Multi-Institutional Study of Stereotactic Radiosurgery for Recurrent WHO Grade 2/3 Meningiomas: An Interim Analysis

PURPOSE/OBJECTIVE(S)

Meningiomas are the most common tumors of the central nervous system (CNS). Approximately 80% are classified as World Health Organization (WHO) grade 1, while 20% correspond to grade 2 or grade 3. In those with grade 2/3 disease, local recurrence is not uncommon. Salvage treatment options vary widely and include resection, external beam radiation therapy (EBRT), stereotactic radiosurgery (SRS), and/or clinical trials. Although retrospective studies have reported on the use of upfront SRS in grade 2/3 meningiomas, large-scale outcomes with SRS in the recurrent setting are lacking. The objective of this study was to report on oncologic outcomes for patients with recurrent grade 2/3 meningioma treated with SRS.

MATERIALS/METHODS

This is an ongoing multi-institutional retrospective cohort study. Eligibility criteria include patients >18 years old with pathologically confirmed WHO grade 2 or 3 meningioma treated with SRS monotherapy at the time of first recurrence. Patients require pathologic confirmation only at time of diagnosis; those with upfront grade 1 disease must have pathologic confirmation of grade 2/3 disease at time of first recurrence. Patients with multifocal disease upfront were excluded from this study.

RESULTS

A total of 60 patients met eligibility criteria. Baseline demographics at time of initial diagnosis are shown in table 1. At the time of first recurrence, 57 (95%) were WHO grade 2, and 3 (5%) were grade 3. Median follow up time from first recurrence was 5.02 years. Median marginal SRS dose was 16 Gy (IQR 14-17) to a 2.67cc planning treatment volume (IQR 1.4-5.1). 92% of patients received single fraction SRS. Median time to second recurrence was 5.92 years. 1, 3, and 5-year progression-free survival (PFS) was 95%, 68%, and 51%, respectively. 1, 3, and 5-year overall survival (OS) was 100%, 98%, and 96%, respectively. On multivariate analysis, grade 3 disease was independently associated with worse PFS (HR 15.7, p = 0.03). Median SRS dose and treatment volume did not correlate with PFS. 1 patient (1.7%) experienced symptomatic radiation necrosis requiring steroids, 3 (5.0%) experienced new seizure activity, and 2 (3.3%) additional patients showed clinical evidence of post-treatment neurocognitive decline.

CONCLUSION

Based on this interim analysis, primary SRS for recurrent grade 2/3 meningioma appears safe and feasible, with outcomes comparable to prospective data on high-risk grade 2/3 patients treated with post-operative fractionated EBRT. We look forward to further analysis with a larger cohort which may help guide further prospective studies.

CT-Guided Online Adaptive Stereotactic Body Radiotherapy for Pancreas Ductal Adenocarcinoma: Dosimetric and Initial Clinical Experience

PURPOSE/OBJECTIVE(S)

Retrospective analysis suggests that dose escalation to a biologically effective dose of more than 70 Gy may improve overall survival in patients with pancreatic ductal adenocarcinoma (PDAC), but such treatments in practice are limited by proximity of organs at risk (OARs). We hypothesized that CT-guided online adaptive radiotherapy (OART) can account for interfraction movement of OARs, reduce dose to OARs, and improve coverage of targets.

MATERIALS/METHODS

This is a single institution retrospective analysis of patients with PDAC treated with OART on a CBCT-based OART platform. All patients were treated to 40 Gy in 5 fractions. PTV overlapping with a 5 mm planning risk volume expansion on the stomach, duodenum and bowel received 25 Gy. Initial treatment plans were created conventionally. For each fraction, PTV and OAR volumes were recontoured with AI assistance after initial cone beam CT (CBCT). The adapted plan was calculated, underwent QA, and then compared to the scheduled plan. A second CBCT was obtained prior to delivery of the selected plan. Total treatment time (first CBCT to end of radiation delivery) and active physician time (first to second CBCT) were recorded. PTV_4000 V95%, PTV_2500 V95%, and D0.03 cc to stomach, duodenum and bowel were reported for scheduled (S) and adapted (A) plans. CTCAEv5.0 toxicities were recorded. Statistical analysis was performed using a two-sided T test and α of 0.05.

RESULTS

Seven patients with unresectable or locally-recurrent PDAC were analyzed, with a total of 35 fractions. Average total time was 33:00 minutes (22:25-49:40) and average active time was 22:48 minutes (14:15-39:34). All fractions were treated with adapted plans. All adapted plans met PTV_4000 V95.0% > 95.0% coverage goal and OAR dose constraints. Dosimetric data for scheduled and adapted plans per fraction are in Table 1. Median follow up was 1.7 months. 5 (71%) patients experienced either Grade 1 or 2 toxicities. No patients experienced Grade 3+ toxicities.

