Small-for-size syndrome secondary to outflow block of the segments V and VIII anastomoses--successful treatment with trans-splenic artery embolization: a case report

Despite the rapid expansion of living donor liver transplantation (LDLT) in the adult population over the last few years, small-for-size syndrome (SFSS) has emerged as an important clinical problem. We have herein reported a patient who developed clinical evidence of prolonged cholestasis and intractable ascites after a small-for-size right lobe LDLT. The SFSS was attributed to outflow block of segments V and VIII anastomoses with severe portal overperfusion injury. It was successfully treated by reduction of portal pressure and blood flow after trans-splenic arterial ligation. We recommend that trans-splenic artery embolization, a technically simple procedure, be applied to treat portal overperfusion injury in SFSS.

Fire and flood management of coastal swamp enabled first rice paddy cultivation in east China

The adoption of cereal cultivation was one of the most important cultural processes in history, marking the transition from hunting and gathering by Mesolithic foragers to the food-producing economy of Neolithic farmers. In the Lower Yangtze region of China, a centre of rice domestication, the timing and system of initial rice cultivation remain unclear. Here we report detailed evidence from Kuahuqiao that reveals the precise cultural and environmental context of rice cultivation at this earliest known Neolithic site in eastern China, 7,700 calibrated years before present (cal. yr bp). Pollen, algal, fungal spore and micro-charcoal data from sediments demonstrate that these Neolithic communities selected lowland swamps for their rice cultivation and settlement, using fire to clear alder-dominated wetland scrub and prepare the site for occupation, then to maintain wet grassland vegetation of paddy type. Regular flooding by slightly brackish water was probably controlled by 'bunding' to maintain crop yields. The site's exploitation ceased when it was overwhelmed by marine inundation 7,550 cal. yr bp. Our results establish that rice cultivation began in coastal wetlands of eastern China, an ecosystem vulnerable to coastal change but of high fertility and productivity, attractions maximized for about two centuries by sustained high levels of cultural management of the environment.

Surgical outcome after removal of idiopathic macular epiretinal membrane in young patients

PURPOSE

To report the clinical features of the eye of young patients with an idiopathic macular epiretinal membrane (ERM), and the visual outcomes after the surgical removal of the ERM.

METHODS

A retrospective review of the medical records of eight young patients (age, 23-39 years; mean, 32.5 years) with an idiopathic macular ERM was performed. The patients underwent vitrectomy and removal of the ERM with peeling of the internal limiting membrane (ILM). The pre- and postoperative visual acuity and intra- and postoperative complications were investigated.

RESULTS

Ophthalmoscopically, the ERMs in seven eyes were white, opaque, and dense, while one was grayish-white and less dense. A posterior vitreous detachment was not present and the ERM adhered strongly to the underlying retina in all eight eyes. The mean best-corrected visual acuity (BCVA) preoperatively was 20/140 (Snellen; range: 20/250-20/63), and the BCVA improved significantly to 20/30 (range: 20/40-20/20) postoperatively with an average follow-up of 14.6 months (range: 6-42 months; Wilcoxon sign-rank test, P<0.001). An improvement of >7 lines was observed in seven of eight eyes. A recurrence of an ERM without involving the macula was detected in one eye (12.5%).

CONCLUSIONS

The clinical features of the ERMs in young patients are different from those in elderly patients, eg, thicker, more adherent to the retina, and still attached to the vitreous. Vitrectomy and removal of ERM with ILM peeling are effective and safe surgical procedures. Removal of the ILM may minimize the recurrence of an ERM.

Diagnostic value and complications of fine needle aspiration for primary liver cancer and its influence on the treatment outcome-a study based on 3011 patients in China

AIM

To determine the diagnostic value and major complications of fine-needle aspiration (FNA) for primary liver cancer (PLC) and its influence on the treatment outcome and prognosis.

METHODS

Information was gathered retrospectively for 3011 patients who presented with suspected PLC. Of which 2528 cases underwent ultrasound-guided fine-needle aspiration (US-FNA) biopsy. Patients were followed up through repeated office visits and imaging studies with a median follow-up of 7 months (range, 1-29 months).

