt2b reduction is an intrinsic defect of Hyp murine teeth.

Clinical characteristics of fulminant-type autoimmune hepatitis: an analysis of eleven cases

BACKGROUND

Although a few adult cases of fulminant-type autoimmune hepatitis have been reported, their clinical features and prognosis have remained uncertain.

AIM

To assess the clinical features and prognosis of patients with fulminant-type autoimmune hepatitis.

METHODS

Eleven patients (10%) diagnosed with fulminant-type autoimmune hepatitis in accordance with the 1999 criteria of the International Autoimmune Hepatitis Group were analysed.

RESULTS

All 11 patients were female, with a median age of 53 years. Five patients survived without liver transplantation, one received a liver transplantation, and five died without liver transplantation. Nine patients (82%) survived for 2 weeks or more following diagnosis, without liver transplantation. Except for the patient receiving a liver transplantation, serum total bilirubin levels measured during the clinical course were significantly higher in non-survivors than in survivors, although the accompanying serum alanine aminotransferase levels measured for the two groups were similar. Most significantly, serum total bilirubin levels in non-survivors worsened during days 8-15, while levels in survivors improved during the same period.

CONCLUSIONS

The short-term prognosis for patients with fulminant-type autoimmune hepatitis may be good. However, patients whose serum total bilirubin levels worsen during days 8-15 should be considered for liver transplantation.

Peripheral blood stem cell mobilization by granulocyte colony-stimulating factor alone and engraftment kinetics following autologous transplantation in children and adolescents with solid tumor

In 56 pediatric and adolescent patients (median age 7 years, range 1-21) with various solid tumors, peripheral blood stem cells (PBSC) were mobilized with granulocyte colony-stimulating factor (G-CSF) alone, and the yields of PBSC and engraftment kinetics following autologous peripheral blood stem cell transplantation (PBSCT) were evaluated retrospectively. Granulocyte colony-stimulating factor (10 microg/kg) was injected subcutaneously for mobilization when patients showed no influence of previous chemotherapy, and administration was continued for 5 days. The peaks of CD34+ cells and colony-forming units-granulocyte/macrophage in the blood were observed on days 4 through 6 of G-CSF administration in all patients. Peripheral blood stem cell harvest was commenced on day 5 of G-CSF treatment. Compared to the results in patients mobilized by chemotherapy plus G-CSF (N=18), the progenitor cell yields were lower in patients mobilized with G-CSF alone. However, there were no significant differences in WBC and ANC engraftment compared to the chemotherapy plus G-CSF mobilization group. Platelet recovery following autologous PBSCT was delayed in patients mobilized with G-CSF alone. The median time taken for ANC and platelet counts to reach 0.5 x 10(9) and 20 x 10(9)/l was 12 days (range: 9-28) and 15 days (8-55), respectively, in all patients who received PBSC mobilized by G-CSF alone. In summary, mobilization with G-CSF alone can mobilize sufficient CD34+ cells for successful autografting and sustained hematological reconstitution in pediatric and adolescent patients with solid tumors, and even in heavily pre-treated patients.

Dentinal defects in Hyp mice not caused by hypophosphatemia alone

The Hyp mouse is a murine homolog of human X-linked hypophosphatemic rickets and displays hypo-mineralization in bone and dentin due to a defect of the phosphate-regulating gene with homology to endopeptidase on the X chromosome (Phex) gene. It has long been considered that the bone and dentin defects in Hyp mice are caused by hypophosphatemia alone, however, several recent studies have indicated the possibility that intrinsic defects are present in Hyp mice osteoblasts. Further, we previously found a hyper-expression of osteocalcin (OC) mRNA in Hyp mouse odontoblasts and suggested the possibility of the presence of intrinsic defects. In the present study, we evaluated morphological features and OC mRNA expression levels in tooth germs of Nor mice with a normal phex gene and a low concentration of serum phosphate, and compared them to those in Hyp and wild-type mice. Nor mice exhibited low serum phosphate levels, however, did not show the characteristic features of dentin defects seen in Hyp mice, such as widened predentin and hyper-expression of OC mRNA. These results suggest that the hypo-mineralization of dentin in Hyp mice is not dependent on serum phosphate level, but rather is affected by intrinsic defects in odontoblasts.

