A case with HER2-overexpressing breast cancer completely responded to humanized anti-HER2 monoclonal antibody

This is a case report of a 57-year-old woman with a history of primary carcinoma of the right breast with metastases to the contralateral axillary lymph node. After a partial response (PR) was induced by high-dose chemotherapy with peripheral blood stem cell transplantation, she underwent mastectomy with biopsy of the bilateral axillary lymph nodes. Six months after surgery, the patient had multiple lung metastases. She was then treated with five cycles of fluorouracil, mitoxantrone and vindesine. Although a PR was achieved, further chemotherapy could not be given because of cardiac dysfunction. Since immunohistochemical staining for the HER2 gene product was strongly positive on the surface of primary tumor cells, humanized anti-HER2 monoclonal antibody (trastuzumab) was given intravenously. The metastatic lesion decreased in size and finally appeared to be only cicatricial. Twenty-one months after the initial administration of trastuzumab, the pulmonary lesion was excised. The pathological examination revealed no tumor cells in the resected specimen so further treatment was stopped. The relapse-free state has continued for 24 months after the pulmonary resection.

[Docetaxel]

To date, in cases of advanced or recurrent breast cancer, combination chemotherapy including anthracycline have been used for 1st-line treatment. Mitomycin C and oral 5-FU were used for cases refractory to such treatment, but the response rate was not satisfactory. Docetaxel is one of the most promising drugs to have emerged in recent years, with phase II studies in previously untreated metastatic breast cancer indicating a high overall response rate of approximately 60%, in the refractory cases for anthracyclines, indicating an overall response rate of 40% using docetaxel at 75 to 100 mg/m2 as a 1-hour intravenous infusion every 21 days. In Japan, the overall response rate was reported as about 50% using single docetaxel given at 60 mg/m2 every 21 days. The dose-limiting toxicity is myelosuppression, which is dose-but not schedule-dependent. In most published studies, there is a 90-95% incidence of grade 3 or 4 neutropenia when docetaxel is administered every 3 weeks. In recent studies, for the purpose of reducing the severity of myelosuppression, weekly docetaxel seems to be an effective and feasible treatment for advanced or recurrent breast cancer.

Clinical development of trastuzumab in breast cancer

The HER-2/neu protein is thought to be a unique and useful target for antibody therapy of cancers overexpressing the HER-2/neu gene. The recombinant humanized anti-HER-2 monoclonal antibody, trastuzumab (Herceptin) is now available for clinical use in the U.S.A. It is also expected to be available in Japan in the near future. In this paper, the details of this novel biologic agent are reviewed in conjunction with a phase I study performed in Japan.

Whole body PET for the evaluation of bony metastases in patients with breast cancer: comparison with 99Tcm-MDP bone scintigraphy

The purpose of this study was to determine the potential role of positron emission tomography (PET) using 2-[18F]-fluoro-2-deoxy-D-glucose (FDG) for the evaluation of bony metastasis compared with 99Tcm-methylene diphosphonate (99Tcm-MDP) bone scintigraphy in patients with breast cancer. Fifty-one female patients with breast cancer who had PET together with a bone scan within 1 month between September 1994 and March 1997 were included in this study. The median age was 49 years (range 29-79 years). The sensitivity, specificity and accuracy of the bone scan were 77.7%, 80.9% and 80.3%, respectively. On the other hand, for the detection of bone metastases PET had a sensitivity, specificity and accuracy of 77.7%, 97.6% and 94.1%, respectively. In the diagnosis of bony metastasis derived from breast cancer, FDG-PET was statistically superior to bone scintigraphy in its specificity. In conclusion, FDG-PET appears to be a powerful tool not only in the diagnosis of the primary lesion and soft tissue metastasis, but also in the diagnosis of bony metastasis among patients with breast cancer.

De Vega annuloplasty and Carpentier-Edwards ring annuloplasty for secondary tricuspid regurgitation

BACKGROUND AND AIM OF THE STUDY

Residual or recurrent tricuspid regurgitation (TR) has been reported after several types of surgical repair. The development of late TR is an important complication of left heart surgery. The results of De Vega annuloplasty were compared with those obtained after Carpentier-Edwards ring (CE ring) annuloplasty in patients with secondary TR.