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of cytological diagnosis by FNA biopsy for detection of liver malignancy were 91.5%, 100.0%, 100.00%, 59.1% and 92.4% respectively. All patients with AFP> or = 400 microg/L were associated with malignancy. Of 1154 patients with AFP<400 microg/L who were finally proved PLC, 945 were detected by FNA alone. Major complications included bleeding in 11 cases (5 of them died later), occurred mainly in hepatocellular carcinoma with superficial location, large tumors and severe cirrhosis, and implantation metastases in 5 cases, which were recognized as a subcutaneous nodule at the previous biopsy site. Implantation metastases were treated with resection or radiotherapy.

CONCLUSION

FNA biopsy is valuable for the diagnosis of PLC. However, complications of post-biopsy hemorrhage should not be ignored, as such bleeding may be fatal. Implantation seems to have little effect on the prognosis.

Glutamine stimulates translation of uncoupling protein 2mRNA

Uncoupling protein 2 (UCP2) belongs to a family of transporters/exchangers of the mitochondrial inner membrane. Using cell lines representing natural sites of UCP2 expression (macrophages, colonocytes, pancreatic beta cells), we show that UCP2 expression is stimulated by glutamine at physiological concentrations. This control is exerted at the translational level. We demonstrate that the upstream open reading frame (ORF1) in the 5' untranslated region (5'UTR) of the UCP2 mRNA is required for this stimulation to take place. Cloning of the 5' UTR of the UCP2 mRNA in front of a GFP cDNA resulted in a reporter gene with which GFP expression could be induced by glutamine. An effect of glutamine on translation of a given mRNA has not been identified before, and this is the first evidence for a link between UCP2 and glutamine, an amino acid oxidized by immune cells or intestinal epithelium and playing a role in the control of insulin secretion.

Comparison of chemotherapy regimens for malignant gliomas with positive MGMT protein expression: Experience of 51 cases

12522

Background: To compare the efficacy and toxicity of three chemotherapy regimens for MGMT positive gliomas. Methods: Fifty-one patients with histologically confirmed malignant gliomas and MGMT positive expression were enrolled in this study. The glioma tissues were examined for MGMT protein expression by immunohistochemistry. The patients were treated with: 1, regimen contained of nitrosourea (nitrosourea group) 11 cases; 2, regimen contained of temozolomide (temozolomide group) 18 cases; regimen contained of neither nitrosourea nor temozolomide(no alkylating agent group) 22 cases. Response to chemotherapy was evaluated according WHO criteria, and toxicity was evaluated according National Cancer Institute (NCI) criteria. Results: The overall objective response rate (CR + PR) for 51 cases with MGMT position gliomas was 20%, and disease control rate (CR+PR+SD) was 59%. The objective response rate and disease control rate in nitrosourea group, temozolomide group, and no alkylating agent group were 0%,18.2%,16.7% and 61.1%,31.8%,77.3%, respectively. There was significant difference between no alkylating agent group and nitrosourea group (P<0.05). Hematological toxicity and nausea/vomiting were main side-effect observed in nitrosourea group. While there was comparative lower incidence of side-effect in temozolomide group. Hematological toxicity, nausea/vomiting, and alopecia were main side-effect observed in no alkylating agent group. Though there was higher incidence of 3–4 grade hematological toxicity in this group, but it could recovered by oneself in one week or through treatment with G-CSF for 3–5 days. Conclusions: Regimen contained no alkylating agent group can obtain higher response rate and thus is worth of recommending to patients with MGMT positive gliomas. However, since modest response rate and good toleration, regimen with temozolomide shouldn’t be given up in MGMT position gliomas. Nevertheless, It is necessary to discover more efficiency way of using temozolomide. Nitrosourea should not be recommended to MGMT position glioma patients.

No significant financial relationships to disclose.

Promoter hypermethylation of GPX3 as a predictor for chemoresistance and survival in head and neck cancer patients