CONCLUSION

Daily OART significantly reduced dose OARs while achieving superior PTV coverage. Treatment was generally well tolerated with no grade 3+ acute toxicity, and required only 22:48 minutes on average of active physician time. Our initial clinical experience demonstrates OART allows for safe dose escalation in the treatment of PDAC.

Combination atezolizumab, bevacizumab, pemetrexed and carboplatin for metastatic EGFR mutated NSCLC after TKI failure

INTRODUCTION

Acquired resistance to TKI is an important unmet need in the management of EGFR mutated lung cancer. Recent clinical trial IMPower150 suggested that combination approach with VEGF inhibitor, check point inhibitor immunotherapy and platinum-based chemotherapy was effective in oncogene driven lung cancer. The current trial examined the efficacy of a modified regimen in an EGFR mutated cohort.

METHODS

An open-labelled, single arm, phase II study was conducted in patients with EGFR mutated NSCLC who had progressed on at least one EGFR TKI. For those with T790M mutation, radiological progression on osimertinib was required for enrolment. Patients were treated with combination atezolizumab (1200 mg), bevacizumab (7.5 mg/kg), pemetrexed (500 mg/m2) and carboplatin (AUC 5) given once every 3 weeks until progression.

RESULTS

Forty patients were enrolled. Median age was 62 (range 45-76) years. More than one half (23/40, 57.5%) had progressed on osimertinib. PD-L1 expression was < 1% in 52.5%. Median follow-up time was 17.8 months. ORR was 62.5%. Median PFS was 9.4 months (95% CI: 7.6 - 12.1). One year OS was 72.5% (95% CI: 0.56-0.83). Treatment related grade 3 or above adverse events (AE) occurred in 37.5% (15/40). Immune-related AE occurred in 32.5% (13/40) patients. Quality of life measures of function and symptoms did not change significantly throughout the course of treatments. Post-trial rechallenge with EGFR TKI containing regimen resulted in PFS of 5.8 months (95% CI 3.9-10.0 months).

CONCLUSION

Combination approach of atezolizumab, bevacizumab, pemetrexed and carboplatin achieved promising efficacy in metastatic EGFR mutated NSCLC after TKI failure. The results were comparable with taxane based regimen of IMPower150 while toxicity profile was improved.

Enhanced inhibitory control by neuropeptide Y Y5 receptor blockade in rats

RATIONALE

The neuropeptide Y (NPY) system acts in synergy with the classic neurotransmitters to regulate a large variety of functions including autonomic, affective, and cognitive processes. Research on the effects of NPY in the central nervous system has focused on food intake control and affective processes, but growing evidence of NPY involvement in attention-deficit/hyperactivity disorder (ADHD) and other psychiatric conditions motivated the present study.

OBJECTIVES

We tested the effects of the novel and highly selective NPY Y5 receptor antagonist Lu AE00654 on impulsivity and the underlying cortico-striatal circuitry in rats to further explore the possible involvement of the NPY system in pathologies characterized by inattention and impulsive behavior.

RESULTS

A low dose of Lu AE00654 (0.03 mg/kg) selectively facilitated response inhibition as measured by the stop-signal task, whereas no effects were found at higher doses (0.3 and 3 mg/kg). Systemic administration of Lu AE00654 also enhanced the inhibitory influence of the dorsal frontal cortex on neurons in the caudate-putamen, this fronto-striatal circuitry being implicated in the executive control of behavior. Finally, by locally injecting a Y5 agonist, we observed reciprocal activation between dorsal frontal cortex and caudate-putamen neurons. Importantly, the effects of the Y5 agonist were attenuated by pretreatment with Lu AE00654, confirming the presence of Y5 binding sites modulating functional interactions within frontal-subcortical circuits.

CONCLUSIONS

These results suggest that the NPY system modulates inhibitory neurotransmission in brain areas important for impulse control, and may be relevant for the treatment of pathologies such as ADHD and drug abuse.

Clinicopathological implications of human papilloma virus (HPV) L1 capsid protein immunoreactivity in HPV16-positive cervical cytology

BACKGROUND

The objective of this study was to investigate the expression of human papilloma virus (HPV) L1 capsid protein in abnormal cervical cytology with HPV16 infection and analyze its association with cervical histopathology in Korean women.

MATERIAL AND METHODS

We performed immunocytochemistry for HPV L1 in 475 abnormal cervical cytology samples from patients with HPV16 infections using the Cytoactiv(®) HPV L1 screening set. We investigated the expression of HPV L1 in cervical cytology samples and compared it with the results of histopathological examination of surgical specimens.