METHODS

The records of 45 patients who underwent surgery for secondary TR between January 1995 and July 2000 were reviewed retrospectively. Twenty-eight patients underwent De Vega annuloplasty, and 17 had a CE ring annuloplasty. The groups were similar with respect to associated cardiac lesions. No significant preoperative differences were observed in NYHA functional class, TR grade, and pulmonary artery pressure between the two groups.

RESULTS

One CE patient died of left ventricular dysfunction after postoperative bleeding. The 28 De Vega patients and remaining 16 CE patients had an uneventful recovery, and were discharged. Tricuspid ring size after repair was similar between groups. Mean (+/- SD) follow up in the entire patient cohort was 39+/-23 months (range: 6 to 75 months). TR recurrence was rated as grade II or III in 13 patients (45%) after De Vega annuloplasty, but was grade II or III in only one patient (6%) patient after CE ring annuloplasty. There was a significant difference in TR recurrence between the groups (p = 0.027), but no significant difference in NYHA class.

CONCLUSION

CE ring annuloplasty significantly decreased the recurrence of TR; thus, CE ring annuloplasty is superior to De Vega annuloplasty in patients with secondary TR.

Coronary artery bypass grafting for patients with an atherosclerotic ascending aorta

OBJECTIVES

We review the outcome of coronary artery bypass grafting in patients with a severe atherosclerotic ascending aorta.

METHODS

Subjects were 31 patients averaging 69.4 +/- 6.9 years old studied from 1990 through 1998. Ascending aortic lesions were assessed using epiaortic echo and 2 types of aortic nonclamping techniques applied. In 29 patients operated on in the early years, bypass grafting was conducted on the hypothermic fibrillated heart in 22 and on the beating heart in 7. The remaining 2 underwent off-pump coronary artery bypass grafting more recently. For cases with multivessel disease, we used composite grafting.

RESULTS

Three patients developed mild stroke and 5 died within 30 days of surgery--4 from multiple emboli (1 accompanied by a stroke) and 1 from perioperative myocardial infarction. One hospital death occurred due to brain damage and multiorgan failure following unexpected rupture of a saphenous vein graft. No cardiac deaths occurred in the late stage of our series. Actuarial survival was 73.0% for 3 years and 68.0% for 5 years. Freedom from cardiac events was favorable in the remaining 25 survivors.

CONCLUSIONS

Outcome was suboptimal for the risks involved. Recent technical advances, including coronary surgery on the beating heart with or without cardiopulmonary bypass using variable in-situ or free arterial grafts, associated with adequate evaluation of systemic atherosclerosis, should improve this outcome.

Transcatheter coil closure of large patent ductus arteriosus with 0.052-inch Gianturco coils using myocardial biopsy forceps in a 70-year-old woman

Small patent ductus arteriosus is generally closed in children using a transcatheter coil. This is done less often in older patients or those with large patent ductus arteriosus. We report successful antegrade transcatheter coil closure of patent ductus arteriosus in a 70-year-old woman. Into the patent ductus arteriosus, using flexible myocardial biopsy forceps, we placed two large 0.052-inch Gianturco coils, which were easily used as multipurpose vascular occlusion coils. The forceps and the coils were readily available and provided complete occlusion. Other delivery devices cannot deliver such large coils. Transcatheter coil closure thus appears to be safe and effective for closing large patent ductus arteriosus in the elderly.

Clinical characteristics of patients with constrictive pericarditis after coronary bypass surgery

Constrictive pericarditis (CP) is an unusual sequela of cardiac surgery, so the present study evaluated the clinical characteristics of patients with CP after coronary artery bypass grafting (CABG). Four hundred and sixty-three patients who underwent isolated CABG between January 1989 and March 1999 were examined retrospectively. The first choice of treatment for postoperative pericardial effusion was non-steroid anti-inflammatory agents, and an increased dose of diuretics. The second treatment choice was corticosteroids or pericardial drainage. When CP was suspected during the follow-up period (mean, 54+/-31 months), cardiac catheterization was carried out to establish the diagnosis. Of the 463 patients undergoing CABG, there were 11 (2.4%) who developed CP after surgery. The median time to the onset of symptoms after CABG was 4 weeks (range, 3-96 weeks). On univariate and multivariate analysis, normal left ventricular ejection fraction, warfarin administration, and early postoperative pericardial effusion were significantly associated with a greater potential of postoperative CP. The effusion was bloody in all cases of pericardial drainage despite warfarin therapy. Not draining the postoperative effusive pericardial effusion was a risk factor for the development of CP. Pericardial drainage for patients with significant effusion after CABG is important for the prevention of subsequent CP, especially in those patients being treated with warfarin or with normal left ventricular function.

Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part II: management and surgical outcome

OBJECT

The purpose of this study was to assess the overall management and surgical outcome of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) among the 85,000 residents of Izumo City, Japan.

METHODS

During 1991 through 1996, 267 patients with ICH and 123 with SAH were treated in Izumo. Of the 267 patients with ICH, 25 underwent hematoma removal by open craniotomy or suboccipital craniectomy and 34 underwent stereotactic evacuation of the hematoma, whereas aneurysm clipping was performed in 71 of the 123 patients with SAH; operability rates were thus 22% for ICH and 58% for SAH (p < 0.0001). The overall 30-day survival rates were 86% for ICH and 66% for SAH (p < 0.0001) and the 2-year survival rates were 73% and 62% (p = 0.0207), respectively. In patients who underwent surgery, 30-day and 2-year survival rates were 93% for ICH and 100% for SAH (p = 0.0262), and 75% for ICH and 97% for SAH (p = 0.0002), respectively. In patients with ICH, the most important predictors of 30-day case-fatality rates were the volume of the hematoma, the Glasgow Coma Scale (GCS) score, rebleeding, and midline shifting, whereas those for 2-year survival were the GCS score, age, rebleeding, and hematoma volume. In patients with SAH, the most important determinants of 30-day case-fatality rates were the GCS score and age, whereas only the GCS score had a significant impact on 2-year survival.

CONCLUSIONS

The overall survival rates for patients with ICH or SAH in Izumo were more favorable than those in previously published epidemiological studies. However, despite improved surgical results, the overall management of ICH and SAH still produced an unsatisfactory outcome, mainly because of primary brain damage.

Effects of a structured psychiatric intervention on immune function of cancer patients

The aim of the present study was to examine the influence of mood state and coping styles on the immune function in Japanese breast cancer patients who participated in a structured group intervention program. The program consisted of five-weekly 90-minute sessions, including psycho-education, psychological support, problem-solving technique and relaxation/imagery. Out of 77 breast cancer patients who participated in this program, 34 were eligible for measurement of immune functions because they received adjuvant chemotherapy. Comparison of the pre- and post-intervention scores of the Profile of Mood States (POMS) revealed significant decreases in Depression (p < 0.05), Lack-of-Vigor (p < 0.01), Tension-Anxiety (p < 0.01), Confusion (p < 0.05) and Total Mood Disturbances (p < 0.01), as expected. Concerning coping styles, there were tendencies to decrease the score of active-cognitive coping (p = 0.09), although the differences were not statistically significant. In contrast, the pre- and post-intervention values of immune parameters such as CD3, CD4, CD8, CD4/8 and natural-killer cell activity showed no significant differences. In this report, we discuss several possibilities underlying these findings. Further studies with a larger number of subjects and controls are needed to reach conculusions.

Case of mesothelioma of the tunica vaginalis testis with characteristic findings on ultrasonography and magnetic resonance imaging

A case of mesothelioma of the right tunica vaginalis testis in a 32-year-old man is reported. Trans-scrotal ultrasonography revealed hydrocele and multiple nodular masses measuring 1.0-4.5 cm in size attached to the parietal vaginal layer. Magnetic resonance imaging demonstrated more clearly nodular masses with irregular surfaces lined on the hydrocele cavity. Histologic diagnosis of the tumor when orchiectomized was mesothelioma. The patient has been free of disease for approximately 3 years since the treatment.

Persistent effects of a structured psychiatric intervention on breast cancer patients' emotions

The aim of the present study was to investigate persistence of the clinical effectiveness of a 5-weekly structured group intervention program for Japanese breast cancer patients. Each program is a series of five 90-min sessions, which include psycho-education, problem-solving, psychological support, relaxation training, and guided imagery. Fifty-seven patients with breast cancer participated in the program and the 47 who completed were analyzed. The results of the Profile of Mood States (POMS) scores were compared before, just after, and 6 months after the intervention. According to the change in POMS scores, the clinical effectiveness of a structured group intervention program persisted for 6 months for the patients who had no psychiatric diagnoses at entry. By contrast, this 5-weekly intervention program did not show persistent effects for patients who had a psychiatric diagnosis at entry. Therefore, additional intervention would be needed for patients with psychiatric diagnosis at entry.

