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.

Tubulointerstitial nephritis associated with Legionnaires' disease

A 47-year-old man was admitted to our hospital for community-acquired pneumonia complicated with acute renal failure. Legionella pneumophila serogroup type 1 was grown in BCYE (buffered charcoal yeast extract) agar for sputum culture. Although his respiratory illness responded to intravenous erythromycin therapy, renal failure worsened and necessitated hemodialysis. Renal biopsy showed profound tubulointerstitial nephritis. After initiation of steroid therapy his renal function improved and he was discharged thereafter. These findings suggest that in Legionnaires' disease with acute renal failure, tubulointerstitial nephritis should also be considered and steroid therapy may be an effective modality for the renal complication.

Chronic hydrocephalus in elderly patients following subarachnoid hemorrhage

BACKGROUND

With the aging of the population, surgery for ruptured intracranial aneurysms is increasing among the elderly. We sought to clarify the characteristics of chronic hydrocephalus following aneurysmal subarachnoid hemorrhage (SAH) in elderly patients.

METHODS

Of the 576 surgically treated patients, 289 were aged 59 years or younger, 169 were 60 to 69, and 118 were 70 years or older. The relationship between chronic hydrocephalus and the causative factors was analyzed for each age group.

RESULTS

Of the 576 patients, chronic hydrocephalus was observed in 215 (37%), with the incidence increasing significantly with age (p < 0.001) and being the highest in the oldest age group. In elderly patients, the incidence of chronic hydrocephalus was relatively high, even after mild SAH. The incidence of chronic hydrocephalus was high regardless of age in patients with severe SAH, such as in those with H&H grades III-IV, SAH grades III-IV, acute hydrocephalus, symptomatic vasospasm, and intraventricular hemorrhage, and in those with vertebro-basilar artery aneurysms.

CONCLUSION

In the elderly, the incidence of chronic hydrocephalus following SAH was significantly higher than in younger patients, even after mild SAH. In elderly patients, careful observation and individualized treatment are necessary even if SAH is mild.

Comparative efficacy of positron emission tomography and ultrasonography in preoperative evaluation of axillary lymph node metastases in breast cancer

PURPOSE

In primary breast cancer, axillary nodal status is the most powerful predictive factor of recurrence. However, axillary lymph node dissection may cause surgical complications. If preoperative evaluation of axillary lymph node metastases is possible, unnecessary axillary lymph node dissections can be avoided. The purpose of this study was to evaluate the efficacy of positron emission tomography (PET) on detection of axillary lymph node metastases in breast cancer.

METHODS

PET scans of the axilla were obtained in 32 patients with primary breast cancer. All patients fasted for at least 4 hours before the examination. After transmission scans for attenuation correction were performed, emission scans after intravenous injection of 2-[18F]-fluoro-2-deoxy-D-glucose (FDG) were obtained.

RESULTS

Overall accuracy of PET alone, ultrasonography alone, and in combination in the detection of axillary metastases were 82%, 79%, and 85% respectively.

CONCLUSION

There were no significant differences between PET, ultrasonography, and PET in combination with ultrasonography regarding sensitivity, specificity and accuracy in the detection of axillary metastases.

