Proposal for a new clinical entity, IgG4-positive multiorgan lymphoproliferative syndrome: analysis of 64 cases of IgG4-related disorders

BACKGROUND

Mikulicz's disease (MD) has been considered as one manifestation of Sjögren's syndrome (SS). Recently, it has also been considered as an IgG(4)-related disorder.

OBJECTIVE

To determine the differences between IgG(4)-related disorders including MD and SS.

METHODS

A study was undertaken to investigate patients with MD and IgG(4)-related disorders registered in Japan and to set up provisional criteria for the new clinical entity IgG(4)-positive multiorgan lymphoproliferative syndrome (IgG(4)+MOLPS). The preliminary diagnostic criteria include raised serum levels of IgG(4) (>135 mg/dl) and infiltration of IgG(4)(+) plasma cells in the tissue (IgG(4)+/IgG+ plasma cells >50%) with fibrosis or sclerosis. The clinical features, laboratory data and pathologies of 64 patients with IgG(4)+MOLPS and 31 patients with typical SS were compared.

RESULTS

The incidence of xerostomia, xerophthalmia and arthralgia, rheumatoid factor and antinuclear, antiSS-A/Ro and antiSS-B/La antibodies was significantly lower in patients with IgG(4)+MOLPS than in those with typical SS. Allergic rhinitis and autoimmune pancreatitis were significantly more frequent and total IgG, IgG(2), IgG(4) and IgE levels were significantly increased in IgG(4)+MOLPS. Histological specimens from patients with IgG(4)+MOLPS revealed marked IgG(4)+ plasma cell infiltration. Many patients with IgG(4)+MOLPS had lymphocytic follicle formation, but lymphoepithelial lesions were rare. Few IgG(4)+ cells were seen in the tissue of patients with typical SS. Thirty-eight patients with IgG(4)+MOLPS treated with glucocorticoids showed marked clinical improvement.

CONCLUSION

Despite similarities in the involved organs, there are considerable clinical and pathological differences between IgG(4)+MOLPS and SS. Based on the clinical features and good response to glucocorticoids, we propose a new clinical entity: IgG(4)+MOLPS.

[Multiple schwannoma of the intrathoracic vagal nerve; report of a case]

A 67-year-old male referred to our hospital for the close examination of abnormal chest X-ray findings. Chest X-ray films showed abnormal shadows in the right lung field. Chest computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed the 3 tumors which located in superior, middle and posterior mediastinum. The operation underwent under the diagnosis of neurogenic tumors originating from the right intrathoracic vagal nerve. At the operation, the tumors existed the vagal nerve distal to the recurrent laryngeal nerve and they were resected with the transection of vagal nerve. The masses were histologically diagnosed as schwannoma. We reported a rare case of multiple schwannoma arising from the intrathoracic vagal nerve. He had no postoperative complications, and he has been free from recurrence for 4 years postoperatively.

Salmonella prevalence in seafood imported into Japan

A total of 353 samples of 29 types of seafood were tested for Salmonella prevalence and total microbial population. Salmonella enterica serotype Weltevreden was isolated from 2 of 47 black tiger prawn samples. The contamination levels of Salmonella were in a range of <30 to 40 most probable number per 100 g. In addition, one sample of black tiger prawns and two samples of white shrimp were positive for Salmonella invA gene on PCR assay. Although the mean aerobic bacterial count was greater than 4 log CFU/g in most of the sample types, those in the two Salmonella-isolated samples of black tiger prawn were 7.48 and 5.18 log CFU/g, respectively. These results indicate the possibility that shrimp and prawns contribute to foodborne infections. The improvement of seafood quality is an important issue, and the information on contamination by pathogens should be provided as feedback to the originating country, with the aim of increasing safety.

