[Consideration of cancer home chemotherapy with cooperation between hospital and clinic]

Recently, the progress in chemotherapy has brought an improvement in the survival rate of patients with non-resectable digestive tract cancer. Simultaneously, maintenance of patients' QOL is regarded as important. In our hospital, we use low-dose FP therapy to maintain QOL and a satisfactory survival rate. To date, we have administered low-dose FP to more than 50 patients with non-resectable digestive cancer. We investigated patients who received home chemotherapy after being evaluated NC, and found no remarkable side effects as a result of this therapy during admission.

Analyses of microsatellite instability and the transforming growth factor-beta receptor type II gene mutation in sporadic human gastrointestinal cancer

Microsatellite instability (MSI) and transforming growth factor-beta receptor type II (RII) gene mutation have been reported in many types of tumors and their instance seem to vary among the tumors investigated. To determine the relation between MSI and RII gene mutation in sporadic gastrointestinal cancer development, 21 esophageal, 19 gastric, and 27 colorectal cancers were investigated. The presence of MSI was screened by single strand conformation polymorphism (SSCP) method using six microsatellite markers. RII gene mutations were detected by SSCP method and direct sequencing. MSI was detected in seven of 21 (33.3%) esophageal cancers, three of 19 (15.8%) gastric cancers and seven of 27 (25.9%) colorectal cancers. However, RII gene mutations were observed in only two of seven (28.6%) MSI-positive colorectal cancers. Our data suggest that among sporadic gastrointestinal cancers, colorectal cancers seem to be the most frequent target organ involved in carcinogenesis through RII gene mutation, which thus appears to be related to organ specificity.

Analysis of Fas system in pulmonary injury of graft-versus-host disease after rat intestinal transplantation

The lung is one of the primary targets of acute graft-versus-host disease (GVHD), which is the principal complication that occurs after allogeneic intestinal transplantation. The purpose of this study is to investigate the involvement of Fas/Fas ligand system in pulmonary injury after rat semi-allogeneic intestinal transplantation. The lungs were serially harvested from LEW x BN F1(LBNF1) recipients of either LEW heterotopic intestinal allografts or LBNF1 isografts, on days 1, 3, 5, 9, and 13 posttransplant. In light microscopy, pulmonary injury became apparent on day 13 in the allogeneic combination, showing a thickening of the alveolar septa. The incidence of apoptosis, examined by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate (dUTP) biotin nick end-labeling, was observed to increase steadily in the alveolar cells accompanied by a progression of GVHD. In an immunohistochemical study, Fas was constitutively expressed in the lung, although Fas ligand was expressed most extensively on day 9. The immunoreactivity of both Fas and Fas ligand were observed in alveolar cells, in addition to leukocytes. An analysis by reverse transcription polymerase chain reaction also revealed that the expression of Fas mRNA was constitutive without any significant change, although that of Fas ligand mRNA increased substantially and peaked on day 9, which was significant compared to the isogeneic combination. In conclusion, transcriptionally up-regulated Fas ligand and increased number of apoptosis suggests that the Fas system may play a role in the pathophysiology of GVHD-induced pulmonary injury.

Elevated intracellular IFN-gamma levels in circulating CD8+ lymphocytes in patients with fulminant hepatitis

BACKGROUND/AIMS

Fulminant hepatitis usually takes a rapidly progressive course, terminating in death within a short period. Experimental studies have demonstrated that immunological mechanisms play an important role, especially those involving virus-specific CD8+ cytotoxic T lymphocytes and their production of interferon-gamma (IFN-gamma). However, there are no immunological markers for prediction of the development of fulminant hepatitis in man.

METHODS

Peripheral blood lymphocytes from four patients with fulminant hepatitis, six with acute hepatitis and 11 healthy volunteers as normal controls were analyzed. Intracellular IFN-gamma production in both CD8 positive and negative T lymphocytes was assessed by flow cytometry.

RESULTS

Populations of CD8+ IFN-gamma+ T lymphocytes were significantly increased in patients with fulminant hepatitis, as compared with those with acute hepatitis and normal controls. Production of IFN-gamma in CD8+ T lymphocytes of patients with fulminant hepatitis was also elevated, furthermore significantly correlating with the prothrombin time (r=-0.64, p<0.01).

CONCLUSIONS

The capacity for IFN-gamma production by CD8+ lymphocytes is up-regulated in fulminant hepatitis, and this may be important for the development of fulminant hepatitis.

Results of retrograde transhepatic biliary drainage after a common bile duct exploration for choledocholithiasis

BACKGROUND/AIMS

The purpose of this study is to assess the benefits of retrograde transhepatic biliary drainage (RTBD) and a primary closure after a common bile duct (CBD) exploration for patients with choledocholithiasis.

METHODOLOGY

We analyzed 143 patients with choledocholithiasis who had been managed by RTBD after undergoing a CBD exploration retrospectively over a 12-year period. The main outcome criteria were frequency of occurrence of post-operative complications which needed a relaparotomy and the clinical long-term results. In addition, the radiographic diameter changes of the CBD at the site of the primary closure and liver function tests after RTBD were also evaluated.

RESULTS

The frequency of bile peritonitis in the patients undergoing the RTBD procedure was only 0.7% (1 out of 143 cases). Cholangiography via the RTBD tube revealed no severe stenosis at the site of primary closure. Liver function returned to normal on day 3 after RTBD (p<0.05). Recurrence of common bile duct stones developed in 2 patients in this series during the follow-up (1-12 years).

CONCLUSIONS

RTBD and a primary closure of the CBD after CBD exploration appears to be a clinically safe and effective method for such patients with choledocholithiasis who had undergone a complete stone removal intra-operatively.