6027

Background: Resistance of cancer cells to cisplatin and its analogues is the major limitation in clinical application of cisplatin-based chemotherapy. The mechanisms by which cancer cells develop resistance to the drugs are still unclear, and there is no way currently to predict the drug resistance of individual tumors. By genome-wide scanning of hypermethylated genes on head and neck cancer cells, we identified glutathione peroxidase 3 (GPX3) as one of the strong candidates whose promoter hypermethylation may be associated with head and neck chemoresistance. In this study, we investigated the potential predictive value of GPX3 methylation for head and neck cancer chemoresistance and patient prognosis. Methods: Promoter methylation and expression of GPX3 gene in head and neck cancer cell lines were examined by plasmid cloning, bisulfite DNA sequencing, reverse transcription-PCR and Western blot. GPX3 methylation in primary cancer tissues was assessed by real-time methylation-specific PCR (MSP). Forty-six head and neck cancer cases, for which chemotherapy response and survival were known, were selected for analysis. Correlation of GPX3 methylation and chemoresistance was tested using two-sided Fisher’s Exact Test and its prediction for patient survival was assessed using Kaplan-Meier survival analysis. Results: Loss of GPX3 expression was observed in 4 of 8 head and neck cancer cell lines and was consistent with cisplatin resistance. Demethylating treatment of the cell lines negative for GPX3 expression significantly restored its expression. Bisulfite DNA sequencing showed that the 5’ flanking promoter region of GPX3 was heavily hypermethylated in all cell lines with expression-silencing of the gene. In the 46 head and neck cancer cases analyzed by MSP, 15 of 23 non-responding cases (65%) showed GPX3 methylation, while 4 of 23 complete and partial response cases (17%) contained low levels of GPX3 methylation (Relative Risk 3.343, two sided Fisher’s exact test, P=0.002). Kaplan-Meier survival analysis showed a relative risk of death of 1.942 in patients with GPX3 methylation. Conclusions: Our findings suggest that GPX3 methylation is a strong candidate predictor for chemoresistance and prognosis of head and neck cancer patients.

No significant financial relationships to disclose.

Pilot phase I study of gefitinib (GEF) in combination with paclitaxel (PAC) and radiation therapy (RT) in patients with locally advanced head and neck squamous cell carcinoma (HNSCC) and effects on epidermal growth factor receptor (EGFR) signaling pathway

16526

Background: The over expression of EGFR in HNSCC stimulates tumor cell proliferation, inhibits apoptosis, and increases resistance to chemotherapy and radiation. We examined the toxicity and maximum tolerated dose (MTD), and the downstream signaling and cellular effects in tumor biopsies in locally advanced HNSCC patients (Pts.) treated with GEF+PAC and RT. Methods: Pilot phase I dose escalation study initiated at GEF 250 mg/d + PAC 45 mg/m2 weekly x 6 with concurrent RT to 72 Gy. Eligibility: Stage III-IVB HNSCC, age=18 years, no prior RT or chemotherapy, ECOG =2, adequate organ function and informed consent. Endpoints: MTD determination, analysis of tumor biopsies for treatment effect on phospho-EGFR, Akt, Erk1/2, STAT3, NF-κB p65, Ki67 expression, TUNEL assay, serial measurement of serum IL-6, IL-8, VEGF, HGF and GROa. Results: 10 Pts., median age 60.7 yrs. (range, 41–83), 7 men and 3 women were treated. The MTD was GEF 250 mg/d + PAC 36 mg/m2 weekly x 6 with concurrent RT. Grade 3/4 toxicities included prolonged (>8 wk duration) mucositis in 7 Pts., infection (1) and interstitial pneumonitis (1). Two Pts. experienced protracted painful oral dysesthesia. There were 5 CR's and 1 PR. Of 7 Pts. undergoing serial biopsy, 1 Pt. showed a significant decrease in phosphorylated-EGFR expression, decreased downstream phosphoprotein signaling and cellular proliferation within 8 days of initiating GEF. Conclusions: Severe and prolonged mucositis was dose-limiting for this schedule of GEF+PAC and RT in locally advanced HNSCC. Inhibition of EGFR activation and downstream signaling by GEF was observed in a minority of Pts. on serial tumor biopsy specimens obtained during treatment.

No significant financial relationships to disclose.

Predictive chemotherapy according to O6-methylguanine-DNA methyltransferase protein expression for treatment of malignant gliomas