What we could know from the semiannually repeated screening with low-dose helical CT in a high-risk cohort over 10 years: Update of Anti-Lung Cancer Association project

7568

Background: There have been several randomized trials of low-dose helical CT (LDCT) screening for lung cancer. However, all trials are in progress. Therefore, before they are completed, we summarized what we could know from an update of Anti-Lung Cancer Association project, which was regarded as a longer-term study with LDCT performed at shorter intervals and with a larger number of detected cancers than any other single-armed studies. Methods: Among 2,120 participants, 1,877 (mean age 64 years, 88% male, and 84% smoker) underwent semiannually repeated screening from 1993 to 2004 (median, 3.5 years). We investigated (1) survival of patients with screening detected lung cancers, (2) presence of a stage shift (indicator of a mortality benefit), (3) appropriate duration of repeated screening, (4) identification of high-risk group by age, sex, and smoking, and (5) appropriate screening intervals by high-risk group (6 months or 1 year). Results: (1) The 5- and 10-year survival rates were 84.5% and 84.5%, respectively, in repeated screening group (n = 57) and were 68.7% and 38.1%, respectively, in initial screening group (n = 19) (P = 0.208). (2) Only in invasive adenocarcinoma, both proportion of stage II to IV and tumor size were negatively correlated with duration of repeated screening (r = −0.77, P = 0.007 and r = − 0.60, P = 0.029, respectively). (3) Detection rate of all incidence cancers were positively correlated with duration of repeated screening (r = 0.50, P = 0.020). However, detection rate remained unchanged until 5 years of repeated screening. Moreover, stage shift did not occur until 5 years of repeated screening. (4) Female sex (HR 2.9, P = 0.015) and smoking (HR 2.7, P = 0.046) were demographic risk factors for lung cancer detection at repeated screening. The accumulated 10-year detection rates for female smokers (n = 91), male smokers (n = 1,557), and non-smokers (n = 229) were 15.1%, 6.2%, and 4.3%, respectively (P = 0.002). (5) The estimated relative cancer detection powers of annual screening to semiannual screening were 50% and 57% for female and male smokers with lung cancer, respectively. Conclusions: Semiannually repeated LDCT screening over 5 years might be beneficial to smokers, especially female smokers.

No significant financial relationships to disclose.

Neurodegeneration of mouse nigrostriatal dopaminergic system induced by repeated oral administration of rotenone is prevented by 4-phenylbutyrate, a chemical chaperone

Parkinson's disease (PD) is a progressive neurodegenerative disorder that is primarily characterized by the degeneration of dopaminergic neurons in the nigrostriatal pathway. Previous studies have demonstrated that chronic systemic exposure of Lewis rats to rotenone produced many features of PD, and cerebral tauopathy was also detected in the case of severe weight loss. The present study was designed to assess the neurotoxicity of rotenone after daily oral administration for 28 days at several doses in C57BL/6 mice. In addition, we examined the protective effects of 4-phenylbutyrate (4-PBA) on nigral dopamine (DA) neurons in rotenone-treated mice. 4-PBA was injected intraperitoneally daily 30 min before each oral administration of rotenone. Chronic oral administration of rotenone at high doses induced specific nigrostriatal DA neurodegeneration, motor deficits and the up-regulation of alpha-synuclein in the surviving DA neurons. In contrast to the Lewis rat model, cerebral tauopathy was not detected in this mouse model. 4-PBA inhibited rotenone-induced neuronal death and decreased the protein level of alpha-synuclein. These results suggest that this rotenone mouse model may be useful for understanding the mechanism of DA neurodegeneration in PD, and that 4-PBA has a neuroprotective effect in the treatment of PD.

The effect of milk basic protein supplementation on bone metabolism during training of young thoroughbred racehorses

REASONS FOR PERFORMING STUDY

In laboratory animals, man and cell culture experiments, milk basic protein was reported to suppress bone resorption and promote bone formation. However, no studies in horses have previously examined the effect of milk basic protein.

OBJECTIVES

To evaluate the effect of milk basic protein supplementation on bone metabolism in young Thoroughbred horses in training.

METHODS

Twenty 2-year-old horses in training were used for 90 days in this study. The treatment group was fed a basal diet with 1 g of milk basic protein and the control group a basal diet only. Blood samples were collected on Days 0, 45 and 90 to determine serum calcium (Ca) and biochemical markers of bone metabolism. Radiographs were taken at the start and end of the study to determine radiographic bone aluminium equivalence (RBAE).

