[Clinical analysis of patients referred for lung transplantation in eastern Japan]

We investigated the indications for lung transplantation (LTx) in Japan and discussed questions regarding the current Japanese criteria of LTx. This study examined 37 patients referred to our institute for LTx. Among these patients, there were 11 cases of primary pulmonary hypertension (PPH), 6 of lymphoangiomyomatosis (LAM), 4 of Eisenmenger's syndrome, 3 of bronchiolitis obliterans, 2 each of bronchiectasis, idiopathic pulmonary fibrosis (IPF), and pneumoconiosis, and 7 of other diseases. The most frequent age group was 30-39 years (12 cases, 32.4%), and more than half of the patients were female (22 cases, 59.5%). The regions of residence of the patients were Tohoku (19 patients), Kanto (16), and Chubu (2). Patients were referred from all over eastern Japan. On evaluation, LTx was contraindicated in 5 cases, in 4 of which mechanical ventilation had been installed before consultation with us. Six patients died before registration on the Japan Organ Transplant Network (JOT). 6 transplant candidates were registered with JOT, but one (PPH) died after 6 months of waiting, and one (LAM) received a lung transplant from a brain dead cadaver donor. We propose to reform and clarify the Japanese criteria for LTx-both indications and contraindications, to include such indications as a survival probability of less than two years, and such contraindications as mechanical ventilation. Early consultation at LTx centers was hoped for, in accordance with the International Guidelines and a transplant window.

[The lung transplantation has come to be done in Japan]

After the establishment of transplantation law, the right pulmonary transplantation was done from the brain dead donor for the first time in Japan at the attached hospital of Institute of Development, Aging and Cancer, Tohoku University on March 29, 2000. The woman in 30's had been deteriorated from progressive lymphangiomyomatosis since 1984. She was waiting for the right lung transplantation in the related hospital of the Institute Hospital since May, 1999. A brain dead donor appeared in Tokyo. After receiving the information from Japan Organ Transplant Network, we immediately started for Tokyo in order to procure the lung. We carried the right lung by Shinkansen. The lung of the donor was transplanted to the patient under the partial extracorporeal circulation on March 29, 2000. The total operating time was 6 hours and 7 minutes: 5 hours and 20 minutes for total ischemic period of the lung and 2 hours and 7 minutes for using extracorporeal circulation. The total amount of bleeding during the operation was 3,695 ml. Postoperative course of the transplanted patient was fair except chylothorax in the operated side, which was successfully controlled by intrathoracic infusion with OK-432. The transplanted patient was discharged from the hospital after 75 days postoperatively.

[The application of poly (L-lactide) sternal coaptation pins for median sternotomy]

Poly (L-lactide) sternal coaptation pin has been developed as an assistant material for the fixation of sternum. We used the novel material to a patient who underwent median sternotomy. A 21-year-old male was suspected to have invasive thymoma in the anterior mediastinum. The median sternotomy was indicated as an approach for the resection of tumor. Tumor was completely resected and there was no invasion to sternum. For the fixation of sternum, three poly (L-lactide) sternal coaptation pins were inserted in the bone marrow of sternum and five stainless steel wires were used as conventional procedure. Sternum was adapted without slippage and no complication from the material was observed in the post-surgical period. The application of poly (L-lactide) sternal coaptation pin is a good option for ensuring the fixation of sternum.

Long-term survival of a patient with stage IV pulmonary large cell carcinoma achieved by combined-modality therapy: report of a case