Immunopathogenesis of hepatic fibrosis in chronic liver injury induced by repeatedly administered concanavalin A

Liver fibrosis is commonly observed in chronic liver disease. However, the immunological mechanisms underlying hepatic fibrosis due to chronic inflammation are not well defined, mainly because suitable experimental models have not been established. We have found that weekly i.v. administration of concanavalin A (Con A) in BALB/c mice brought about a striking alanine aminotransferase increase, resulting in piecemeal necrosis with bridging fibrosis in the parenchyma. Using this fibrosis model, we demonstrated the kinetics of cytokine mRNA expression in liver. Transforming growth factor (TGF)-beta1, TGF-alpha, basic fibroblast growth factor (bFGF) and hepatocyte growth factor mRNAs were up-regulated after each Con A administration. Furthermore, either anti-IFN-gamma, anti-tumor necrosis factor (TNF)-alpha or anti-TGF-beta mAb given together with Con A markedly inhibited the development of hepatic fibrosis. Treatment with either anti-IFN-gamma or anti-TNF-alpha mAb also completely prevented hepatic injury; in contrast, treatment with anti-TGF-beta mAb did not. The treatment with anti-TGF-beta mAb did not affect the levels of hepatic mRNAs for either IFN-gamma or TNF-alpha after Con A injection. Treatment with either anti-IFN-gamma or anti-TNF-alpha did not affect the expression levels of TGF-beta in the liver. In conclusion, the continuous presence of both severe liver damage and up-regulation of TGF-beta synthesis is necessary to induce hepatic fibrosis in this model.

Early detection of apoptosis and fas ligand expression in hepatic graft-versus-host disease after rat small bowel transplantation

BACKGROUND

The liver is one of the primary targets of acute graft-versus-host disease (GVHD), which is the principal complication that occurs after allogeneic intestinal transplantation. The purpose of this study is to investigate the involvement of the Fas/Fas ligand system in hepatic GVHD after rat semiallogeneic intestinal transplantation.

MATERIALS AND METHODS

Liver samples were serially harvested from LEW x BN F(1) (LBNF(1)) recipients of either LEW heterotopic intestinal allografts (group 1) or LBNF(1) isografts (group 2), on Days 1, 3, 5, 9, and 13 posttransplant.

RESULTS

In group 1, hepatic injuries as assessed by either serum aspartate aminotransferase (AST) level, alanine aminotransferase (ALT) level, or cellular infiltration on HE staining became apparent after Day 13. The incidence of apoptosis, examined by terminal deoxynucleotidyl transferase-mediated dUTP biotin nick end-labeling (TUNEL), was observed to steadily increase in the liver from Day 5 accompanied by a progression of GVHD: 17.5 +/- 3.1 and 3.1 +/- 0.4 cells/field (200x) in groups 1 and 2, respectively. In an immunohistochemical study, Fas was constitutively expressed in the liver in both groups, while Fas ligand was expressed most extensively on Day 13 in group 1. Immunoreactivity of both Fas and Fas ligand was observed in hepatocytes, in addition to leukocytes. Analysis by reverse transcription polymerase chain reaction also revealed the expression of Fas mRNA to be constitutive in both groups, while that of Fas ligand mRNA increased significantly from Day 5 and peaked on Day 13 in group 1, and the expression was 10 times stronger than that for isogeneic combination (group 2).

CONCLUSION

Early detection of upregulated Fas ligand and increased apoptosis is thus considered to be potentially a useful tool for the diagnosis of hepatic GVHD.

Microsatellite instability in double cancers of the esophagus and head and neck

It is generally accepted that patients with squamous cancers of the esophagus are known to have a high risk of concomitant head and neck cancer. However, there have been only a few reports describing microsatellite instability (MSI) in patients with both esophageal squamous cell carcinoma and head and neck cancers. To evaluate the role of genetic instability in carcinogenesis in such patients, we analyzed six microsatellite loci in 21 tumors from 10 patients who had developed primary cancers of both the esophagus and the head and neck. MSI was detected in 6 out of 10 patients. In five patients with double cancer, MSI was observed at the same microsatellite loci in both the esophageal and the head and neck tumors obtained from the same individuals. These data suggest that such patients may have the same underlying defect in the mismatch repair system, providing insight into possible mechanisms for field carcinogenesis.

Age-related decrease in brain-derived neurotrophic factor gene expression in the brain of the zitter rat with genetic spongiform encephalopathy

The zitter rat exhibits a progressive degradation in neuronal cells and genetic spongiform encephalopathy with age. In order to elucidate the involvement of the expression of the neurotrophic factor in neuropathology of the rat, we quantified mRNA levels of neurotrophic factors (nerve growth factor, brain-derived neurotrophic factor (BDNF), and neurotrophin-3, ciliary neurotrophic factor and glial-cell-line-derived neurotrophic factor) in the zitter rat brain. Expression of the BDNF gene was lower in the zitter rat brain (cerebrum, cerebellum, and brainstem regions). Interestingly, kinase activity of mitogen activated protein kinase (MAPK) Erk2 involved in the expression of BDNF was also down regulated, despite an unchanging expression of MAPK protein. These results show the possible involvement of a MAPK pathway in BDNF mRNA reduction in the zitter rat brain.

Solution structures of the first and second RNA-binding domains of human U2 small nuclear ribonucleoprotein particle auxiliary factor (U2AF(65))

The large subunit of the human U2 small nuclear ribonucleoprotein particle auxiliary factor (hU2AF(65)) is an essential RNA-splicing factor required for the recognition of the polypyrimidine tract immediately upstream of the 3' splice site. In the present study, we determined the solution structures of two hU2AF(65) fragments, corresponding to the first and second RNA-binding domains (RBD1 and RBD2, respectively), by nuclear magnetic resonance spectroscopy. The tertiary structure of RBD2 is similar to that of typical RNA-binding domains with the beta1-alpha1-beta2-beta3-alpha2-beta4 topology. In contrast, the hU2AF(65) RBD1 structure has unique features: (i) the alpha1 helix is elongated by one turn toward the C-terminus; (ii) the loop between alpha1 and beta2 (the alpha1/beta2 loop) is much longer and has a defined conformation; (iii) the beta2 strand is (188)AVQIN(192), which was not predicted by sequence alignments; and (iv) the beta2/beta3 loop is much shorter. Chemical shift perturbation experiments showed that the U2AF-binding RNA fragments interact with the four beta-strands of RBD2 whereas, in contrast, they interact with beta1, beta3 and beta4, but not with beta2 or the alpha1/beta2 loop, of RBD1. The characteristic alpha1-beta2 structure of the hU2AF(65) RBD1 may interact with other proteins, such as UAP56.