Three cases of malignant lymphoma of the breast

We report three cases of malignant lymphoma (ML) of the breast and discuss diagnosis and management. The first case is a 35-year-old woman who had a left breast tumor. Fine needle aspiration cytology (FNAC) showed ML. Mastectomy was performed without any adjuvant chemotherapy. Histology revealed diffuse large B-cell lymphoma of REAL classification. Seventy one months after surgery, lesions indicating relapse were detected in nodes of the right axilla, mediastinum and para-aorta. She underwent eight cycles of CHOP regimen, but 1 month after the chemotherapy a brain metastasis was detected. The patient then received a high-dose methotrexate regimen with whole-skull irradiation. The second case is a 47-year-old woman who had anterior neck swelling and bilateral breast tumors. Histology of the tumor revealed diffuse large B-cell lymphoma. The patient underwent eight cycles of CHOP regimen and high-dose chemotherapy (HDC) with peripheral blood stem cell transplantation (PBSCT). Forty eight months after the PBSCT, there is no evidence of disease. The third case is a 38-year-old woman who had a right breast tumor. FNAC of the breast tumor showed ML and a CT scan of the chest revealed lymphadenopathy at the crus of the diaphragm. Histology of the tumor revealed low-grade B-cell lymphoma of MALT type. The patient underwent six cycles of CHOP regimen and HDC supported by PBSCT. Eighteen months after the PBSCT, relapse lesions were detected in nodes of the neck, mediastinum and renal hilum. The patient received nine cycles of a THP-COP regimen.

Dose escalation and pharmacokinetic study of a humanized anti-HER2 monoclonal antibody in patients with HER2/neu-overexpressing metastatic breast cancer

We conducted a phase I pharmacokinetic dose escalation study of a recombinant humanized anti-p185HER2 monoclonal antibody (MKC-454) in 18 patients with metastatic breast cancer refractory to chemotherapy. Three or six patients at each dose level received 1, 2, 4 and 8 mg kg(-1) of MKC-454 as 90-min intravenous infusions. The first dose was followed in 3 weeks by nine weekly doses. Target trough serum concentration has been set at 10 microg ml(-1) based on in vitro observations. The mean value of minimum trough serum concentrations at each dose level were 3.58 +/- 0.63, 6.53 +/- 5.26, 40.2 +/- 7.12 and 87.9 +/- 23.5 microg ml(-1) respectively. At 2 mg kg(-1), although minimum trough serum concentrations were lower than the target trough concentration with a wide range of variation, trough concentrations increased and exceeded the target concentration, as administrations were repeated weekly. Finally 2 mg kg(-1) was considered to be sufficient to achieve the target trough concentration by the weekly dosing regimen. One patient receiving 1 mg kg(-1) had grade 3 fever, one at the 1 mg kg(-1) level had severe fatigue defined as grade 3, and one at 8 mg kg(-1) had severe bone pain of grade 3. No antibodies against MKC-454 were detected in any patients. Objective tumour responses were observed in two patients; one receiving 4 mg kg(-1) had a partial response in lung metastases and the other receiving 8 mg kg(-1) had a complete response in soft tissue metastases. These results indicate that MKC-454 is well tolerated and effective in patients with refractory metastatic breast cancers overexpressing the HER2 proto-oncogene. Further evaluation of this agent with 2-4 mg kg(-1) weekly intravenous infusion is warranted.

Combined cardiac surgery and total thyroidectomy: a case report

A 65-year-old woman with aortic stenosis, ischemic heart disease, and Graves' disease had complained of effort angina. She then suffered from liver dysfunction due to treatment with antithyroid drugs. One year after the start of radioiodine administration, she demonstrated unstable angina with palpitation and sweating. Laboratory studies revealed a recurrent hyperthyroid state, and a second coronary angiogram revealed progressive ischemic heart disease. Combined coronary artery bypass grafting, aortic valve replacement, and total thyroidectomy were performed. The postoperative course was uneventful without any problems associated with hyperthyroidism or hypothyroidism. Combined cardiac surgery and total thyroidectomy can be performed safely if the perioperative levels of thyroid hormone are maintained at euthyroid or hypothyroid levels.