Acute eosinophilic pneumonia following cigarette smoking

Two cases of acute eosinophilic pneumonia following cigarette smoking are analyzed for characteristic features. The first patient noted dyspnea 14 days after initiation of smoking. The second patient noted dyspnea 12 days after beginning to smoke. Both cases had characteristic features including occurrence at an age younger than 30 years; less than 1 month duration of cigarette smoking before onset of disease; and no identifiable cause of acute eosinophilic pneumonia apart from smoking. We believe that acute eosinophilic pneumonia following cigarette smoking, which has characteristic features as described above, should be considered as a distinct subtype of AEP.

Identification of viral induced genes in Ig+ leucocytes of Japanese flounder Paralichthys olivaceus, by differential hybridisation with subtracted and un-subtracted cDNA probes

Up-regulated genes of leucocytes expressing immunoglobulin (Ig+ leucocytes) of hirame rhabdovirus (HRV)-infected Japanese flounder were identified by differential hybridisation, using subtracted and un-subtracted cDNA probes. Ig+ leucocytes were separated from apparently healthy and HRV-infected Japanese flounder by the magnetic beads antibody method using mouse anti-Japanese flounder Ig monoclonal antibody (mab). A cDNA library was constructed from HRV-infected Japanese flounder leucocytes, and was screened with subtracted cDNA probes enriched in genes up-regulated by HRV infection. Fifty cDNAs were isolated for further analysis. These included cDNAs coding for homologues of interferon-inducible 56K protein (IFI56), Stat3, CEF-10, RGS5, inducible poly(A) binding protein, prolylcarboxylpeptidase, basigin III (Ig superfamily), MUC-18 (Ig superfamily), proteasome-nexin 1 (SERPIN), herpes virus entry mediator (TNFR family), collagenase III, gelatinase-b, megakaryocyte stimulating factor, Rab8-interacting protein, IgM, IgD and 20 unknown cDNA clones. The majority of these identified genes are reported for the first time in fish. From leucocytes mRNA for homologues of IFI56, CEF-10, Stat3, SERPIN and inducible poly (A) binding protein expression was shown to increase following HRV infection.

[Long-term effect of polystan monocusp ventricular outflow patch after right ventricular outflow tract reconstruction]

Forty-eight patients who underwent right ventricular outflow tract reconstruction with Monocusp Ventricular Outflow Patch (MVOP) fifty-five times and survived surgery, were reviewed in this study. Mean age at surgery was 6.4 years-old and mean follow-up interval was 75.2 months. There was no late death, however reoperation was performed 7 times. Freedom from reoperation rate was 97.2% and 80.7% after 5 and 10 years after surgery, respectively. The main cause for reoperation were right ventricular outflow obstruction RVOTO (5 cases). All of the RVOTO occurred at the distal end of the anastomosis. However, there was no RVOTO in patients who underwent RVOTR with MVOP during the past ten years. So, we considered the cause of RVOTO a technical problem. Pulmonary regurgitation was one to two degree early after surgery, and had worsened by almost two or three degrees more than 5 years after surgery. Moreover, five of six patients who underwent cardiac catheterization more than 10 years after surgery had three degrees of pulmonary regurgitation as well as a large CTR. In conclusion, according to long-term results, especially more than 10 years post operatively, pulmonary regurgitation was the most important problem.

Granular-lattice (Avellino) corneal dystrophy

Granular-lattice (Avellino) corneal dystrophy has rarely been reported in the literature. It consists of a combination of granular and lattice dystrophy. We describe the histopathologic examination of the corneal button of one Japanese patient who had undergone unilateral keratoplasty because of severely decreased vision caused by what had been diagnosed clinically as granular dystrophy. However, on pathologic examination, lesions characteristic of both granular dystrophy and lattice dystrophy were found. We also describe 2 Japanese patients who had a clinical appearance characteristic of both granular and lattice dystrophy. Granular-lattice corneal dystrophy was found in a wider geographic distribution than previously proposed and should not be named after the geographic area.