Drug-associated cholelithiasis: a case of sulindac stone formation and the incorporation of sulindac metabolites into the gallstones

A case of drug-associated cholelithiasis (sulindac chlecystohepatolithiasis) in a 63-yr-old woman is reported. The patient was admitted to our hospital to undergo treatment for rheumatoid arthritis of 20 yr duration. She was treated with nonsteroidal anti-inflammatory drugs (NSAID: sulindac). Two months later, she presented with right upper quadrant pain. Diagnostic studies including ultrasonography (US), computed tomography (CT) and endoscopic retrograde cholangiography (ERC), led to the diagnosis of cholecystohepatolithiasis. She underwent cholecystectomy and choledochotomy with an extraction of intrahepatic stones. The intrahepatic stones were light yellow in color with a claylike appearance. Unexpectedly, an infrared spectroscopic analysis of the stone showed it to consist of sulindac metabolites. In addition, the dilated segment of the intrahepatic bile duct naturally returned to its normal size after the discontinuation of the drug administration. This is the first reported case of sulindac stone formation in the bile duct. No similar problems with other NSAIDs have been reported previously.

Vascular reconstruction of the hepatic artery using the gastroepiploic artery: a case report

A 59 year-old woman with obstructive jaundice secondary to proximal bile duct carcinoma underwent percutaneous transhepatic biliary drainage (PTDB). This revealed complete obstruction of the bifurcation of the hilar hepatic duct and encasement of the right hepatic artery. Wedged hilar hepatectomy with combined resection of the extrahepatic bile duct, gallbladder, and the encased right hepatic artery was performed. The hepatic artery was reconstructed using an in situ right gastroepiploic artery (GEA) pedicle graft. The anastomosis was protected with fatty tissue from the greater omentum. This technique can be used to reconstruct the hepatic artery after radical surgery for malignant hepatobiliary and pancreatic disease.

Percutaneous transhepatic cholangioscopic lithotripsy and change of biliary manometry patterns

BACKGROUND/AIMS

Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is used to remove bile duct stones. This work aims to evaluate the clinical usefulness of PTCSL and the reversibility of the terminal bile duct dysfunctions after PTCSL.

METHODOLOGY

Thirty patients who underwent PTCSL using mechanical and/or electrohydraulic lithotripsy over the past 10 years (20 patients with common bile duct stones and 10 with intrahepatic bile duct stones) were evaluated. Terminal bile ductal pressure was measured using the percutaneous transhepatic biliary drainage (PTBD) tube prior to and after lithotripsy by means of variable-load cholangiomanometry.

RESULTS

Complete stone extraction was possible in 26 patients (86.7%). The other 4 patients had intrahepatic stones. Complications included 2 cases of hemobilia, one of pneumonia, and 3 of localized peritonitis. Of 26 patients without residual stones, only 4 patients had a linear pressure flow (P-F) pattern which indicates normal biliary tract function prior to lithotripsy. In 17 of 22 patients with other type P-F patterns, however, these types also changed to a linear pattern after complete removal of stones. The P-F pattern of the other 5 patients remained unchanged.

CONCLUSIONS

PTCSL is a safe and efficient method treating biliary tract lesions while preserving the function of the sphincter of Oddi. The terminal biliary tract function normalized after stone removal. Thus, PTCSL was useful for patients with complicated bile duct stones not accessible to endoscopic retrograde management.

Extracorporeal bypass using a centrifugal pump during resection of malignant liver tumors

BACKGROUND/AIMS

Total hepatic vascular exclusion (THVE) during extracorporeal bypass is used for hepatic resection in patients with malignant liver tumors. The aim of this study was to determine the efficacy of hepatectomy during total hepatic vascular exclusion using a centrifugal pump (Bio-pump).

METHODOLOGY

Fourteen patients with malignant liver tumors who underwent hepatectomy during total hepatic vascular exclusion using the Bio-pump were studied retrospectively.

RESULTS

In 3 of 14 patients, insufficient hepatic vascular exclusion was achieved. Six patients underwent tumor resection during total hepatic vascular exclusion, without extracorporeal bypass. In the remaining 5 patients, flow exclusion averaging 1500 ml was achieved with the Bio-pump, and hepatectomy was performed during the procedure. In these 5 patients, the mean operative time and blood loss were 11 hours 38 minutes and 6850 +/- 2451 ml. The Bio-pump bypass time, the excluded blood flow and the mean blood pressure were 82 minutes, 1650 ml and 108/53 mmHg, respectively. The arterial ketone body ratio (AKBR) decreased from a pre-operative value of 1.85-0.32 during total hepatic vascular exclusion.

CONCLUSIONS

Total hepatic vascular exclusion was useful for hepatectomy in patients with tumor invasion into the hepatic vein and inferior vena cava, or tumor thrombus in the inferior vena cava and right atrium. However, this technique did not decrease blood loss or improve outcome in patients undergoing hepatectomy.

Analysis of the Fas system and Bcl-2 in rat liver allograft rejection

BACKGROUND

Apoptosis is involved in the mechanism of cell death observed in liver allograft rejection. The liver cells are sensitive to Fas-mediated apoptosis; however, little is known about the involvement of the Fas system in liver allograft rejection. We used rat models to investigate the expression of Fas/Fas ligand and apoptosis-related proteins during liver allograft rejection.

