Primary embryonal carcinoma of heart with SVC syndrome

We present a case report of a 25-year-old man with embryonal carcinoma of right atrium and multiple lung metastases featuring SVC syndrome. We resected the cardiac tumor which occupied the right atrium and performed left upper lobectomy. No tumor mass or vestige was detected in the testes. Cis-platinum based combination chemotherapy was performed for residual lung tumors, which leads to the complete remission.

[Cardiac surgery for chronic dialysis patients]

Chronic dialysis patients who received open heart surgery were examined, and main concern was perioperative management. There were 12 chronic dialysis patients and open heart surgeries were performed between October 1990 and June 2000. The patients were comprised of 7 men and 5 women with the average age being 64 with plus or minus 7.9. The operative procedure of 6 coronary artery bypass grafting (CABG) [on-pump], 1 CABG + mitral valve replacement (MVR), 3 aortic valve replacement (AVR), 1 mitral valvuloplasty (MVP) and 1 ascending aorta replacement were performed. All patients were discharged from the hospital with good conditions 27.1 days after operation. There were no hospital deaths. One postoperative complication of mediastinitis of the sternum has been found. A conventional dialysis was performed the day before the operation and an intra-operative hemodialysis (HD) was performed, placing a dialyzer into a cardiopulmonary system during the operation. For the perioperative management, HD was started the day or 2 days after the operation with no immediate postoperative hemocatharsis and returned to the normal HD 7 days after the operation. The result of the perioperative management has been good.

Expression of ABH/Lewis-related antigens as prognostic factors in patients with breast cancer

PURPOSE

The prognostic value of altered blood group factor and Lewis-related carbohydrate antigen expression in breast cancers has not been fully determined.

METHODS

To this end, breast carcinoma samples from 87 radical mastectomy patients with primary cancer were analyzed by immunohistochemistry for the ABH factors, Le(a), sialyl Le(a), Le(x), and sialyl Le(x).

RESULTS

It was found that ABH, Le(a), sialyl Le(a), Le(x), and sialyl Le(x) antigens were expressed in 25 (21.8%), 26 (22.6%), 26 (22.6%), 36 (31.3%), and 37 specimens (32.2%), respectively. Tumors with lymph node metastasis expressed Le(x) or sialyl Le(x) antigens more frequently than those without lymph node metastasis ( P=0.0020 or P=0.039, respectively). The survival time of patient s after surgery was significantly shorter for those whose tumors expressed Le(x) or sialyl Le(x) than for those without Le(x)- or sialyl Le(x)-positive tumors ( P=0.0028 and P=0.0029, respectively). Cox's multiple regression analysis revealed that sialyl Le(x) expression was an independent prognostic factor for patient survival regardless of primary tumor (T factor) and lymph node (N factor) status (hazards ratio, 3.80).

CONCLUSIONS

Thus, expression of sialyl Le(x) antigen in tumor cells is associated with poor prognosis in patients with breast cancer and must be considered in the design of future therapeutic trials.

[An elderly case of ruptured aortic arch aneurysm 3 years after coronary artery bypass grafting]

We reported a case of trans-aortic endovascular stent grafting (open stent method) for ruptured true aneurysm of the aortic arch. A 83-year-old female, who had suddenly complained back pain and been diagnosed as the ruptured aortic arch aneurysm by computer tomography, was admitted for an emergent surgery. We performed emergent trans-aortic endovascular stent grafting (open stent method). Postoperatively she had no complication and recovered uneventfully.

Phase I/II and pharmacologic study of irinotecan and carboplatin for patients with lung cancer

PURPOSE

To determine the maximum tolerated dose (MTD) of irinotecan combined with carboplatin, to evaluate its efficacy and toxicity for patients with lung cancer, and to examine its pharmacokinetics and pharmacodynamics.

METHODS

The dose of irinotecan was escalated from 40 mg/m2 per week in increments of 10 mg/m2. Carboplatin was fixed at 300 mg/m2. Multivariate regression models with an interaction term were used to evaluate synergistic pharmacodynamic interactions.

RESULTS

The MTD and recommended dose of irinotecan were 60 and 50 mg/m2, respectively. Dose-limiting toxicities were grade 4 neutropenia and grade 3 or 4 diarrhea. In phase II studies, response rates were 81.3% (95% confidence interval 61.8-100%) in 16 patients with small-cell lung cancer and 22.2% (2.7-41.8%) in 18 patients with non-small-cell lung cancer. Two patients (6%) experienced grade 4 neutropenia, thrombocytopenia, and grade 3 diarrhea. The area under the plasma concentration versus time curve (AUC) of carboplatin ranged from 2.87 to 9.31 mg x min/ml, with a median of 4.66 mg x min/ml. In pharmacodynamic analyses, the log-transformed surviving fraction in platelet count (SFp) showed a significant association with the AUC of carboplatin (P=0.010), while that in neutrophil count (SFn) was not significantly correlated with any pharmacokinetic parameter. The interaction term was not significant in either case.