A case of an inflammatory variant of epidermolysis bullosa acquisita: chronic bullous dermatosis associated with nonscarring mucosal blisters and circulating IgG anti-type-VII-collagen antibody

A 42-year-old man showed prominent blistering lesions of the mouth and esophagus in addition to a few bullous lesions of the skin. Direct immunofluorescence microscopy revealed distinct linear deposition of IgG and C3 at the epidermal basement membrane zone where slight deposition of IgA and IgM was also observed. In direct immunoelectron-microscopic examination, antibody was detected in the sublamina densa of the basement membrane zone. Immunoblot analysis with dermal extracts demonstrated that the patient's serum contained circulating IgG antibodies against the 290-kD protein, which comigrated with type VII collagen. The lesions healed without any scars. The results of these studies corresponded to the laboratory findings in epidermolysis bullosa acquisita (EBA), although the clinical features were distinct from classic EBA.

Persistence of the benefits of a structured psychiatric intervention for breast cancer patients with lymph node metastases

The aim of this study was to investigate the persistence of clinical effectiveness of a 5 week structured group intervention program for Japanese breast cancer patients. A total of 47 patients with breast cancer completed the full program. The results of the Profile of Mood States (POMS) scores were compared before, immediately after, and 6 months after the intervention program. As analysed by POMS scores, the clinical effectiveness of a structured group intervention program persisted for 6 months for patients without nodal metastases. In contrast, the intervention program did not show a lasting effect for patients with nodal metastases. This study demonstrated the short-term effectiveness of structured interventions among Japanese cancer patients, but persistence of the effects of intervention was found only among patients without nodal metastases. For patients with nodal metastases, additional intervention would be needed.

Growth factor-expressing mast cells accumulate at the thyroid tissue-regenerative site of subacute thyroiditis

The localization and biological roles of the multifunctional cell type mast cells remain unclear in subacute thyroiditis that is characterized by both epithelioid granuloma formation and thyroid tissue repair. We examined their immunolocalization with tryptase of a mast cell marker, using the biopsy specimens from 12 cases. In the epithelioid granuloma, no mast cells were detected in any of the cases, although a small number of them (4.6 +/- 2.4) were seen at the fibrous stroma around the granuloma in all cases. By contrast, in all cases, increased mast cells (28 +/- 7.2) localized at the thyroid tissue-regenerative site where both thyroid folliculogenesis and angiogenesis take place. To elucidate possible roles of mast cells in the disease, we also examined their immunoexpressions of vascular endothelial cell growth factor (VEGF), basic fibroblast growth factor (bFGF), platelet-derived growth factor-BB (PDGF), transforming growth factor-beta1 (TGF-beta1) and epidermal growth factor (EGF), which affect thyroid folliculogenesis and angiogenesis. In all 12 cases, mast cells displayed all of these growth factors in a manner not specific to the infiltrating site. The data suggest that growth factor-expressing mast cells may play crucial roles in the thyroid tissue repair of subacute thyroiditis, modulating thyroid folliculogenesis and angiogenesis; and that the multifunctionality of the cells may be partly dependent on their expressions of various growth factors.

Trans-mesosigmoid cutaneous ureterostomy

BACKGROUND

A new method was developed in order to create a single stoma cutaneous ureterostomy in which both ureters traverse the abdominal cavity and yet are buttressed by the mesosigmoid and covered by its visceral peritoneum.

METHODS

The long mesenterium which is attached to the most mobile part of the sigmoid colon was used for the bilateral ureteral pathway. Tunnels for the ureteral path were made just underneath the visceral peritoneum on the bilateral side of the mesosigmoid. Through the tunnels both ureteral ends were brought from the retroperitoneal space to the mesenterocolonic junction (MCJ) and the MCJ is then approximated and sutured to the inside of the ureteral tract through the abdominal wall. The ureters brought outside the skin, are conjoined and sutured to the V skin flap. Eight patients who carried a high risk for operation and/or had a bladder tumor judged to be incurable underwent this cutaneous ureterostomy.