MATERIALS AND METHODS

DA rats to Lewis, and Lewis to Lewis orthotopic liver transplantation were performed; liver samples were collected on days 1, 3, 5, 7, and 9 postoperatively (each n = 3). Apoptosis was monitored by TUNEL and electron microscopy. The expression of Fas, FasL, bcl-2, and bax was examined at the mRNA level and by means of immunohistochemistry.

RESULTS

The TUNEL index in the allografts and isografts on day 7 was 20.1 +/- 1.5 and 7.7 +/- 2.6/1000 cells, respectively. Fas and bax mRNA were constitutively expressed in both of the groups. The expression of Fas ligand mRNA in the allografts which rose on day 5 was 10 times stronger compared to that in the isografts. On the other hand, bcl-2 mRNA was generally expressed in the isografts while it decreased in the allografts. The immunohistochemical analysis also showed an increased reactivity of Fas ligand on day 5 in the allograft, which was observed both in parenchymal and nonparenchymal cells.

CONCLUSIONS

These results strongly suggest that Fas/Fas ligand interaction mediates the liver injury during allograft rejection. In addition, other regulatory factors of apoptosis, such as bcl-2, might also be involved in this pathogenesis.

Stable gene expression with VSV-G pseudotyped-retrovirus vector in the rat liver

BACKGROUND

Pseudotyped-retrovirus-mediated gene transfer to the regenerating rat liver was investigated in vivo and the findings were compared with those for retrovirus-mediated gene transfer.

MATERIALS AND METHODS

Four weeks prior to gene transfer, the spleen was transpositioned to the left subcutaneous position to develop a port-splenic shunt. Twenty-four hours after a partial hepatectomy (68%) was performed, the liver was perfused in situ and kept in contact with either a pseudotyped-retrovirus vector encoding LacZ (7 x 10(7) cfu/ml, Group 1) or a retrovirus vector encoding LacZ (1 x 10(4) cfu/ml, Group 2) for 30 min. The animals were sacrificed at various points after gene transfer, and X-gal staining, reversed polymerase chain reaction (RT-PCR), and ONPG assay were performed to detect the transferred LacZ cDNA.

RESULTS

In X-gal staining, the transferred LacZ cDNA started to show a strong beta-galactosidase activity in 30 to 50% of the hepatocytes at 3 days after gene transfer. Positive staining continued to be recognized until 28 days with a slight decrease in its intensity thereafter. On the other hand, Group 2 animals showed weak staining, which was observed in about 10 to 15% of the hepatocytes from 3 days after gene transfer and then decreased thereafter. In RT-PCR, positive mRNA of LacZ was detected constitutively until 28 days after gene transfer in Group 1, whereas two-thirds of the samples showed a negative band in Groups 2 at 3 days after gene transfer.

CONCLUSION

In conclusion, the pseudotyped-retrovirus vector was useful in establishing a stable and strong expression of the in vivo gene transfer, while targeting the regenerating liver.

Increased 9,13-di-cis-retinoic acid in rat hepatic fibrosis: implication for a potential link between retinoid loss and TGF-beta mediated fibrogenesis in vivo

BACKGROUND/AIMS

During hepatic fibrosis, hepatic stellate cells (HSCs) transform into myofibroblastic cells and lose their intracellular droplets of retinyl esters, the storage form of vitamin A. Recently, we have demonstrated that 9,13-di-cis-retinoic acid (RA), a geometric isomer identified as a stable and major metabolite of vitamin A in circulation, stimulates the synthesis of plasminogen activator (PA) and induces PA/plasmin-dependent latent transforming growth factor (TGF)-beta activation in HSC cultures, probably via induction and activation of RA receptor (RAR) alpha. The aim of the present study was to address a potential link between the loss of retinyl esters to increased formation of RA(s), which might play a role in facilitating TGF-beta-mediated liver fibrogenesis in vivo.

METHODS

We examined the effect of 9,13-di-cis-RA on transactivating activity of RARalpha in HeLa cells as well as its effect on PA- and TGF-beta-dependent collagen synthesis in rat and human HSC cultures. We measured the changes in 9,13-di-cis-RA levels both during activation of rat HSCs in vitro and during porcine serum-induced rat hepatic fibrosis in vivo and correlated this with RAR alpha/beta, PA, TGF-beta and type I procollagen mRNA expression in the fibrotic liver.

RESULTS

9,13-di-cis-RA transactivated RARalpha, and provoked PA/plasmin and TGF-beta-dependent procollagen synthesis in HSCs. 9,13-di-cis-RA levels were increased both in activated HSCs in vitro and in fibrotic liver accompanying the enhanced expression of RAR alpha/beta, PA, TGF-beta and procollagen in vivo.

CONCLUSIONS

These findings suggest a potential link between 9,13-di-cis RA formation and hepatic fibrosis via formation of TGF-beta in vivo, and thus provide further insight into the biologic role of retinoids during hepatic fibrogenesis.

Common bile duct blood clot: an unusual cause of ductal filling defects for calculi

We report a case of obstructive jaundice caused by a blood clot in the common bile duct in a 75-year-old man with cirrhosis. Five years prior to his admission, he had undergone a left hepatectomy for hepatocellular carcinoma. At the present admission, he appeared icteric, and endoscopic retrograde cholangiography revealed filling defects in the common bile duct. Choledochotomy was therefore performed for possible common duct stones, and exploration of the duct showed blood clot casts filling the duct. The casts were easily removed, and the patient's postoperative course was uneventful. However, he developed ascites and jaundice 1 month later and died of liver failure approximately 3 months after undergoing the choledochotomy. Autopsy revealed hemorrhagic necrosis in the proximal intrahepatic duct of the posterior segment, which was considered to be the cause of the observed hemobilia, as well as the blood clot in the common bile duct at surgery. We report this rare case and discuss the cause of hemobilia.