We describe herein the case of a 59-year-old-man with stage IV pulmonary large cell carcinoma and a giant brain metastasis, in whom two sublines with different growth characteristics and drug sensitivities in vitro were established from the primary tumor. Disease-free survival for more than 5 years after surgery was achieved by combined-modality therapy together with surgery to remove the primary tumor, radiation to the brain metastasis, and chemotherapy to presumed hematogenous dissemination. Subline 1 proliferated in a monolayer of epithelial-like cells, while subline 2 showed a floating colony pattern of proliferation, resembling the typical growth characteristics of small cell lung cancer (SCLC) cells in vitro. Subline 2 was sensitive to a number of drugs, namely, vincristine (VCR), cyclophosphamide (CPM), adriamycin (ADR), and cisplatin (CDDP), whereas subline 1 was resistant to many drugs. The patient was treated with a combination of 44 Gy of whole-brain irradiation and a number of cycles of chemotherapy comprised of ADR, VCR, and CPM, followed by CDDP, VCR, and CPM, based on the results of sensitivity testing of the subline 2 cells. As a result, the patient has been disease-free for more than 5 years postoperatively. In conclusion, this case report serves to demonstrate that meticulous combined-modality treatment taking tumor heterogeneity in human cancers into account may be necessary to achieve breakthroughs in current cancer therapy for advanced lung cancer.

[Present condition of lung transplantation candidates in eastern Japan]

We investigated the present condition of lung transplant candidates and the familiarity of doctors in eastern Japan by questionnaire. We shipped questionnaires to 614 hospitals in the Hokkaido district, the Tohoku district, the Kanto district and Niigata Prefecture, a received responses from 216 departments (200 hospitals). The percentage of respondents was 32.6%. There were 191 lung transplant candidates, 97 men and 94 women, in the past two years. Moreover, there were 45 patients with primary pulmonary hypertension (PPH), 38 with idiopathic pulmonary fibrosis, 23 with pulmonary emphysema, 20 with pulmonary lymphangiomyomatosis, among others. Currently, however, there are 88 patients who are lung transplant candidates, a large number, in eastern Japan. On the other hand, only 38 of 68 departments had informed their patients about lung transplantation. It was a lamentable result for transplant surgeons, and points urgently to the importance of giving information about lung transplantation.

Results of surgical treatment of lung cancer involving the diaphragm

OBJECTIVES

Lung cancers with diaphragmatic invasion are categorized as T3 lesions, but the surgical results have not been well known. We retrospectively surveyed patients with resected primary lung cancers involving the diaphragm.

METHODS

A total of 16,771 patients underwent surgical resection for lung carcinoma between 1986 and 1995 at 31 institutions of the Lung Cancer Surgical Study Group in Japan. By investigating the database, we identified 63 patients (0. 38%) who underwent resection of T3 lung cancer invading the diaphragm. These patients constituted the study population, and their clinical and pathologic records were retrospectively analyzed.

RESULTS

Tumor invasion to the diaphragm was diagnosed before operation only in 17 patients (27.0%). Complete resections of the primary lung tumors with the invaded diaphragm were performed in 55 patients (87.3%), of whom 26 had T3 N0 M0 diseases and 29 had T3 Nl-2 M0 diseases. The operative mortality was 1.6% in all patients. The 5-year survival of patients with complete resection was 22.6%, but there was no 4-year survivor in patients with incomplete resection (P =.024). The survivals of patients with completely resected T3 N0 M0 and T3 N1-2 M0 tumors were 28.3% and 18.1%, respectively (P =.013). In those patients, the depth of diaphragmatic involvement significantly affected the prognosis. The 5-year survival of the patients with shallow invasion (parietal pleura or subpleural tissue involvement) was 33.0%, whereas that of the patients with deep invasion (muscle or peritoneal infiltration) was 14.3% (P =.036).

CONCLUSIONS

In selected patients with lung carcinoma and diaphragmatic invasion, combined resection of the lung and diaphragm offers the prospect of cure with acceptable mortality. However, primary lung tumors with diaphragmatic invasion, especially invasion of the muscle layer or deeper tissue, are not considered to be T3 lesions, because these cancers are generally technically resectable but oncologically almost incurable.