12530

Background: To evaluate the response to predictable chemotherapy according to O6-methylguanine-DNA methyltransferase (MGMT) expression pattern and toxicity in patients with malignant gliomas. Methods: Twenty-eight patients with histologically confirmed malignant gliomas were enrolled in this study. The glioma tissues were examined for MGMT protein expression by immunohistochemistry. The chemotherapeutic regimen wasn’t consisted of nitrosourea or temozolomide in patients with MGMT positive expression, while no limitation using nitrosourea or temozolomide in patients with MGMT negative expression. The patients who received 2 or more than 2 cycles of chemotherapy were evaluated for response to therapy according WHO standard, and toxicity according National Cancer Institute (NCI) standard. Results: Twenty-four patients were used one regimen while 4 patients received two regimens chemotherapy, and thus overall 32 cases were evaluated for response to chemotherapy. The complete response (CR) was observed in 5 cases (16%),partial response (PR) in 6 cases (19%), stable disease (SD) was seen in 12 cases (38%), and 9 cases (28%) developed progressive disease (PD). Objective response rate (CR + PR) was 35%, and response plus stable disease rate (CR+PR+SD) was 73%. Hematological toxicity was the principal limiting side-effect observed in this study. Seven patients (25%, 7/28) experienced grade 3 or 4 leucopenia and one (4%,1/28) grade 4 thrombocytopenia who received platelet transfusion. No hemorrhagic event due to thrombocytopenia occurred. Non- hematological toxicity mainly was nausea/vomiting and alopecia. Grade 3 nausea/vomiting occurred in 7% of patients (2/28) and grade 3 alopecia in 7% of patients (2/28). Conclusions: The predictive chemotherapy according to MGMT protein expression in patients with malignant gliomas could improve overall response rate with acceptable side-effect, as compared with conventional chemotherapeutic regimen, and thus worth for further investigation.

No significant financial relationships to disclose.

Prognostic factors for patients with Ewing sarcoma (EWS) at first recurrence

10011

Background: The prognosis for patients with recurrent Ewing sarcoma (EWS) is very poor with 5-year survival of 13%. Since 30–40% of patients with newly diagnosed, non-metastatic EWS develop recurrence, the Children's Oncology Group (COG) sought to evaluate prognostic factors for these patients. Data was derived from the phase III, multi-institutional study INT 0091. Methods: Between 1988 and 1994, five hundred and seventy-eight eligible patients with previously untreated EWS or PNET of bone were enrolled on INT 0091. Patients who experienced recurrence or disease progression as their first analytic event were considered. Survival was calculated from date of disease progression to death or last patient contact. Comparisons of the risk for death across groups were accomplished using the log-rank test. Survivor functions were estimated by the method of Kaplan and Meier. Results: Two hundred and sixty-two patients experienced disease progression or recurrence. The median time to first recurrence was 1.3 years (range 0–7.4 years) for all patients, 1.4 years (range 0 to 7.4 years) for patients with initially localized disease and 1 year (range 0 to 6 years) for patients with initially metastatic disease. Time to first recurrence from date of initial diagnosis was a predictor of post-recurrence survival (p<0.0001). Twenty-one percent of patients whose disease recurred or progressed experienced first recurrence 2 or more years from initial diagnosis and had an estimated 5 year post-recurrence survival of 30%. This compares with 7% for those whose first recurrence or progression was earlier. No statistical difference was detected when patients whose disease recurred < 12 months were compared with those whose recurrence was 12–24 months from initial diagnosis. Significant risk factors for death after recurrence included metastatic disease at initial diagnosis, elevated LDH at initial diagnosis and female gender. In patients non-metastatic at initial diagnosis pelvic primary site was also a risk factor for death after recurrence. Conclusions: Patients with longer time to first recurrence represent the subset of patients most likely to survive following recurrence. All patients with recurrent Ewing sarcoma would benefit from collaborative trials to investigate new therapeutic options.

No significant financial relationships to disclose.

Phase II study of weekly docetaxel plus cisplatin as first-line therapy in advanced or metastatic non-small cell lung cancer (CHN TAX-206)

18173

Background: There has been increasing interest in the use of weekly administration of docetaxel as a way of reducing its hemotologic toxicity. Weekly docetaxel plus cisplatin has also shown promising efficacy and well tolerability for first-line treatment of advanced or metastatic NSCLC in our previous phase I study (2002 ASCO, abstract No 2744). We conducted this phase II trial to further evaluate this regimen’s efficacy and toxicity. Methods: Patients with histologically confirmed stage IIIB or IV NSCLC were treated with docetaxel (35 mg/m2, 30 min. iv. infusion) on days 1, 8, 15 and cisplatin (75 mg/m2, 30 min. iv. infusion) on day 1 repeated every 4 weeks for up to 6 cycles. Pts received oral dexamethasone 7.5 mg twice daily from the day before chemotherapy and consecutive two days thereafter. The primary endpoint of this phase II study is efficacy of the regimen. Results: A total of 83 patients were enrolled from July 2002 to June 2004, 75 patients were evaluable for response and 83 for safety. Median age was 55 years (range 29–70 years); and 69.9% were male; adenocarcinoma/squamous cell carcinoma/others (65/12/6); stage IIIB /IV( 47/36); ECOG PS 0/1(52/31). Median number of chemotherapy cycles was 3(1–5). One CR (complete response) and 22 PR (partial response) were achieved with an ORR of 30.7% in the evaluable patients. The 1-year survival was 48.6% with a median survival of 10.7 months (range: 3–34 months). Neutropenia was the most common adverse event, though most were mild; Grade III/IV toxicities per patient were: Neutropenia (15.6%), asthenia (11%), skin/nail toxicity (10.8%) and vomiting (9.6%). Febrile neutropenia was not observed. Conclusions: In the present study, the combination of weekly administration docetaxel combining with cisplatin appears well tolerated with very low frequency of severe hematologic toxicity and similarly efficacious as 3-weekly docetaxel in NSCLC pts.