IL-12 induces specific cytotoxicity against regenerating hepatocytes in vivo

Although impaired liver regeneration is thought to be a major cause of death in patients with fulminant hepatitis, the mechanisms are not well defined. Since IL-12 synthesis has been reported to be up-regulated in murine hepatitis virus infection, we studied the influence of continuous IL-12 stimulation on murine liver regeneration using flow cytometric and functional analyses. In non-hepatectomized mice, interestingly, the number of hepatic NK cells was significantly decreased on day 7, after six IL-12 injections, and day 14, after 13 IL-12 injections. The number of hepatic NKT cells was markedly increased on day 7 and day 14 of daily IL-12 treatment. The cytotoxic activity of hepatic lymphocytes against both YAC-1 and p815 cells was enhanced on day 2, after single IL-12 injection, and day 7, after six IL-12 injections. In contrast, hepatic lymphocytes isolated 24 h after partial hepatectomy with IL-12 pretreatment did not show any cytolytic activity against either YAC-1 cells or p815 cells. However, continuous IL-12 stimulation resulted in a significantly higher serum alanine aminotransferase (sALT) level 24 h after the partial hepatectomy as compared with sALT levels in mice subjected to either partial hepatectomy or IL-12 pretreatment alone. On the other hand, the expression of hepatic TNF-alpha mRNA was markedly enhanced by continuous IL-12 stimulation even 24 h after partial hepatectomy, as compared with that in non-treated mice and hepatectomy alone. Simultaneous administration of anti-tumor necrosis factor (TNF)-alpha mAb completely inhibited IL-12-induced in vivo enhancement of liver damage after partial hepatectomy. In conclusion, IL-12 induces the specific cytolytic activity against regenerating hepatocytes in vivo mainly through the enhancement of TNF-alpha synthesis.

Structural basis for recognition of the tra mRNA precursor by the Sex-lethal protein

The Sex-lethal (Sxl) protein of Drosophila melanogaster regulates alternative splicing of the transformer (tra) messenger RNA precursor by binding to the tra polypyrimidine tract during the sex-determination process. The crystal structure has now been determined at 2.6 A resolution of the complex formed between two tandemly arranged RNA-binding domains of the Sxl protein and a 12-nucleotide, single-stranded RNA derived from the tra polypyrimidine tract. The two RNA-binding domains have their beta-sheet platforms facing each other to form a V-shaped cleft. The RNA is characteristically extended and bound in this cleft, where the UGUUUUUUU sequence is specifically recognized by the protein. This structure offers the first insight, to our knowledge, into how a protein binds specifically to a cognate RNA without any intramolecular base-pairing.

Preliminary report on local resection with lymphadenectomy for early gastric cancer

BACKGROUND

The frequency of lymph node metastasis in mucosal gastric cancers 2-4 cm in diameter was low (three (1.3 per cent) of 234) in patients treated in this unit between 1966 and 1995. This study was a prospective report on local resection with lymphadenectomy for early gastric cancer.

METHODS

Eight patients with a single early gastric cancer underwent local resection with lymphadenectomy. The tumour was excised with a non-cancerous rim of approximately 2 cm. The extent of lymphadenectomy depended on tumour location. Intraoperative endoscopic examination and frozen-section analysis of the dissected nodes were used to determine the resection line and evaluate nodal status.

RESULTS

Mean operating time, blood loss and number of dissected nodes were 171 min, 87 ml and 8 respectively. There were no operative complications. Cancer invasion was confined to the mucosa in six tumours but two patients had minute submucosal invasion. The maximum diameter of the resected specimens was 10 cm and no nodal involvement was detected. No patient developed postgastrectomy syndrome.

CONCLUSION

For selected patients with early gastric cancer, local resection with lymphadenectomy can provide a good quality of life without compromising cure rate.

Mucosa-associated lymphoid tissue (MALT) of the gallbladder: a clinicopathological correlation

OBJECTIVE

Lymph follicles are frequently found on histological examination of a surgically removed gallbladder. The significance of these lymph follicles is not clearly understood. The aim of this study was to examine the clinicopathological correlation between the lymph follicles in the gallbladder morphologically and the mucosa-associated lymphoid tissue (MALT) in the gut.

METHODS

The gallbladders were fixed and cut serially. The tissue slices were processed in the routine manner for a histological examination. The histological criteria for MALT in this study was defined as the presence of lymph follicles with germinal centers in the lamina propria mucosae in approximately equal numbers in all portions of the gallbladders from the neck to the fundus. Biliary bile obtained at surgery was cultured for a bacteriological examination in the hospital laboratory. The types of gallstones were classified according to the Classification of Gallstones by the Japanese Society of Gastroenterology.

RESULTS

Of the 1341 patients, 158 (11.8%) patients fulfilled the histological criteria, including 64 men and 94 women with an average age of 64.2 years. Gallstones were present in 89.2% of the patients, and 74.5% of these were calcium bilirubinate gallstones. Cultures of the bile were positive in 95.4% of the patients. A variety of bacterial species were thus found, most commonly Escherichia coli and Klebsiella spp. Grossly, the gallbladders usually showed a granular appearance of the mucosa.

CONCLUSION

The MALT in the gallbladder is not a rare condition and is frequently encountered in clinical practice. This lymphoid tissue may represent a mucosal and morphological immune phenomenon for infection rather than a substrate for the development of low-grade B-cell lymphoma.