Factors associated with granulocyte colony-stimulating factor-induced peripheral blood stem cell yield in healthy donors

BACKGROUND AND OBJECTIVES

Poor collection results are a clinical problem in granulocyte-colony stimulating factor (G-CSF)-induced peripheral blood stem cell (PBSC) collection in healthy donors. It would be beneficial to be able to predict the PBSC yield from allogeneic donors before mobilization or harvesting.

MATERIALS AND METHODS

We examined the relationship between certain donor characteristics and the effectiveness of G-CSF-induced PBSC collection in 59 healthy family donors aged 3-63 years old (median 16 years). G-CSF was administered subcutaneously at 10 microg/kg for mobilization, daily for 5 days, and PBSC harvest using a continuous blood cell separator was started on day 5 of G-CSF treatment. Total cell yields were calculated as the number per unit of processed blood (l) per unit weight of the donor (kg).

RESULTS

In a univariate analysis, the donor's age, body mass index (BMI), white blood cell (WBC) count before mobilization, and platelet count before and during mobilization were significantly correlated with the yield of mononuclear cells (MNC), CD34(+) cells and granulocyte-macrophage colony-forming units (GM-CFU). Younger age (P < 0.001), a low BMI (P = 0.002), a high WBC count before mobilization (P = 0.004), a high platelet count before (P = 0.012) and during (P < 0.05) mobilization, and a low speed of withdrawal (P = 0.019) were associated with a higher CD34(+) cell yield. No significant correlation was found for gender, the type of G-CSF, the serum level of G-CSF, the type of cell separator, or the type of blood access. A multivariate forward and backward stepwise selection regression analysis showed that the factors associated with CD34(+) cell yield were age, platelet count before and during mobilization, and circulating CD34(+) cell concentration on day 2 of G-CSF treatment.

CONCLUSION

In this small preliminary study, we found that donor age is the most important factor in predicting G-CSF-induced PBSC yields. Old age and low platelet counts before mobilization might be useful indicators for identifying poor mobilizers. Further validation of these findings in a larger number of donors are needed to establish whether these findings apply to other populations.

Semiclassical study on tunneling processes via complex-domain chaos

We investigate the semiclassical mechanism of tunneling processes in nonintegrable systems. The significant role of complex-phase-space chaos in the description of the tunneling processes is elucidated by studying a kicked scattering model. Behaviors of tunneling orbits are encoded into symbolic sequences based on the structure of a complex homoclinic tangle. By means of the symbolic coding, the phase space itineraries of tunneling orbits are related with the amounts of imaginary parts of actions gained by the orbits, so that the systematic search of dominant tunneling orbits becomes possible.

Autoimmune hepatitis following allogeneic PBSCT from an HLA-matched sibling

A 7-year-old boy with acute lymphoblastic leukemia (ALL) in second remission received an allogeneic PBSCT from his HLA-matched sister. Acute grade II graft-versus-host disease (GVHD) resolved with corticosteroids. Chronic GVHD in the skin and oral mucosa at around day 60 responded to corticosteroids and cyclosporin A. At 6 months after the transplant, he developed hepatic dysfunction with elevated serum transaminases and gamma-globulin. Liver biopsy revealed chronic inflammation with lymphocytes and plasma cells in portal areas without destruction of bile ducts, suggesting autoimmune hepatitis. While rare, autoimmune hepatitis should be considered a potential long-term complication in patients with hepatic dysfunction in the late post-transplant phase.