RESULTS

All cases except one with low urinary output could be managed without catheter indwelling during the follow-up period. Three patients suffered from paralytic ileus and one required laparotomy for mechanical ileus during the short postoperative period. Postoperative excretory urography evaluated 14 kidneys during the follow-up period from 2 to 61 months and showed normal upper urinary tract in 11 and a mildly hydronephrotic tract in three.

CONCLUSIONS

Transmesosigmoid cutaneous ureterostomy provides a single catheterless stoma even when the available ureters are relatively short. It appears to be a good method for supravesical urinary diversion when indicated.

In vivo chemosensitivity of human malignant cystosarcoma phyllodes xenografts

Malignant cystosarcoma phyllodes (MCSP) is a rare breast tumor. Chemotherapeutic regimens for treatment of MCSP have not been established. We previously established an MCSP xenograft line MC-3-JCK. In this study, we established a new MCSP xenograft line, MC-10-JCK, by serial transplantation in nude mice. We studied the chemosensitivity of these two MCSP tumor xenografts to anticancer drugs in vivo. We also examined the expression of multidrug resistance-related proteins such as p-glycoprotein (Pgp) and multidrug resistance-associated protein (MRP) by immunohistochemical analysis. These two xenografts were sensitive to doxorubicin, vincristine and cyclophosphamide in vivo. Immunohistochemically, clinical specimens and xenografts were negative for Pgp and MRP expression. These results are consistent with the chemosensitivity of human MCSP to lipophilic anticancer compounds.

The levels and kinetics of oxygen tension detectable at the surface of human dermal fibroblast cultures

Low oxygen tension has recently been shown to stimulate cell growth and clonal expansion, as well as synthesis and transcription of certain growth factors and extracellular matrix components. These results have been obtained by exposing cell cultures to a hypoxic environment. Using an oxygen probe, we have now studied how experimental conditions affect the oxygen tension detectable at the cell surface. Dissolved oxygen tension was directly related to the height of the medium above the cell surface (r = 0.8793, P = 0.021), but was constant when no cells were present in the flask (r = -0. 9732, P = 0.001). In both human dermal fibroblasts and NIH/3T3 cultures, oxygen tension decreased linearly as cell density increased (r = -0.835, P < 0.0001; r = -0.916, P < 0.0001, respectively). When human dermal fibroblasts were exposed to 2% O(2), maximum hypoxic levels (0 mmHg) were achieved within approximately 15 min, and the recovery time was within a similar time frame. The addition of rotenone, an inhibitor of cellular respiration, blocked this decrease in oxygen tension at the cell surface, suggesting that cellular consumption of oxygen is responsible for the decline. Finally, we examined the cell-surface oxygen tension in control and acutely wounded human skin equivalents (HSE), consisting of a keratinocyte layer over a type I collagen matrix containing fibroblasts. We found that oxygen tension dropped significantly (P < 0.0001) in acutely wounded areas of HSE as compared to unwounded areas of HSE and that this drop was prevented by the addition of mitomycin C. These results indicate that cell-surface oxygen tension is indirectly related to cell density, and that the amount of detectable oxygen at the cell surface is a function of cell density, the oxygen tension in the incubator, and increased cellular activity, as occurs after injury.

Analgesic effects of sub-Tenon's versus retrobulbar anesthesia in planned extracapsular cataract extraction

BACKGROUND

A prospective study was conducted to compare the analgesic effects of sub-Tenon's and retrobulbar anesthesia by assessing patients' response to the visceral stimulus.

METHODS

Seven hundred and twenty eyes of 720 patients underwent extracapsular cataract extraction and posterior chamber intraocular lens implantation. They received retrobulbar anesthesia with 3 ml lidocaine (225 eyes), retrobulbar anesthesia with 5 ml lidocaine (216 eyes), or sub-Tenon's anesthesia with 3 ml lidocaine (279 eyes). Pain scores were recorded when an acetylcholine chloride solution was injected into the anterior chamber to attain miosis after lens implantation.

RESULTS

Pain scores were significantly different among the three anesthesia groups (P<0.0001, Kruskal-Wallis test). The multiple comparison revealed that analgesic effects were highest with sub-Tenon's anesthesia, followed by 5-ml retrobulbar and 3-ml retrobulbar anesthesia.

CONCLUSION

Sub-Tenon's anesthesia is an effective and reliable anesthetic method in cataract surgery.