Effects of cytokines on the binding of leukocytes to cultured rat hepatocytes and on the expression of ICAM-1 by hepatocytes

Adhesions of leukocytes to hepatocytes and sinusoidal endothelial cells mediates the induction and progression of hepatic injury. However, in contrast to endothelial cells, information regarding the regulation of interactions between leukocytes and hepatocytes is limited. In the present study, we investigated the effect of inflammatory mediators including lipopolysaccharide (LPS), staphylococcal enterotoxin B (SEB), interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), and interleukin-1beta (IL-1beta) on the adhesion of polymorphonuclear leukocytes or lymphocytes to primary cultured rat hepatocytes, and on the expression of intercellular adhesion molecule-1 (ICAM-1) gene in hepatocytes. Both polymorphonuclear leukocyte and lymphocyte adhesion to hepatocytes were enhanced after exposure of hepatocytes to IFN-gamma and TNF-alpha, but not after exposure to LPS, SEB or IL-1beta. The adhesion induced by either IFN-gamma or TNF-alpha was inhibited by monoclonal antibodies against ICAM-1 or lymphocyte function-associated antigen-1 (LFA-1). Nonstimulated hepatocytes expressed faintly ICAM-1 mRNA, which increased slightly during the culture period. ICAM-1 mRNA expression was up-regulated to a greater extent by incubating hepatocytes with IFN-gamma or TNF-alpha, and peaked after 12 hr of incubation with TNF-alpha and after 24 hr with IFN-gamma. These results indicate that IFN-gamma and TNF-alpha induce the expression of ICAM-1 on parenchymal hepatocytes and that the LFA-1-ICAM-1 pathway plays an important role in the interaction between hepatocytes and neutrophils or lymphocytes.

Protective effects of ulinastatin against ischemia-reperfusion injury

We investigated the protective effect of urinary trypsin inhibitor (ulinastatin: UTI) in vitro, in relation to the neutrophil activity in hepatic ischemia/reperfusion (I/R) injury. The rat liver was removed and preserved in cold Ringer's lactate solution for 60 min, followed by 120 min of reperfusion with oxygenated perfusate. The rats were divided into four groups (n = 8 in each group). The livers were perfused with Krebs-Henseleit (K-H) solution containing no additives in group 1, 50,000 U/kg of UTI in group 2, 3.5 x 10(6) of neutrophils in group 3, and both neutrophils and UTI in group 4. In group 3, the AST and ALT levels were always higher than those in other three groups at any point evaluated (P < 0.01) and the LDH levels were observed to be significantly higher than those in other three groups at 0, 5, 10, 60, and 90 min after reperfusion (P < 0. 01). These increase were suppressed by additional pretreatment with UTI in group 4. The bile flow during reperfusion was significantly suppressed in group 3 compared to that of group 4, at both 30 (P < 0. 01) and 60 (P < 0.05) min after reperfusion. The MPO activity after reperfusion in group 3 also significantly increased compared to other three groups (P < 0.01). These data thus suggest that UTI ameliorated the ischemia/reperfusion injury in vitro by inhibiting of neutrophil accumulation in the postischemic liver.

Chemical shift perturbation studies of the interactions of the second RNA-binding domain of the Drosophila sex-lethal protein with the transformer pre-mRNA polyuridine tract and 3' splice-site sequences

The interactions of the second RNA-binding domain of the Drosophila melanogaster Sex-lethal protein (Sxl RBD2) with the oligoribonucleotides, GUUUUUUUU (GU8) and CUAGUG, representing the sequences surrounding an alternative 3'-splicing site of the transformer pre-mRNA (GU8CUAGUG), were studied using heteronuclear two-dimensional NMR techniques. The 1H and 15N chemical shifts of the backbone amide resonances upon titration of Sxl RBD2 with each of these RNAs were recorded. It was found that Sxl RBD2 can bind not only to the polyuridine tract, GU8, but also to the downstream 3' splice-site sequence, CUAGUG, with similar affinities. In contrast, a nonspecific sequence, C8, did not bind to Sxl RBD2. This result is consistent with previous in vitro RNA-selection and UV-cross-linking results which indicated that the Sex-lethal protein binds to the uridine stretch and the AG dinucleotide in the consensus sequence, AUnNnAGU. In both cases, the chemical-shift perturbations were significant for almost the same amino acid residues, including the two central beta-strands formed by the RNP2-motif and RNP1-motif with the two highly conserved aromatic residues (Y214 and F256) in the middle. As the first RNA-binding domain of Sex-lethal (Sxl RBD1) has a characteristic aliphatic residue at one of the two corresponding positions (I128 and F170), Y214 of Sxl RBD2 was replaced by Ile using site-directed mutagenesis. On the one hand, the 1H and 15N chemical-shift perturbations indicated that GU8 binds to the same interface of mutant Sxl RBD2 as of wild-type Sxl RBD2, although its binding affinity was decreased significantly. On the other hand, the specific binding of Sxl RBD2 to CUAGUG was abolished almost completely by the Y-->I mutation. Taken together, the present results indicate that the interface residues that bind with GU8 and CUAGUG are much the same, but the role of the Y214 residue is clearly different between these two target sequences.

Characteristics of hepatocellular carcinoma in patients with negative virus markers: clinicopathologic study of resected tumors

Fifty-one cases of resected hepatocellular carcinoma (HCC) were retrospectively analyzed to evaluate the clinicopathologic features of HCC in patients with negative virus markers. The data were compared between three groups: hepatitis B surface antigen positive (HB, n = 11), hepatitis C virus antibody positive (HC, n = 21), and non-BC (both HbsAg and HCVAb negative, n = 12). Seven patients were excluded from the study because of operative death (n = 3), a history of alcohol abuse (n = 3), or the presence of dual positive HB and HC virus markers (n = 1). The data were analyzed by either an analysis of variance (ANOVA) or a contingency table. The age of the non-BC patients was higher (63.0 +/- 4.1, +/- SE) than that of HB patients (54.0 +/- 3.2, p < 0.05) but was identical to that of the HC group (62.0 +/- 1.8). Among the preoperative laboratory data, the serum glutamic oxaloacetate and glutamate pyruvate transaminoses (GOT, GPT) levels were statistically lower in the non-BC patients (32.8 +/- 4.8 and 28.0 +/- 4.4 IU/L, respectively) than in the HB and HC patients. The pathologic features of the resected specimens in the non-BC patients showed more invasive growth than in specimens from the HB or HC patients. The clinical stages (defined based on the criteria of the Japanese Association of Hepatocellular Carcinoma) were also more advanced in the non-BC patients than in the other groups. Postoperative survival time showed no significant difference among the groups. In conclusion, the non-BC patients had comparatively greater invasive growth and more advanced clinical stages than the HB and HC patients, despite the absence of liver cirrhosis, and so demonstrated the same poor survival data as observed in the HB and HC patients.