Novel arbekacin- and amikacin-modifying enzyme of methicillin-resistant Staphylococcus aureus

An aminoglycoside-modifying enzyme in arbekacin-resistant methicillin-resistant Staphylococcus aureus (MRSA), exhibiting 4'''-N-acetylation, was examined. Although the MRSA strain with AAC(4''') had no AAC(6')-APH(2") activity, a DNA fragment of the AAC(6')-APH(2") gene was amplified by PCR and the purified N-terminal 30-amino acid sequence of this AAC(4''') was identical to AAC(6')-APH(2"). Direct DNA sequencing of this 'silent' AAC(6')-APH(2") gene revealed a single point mutation leading to a substitution of Gly for Asp80, through which the secondary structure is affected. A change in protein conformation could lead to a cleavage and a change of the enzymatic activity. We propose a new aminoglycoside-resistance mediated by AAC(4''') is caused by a mutation-modified AAC(6')-APH(2").

Effects of EP4 solution and LPD solution vs Euro-Collins solution on Na(+)/K(+)-ATPase activity in rat alveolar type II cells and human alveolar epithelial cell line A549 cells

BACKGROUND

Intact alveolar epithelial Na(+)/K(+)- adenosinetriphosphatase (ATPase) function is important in preventing alveolar fluid accumulation after lung transplantation. We examined whether the type of preservation solution used influences Na(+)/K(+)-ATPase activity in alveolar epithelial cells.

METHODS

Rat alveolar type II cells were preserved with EP4, low-potassium dextran (LPD), or Euro-Collins solution at 7 degrees C for 5 and 20 hours. To assess cell toxicity, we measured cell viability and lactate dehydrogenase release. Na(+)/K(+)-ATPase activity was measured as ouabain-sensitive ATPase hydrolysis. We also examined the effect of terbutaline (10(-3) mol/liter) and dibutyryl cyclic adenosine monophosphate (dbcAMP) (10(-3) mol/liter) on Na(+)/K(+)-ATPase activity in A549 cells preserved for 5 hours.

RESULTS

All solutions caused significant damage of rat alveolar type II cells at 20 hours. However, Na(+)/K(+)-ATPase activity was preserved at normal levels with EP4 and LPD over 20 hours. Terbutaline and dbcAMP significantly increased Na(+)/K(+)-ATPase activity in A549 cells preserved with EP4 and LPD solutions for 5 hours. However, we observed no activation in the cells preserved with Euro-Collins solution. We found no significant difference in intracellular cAMP levels after terbutaline challenge among the types of preservation solution.

CONCLUSIONS

We conclude that extracellular-type solutions such as EP4 and LPD may be preferable for maintaining not only the basal activity but also the ability to activate Na(+)/K(+)-ATPase in response to beta-adrenergic agonists, in alveolar epithelial cells.

Differences in TNF-alpha producing activity from murine peritoneal macrophages induced by lipopolysaccharides of Prevotella heparinolytica and Porphyromonas gingivalis

We compared the effects of LPSs from P. gingivalis and P. heparinolytica on the induction of tumor necrosis factor-alpha (TNF-alpha) production by murine peritoneal macrophages. The lipopolysaccharide (LPS) preparation from P. gingivalis showed a typical ladder pattern in SDS-PAGE, whereas that from P. heparinolytica formed several stained bands without a ladder pattern. When the macrophages from C3H/HeJ mice were incubated with P. gingivalis LPS, the level of TNF-alpha released in the culture supernatants was significantly higher than that with P. heparinolytica. All tested reagents except genistein strongly inhibited the production of TNF-alpha by the macrophages after induction by either LPS. These results suggested the following possibilities, i) the induction level of TNF-alpha by P. heparinolytica is similar to that of Salmonella minnesota, ii) tyrosine phosphorylation is not the only pathway for the TNF-alpha production induced by these LPSs, iii) different regulatory mechanisms are involved in TNF-alpha production in P. gingivalis LPS stimulated and P. heparinolytica LPS stimulated cells.