CONCLUSIONS

These results indicate that AUC-based dosing of carboplatin is still rational in combination chemotherapy. A more sensitive method for predicting life-threatening toxicities is needed, however, because traditional pharmacokinetic parameters were not adequate tools for identifying patients at high risk of severe neutropenia and diarrhea. This combination regimen has only modest activity, and further studies are necessary to evaluate a different dose schedule.

Frank-Starling mechanism retains recirculation fraction of myocardial Ca(2+) in the beating heart

Myocardial Ca(2+) handling in excitation-contraction coupling is the second primary determinant of energy or O(2) demand in a working heart. The intracellular and extracellular routes remove myocardial Ca(2+) that was released into the sarcoplasma with different Ca(2+): ATP stoichiometries. The intracellular route is twice as economical as the extracellular route. Therefore the fraction of total Ca(2+) removed via the sarcoplasmic reticulum, i.e., the recirculation fraction of intracellular Ca(2+) (RF), determines the economy of myocardial Ca(2+) handling. RF has conventionally been estimated as the exponential decay rate of postextrasystolic potentiation (PESP). However, we have found that PESP usually decays in alternans, but not exponentially in the canine left ventricle beating above 100 beats/min. We have succeeded in estimating RF from the exponential decay component of an alternans PESP. We previously found that the Frank-Starling mechanism or varied ventricular preload did not affect the economy of myocardial Ca(2+) handling. Then, to account for this important finding, we hypothesized that the Frank-Starling mechanism would not affect RF at a constant heart rate. We tested this hypothesis and found its supportive evidence in 11 canine left ventricles. We conclude that RF at a constant heart rate would remain constant, independent of the Frank-Starling mechanism.

Prognostic value of performance status assessed by patients themselves, nurses, and oncologists in advanced non-small cell lung cancer

Accuracy in the assessment of performance status by oncologists has not been well evaluated. We investigated possible discrepancies in the assessment of performance status among patients, nurses, and oncologists, and evaluated the prognostic importance of each assessment. Two hundred and six inpatients with inoperable, advanced non-small cell lung cancer were investigated prospectively. Weighted Kappa statistics for inter-observer agreement were 0.53 between oncologists and patients and 0.63 between oncologists and nurses. There was a significant difference among the assessments by the three groups (P < 0.001). Oncologists gave the healthiest performance status assessment, nurses an intermediate assessment, and patients the poorest. When included separately in the Cox model, the assessment by each group was significantly correlated with survival. However, the assessment by the patients themselves failed to distinguish survival of patients with performance status 1 and 2. Among the three models including patient-, nurse-, and oncologist-assessed PS, that including oncologist-assessed PS best fitted to the observed survival data. These results showed that the assessment by the patients themselves is different from those by the nurses and the oncologists and provided additional support for the use of the assessment by oncologists in clinical oncology.

Phase I and pharmacological study of a new camptothecin derivative, exatecan mesylate (DX-8951f), infused over 30 minutes every three weeks

PURPOSE

A Phase I study of exatecan, a new water-soluble camptothecin derivative, was conducted to determine the maximum tolerated dose and a recommended dose, according to an internationally standardized core protocol. Pharmacological profiles of lactone and total (lactone + carboxylate) exatecan were also investigated.

PATIENTS AND METHODS

Fifteen patients with advanced solid malignancies were treated with 3, 5, and 6.65 mg/m(2) of exatecan infused over 30 min every 3 weeks. Concentrations of lactone, total drug, and a metabolite in plasma and urine were determined during the first course.

RESULTS

Dose-limiting neutropenia and liver dysfunction were observed in two of six patients at 6.65 mg/m(2), but no grade 3 or worse diarrhea was observed. Emesis was moderate, and no grade 3 or worse nausea and vomiting were observed at a recommended dose of 5 mg/m(2), with prophylactic use of granisetron. Pharmacokinetics were linear and had moderate variability; clearances of lactone and total drug were 6.8 +/- 2.8 and 2.1 +/- 1.1 (mean +/- SD) l/h/m(2), respectively. The ratio of lactone concentration to total drug concentration in plasma decreased from 0.81 +/- 0.06 at the end of infusion to 0.15 +/- 0.06 10 h after the infusion. The lactone:total ratio of drug exposure was 0.30 +/- 0.08, ranging from 0.16 to 0.43. Neutropenia was related to the drug exposure of both lactone and total drug.