Pedunculated exogastric leiomyosarcoma: case report and brief literature review

A case report and review of the literature on pedunculated exogastric leiomyosarcomas are presented. Although about one-fourth of the stromal tumors (common leiomyomas and leiomyosarcomas) of the stomach grow in an exogastric configuration, pedunculated exogastric leiomyosarcomas are extremely rare. At present there is no evidence of intraperitoneal seeding from exogastric leiomyosarcomas. Consequently, a local resection with an adequate margin is sufficient when no invasion to the adjacent structures, is observed.

[Study of optimal CHOP dose ranges for elderly patients with non-Hodgkin's lymphoma]

Two groups of intermediate-to high-grade non-Hodgkin's lymphoma patients aged 65 years and over were enrolled in a dose-range study of CHOP therapy utilizing 5 doses (1/2, 7/12, 2/3, 5/6, full CHOP): 11 patients 65-79 years of age (group A) and 9 patients 80 years or older (group B). The patients were enrolled consecutively; the study was designed so that if 3 patients completed 3 cycles of CHOP on schedule without major problems, the next highest dose was administered. If 2 patients experienced any major problems during 6 cycles at a given dose, treatment was discontinued and the dose prior to that particular dose was regarded as the optimal dose. The 6 treatment cycles were completed by 3 of 3 (2/3 CHOP), 3 of 4 (5/6 CHOP), and 1 of 4 (full CHOP) group A patients; and by 3 of 3 (1/2 CHOP), 2 of 3 (7/12 CHOP) and 1 of 3 (2/3 CHOP) group B patients. The results indicated that the optimal doses for group A and B were five-sixths and seven-twelfths of the standard CHOP dose, respectively.

Analyses of microsatellite instability and the transforming growth factor-beta receptor type II gene mutation in sporadic breast cancer and their correlation with clinicopathological features

To determine the incidence of microsatellite instability (MSI) and its relationship with both clinicopathologic parameters and patient survival, 101 cases of breast cancer were investigated. In addition, transforming growth factor-beta (TGF-beta) receptor type II (RII) gene mutation was also examined to clarify the relation to MSI in breast cancer development. MSI and RII gene mutation were screened by single strand conformation polymorphism (SSCP). The mutations of the RII gene were confirmed by a direct sequence. An association between the MSI status and the clinicopathological features was examined to assess the potential of the MSI status as a prognostic indicator in sporadic breast cancer cases. MSI was detected in 12 of 101 (11.9%) breast cancer cases. The positive MSI breast cancer cases showed relatively more advanced disease than negative MSI cases, and also exhibited relatively poorer prognoses. No RII gene mutations were observed in any of the breast cancer cases. Our data suggest that the MSI status may thus be a useful indicator for the prognosis of sporadic breast cancer cases. However, the breast seems to be an infrequent target organ for cancer development through RII gene mutations. As a result, tumor progression through this pathway appears to be related to organ specificity. For positive MSI breast cancers, other target genes therefore still need to be identified.

[Genetic alterations in human malignant tumor]

To clarify the genetic background of cancer patients, microsatellite instability (MSI) and mutations of transforming growth factor-beta type II receptor (RII), p53 and k-ras gene were investigated. MSI were detected in 33.3% of esophageal, 15.8% of gastric, 21.4% of colorectal, 4.5% of bile duct, 0% of gallbladder, 13.3% of pancreatic, 11.6% of breast and 10.5% of thyroid cancers. Mutations of RII gene were detected in only 2 of 9 MSI-positive colorectal cancers. k-ras gene mutations were investigated in colorectal, bile duct, gallbladder, breast and thyroid cancer and were detected in 11.9%, 36.4%, 64.3%, 0%, 0% of each. p53 gene mutations were investigated in colorectal and breast cancer and were detected in 9.5% and 9.3%, respectively. In addition, 4 colorectal cancer cases exhibited more than two kinds of genetic alteration, while breast cancer cases showed only single kind. From these findings, it is suggested that 1) the incidence of each genetic alteration differed among the cancers investigated and organ specificity may exist; 2) the genetic alterations investigated here contributed to a minor part of cancer development, which requires the identification of more unknown genes related to carcinogenesis; 3) to clarify the molecular mechanism of cancer development, the genetic alterations including genomic instability and mutations of several kinds of genes related to cancer development in each case should also be determined along with their genetic molecular profile.