RESULTS

Serum osteocalcin (OC) was significantly higher at Day 45 after the beginning of the study in the treatment group compared to that in the control group. The treatment group showed a greater increase in the total RBAE change at the end of this study compared to that in the control group. However, there were no significant differences in serum Ca and carboxy-terminal telopeptide of type I collagen (ICTP) between groups.

CONCLUSIONS AND POTENTIAL RELEVANCE

These findings provide preliminary evidence that milk basic protein has an effect on bone formation in 2-year-old Thoroughbred horses in training. However, further studies in larger groups of horses are now required to substantiate our findings.

Inhibitory effects of ticlopidine on platelet function as assessed by three different methods

The inhibitory effects of ticlopidine on platelet function were evaluated in 18 healthy male volunteers using three different platelet function tests. Three methods include the recently developed small collagen-beads method, which evaluates the platelet response in whole blood samples under shear stress conditions, the conventional platelet aggregometry and a cone-plate viscometer which measures shear-induced platelet aggregation (SIPA). The latter two methods use platelet-rich plasma as measurement samples instead of whole blood. SIPA was significantly inhibited by the oral intake of ticlopidine. The conventional platelet aggregometry detected significant inhibition of ticlopidine on ADP-induced platelet aggregation. In contrast, ticlopidine moderately inhibited platelet aggregation induced by low concentrations of collagen, but not by high concentrations of collagen. With the collagen-bead column method, ticlopidine significantly inhibited platelet retention rates when the retention rates exceeded 30% prior to ticlopidine uptake. On the other hand, there was no significant inhibition when the original retention rates prior to ticlopidine uptake were below 30%. The three methods all proved useful to evaluate the effect of ticlopidine on platelet function. However, taking into consideration easy procedures, lower costs and use of whole blood samples under shear stress conditions, we suggest the collagen-bead column can serve as an appropriate method for monitoring ticlopidine therapy.

[Two cases of heparin-induced thrombocytopenia (HIT) and a review of the literature]

We experienced two cases of heparin-induced thrombocytopenia (HIT) which occurred during unfractionated heparin treatment. The first patient was a 72-year-old man, who was admitted to our hospital because of sudden onset dyspnea in January 2000. He was diagnosed as having a pulmonary embolism and heparin was started. Nine days later, progressive embolization of the pulmonary artery and femoral vein was found and thrombocytopenia (platelet count 20 x 10(9)/l) was observed 14 days after that. Cessation of heparin and administration of argatroban resulted in progressive normalization of the platelet count. The second patient was a 62-year-old woman, who was admitted to our hospital in April 2001, with the chief complaint of sudden onset dyspnea. She was diagnosed as having acute left-sided heart failure and heparin was started. Fifteen 15 days later, thrombocytopenia (platelet count 17 x 10(9)/l) was observed. Cessation of heparin resulted in normalization of the platelet count. Both cases were positive for anti-heparin-platelet factor 4 (PF4) antibody. Here we report on the clinical course of two cases of HIT with a review of the literature.

MYCN gene amplification is a powerful prognostic factor even in infantile neuroblastoma detected by mass screening

MYCN is the most powerful prognostic factor in cases of older children. However, how MYCN is related to the prognosis of infantile cases is not clear. A mass screening program was carried out by measuring urinary catecholamine metabolites (VMA and HVA) from 6-month-old infants. Of 2084 cases detected by the screening program, MYCN amplification (MNA) was examined by Southern blot analyses in 1533 cases from 1987 to 2000. Of the 1533 cases examined, 1500 (97.8%) showed no MNA, 20 cases (1.3%) showed MNA from three to nine copies, and 13 (0.8%) cases showed more than 10 copies. The 4-year overall survival rates of these three groups (99, 89 and 53%, respectively) were significantly different (P<0.001), indicating that MYCN copy number correlates with the prognosis. Cases with MNA more than 10 copies were more advanced than those without amplification (stage III, IV vs I, II, IVs; P<0.001). Patients with MNA more than 10 copies had significantly higher serum levels of neuron-specific-enolase (NSE) and ferritin than non-amplified patients (P=0.049, P=0.025, respectively). MYCN amplification was strongly correlated with a poor prognosis in infantile neuroblastoma cases. Therefore, for the selection of appropriate treatment, an accurate determination of MNA is indispensable.