CONCLUSIONS

The recommended dose of exatecan infused over 30 min every 3 weeks is 5 mg/m(2), with a favorable toxicity profile of mild and infrequent diarrhea. Interpatient variability of pharmacokinetics was similar to or smaller than that with other camptothecin derivatives.

Intraarterial infusion of papaverine and change of cerebral hemodynamics in symptomatic cerebral vasospasm

In 43 cases with symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage treated by intraarterial infusion of papaverine (IAP), we studied cerebral hemodynamics by measuring cerebral circulation time (CCT) using digital subtraction angiogram. CCT on the middle cerebral artery site was defined as CCT-LAV and on the anterior cerebral artery side as CCT-MAV. In the CCT-LAV, two phases were further defined; the arterial phase (CCT-A) and the capillary phase (CCT-CAP). Mean CCT-LAV before and after IAP was 6.35+/-1.69 sec, 4.91+/-1.56 sec, and mean CCT-MAV was 6.15+/-1.68 sec, 4.80+/-1.58 sec, each showing a significant shortening. Mean CCT-A before and after IAP was 0.274+/-0.105 sec, 0.226+/-0.066 sec and mean CCT-CAP was 6.00+/-1.62 sec and 4.60+/-1.55 sec. The shortening rate of CCT-A and CCT-CAP were 11.2+/-25.7% and 22.7+/-14.6% respectively. Our study confirmed that IAP shortened CCT and improved cerebral hemodynamics. Compared with CCT-A, CCT-CAP was shortened significantly, suggesting that IAP is working not only in the proximal vessels but also in the distal vessels, that is, effective for resolution of vasospasm in the view of cerebral microcirculation. Clinical outcome was not improved statistically, however, it is the fact that there are not a few cases improved neurologically and IAP is still useful for vasospasm as a means to directly dilate intracranial peripheral arteries.

Direct determination of silicon in powdered aluminium oxide by use of slurry sampling with in situ fusion graphite-furnace atomic-absorption spectrometry

A direct method for determination of silicon in powdered high-purity aluminium oxide samples, by slurry sampling with in situ fusion graphite-furnace atomic-absorption spectrometry (GF-AAS), has been established. A slurry sample was prepared by 10-min ultrasonication of a powdered sample in an aqueous solution containing both sodium carbonate and boric acid as a mixed flux. An appropriate portion of the slurry was introduced into a pyrolytic graphite furnace equipped with a platform. Silicon compounds to be determined and aluminium oxide were fused by the in situ fusion process with the flux in the furnace under optimized heating conditions, and the silicon absorbance was then measured directly. The calibration curve was prepared by use of a silicon standard solution containing the same concentration of the flux as the slurry sample. The accuracy of the proposed method was confirmed by analysis of certified reference materials. The proposed method gave statistically accurate values at the 95% confidence level. The detection limit was 3.3 microg g(-1) in solid samples, when 300 mg/20 mL slurry was prepared and a 10 microL portion of the slurry was measured. The precision of the determination (RSD for more than four separate determinations) was 14% and 2%, respectively, for levels of 10 and 100 microg g(-1) silicon in aluminium oxide.

Clinical effect of irinotecan in advanced and metastatic breast cancer patients previously treated with doxorubicin- and docetaxel-containing regimens

BACKGROUND

Previous phase II trials in Japan suggested that irinotecan was a promising agent for advanced or metastatic breast cancer pretreated with anthracycline. However, irinotecan has not yet been evaluated in the salvage setting for breast cancer pretreated with both anthracycline and taxane, which are two active agents for breast cancer.

METHODS

The efficacy and safety of irinotecan were retrospectively evaluated in patients with breast cancer who had previously been treated with both doxorubicin and docetaxel. From 1996 to 1999, irinotecan was administered to 20 patients, all with a performance status of <2. Irinotecan treatment was repeated in approximately 6 week cycles consisting of the administration of irinotecan once weekly for 4 weeks followed by a 2 week rest. The median dose of irinotecan administered was 100 mg/m(2) weekly. The median number of irinotecan cycles given was 1 (range: 1-8 cycles). The median total dose was 388 mg/m(2) (range: 50-2400 mg/m(2)).

RESULTS

Performance status declined to >3 after treatment with irinotecan in four patients. Two patients had grade 3 leukopenia; three had grade 3 anemia and one had a creatinine elevation of grade 4. The objective response rate for all patients was 5.0% (95% CI: 0-15.5%). The median time to progression and overall survival were 35 days (range: 17-285 days) and 124 days (range: 17-667 days), respectively, since the start of the administration of irinotecan.