Autografting with peripheral blood CD34-positive cells following high-dose chemotherapy against breast cancer

We report autologous CD34+ cell transplantation performed in 3 cases of recurrent breast cancer. The hematological recovery in these cases was assessed by comparing with that in the previous cases of autologous hematopoietic stem cell transplantation performed with the same high-dose chemotherapy regimen. Patient 1 was a 32-year-old woman with pulmonary and skeletal metastases; patient 2, a 55-year-old woman with pulmonary metastases; and patient 3, a 48-year-old woman with hepatic metastases. On day 1, cyclophosphamide 1000 mg/m2 and epirubicin 130 mg/m2 were administered concurrently with granulocyte colony-stimulating factor, and peripheral blood stem cells were harvested on days 14-16. These stem cells were processed using anti-CD34 monoclonal antibody and an immunomagnetic bead device, Isolex 300i. The high-dose chemotherapy regimen consisted of cyclophosphamide 2000 mg/m2/day, div, and thiotepa 200 mg/m2/day, div on day -5, -4, and -3. The harvested CD34+ cells numbered 3.9 +/- 2.8 x 10(6)/kg (range: 0.73-7.8/10(6)/kg), and the CFU-GM, 8.3 +/- 5.6 x 10(5)/kg (range: 1.2-15.1/10(5)/kg). After the separation, the percent of CD34+ cells was 81.9 +/- 11.6% (range: 65.8-96.4%), the CD34+ cell yield, 71.8 +/- 30.2% (range: 46.0-129.6%), and the CFU-GM yield, 48.9 +/- 9.1% (range: 35.3-62.0%). At the time of transplantation, the number of nucleated cells was 0.55 +/- 0.31 x 10(5)/kg, and that of CFU-GM, 31.2 +/- 17.8 x 10(5)/kg. Comparison of the hematological recovery in these three cases with that in patients receiving an identical high-dose chemotherapy regimen revealed recovery rates significantly faster than in patients having bone marrow transplants, and approximately identical with that in peripheral blood stem cell transplantation cases.

Comparison of sub-Tenon's anaesthesia by different delivery techniques in cataract surgery

PURPOSE

To compare the analgesic effects of three different delivery techniques of sub-Tenon's anaesthesia in cataract surgery by assessing patients' response to the visceral stimulus.

METHODS

A prospective, randomised study was conducted on 345 eyes of 345 patients undergoing phacoemulsification and posterior chamber intraocular lens implantation. They received anaesthetic infiltration into the sub-Tenon's space through a conjunctival incision (115 eyes), infiltration into the posterior sub-Tenon's space (retrobulbar space) through a conjunctival incision (114 eyes), or injection into the intra-Tenon's space (subconjunctival space) without making a conjunctival incision (116 eyes). Pain scores were recorded when the anterior chamber was irrigated with an acetylcholine chloride solution to achieve miosis after lens implantation.

RESULTS

There were no significant differences in pain scores among the three groups (chi-squared test of homogeneity, p = 0.814). Approximately 10-20% of patients reported slight to severe pain at the time of acetylcholine administration.

CONCLUSIONS

The three anaesthetic delivery methods of sub-Tenon's anaesthesia possess similar and reasonable analgesic effects in cataract surgery, but may not block visceral stimuli completely.

Proliferation and differentiation of rat dorsal prostatic epithelial cells in collagen gel matrix culture, focusing upon effects of adipocytes

BACKGROUND

Prostatic epithelial cells organize functional acinus structures under epithelial extracellular matrix and epithelial-stromal cell interactions. Recently, the adipose tissue, which surrounds and even exists within the prostate, has been suggested to affect the differentiation and proliferation of some cell types. Therefore, tissue fragments, which consist mainly of epithelial and fibromuscular stromal cells, were cultured in three-dimensional collagen gel matrix culture with adipocytes.

METHODS

Tissue fragments of rat dorsal prostate, including both epithelial and fibromuscular stromal components, were cultured in collagen gel with or without adipocytes. Epithelial cell differentiation was evaluated with the reconstruction of acinus-like structures and with immunohistochemistry of rat dorsal prostate-specific proteins, dorsal protein-1 and probasin. The proliferation was examined by uridine uptake.