[Effects of octreotide acetate on intractable chylothorax after surgery for congenital heart diseases]

We experienced 2 infants in whom octreotide acetate was effective on intractable chylothorax after surgery for congenital heart diseases. They were 8- and 5-month-old. They were diagnosed as having corrected transposition of the great arteries (TGA) and tetralogy of Fallot respectively, and underwent bidirectional Glenn anastomosis and right modified Blalock Taussig shunt. Chylothorax was revealed on the 11th and the 1st postoperative day, and was not improved by any conventional therapy in either case. Then octreotide acetate was infused continuously with 0.1-0.6 micorg/kg/hour for 24 and 7 days. Chylothorax disappeared completely without any complications such as disturbance of blood sugar level or growth retardation. Octreotide acetate was effective and safe even in infants in intractable chylothorax after surgery for congenital heart diseases, as long as used for short period.

The adenocarcinoma-specific stage shift: Closely-repeated low-dose helical CT screening in a high-risk cohort for 10 years

1006

Background: Trials of CT screening for lung cancer have not yet proven the presence of a stage shift, to say nothing of a mortality benefit. On the basis of an update from Anti-Lung Cancer Association project, we investigated whether the stage shift did occur during the long-term closely-repeated low-dose helical CT screening in a high-risk cohort. Methods: A total of2,120 participants (mean age 63 yrs, 87% male, and 83% smoker) underwent low-dose helical CT screening semiannually from 1993 to 2004 (median, 3.5 years). Results: Nineteen prevalence and 57 incidence lung cancers were detected. In comparison between baseline and repeated screening, the detection rate was 0.90% vs. 0.32% (P < 0.001) and the tumor size was 24mm vs. 17mm (P = 0.018). Adenocarcinoma (74% and 63%) and stage IA (58% and 79%) were observed most commonly in both screen-groups, respectively, but their proportions showed no significant difference between groups, respectively. Regarding the survival of lung cancer patients, screening type was not a significant prognostic factor. In repeated screening,the detection rate oflung cancer except bronchioloalveolar carcinoma increased significantly depending on CT repeating times (r = 0.50, P = 0.020). Moreover, the proportion of stage II-IV and the tumor size decreased significantly only in invasive adenocarcinoma (r = -0.77, P = 0.007 and r = -0.60, P = 0.029, respectively). Conclusions: The adenocarcinoma-specific stage shift did occur in a high-risk cohort. Considering larger proportion of adenocarcinoma in this population, smokers might benefit from the long-term closely-repeated low-dose helical CT screening.

No significant financial relationships to disclose.

Clinical significance of extranuclear expression of hormone receptors in breast cancer

644

Background: Hormone receptor (HR)-positive breast cancer cells grow through estrogen receptor (ER)-signaling pathways that mediate both genomic and nongenomic actions, which cross-talk with growth factors associated with resistance to tamoxifen. The aim of this study is to explore the clinical significance of extranuclear expression of ER and PR in the cross-talk between HR and growth factor signaling pathways. Methods: We examined the extranuclear expression of ER and PR in 219 primary breast cancers by immunohistochemical staining. Specimens showing such expression were further examined for the expression of pAkt and aromatase. Due to heterogeneity, staining was scored on the basis of intensity and distribution in the tumors. Results: Extranuclear expression of ER or PR was observed in 21 cases (9.5%), which included 4 cases (19.0%) for ER and 20 cases (95.2%) for PR. Among these patients, HER-2, pAkt, and aromatase-positivity were observed in 14 cases (66.6%), 13 cases (61.9%), and 14 cases (66.6%), respectively. On the basis of nuclear HR expression, 11 of these cases were categorized as ER-positive/PR-negative, while 2 were ER-negative/PR-positive. Of those 13 cases, increased pAkt staining was found in 11 cases (84.6%). In particular, among the 11 ER-positive/PR-negative, elevated pAkt and aromatase were found in 10 (90.9%; p<0.01) and 9 cases (81.8%), respectively. Conclusion: PR is more frequently expressed extranuclearly than ER in primary breast cancer, and extranuclear HRs cross-talk with the Akt/HER-2-signaling pathway and activation of aromatase, providing an explanation for the observation that aromatase inhibitors are more beneficial than tamoxifen for ER-positive/PR-negative patients.