Primary structure and autoproteolysis of brevilysin H6 from the venom of Gloydius halys brevicaudus

The complete amino acid sequence of brevilysin H6 (H6), a zinc-protease isolated from Gloydius halys brevicaudus venom, was determined by a manual Edman degradation method. H6 has an amino-terminal pyroglutamic acid and consists of a total of 419 residues. An N-linked sugar chain is attached at Asn-181. The molecule is composed of three domains (metalloprotease, disintegrin-like and cysteine-rich domains), as commonly found in other high molecular mass metalloproteases from snake venoms. In the absence of calcium ions, H6 is autocatalytically degraded with a half-life of 47 min to give 29 and 45 kDa fragments, which correspond to residues 208-419 and 99-419 of H6, respectively. Thus, the autoproteolysis seemed to start from the cleavage of either the Leu(98)-Leu(99) or Asp(207)-Ile(208) bond. Calcium ions suppressed both the formation of the 45 kDa fragment and the rate of autoproteolysis. Calcium ions also contributed to the stability of H6 against pH, heating, urea and cysteine. More than twenty-five peptide bonds adjacent to hydrophobic residues in the metalloprotease domain were progressively cleaved during the autoproteolysis.

[An office technique for myringoplasty without the use of fibrin glue]

A simple method for office closure of eardrum perforation using an atero-collagen graft used for dermal defects (Terdermis) without fibrin glue was developed. Eardrum perforations were successfully closed in 71.4% of all cases (63 ears) after the initial treatment. Neither skin incision nor the use of temporal fascial grafts was necessary in this method. The merit of the method is that there is no possibility of blood infection because no blood materials are used.

[A case of mediastinal pseudocyst with unusual cystic findings in computed tomography]

We report here a case of mediastinal pseudocyst with unusual CT findings. A 25-year-old woman was admitted to our hospital due to a chest abnormal shadow. She had a cystic mass which was located at anterior mediastinum and was adjacent to great vessels broadly without invasive findings. The intraoperative and histological findings revealed that the cystic mass was a pseudocyst which had been generated by the rupture of a thymic cyst to the mediastinum.

Difference in the effects of low temperatures on the tension of human pulmonary artery and vein ring segments

BACKGROUND

Although limited data suggest that pulmonary flushing with organ preservation solutions should not be performed at too low temperatures, the influence of temperature on pulmonary vascular tone is unclear.

OBJECTIVE

The purpose of this study was to examine the effect of low temperatures of the tension of human pulmonary artery and vein ring segments and the vascular resistance of perfused rat lungs.

METHODS

5 sets of human pulmonary artery and vein ring segments were suspended from a force displacement transducer at 37, 24 and 8 degrees C, and the effect of 30 mM K(+) on the tension was monitored. The effect of 30 mM K(+) on vascular resistance was also examined at low temperatures in 5 perfused rat lungs.

RESULTS

Pulmonary artery segments dilated at 24 degrees C, and more significant vasodilatation was observed at 8 degrees C. In contrast, there was a significant constriction of pulmonary veins at 8 degrees C. Vasoconstriction induced by 30 mM K(+) at 37 degrees C was significantly inhibited at low temperatures in both pulmonary arteries and veins. In rat lungs, perfusion at 8 degrees C caused a significant increase in pulmonary vascular resistance, even though no further increase was observed in the presence of 30 mM K(+).

CONCLUSIONS

Our data indicate that pulmonary arteries dilate and the veins constrict at 8 degrees C and may increase pulmonary vascular resistance. We conclude that the different effect of low temperatures between pulmonary arteries and veins may explain why pulmonary vascular flushing with organ preservation solutions at room temperature is more satisfactory.

MDM2 expression is associated with progress of disease and WAF1 expression in resected lung cancer

Although MDM2, p21/WAF1, and p53 are considered as regulating each other based on in vitro studies, the relation in human lung cancer is not fully understood. The expressions of these proteins were examined immunohistochemically in 112 resected non-small cell lung cancer specimens and the correlation between them were analyzed. MDM2 was expressed in 45% of all lung cancers. In advanced stage, MDM2-positive cases were observed more frequently than in early stage, showing significant difference. No significant difference was observed in the prognosis of the patients regardless of the expression of any protein. Although no correlation was observed between MDM2 expression and p53 expression, or between p21/WAF1 expression and p53 expression, MDM2 expression was strongly related with p21/WAF1 expression. Therefore, MDM2 expression may relate to the progress of the stage of lung cancer, and MDM2 expression and p21/WAF1 expression may be associated not through the p53-related pathway.