No significant financial relationships to disclose.

VEGF-D expression in lung adenocarcinoma with or without acquired resistance to gefitinib and normal lung

18166

Background: VEGF-D is related with pathogenesis and metastasis of lung cancer, however, its relationship with resistance to gefitinib in NSCLC remains unknown. Methods: Lung adenocarcinoma, normal lung tissues adjacent to the carcinoma and adenocarcinoma with acquired resistance to gefitinib including some metastastic lymph nodes were obtained during operation. Relative quantitation of VEGF-D gene expression was performed by SYBR Green real-time PCR with beta actin gene as the endogenous control. VEGF-D expression of each group was analyzed by comparing them qualitatively and quantitatively. The expression ratios were compared by Fisher’s exact test and expression levels were compared by two-related-samples nonparametric test. Results: CVEGF-D expression ratio of lung adenocarcinoma with acquired resistance to gefitinib (16.7%, 1/6) was not different from lung adenocarcinoma (50%, 7/14, P=0.325) but was significantly lower than that of normal lung (93.8%, 15/16, P=0.001). The logarithmically transformed VEGF-D relative expression levels in six lung adenocarcinomas and the matched normal lung tissues, which were 2.214±0.376 and 3.388±0.209, were found to be significantly different from each other by the analysis of Wilcoxon signed ranks test (P=0.028). Conclusions: VEGF-D expression is in a high-level state in normal lung tissues while in low-level or absent in lung adenocarcinoma with or without acquired resistance to gefitinib, suggesting that the role VEGF-D plays in normal lung tissue could be different from in lung adenocarcinoma with or without acquired resistance to gefitinib.

No significant financial relationships to disclose.

Effects of a novel anti-exospore monoclonal antibody on microsporidialNosema bombycisgermination and reproductionin vitro

A monoclonal antibody (mAb) 3C2, against an exospore protein of the microsporidiumNosema bombycis(N. bombycis) was prepared, and its effects on microsporidial germination and reproductionin vitrowere studied. MAb 3C2 was effective in inhibiting the germination and subsequent infection ofBombyx moricells compared to the control mAb. The antigen was isolated by 2-dimensional gel electrophoresis. Immunoblotting revealed it to be an 84 kDa protein corresponding to pI (7·2) on the 2-D gel. The present results suggest that the antibodies can be used for diagnostic purposes and for developing new therapeutic strategies in controlling microsporidian diseases.

Introduction of Microsurgical Technique to Biliary Reconstruction in Living Donor Liver Transplantation

OBJECTIVE

High rates of biliary complications continue to be a major concern associated with living donor liver transplantation (LDLT). In this article, we report our experience of applying a microsurgical technique to biliary reconstruction in LDLT.

PATIENTS AND METHODS

From January 2001 to December 2005, 32 patients underwent LDLTs (8 children and 24 adults). Biliary reconstruction for 43 hepatic duct orifices in the 32 donor grafts 21 duct-to-duct anastomoses, and 22 cholangiojejunostomies. Nine cholangiojejunostomies in 4 donors used a microsurgical technique under an operative microscope.

RESULTS

Biliary complications weren't observed among the cases of cholangiojejunostomy using a microsurgical technique. An anastomotic biliary leakage was found in a recipient with cholangiojejunostomy performed using a surgical loupe and a biliary stricture in another recipient who underwent duct-to-duct anastomoses using a surgical loupe.

CONCLUSION

Introduction of a microsurgical technique for biliary reconstruction in LDLT, especially using an operating microscope in the setting of hepatico-jejunostomy for small hepatic duct (< or =2 mm in diameter), showed good results. We believe that using the operative microscope for biliary reconstruction could reduce the incidence of biliary complications associated with LDLT.