Ixodid tick species recovered from domestic dogs in Japan

The species of ixodid ticks (Acari: Ixodidae) recovered from domestic dogs in Japan between September to November 2000 and April to June 2001 were identified. A total of 4122 ticks, including 1624 larvae, 1200 nymphs, 1016 females and 282 males were removed from 1221 dogs during these periods. Haemaphysalis longicornis (Neumann) was the most frequently found (40.3% of dogs), followed by H. flava (Neumann) (16.1% of dogs), Rhipicephalus sanguineus (Latreille) (4.8% of dogs) and Ixodes ovatus (Neumann) (4.1% of dogs). Small numbers of H. hystricis (Supino), H. campanulata (Warburton), H. japonica (Warburton), H. ias (Nakamura and Yajima), I. persulcatus (Schulze), I. nipponensis (Kitaoka and Saito) and Amblyomma testudinarium (Koch) were also recovered. In the spring sample, a total of 1408 ticks (78 larvae, 411 nymphs, 792 adult females and 127 adult males) were recovered from 570 dogs. The autumn sample included a larger proportion of larval stage and fewer adult ticks (1546 larvae, 789 nymphs, 224 adult females and 155 adult males). Haemaphysalis longicornis, H. flava and I. ovatus showed a wide geographical distribution from northern to southern Japan, whereas R. sanguineus were mainly distributed in the subtropical Okinawa prefecture with a few exceptions. Dogs in rural areas more frequently carried H. longicornis, H. flava and I. ovatus than dogs in urban or suburban areas, whereas R. sanguineus was more associated with the dogs in urban/suburban areas. Exposure to a garden was significantly associated with R. sanguineus and exposure to woodland was significantly associated with H. flava and I. ovatus. This is the first systematic survey of canine ticks in Japan.

Progressive development of insulin resistance phenotype in male mice with complete aromatase (CYP19) deficiency

Aromatase (CYP19) is a cytochrome P450 enzyme that catalyzes the formation of aromatic C18 estrogens from C19 androgens. It is expressed in various tissues and contributes to sex-specific differences in cellular metabolism. We have generated aromatase-knockout (ArKO) mice in order to study the role of estrogen in the regulation of glucose metabolism. The mean body weights of male ArKO (-/-) mice (n=7) and wild-type littermates (+/+) (n=7) at 10 and 12 weeks of age were 26.7+/-1.9 g vs 26.1+/-0.8 g and 28.8+/-1.4 g vs 26.9+/-1.0 g respectively. The body weights of the ArKO and wild-type mice diverged between 10 and 12 weeks of age with the ArKO males weighing significantly more than their wild-type littermates (P<0.05). The ArKO males showed significantly higher blood glucose levels during an intraperitoneal glucose tolerance test compared with wild-type littermates beginning at 18 weeks of age. By 24 weeks of age, they had higher fasting blood glucose levels compared with wild-type littermates (133.8+/-22.8 mg/dl vs 87.8+/-20.3 mg/dl respectively; P<0.01). An intraperitoneal injection of insulin (0.75 mU insulin/g) caused a continuous decline in blood glucose levels in wild-type mice whereas ArKO males at 18 weeks and older exhibited a rebound increase in glucose levels 30 min after insulin injection. Thus, ArKO male mice appear to develop glucose intolerance and insulin resistance in an age-dependent manner. There was no difference in fasting serum triglyceride and total cholesterol levels between ArKO male mice and wild-type littermates at 13 and 25 weeks of age. However, serum triglyceride and cholesterol levels were significantly elevated following a meal in ArKO mice at 36 weeks of age. Serum testosterone levels in ArKO male mice were continuously higher compared with wild-type littermates. Treatment of ArKO males with 17beta-estradiol improved the glucose response as measured by intraperitoneal glucose and insulin tolerance tests. Treatment with fibrates and thiazolidinediones also led to an improvement in insulin resistance and reduced androgen levels. As complete aromatase deficiency in man is associated with insulin resistance, obesity and hyperlipidemia, the ArKO mouse may be a useful animal model for examining the role of estrogens in the control of glucose and lipid homeostasis.

Visual results and complications of temporal incision phacoemulsification performed with the non-dominant left hand by junior ophthalmologists

AIMS

To assess the results of temporal incision phacoemulsification and aspiration performed with dominant and non-dominant hand of ophthalmology trainees.