CONCLUSIONS

Salvage chemotherapy with irinotecan may be inactive against advanced and metastatic breast cancer pretreated with doxorubicin and docetaxel. We will evaluate irinotecan for advanced and metastatic breast cancer patients as first- or second-line chemotherapy combined with anthracycline or taxane.

Preconcentration by coprecipitation of arsenic and tin in natural waters with a Ni-pyrrolidine dithiocarbamate complex and their direct determination by solid-sampling atomic-absorption spectrometry

A method for the determination of trace amounts of arsenic and tin in natural waters is described. Trace amounts of arsenic and tin were preconcentrated by coprecipitation with a Ni-ammonium pyrrolidine dithiocarbamate (APDC) complex. The coprecipitates obtained were directly analyzed by graphite-furnace atomic-absorption spectrometry (GFAAS) using the Ni-APDC complex solid-sampling technique. The coprecipitation conditions used for the trace amounts of arsenic and tin in natural water were investigated in detail. It was found that arsenic and tin at sub-ng mL(-1) levels were both coprecipitated quantitatively by Ni(PDC)2 in the pH range 2-3. The concentration factors by coprecipitation reached approximately 40,000 when 2 mg nickel was added as a carrier element to 500 mL of the water sample. The proposed method has been applied to the determination of trace amounts of arsenic and tin in river water and seawater reference materials, and the detection limits for arsenic and tin, which were calculated from three times of the standard deviation of the procedural blanks, are 0.02 ng mL(-1) and 0.04 ng mL(-1), respectively, for 500-mL volumes of water sample.

Factors affecting the pharmacokinetics of CPT-11: the body mass index, age and sex are independent predictors of pharmacokinetic parameters of CPT-11

This study was conducted to describe the relationship between pharmacokinetics of CPT-11 and its active metabolite SN-38, and clinical values with special emphasis on the influence of relative weight referring to the appropriateness of a conventional dose adjustment method by body surface area (BSA). Thirty-six patients received 100 mg/m2 of CPT-11 intravenously over 90 min. Body Mass Index (BMI) was used as a measure of relative weight which is calculated from the equation: BMI=weight(kg)/[height(m)]2. The area under the concentration-time curve (AUC) of CPT-11 was significantly correlated with sex, age, poorer creatinine clearance and indocyanine green retention test (ICG). The peak plasma concentration (Cmax) of CPT-11 was significantly correlated with sex a larger BMI, BSA and age. The AUC of SN-38 was significantly correlated with ICG. The volume of distribution at steady state of CPT-11 inversely correlated with BMI. Multiple regression analysis revealed that the best fitting model with significant independent predictors for AUC of CPT-11 included age and sex (F=6.93, R2=0.29). That of Cmax of CPT-11 included sex and BMI (F=8.96, R2=0.35). The only independent predictor of AUC of SN-38 was ICG (F=7.75, R2=0.19). These results indicated that several factors affect pharmacological behaviors of CPT-11 even in patients with normal organ functions. The dose modification method based solely on BSA is not sufficient to reduce interpatient variability of cancer chemotherapy. The influence of relative weight, sex and age on pharmacokinetics/pharmacodynamics should be taken into consideration in every pharmacological approach to establish the ideal dose modification method.

Lung cancer treated surgically in patients <50 years of age

STUDY OBJECTIVES

Some investigators have suggested that lung cancer in young patients has a more aggressive course and a poorer prognosis than lung cancer in older patients. The aim of this study was to determine if the basal characteristics and survival in younger patients with lung cancer undergoing surgical resection differ from those of older patients.

DESIGN

Retrospective clinical study.

PATIENTS

Of 1,208 consecutive patients who underwent surgery for primary lung cancer between June 1984 and March 2000, we reviewed the medical records of 110 younger patients who were < 50 years of age at the time of surgery and compared them with 1,098 older patients (> or = 50 years of age). All deaths were included.

RESULTS

In the younger patient group, asymptomatic disease and adenocarcinoma was significantly more frequent, the rate of smoking was significantly higher, and the amount of smoking (Brinkman index) was significantly larger. For the 94 younger patients with complete resection, the 5-year survival rate was 61.0%, which was not significantly higher than that for the 923 older patients (57.7%). However, the 53 younger patients with stage I disease (5-year survival of 84.3%) had significantly better survival than older patients with the same condition (71.6%). Survival of patients in stage II or stage III disease was not significantly different.