RESULTS

Under coculture of the fragments and adipocytes, epithelial cells reconstructed more differentiated acinus-like structures surrounded by fibromuscular stromal cells than tissue fragment culture without adipocytes. Dorsal protein-1 and probasin expressions of epithelial cells in this coculture system were the same as in rat prostate in vivo. In the coculture, epithelial cells had a higher proliferation activity.

CONCLUSION

These results indicate that adipocytes promote proliferation and differentiation of prostatic epithelial cells. Our new culture model with adipocytes suggests the importance of cell-cell interactions, including those of epithelial cells and adipocytes.

Palpability of breast tumors--correlation with ultrasonic findings

With the recent development of high-resolution real-time ultrasonic devices and their application to clinical examination and breast screening, small non-palpable breast lesions have frequently been detected and controversy has arisen concerning their diagnosis and treatment. In order to evaluate the relationship between ultrasonic B-mode images and palpability of breast tumors, 71 breast tumors including 21 cancers were analyzed. Five basic measurements on tumor size and location were performed followed by calculation of secondary parameters of palpability. Larger size (D and W), less distance from the skin surface (S-T), less embeddedness within or more protrusion from the mammary gland (G-T) and greater relative size of tumor with respect to whole breast thickness (D/(S-P)) were found to be significantly related to greater palpability of breast tumors. Among the qualitative diagnostic criteria for breast tumors, an irregular shape, rough border, thick boundary echoes, heterogeneous internal echoes and indirect signs were statistically more frequent in palpable than non-palpable tumors, and in malignant than in benign tumors. In cases of cancer, palpability was related significantly only to size and to heterogeneous internal echoes. For early detection of breast cancer, identification of breast cancer among small non-palpable breast lesions less than 1 cm in size in ultrasonic B-mode images is considered to be essential.

Anesthetic dose and analgesic effects of sub-Tenon's anesthesia in cataract surgery

PURPOSE

To compare the analgesic effects of different doses of sub-Tenon's anesthesia in cataract surgery by assessing patient response to visceral stimulus.

SETTING

Inouye Eye Hospital, Tokyo, Japan.

METHODS

A prospective study was done of 1019 eyes of 1019 patients having phacoemulsification and posterior chamber intraocular lens implantation. They received a 1.0 mL (391 eyes), 2.0 mL (366 eyes), or 3.0 mL (262 eyes) anesthetic infiltration into the sub-Tenon's space. Pain scores were recorded when the anterior chamber was irrigated with an acetylcholine chloride solution to attain miosis after lens implantation.

RESULTS

The distribution of pain scores was significantly different among the 3 groups (P < .0001, Kruskal-Wallis test). Multiple comparison revealed that the 3.0 mL anesthetic infiltration offered significantly higher analgesic effects than the 2 lower doses. The 3.0 mL sub-Tenon's anesthesia effectively blocked the visceral stimulus.

CONCLUSION

For cataract surgery, 3 mL is the optimal dose of anesthetic solution in sub-Tenon's anesthesia.

Sequence and expression of a cDNA encoding the red seabream androgen receptor

The cDNA of the androgen receptor (AR) has been isolated from the ovary of red seabream, Pagrus major, and sequenced. The amino acid sequence of red seabream AR (rsAR) shows about 45% identity with those of Xenopus, rat, mouse, and human ARS. It is shown that rsAR has the ability to trans-activate the responsive gene depending on the presence of androgen.

A dose-finding study of lenograstim (glycosylated rHuG-CSF) for peripheral blood stem cell mobilization during postoperative adjuvant chemotherapy in patients with breast cancer. Lenograstim/Breast Cancer Study Group

BACKGROUND

The optimum dose of granulocyte colony-stimulating factor (G-CSF) for peripheral blood stem cell (PBSC) mobilization after disease-oriented, conventional-dose chemotherapy remains unknown.