Infiltration of CD8+ T cells in non-small cell lung cancer is associated with dedifferentiation of cancer cells, but not with prognosis

CD8+ T cells infiltrating within cancer cell nests in human colorectal cancer were associated with a favorable patients' survival, suggesting the presence of anti-tumor immunity. The present study was designed to examine this concept in non-small cell lung cancer (NSCLC) by a retrospective analysis of 128 surgically resected cases. Immunohistochemical analysis showed that the number of CD8+ T cells within cancer cell nests in NSCLC was related to the histological subtype (large cell carcinoma or squamous cell carcinoma > adenocarcinoma) and the degree of dedifferentiation (undifferentiated type > differentiated type). In contrast to colorectal cancer, the number of CD8+ T cells in NSCLC had no statistically significant impact on the patients' survival. The present study demonstrated that the degree of infiltration of CD8+ T cells within cancer cell nests is dependent on the dedifferentiation of cancer cells in NSCLC, which could be one of the important aspects for the study of tumor immunity.

[Strategy of treatment for roentgenographically occult lung cancer]

Roentgenographically occult bronchogenic squamous cell carcinomas(ROCs) are very small hilar type lung cancer that grow superficially and localize mainly in the bronchial wall, and these patients are expected to have an excellent prognosis after resection. When a ROC is limited within bronchoscopic visibility and less than 10 mm in longitudinal extension and its bronchoscopic findings are slight thickening and flat or wavelet, the tumor is a good candidate for photodynamic therapy. When a ROC is limited within bronchoscopic visibility, the tumor is a good candidate for segmentectomy with curative intent. The tumor invading beyond bronchial wall and/or nodal involvement should be treated by standard operation.

Comparative in vitro activity of S-4661, a new parenteral carbapenem, and other antimicrobial agents against respiratory pathogens

The activity of S-4661, a new parenteral carbapenem antibiotic, was evaluated against 202 recent clinical isolates of respiratory pathogens. S-4661 was similar to or 2 times more active than imipenem, meropenem, and biapenem, and 8-128 times more active than ceftazidime against gram-positive bacteria. Against gram-negative bacteria, S-4661 was slightly less active than meropenem, but 2-8 times more active than the other agents. In particular, against Pseudomonas aeruginosa S-4661 showed the most potent activity. Thus it was found that S-4661 possesses a potent and well-balanced activity against respiratory pathogens.

Combined modality therapy including surgery for stage III small-cell lung cancer on the basis of the sensitivity assay in vitro

Fifty-nine consecutive patients with clinical stage (cStage) I-III resectable small-cell lung cancer (SCLC) underwent surgery with adjuvant chemotherapy based on an in vitro sensitivity assay between April 1982 and March 1992. In 42 (71%) of these patients, a stable passage of cancer cells from resected specimens was possible and the sensitivity of these cultured SCLC cells to anticancer drugs was examined by the MTT method. In the sensitivity assay, vincristine (VCR) showed the most intense specific efficacy for SCLC, followed by cyclophosphamide (CPM) and cisplatin (CDDP). The 5-year survival rates for pathological stage (pStage) I, pStage II, and pStage III were 55%, 33%, and 23%, respectively. The 5-year survival of the patients with pStage III operated on in the first 5 years was 7% (1/14). On the other hand, 6 of the 16 pStage III patients (38%) operated on during the second 5-year period, who were generally treated with pre- and postoperative adjuvant chemotherapy combined with three drugs, survived over 5 years. In conclusion, these results suggest that combined modality therapy including surgery is necessary, and adjuvant chemotherapy combined with VCR, CPM, and CDDP may be useful in the treatment of Stage III SCLC disease, for the purpose of achieving a long-term survival with both a good performance status and quality of life for the patients.