METHODS

Retrospective analysis were made of 203 surgeries with dominant hand and 207 with non-dominant by five trainees at two institutions. Trainees sat at the patient's head, manipulating instruments with the dominant right hand for the right eye, and the non-dominant left hand for the left eye.

RESULTS

Vitreous loss occurred in 12 (5.9%) of 203 dominant operated eyes and seven (3.4%) of 207 non-dominant operated eyes. The rate of endothelial cell loss was 6.1% (9.8%) in dominant and 7.4% (12.4%) in non-dominant. Mean ultrasound time were 1.81 (0.70) minutes in dominant and 1.78 (0.78) minutes in non-dominant. One trainee showed statistically significant excesses in incidence of vitreous loss in dominant operated eyes (8.7%, p=0.0270), and one showed statistically significant prolongation of the operation in nondominant operated eyes (26.3 minutes, p=0.0315). In all other trainees, all parameters had no difference in both sides.

CONCLUSIONS

Ophthalmology trainees could successfully learn the technique with both hands. The authors consider that the skill of the non-dominant hand may be knowledge based and that surgeons avoid mistakes by mental efforts.

Prognostic implications of histological features in patients with chromophobe cell renal carcinoma

OBJECTIVE

To assess the relationship between the histological features of renal chromophobe cell carcinoma (CCC) and clinical outcome in patients with renal cell carcinoma.

PATIENTS AND METHODS

From 1957 to 1996, 41 patients with CCC of the kidney (4.9% of all kidney carcinomas) were treated at our university hospitals. Of these histologically defined cases, four who died from other types of cancer and two who were lost to follow-up were excluded, leaving 35 patients in the study; the carcinoma was classified as the typical variant in 26 and the eosinophilic variant in nine. Based on the differences of the variants, the histological features affecting prognosis were analysed.

RESULTS

The overall survival rates at 1, 3, 5, 10, 15 and 20 years were 97%, 82%, 82%, 70%, 62% and 47%, respectively. The prognosis was more favourable in those with the eosinophilic than for the typical variant (there were no cancer-related deaths in the former). Of those with the typical variant, five died within 2 years of surgery; of these, three with high-stage disease had various degrees of sarcomatoid change. Conversely, two patients had a recurrence > 10 years after surgery (late recurrence). Both these patients and the others who later died from cancer had no sarcomatoid change in the tumour areas examined.

CONCLUSION

The eosinophilic variant of CCC has a better prognosis; on the contrary, during long-term surveillance, early recurrence was detected especially in those with sarcomatoid change and late recurrence only in two typical variant. These prognostic implications of the histological differences are important for understanding the outcome of renal CCC.

Decrease in circulating hematopoietic progenitor cells by trapping in the pulmonary circulation

BACKGROUND

When stem-cell grafts are infused into the venous circulation and stem/progenitor cells egress from BM, pulmonary capillary beds are the first microcirculation site that they encounter. This provides the potential for circulating progenitor cells to be trapped in the pulmonary circulation.

METHODS

We compared the number of progenitor cells [CD34(+) cells, colony-forming unit-granulocyte-macrophage (CFU-GM), CD34(+) CD41(+) cells and CFU-megakaryocyte (CFU-meg)] and their expression of cell-adhesion molecules (CAM) in samples taken simultaneously from radial arteries and central veins of 21 patients following PBSC mobilization.

RESULTS

The mean (+/- SD) frequency of progenitor cells in the radial arteries was reduced to 79% +/- 25% for CD34(+) cells, 73% +/- 27% for CFU-GM, 77% +/- 25% for CD34(+) CD41(+) cells and 70% +/- 29% for CFU-meg of the number in the central veins. This suggests that some progenitor cells might be trapped in the lung. No association between progenitor-cell expression of CAM and pulmonary trapping was observed.

DISCUSSION

Our data demonstrate pulmonary trapping of PBSC during mobilization, suggesting a potential inhibitory effect on PBSC harvest and medullary trafficking following graft infusion. However, the impact associated with pulmonary PBSC trapping may be negligible in the clinical setting if sufficient cells are infused.