Resection of triple synchronous cancers: a case report

We herein present a case of synchronous triple cancer, which was successfully resected in a curative manner. These cancers consisted of primary duodenal, pancreatic and lung cancers, which were diagnosed in an asymptomatic 74 year-old male, who was referred to our department on December 14, 1996. On admission, his laboratory data showed no abnormality, including tumor markers (CEA 1.0, CA 19-9 1.0, AFP 8.1 U/ml), but he did show an impaired pulmonary function (FEV1.0: 57%). Upper gastrointestinal endoscopy showed a smooth surfaced duodenal tumor measuring 4 cm in size. The second tumor was found at the head of the pancreas by computed tomography (CT), showing a hypervascular mass measuring 3.0 cm, along with neighboring multiple cysts. In endoscopic retrograde cholangiopancreatography (ERCP), marked mucous secretion was observed through the papilla, while a filling defect was found in the dilated pancreatic duct. In a routine chest X-ray, a third tumor, which measured 1.5 cm in diameter, was recognized in the right upper lobe of the lung, and a moderately differentiated squamous cell carcinoma was also detected by a percutaneous CT guided biopsy. The pancreatic and duodenal tumors were surgically resected by a pancreatoduodenectomy (Stage I) in January 1997 and, 5 months later, a lung tumor underwent partial resection (Stage I). This patient tolerated these surgical procedures well and presently leads a normal, healthy life after discharge. In summary, a successful resection of synchronous triple cancers, which has never been previously reported in this specific combination, is described.

Revision of ventriculo-peritoneal shunt under laparoscopic guidance in patients with hydrocephalus

Ventriculo-peritoneal (V-P) shunt is a common treatment for hydrocephalus. However, shunt insufficiency due to obstruction, dislocation, and detachment of the peritoneal tube is frequently encountered. We designed a new technique in which the peritoneal tube is inserted into a target site of the abdominal cavity under laparoscopic guidance. We operated on 9 patients with hydrocephalus using this technique. Shunt insufficiency of the peritoneal tube had been observed in all patients, and 7 patients had undergone repeated revision of the peritoneal tube before this procedure. Our laparoscopic-assisted method ensured tube insertion into the appropriate site, and minimized the abdominal wound and postoperative adhesions. This method also made it possible to differentiate abdominal pain induced by shunt failure from pain caused by other diseases, including appendicitis. In conclusion, we consider this new technique for V-P shunt performed under laparoscopic guidance to be very useful.

Large synovial cyst of the pelvis containing rice bodies. A case report

Although synovial pelvic cysts are very uncommon they enter into the differential diagnosis of presacral and ovarian cysts. In the elderly male whom we report, a large cyst arose from the hip and extended during a five year period to involve the entire pelvic cavity. The cyst, which contained a large number of "rice bodies" was excised surgically.

[Three patients with terminal gastric cancer who achieved good QOL through home hospice care]

In our G.I. department, patients with inoperable or recurrent cancer of the digestive organs are treated by chemotherapy and/or radiation therapy. Since the efficacy of these modalities has been poor in our hospital as in others, we have attempted to maintain good quality of life (QOL) in these patients by offering hospice care in the hospital or at home. Home care is provided to those who choose not to have chemotherapy or do not respond well to it. These patients live within 20 km of the hospital and are cared for at home by a visiting nurse or through visits to our outpatient clinic. However, in the latter patients who do not have access to good public transportation, clinic visits are a hardship to both patients and their families even though they do well with home hospice care. Home hospice care is also difficult for those who do not have adequate family support available. We report here three patients with terminal gastric cancer who appeared to experience good QOL through home hospice care.

Antiproliferative effect of carotenoids on human colon cancer cells without conversion to retinoic acid

The present study employed two human colon cancer cell lines, DLD-1 and Colo 320DM, to investigate whether the provitamin A activity of carotenoids is necessary for their antitumor effect on colon cancer. Carotenoids, including alpha- and beta-carotene and canthaxanthin, significantly suppressed cell viability [measured by tetrazolium (MTT) assay], DNA synthesis (measured by [3H]thymidine uptake), and cell proliferation (measured by cell counting) and thus showed growth-inhibitory effects on both cancer cell lines. Because canthaxanthin does not have provitamin A activity, these results suggest that the carotenoid directly inhibited the cell growth. Moreover, the effective dose of retinoic acid, an active metabolite of vitamin A, was much higher than that of alpha- or beta-carotene. A retinoic acid-inducible gene, retinoic acid receptor-beta, was not enhanced in either type of cancer cell by treatment with alpha- or beta-carotene. Therefore, like canthaxanthin, alpha- and beta-carotene might also exert their tumor-suppressing effects without being converted to retinoids. These results suggest that a certain antitumor activity of carotenoids may not necessarily require their provitamin A activity.

Inhibitory effect of troglitazone on diabetic neuropathy in streptozotocin-induced diabetic rats

Free-radical scavengers and inhibitors of tumour necrosis factor-alpha (TNF-alpha) such as N-acetylcysteine and pentoxifylline have been shown to inhibit the development of peripheral neuropathy in streptozotocin(STZ)-induced diabetic rats. In this study we examined the effect of troglitazone, an anti-diabetic thiazolidinedione, on diabetic neuropathy, since it also is a free-radical scavenger and a TNF-alpha inhibitor. Rats were fed powder chow mixed with troglitazone at 0.5% and 0.125% ad libitum. Although blood glucose concentrations were remarkably higher and body weight lower in diabetic than in nondiabetic rats, troglitazone had no effect on these throughout the 24-week experiment. Serum lipoperoxide concentrations, tibial nerve lipoperoxide content and serum TNF-alpha activity induced by lipopolysaccharide was increased in diabetic rats, but inhibited in troglitazone-treated rats. Motor nerve conduction velocity (MNCV) of the tibial nerve slowed in diabetic rats, compared with that in nondiabetic rats. On the other hand, the slowed MNCV was (p < 0.05-0.01) inhibited after weeks 12 and 16 of the experiment in diabetic rats treated with high and low doses of troglitazone, respectively. Morphometric analysis showed that troglitazone suppressed the decrease of the myelinated fibre area (p < 0.05), axon/myelin ratio (p < 0.01) and fascicular area (p < 0.05) and suppressed the increase of myelinated fibre density (p < 0.001) in diabetic rats. These results indicate that troglitazone has a beneficial effect on peripheral neuropathy in STZ-induced diabetic rats irrespective of blood glucose concentrations.