METHODS

A multicenter dose-finding study of glycosylated G-CSF (lenograstim) for the mobilization of PBSCs following adjuvant CAF chemotherapy (cyclophosphamide, doxorubicin and 5-fluorouracil) was performed in 38 patients with postoperative breast cancer. Each 10, ten and eight patients were sequentially allocated to one of the three dose groups (2, 5 and 10 micrograms/kg, respectively) of lenograstim. Lenograstim was administered subcutaneously (s.c.) daily from day 8 to the day of the last apheresis and CD34+ cells and colony-forming units-granulocyte macrophage (CFU-GMs) in peripheral blood were measured serially. Additionally, 10 patients who received adjuvant CAF chemotherapy alone also participated in the study, as a control.

RESULTS

Lenograstim was well tolerated up to 10 micrograms/kg, except for one patient given 10 micrograms/kg who developed transient grade 3 hepatic enzyme elevation. The peak levels of CD34+ cells and CFU-GMs in peripheral blood showed dose-response relationships. The median peak CD34+ cells for the 0, 2, 5 and 10 micrograms/kg dose groups were 5.4, 34.3, 55.0 and 127.6 cells/microliter, respectively, and those of CFU-GMs for the 0, 2, 5 and 10 micrograms/kg dose groups were 0.01, 0.33, 1.32 and 3.30 CFU-GMs/microliter, respectively.

CONCLUSIONS

Considering the previous reports suggesting that a pre-apheresis number of 40-50 CD34+ cells/microliter in peripheral blood is highly predictive for achievement of more than 2.5 x 10(6) CD34+ cells/kg in a standard apheresis procedure of 10 litres, the optimum dose of lenograstim for PBSC mobilization following CAF chemotherapy in patients with postoperative breast cancer is 5 micrograms/kg/day s.c.

Nurses' perspectives concerning do-not-resuscitate (DNR) orders

The purpose of this study was to investigate the views of the nursing staff concerning do-not-resuscitate (DNR) orders at the Tokai University Hospital where a controversial incident occurred several years ago. A 'Questionnaire on DNR Orders' was circulated and the anonymous answers were collected two weeks later. The questionnaire was returned by 706 of 780 (90.5%) nurses from every ward/specialty, which revealed that 87% of the nurses felt that DNRs were occasionally necessary, with more than 40% of the nurses answering that they took part in DNR. Further, 36% of the nurses stated that patient consent was indispensable, and 64% thought that the patient's family and physician could decide DNR in the event the patient was physically unable to give consent. Moreover, 66% of the nurses expected the establishment of a DNR order sheet to be formulated as a matter of hospital policy; only 5% of the nurses thought that such an order sheet would not be necessary. Comparing these results with a previous study polling physicians at the Tokai University Hospital, nurses are more likely than physicians to think that patient consent is indispensable, and want the establishment of a standardized DNR order sheet as hospital policy. There is, in fact, a "tacit understanding" between physicians and patients' families in medical practice in Japan. However, DNR is definitely a medical decision. Therefore it should be clearly stated in a standardized format, although such a procedure presently seems unlikely, in view of the Japanese traditional value system.

Sequence and expression of a cDNA encoding the red sea bream androgen receptor

The cDNA of the androgen receptor (AR) has been isolated from the ovary of red sea bream, Pagrus major, and sequenced. The amino acid sequence of red sea bream AR (rsAR) shows about 45% identity with that of Xenopus, rat, mouse, and human AR. It is shown that rsAR has the ability to trans-activate the responsive gene depending on the presence of androgen.

[Treatment of advanced breast cancer: current issues]

Because the great majority of patients with advanced breast cancer have been traditionally placed under the care of surgeons, therapeutic planning is usually done by making operative management the key even at the present time when operable breast cancer is appropriately recognized to represent a systemic disease. For advanced breast cancer to be treated more effectively, systematically planned multimodality treatment must be undertaken. The development of G-CSF and stem cell transplantation to counter hematopoietic toxicity have allowed the safe use of high-dose intensity chemotherapy, which has also been applied in the neoadjuvant setting. Recent experience with neoadjuvant chemotherapy (NACT) has shown promise and indeed some good responders have been offered breast conserving surgery. NACT also serves as an in vivo chemosensitivity test, the results of which are to be exploited in chemo-hormonal therapy after locoregional treatment. Although further studies are required to evaluate this treatment more precisely, multicycle dose-intensified chemotherapy can now be safely and liberally incorporated into systematically planned multimodality treatment for advanced breast cancer.