A potent inhibitor of inducible nitric oxide synthase, ONO-1714, a cyclic amidine derivative

(1S,5S,6R,7R)-7-Chloro-3-imino-5-methyl-2-azabicyclo[4.1.0]heptane hydrochloride (ONO-1714), a novel cyclic amidine analogue, inhibits human inducible nitric oxide (iNOS) with a K(i) of 1.88 nM and rodent iNOS with similar potency in vitro. ONO-1714 was found to be 10-fold selective for human iNOS over human endothelial NOS (ecNOS). When the inhibitory activity of ONO-1714 was compared for iNOS, it was found to be 451-fold and >20,000-fold more potent than L-NMMA and aminoguanidine (AG), respectively. In terms of human iNOS selectivity, ONO-1714 was approximately 34- and 2-fold more selective for iNOS than L-NMMA and AG, respectively. ONO-1714 inhibited the LPS-induced elevation of plasma nitrate/nitrite in mice with an ID(50) value of 0.010 mg/kg, s.c. The maximum tolerated dose of ONO-1714 was 30 mg/kg, i.v. Thus, ONO-1714 represents one of the most potent iNOS inhibitors in vitro and in vivo to date and has great potentials for use as an inhibitor for clarifying the pathophysiological roles of iNOS and for use as a therapeutic agent.

Transition from squamous cell carcinoma to adenocarcinoma in adenosquamous carcinoma of the lung

The heterogeneity of tumor cells is frequently observed in lung cancer, but the clonality of these cells has not yet been established. The distinct components of 12 lung adenosquamous carcinomas were compared by genetic alterations of p53 and K-ras, chromosomal abnormalities at 9p21 and 9q31-32, and immunohistochemical reactions. The immunoreactivity of p53 was consistent in both adenocarcinomatous and squamous cell carcinomatous components as well as in the transitional areas, retaining the morphological characteristics of the distinct components. The same p53 mutation was found in both components of each tumor with p53 overexpression. No K-ras mutations were detected in any of the tumors examined. Three of the four tumors with chromosomal abnormalities detected, one at 9p21 and two at 9q31-32, had coincident abnormalities between the distinct components, whereas one tumor deleted homozygously at 9p21 (D9S259) in the adenocarcinomatous component with loss of heterozygosity in the other component. The expression of squamous cell carcinoma-related antigen in adenocarcinomatous components was significantly higher than that of lung adenocarcinomas (57 +/- 5.8% vs. 1.0 +/- 0.5%, P < 0.0001), whereas Mucin 1 expression is less in these components (9.0 +/- 4.9% vs. 55 +/- 8.2%, P = 0.003). These results suggest monoclonal transition from squamous cell carcinoma to adenocarcinoma in lung adenosquamous carcinoma.

A novel nuclear phosphoprotein, GANP, is up-regulated in centrocytes of the germinal center and associated with MCM3, a protein essential for DNA replication

Antigen (Ag) immunization induces formation of the germinal center (GC), with large, rapidly proliferating centroblasts in the dark zone, and small, nondividing centrocytes in the light zone. We identified a novel nuclear protein, GANP, that is up-regulated in centrocytes. We found that GANP was up-regulated in GC B cells of Peyer's patches in normal mice and in spleens from Ag-immunized mice. GANP-positive cells appeared in the light zone of the GC, with coexpression of the peanut agglutinin (PNA) (PNA)-positive B220-positive phenotype. The expression of GANP was strikingly correlated with GC formation because Bcl6-deficient mice did not show the up-regulation of GANP. GANP-positive cells were mostly surrounded by follicular dendritic cells. Stimulation with anti-micro and anti-CD40 induced up-regulation of ganp messenger RNA as well as GANP protein in B220-positive B cells in vitro. GANP is a 210-kd protein localized in both the cytoplasm and nuclei, with a homologous region to Map80 that is associated with MCM3, a protein essential for DNA replication. Remarkably, GANP is associated with MCM3 in B cells and MCM3 is also up-regulated in the GC area. These results suggest that the up-regulation of GANP might participate in the development of Ag-driven B cells in GCs through its interaction with MCM3.