No significant financial relationships to disclose.

Extranuclear expression of hormone receptors in primary breast cancer

BACKGROUND

Hormone receptor (HR)-positive breast cancer cells grow through estrogen receptor (ER)-signaling pathways that mediate both genomic and nongenomic actions, which cross-talk with growth factors associated with resistance to tamoxifen. The aim of this study was to explore the cross-talk between extranuclear expression of ER and progesterone receptor (PR) and growth factor signaling pathways in primary breast cancer.

PATIENTS AND METHODS

The extranuclear expression of ER and PR was examined in 219 primary breast cancers by immunohistochemical staining. Specimens showing such expression were further examined for the expression of pAkt and aromatase. Staining reactions were scored on the basis of intensity and distribution in the tumors.

RESULTS

Extranuclear expression of ER or PR was observed in 21 cases (9.5%), which included four cases for ER and 20 cases for PR. Among these patients, HER-2, pAkt, and aromatase-positivity were observed in 14 cases (66.6%), 13 cases (61.9%), and 14 cases (66.6%), respectively. On the basis of nuclear HR expression, 11 of these cases were categorized as ER-positive/PR-negative, while two were ER-negative/PR-positive. Of these 13 cases, increased pAkt staining was found in 11 cases (84.6%). In particular, among the 11 ER-positive/PR-negative cases, elevated pAkt and aromatase were found in 10 (90.9%; P<0.01) and nine cases (81.8%), respectively.

CONCLUSIONS

PR is expressed extranuclearly more frequently than ER in primary breast cancer, and extranuclear HRs cross-talk with the Akt/HER-2-signaling pathways and activation of aromatase. These observations may explain the more beneficial effects of aromatase inhibitors than tamoxifen for ER-positive/PR-negative patients.

Threshold of regional cerebral blood flow for infarction in patients with acute cerebral ischemia

Threshold of regional cerebral blood flow (rCBF) for cerebral tissue survival in relation to time was studied in patients with acute cerebral ischemia with xenon-enhanced computed tomography (XeCT). Case 1: A 58-year-old man with right hemiparesis, total aphasia and a high intensity area of 1 cm 2 in the left insula on diffusion weighted image underwent XeCT CBF study before and after intra-arterial local thrombolytic therapy (IALT) on the occluded middle cerebral artery (MCA) 4 hours and 7 hours after stroke onset, respectively. Case 2: A 65-year-old woman with recurrent transient ischemic attacks (TIAs) caused by severe stenosis of the left MCA underwent XeCT CBF study 5 hours after onset of the last attack. XeCT was conducted by 5-min wash-in method. In Case 1 the rCBF in the pre-IALT MCA territory was 4 to 19 ml/100 g/min. The area where rCBF in the post-IALT increased to above 15 ml/100g/min were saved, but the other area where it remained in the 9 to 14 ml/100 g/min evolved into infarct on subsequent CT scan/MR (magnetic resonance) imaging. The patient was discharged with only mild motor dysphasia. In Case 2 the left corona radiata showed rCBF of 7 ml/100 g/min and this area evolved into infarct on MR imaging. The patient was discharged home with right hemiparesis. Our results showed validity of the rCBF threshold in acute cerebral ischemia reported by Jones et al. Residual rCBF in the acute stage of cerebral ischemic stroke can predict the fate of the lesion.

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

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