Ruptured de novo aneurysm induced by ethyl 2-cyanoacrylate: case report

OBJECTIVE AND IMPORTANCE

We report a rare case of a ruptured de novo aneurysm induced by ethyl 2-cyanoacrylate.

CLINICAL PRESENTATION

A 44-year-old woman had undergone microvascular decompression for a right-sided facial spasm. The preoperative vertebral angiogram did not show any aneurysmal dilation. The right anteroinferior cerebellar artery, which was compressing the exit zone of the facial nerve, was detached and fixed to the dura mater with ethyl 2-cyanoacrylate. Nine years later, the patient suffered a subarachnoid hemorrhage caused by the rupture of a newly developed aneurysm of the right anteroinferior cerebellar artery.

INTERVENTION

The aneurysm was clipped 2 days after onset of the subarachnoid hemorrhage. It consisted of two bulges in the arterial wall on the proximal side of the meatal loop. One bulge was stuck to the dura mater of the pyramis by ethyl 2-cyanoacrylate, which had been used in the microvascular decompression 9 years previously.

CONCLUSION

This is the first reported clinical case of a de novo aneurysm induced by a cyanoacrylate adhesive. Ethyl 2-cyanoacrylate can damage the arterial wall and induce a de novo aneurysm.

Immunohistochemical detection of tumor cells in the bone marrow of breast cancer patients

BACKGROUND

Contamination of bone marrow and peripheral blood stem cells with tumor cells is a problem that may be encountered when autologous hematopoietic stem cell transplantation is conducted concurrently with high-dose chemotherapy.

METHODS

Using monoclonal antibodies to a variety of tumors, the detection of tumor cells in the bone marrow of breast cancer patients was studied by immunohistochemistry.

RESULTS

KL-1 and CAM5.2 were strongly reactive with breast cancer cells, but not with normal bone marrow cells. The reactivity of the tumor cells with EMA was not strong, and DF-3 and 115D8 yielded only slightly positive reactions. These latter antibodies also exhibited some reactivity to normal bone marrow cells. When tumor cells were admixed with normal cells, the sensitivity of CAM5.2 and EMA permitted the detection of one cell in 10(4), but with KL-1, the detection of one in 10(5) cells was possible. When immunohistochemical staining was used in testing 40 patients with advanced or recurrent breast cancer, positive reactions were obtained in four of 27 patients (14.8%) with KL-1, four of 26 (15.4%) with CAM5.2, and nine of 37 (23.7%) with KL-1 + CAM5.2, figures similar to those reported by others who studied stage IV patients.

CONCLUSIONS

Immunohistochemical staining with KL-1 and CAM5.2 is therefore considered to be a useful technique for detecting contamination by tumor cells.

Dose-Intensified Chemotherapy for Breast Cancer: Present and Future Prospects

With the trend to maximize chemotherapy in breast cancer, the use of peripheral blood stem cells in addition to hematopoietic growth factors to alleviate myelosuppression caused by dose-intensified chemotherapy has been shown to be beneficial. In treatment of metastatic breast cancer, response rates and complete response rates as high as 100%and nearly 80%, respectively, have been reported. Such treatments have shown even greater promise in an adjuvant setting for high-risk breast cancer. High-dose chemotherapy studies, however, involve highly-selected patient populations who are generally compared with unselected patients, and controversy still surrounds the question of whether it is substantially superior to conventional-dose chemotherapy. There are now more than sufficient data to justify ongoing randomized trials, and the most important overall recommedation is to encourage patients to participate in these clinical trials.