CONCLUSION

The younger patients had significantly better prognoses, and a statistical difference was shown especially in the early stage, while in the advanced stage the malignancy of the lung cancer itself surpassed the difference in survival.

Influence of the CYP2D6*10 allele on the metabolism of mexiletine by human liver microsomes

AIMS

To study the influence of CYP2D6*10 on the formation of p-hydroxymexiletine (PHM) and hydroxymethylmexiletine (HMM) using microsomes from human liver of known genotypes.

METHODS

Microsomes from human livers of genotype CYP2D6*1/*1 (n = 5), *1/*10 (n = 6) and *10/*10 (n = 6) were used in this study. The formation of PHM and HMM was determined by high-performance liquid chromatography.

RESULTS

The formation rates of PHM and HMM were decreased by more than 50% and 85% in CYP2D6*1/*10 and *10/*10 microsomes, respectively, compared with *1/*1 microsomes.

CONCLUSIONS

The metabolism of mexiletine to form PHM and HMM appears to be impaired to a significant extent in human liver microsomes from hetero- and homozygotes of CYP2D6*10.

Treatable subsets in cancer of unknown primary origin

The purpose of this study was to investigate the treatable subsets in cancer of unknown primary origin (CUP). Fifty patients (27 males and 23 females; median age, 53 years) with CUP diagnosed between April 1992 and June 1999 were analyzed retrospectively. Of the 50 patients, 39 received chemotherapy: platinum-based in 31, non-platinum-based in 4, and clinical trials of new agents in 4. Of the 39 patients, 13 (33.3%; 95% confidence interval: 19.1 - 50.2%) showed objective responses, with 4 complete responders. Patients with poorly differentiated carcinomas in whom beta-subunit of human chorionic gonadotropin (beta-HCG) was elevated more than 10 mIU / ml and female patients with peritoneal adenocarcinomatosis achieved high response rates (83.3% and 80%, respectively) with platinum-based chemotherapy, as compared with only a 15.3% response rate in the remaining patients. Platinum-based chemotherapy provided promising results in patients with poorly differentiated carcinomas and in female patients with peritoneal adenocarcinomatosis. Significantly elevated serum levels of beta-HCG in patients with poorly differentiated carcinoma might predict a better response to platinum-based chemotherapy. However, the investigation of novel chemotherapeutic approaches is warranted for other groups of patients with CUP.

[Complete remission of brain metastases from prostate cancer by gamma knife radiosurgery: a case report]

A 59-year-old male visited us with a chief complaint of dysuria. The serum prostate specific antigen (PSA) level was within normal limits, and intravenous pyelography and urethrocystography showed no abnormal findings. Because of his urinary retention, transurethral resection of prostate was performed under a clinical diagnosis of benign prostatic hyperplasia. The pathological diagnosis was poorly differentiated adenocarcinoma of the prostate. Not only combination hormone therapy with goserelin acetate and flutamide, but also intermittent arterial infusion chemotherapy with cisplatin (CDDP) and pirarubicin (THP) using a reservoir system was administered. Additionally total pelvic irradiation was delivered. Magnetic resonance imaging (MRI) demonstrated that his prostate was reduced to less than 50% in size and he had no difficulty in voiding. He suddenly developed dysarthria and hemiplegia 3 months later. MRI and computed tomography (CT) revealed multiple brain metastases. After the gamma knife radiosurgery, neurological findings disappeared and MRI showed dramatic shrinkage of metastatic brain tumors. Metastasis to the pancreas was recognized on CT and he died of multiple organ failure 30 months after his first visit.

Triterpene and flavanone glycoside from Rhododendron simsii

Antioxidative substances were isolated from the leaves of Rhododendron simsii. These were a triterpene and flavanone glycoside, together with the known matteucinol and two known benzoic acid derivatives. Their structures were characterized as 19,24-dihydroxyurs-12-en-3-one-28-oic acid and 7-O-beta-D-apiofuranosyl-(1-->6)-beta-D-glucopyranosylmatteucinol by spectroscopic analysis.

Anchoring the Duran flexible annuloplasty ring with continuous sutures

We practised a deviced method of anchoring the Duran flexible ring with continuous sutures. After passing through 3/0 monofilament sutures at the right and left fibrous trigones, both sutures are passed through the ring between the corresponding ring marker and continuous sutures are placed to attach the ring to the mitral valve annulus. This technique requires less time to anchor the ring than the original method with interrupted sutures and can prevent narrowing the mitral valve annulus following the deformity of the flexible ring. This technique can contribute to extend the indication of the prosthetic ring in mitral valve surgery.