RESULTS

Of a total of 475 cases, 188 (39.6%) were immunocytochemically positive and 287 (60.4%) negative for HPV L1. The immunocytochemical expression rates of HPV L1 in atypical squamous cells of unknown significance (ASCUS), low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL), and cancer were 21.8%, 59.7%, 19.1%, and 0.0%, respectively. LSIL exhibited the highest rate of HPV L1 positivity. Of a total of 475 cases, the multiple-type HPV infection rate, including HPV16, in HPV L1-negative cytology samples was 27.5%, which was significantly higher than that in HPV L1-positive cytology samples (p = 0.037). The absence of HPV L1 expression in ASCUS and LSIL was significantly associated with high-grade (≥ cervical intraepithelial neoplasia [CIN] 2) than low-grade (≤ CIN1) histopathology diagnoses (p < 0.05), but was not significantly different between HPV16 single and multiple-type HPV infections (p > 0.05). On the other hand, among 188 HPV L1-positive cases, 30.6% of multiple-type HPV infections showed high-grade histopathology diagnoses (≥ CIN3), significantly higher than the percentage of HPV16 single infections (8.6%) (p = 0.0004) CONCLUSIONS: Our study demonstrates that the expression of HPV L1 is low in advanced dysplasia. Furthermore, the absence of HPV L1 in HPV16-positive low-grade cytology (i.e., ASCUS and LSIL) is strongly associated with high-grade histopathology diagnoses. The multiplicity of HPV infections may have an important role in high-grade histopathology diagnoses (≥ CIN3) in HPV L1-positive cases.

Comparison of the inhibitory effect of gonadotropin releasing hormone (GnRH) agonist, selective estrogen receptor modulator (SERM), antiprogesterone on myoma cell proliferation in vitro

Uterine myomas are the most common gynecologic tumor in women of reproductive age. Treatment options of uterine myomas consist of surgical, medical and interventional therapy such as uterine artery embolization or myolysis. Given that it is the most common type of tumor in women of reproductive age, the treatment of uterine myomas must prioritize uterine conservation. There are several drugs for medical treatment of uterine myoma such as gonadotropin releasing hormone (GnRH) agonist, selective estrogen receptor modulator (SERM) and antiprogesterone. The objective of this study was to compare the effect of GnRH agonist, SERM, and antiprogesterone in the treatment of uterine myomas in vitro. The effect of drugs was evaluated through the cell viability assay in cultured leiomyoma cells, western blot analysis of proliferating cell nuclear antigen (PCNA), and BCL-2 protein expression. As a result, mifepristone single-treated group represents the most significant reduction in myoma cell viability and proliferation. When pretreated with leuprolide acetate, raloxifene shows more significant reduction in myoma cell viability and proliferation than mifepristone. This study suggests one of the possible mechanisms how medications act on uterine myoma, especially at the molecular level.

A review of central retinal artery occlusion: clinical presentation and management

Central retinal artery occlusion (CRAO) is an ophthalmic emergency and the ocular analogue of cerebral stroke. Best evidence reflects that over three-quarters of patients suffer profound acute visual loss with a visual acuity of 20/400 or worse. This results in a reduced functional capacity and quality of life. There is also an increased risk of subsequent cerebral stroke and ischaemic heart disease. There are no current guideline-endorsed therapies, although the use of tissue plasminogen activator (tPA) has been investigated in two randomized controlled trials. This review will describe the pathophysiology, epidemiology, and clinical features of CRAO, and discuss current and future treatments, including the use of tPA in further clinical trials.

Expression of MUC5AC and Trefoil Peptide 1 (TFF1) in the Subtypes of Intestinal Metaplasia

Background/Aims

Alterations of the expression pattern of mucins and trefoil peptides have been described in gastric adenocarcinomas and in their precursor lesions. The aim of this study was to determine the progression patterns of intestinal metaplasia (IM) subtypes by analyzing the expression patterns of TFF1 and MUC5AC in different subtypes of IM of the stomach.

Methods

Endoscopic gastric biopsies of the antrum and body were obtained from patients with dyspepsia and endoscopic IM. Alcian blue/periodic acid-Schiff staining and the high iron diamine technique were used to classify the subtypes of IM. Immunoreactivity for MUC5AC and TFF1 was estimated in different types of IM.

Results

IM was detected in 128 samples from 80 patients; type I was found in 48 samples, type II was found in 37 samples, and type III was found in 43 samples. There was a gradual decrease in MUC5AC and TFF1 expression during the progression of IM from type I to type III via the type II intermediate.

Conclusions

This downregulation of MUC5AC and TFF1 expression may challenge the sequential progression of IM from type I to type III via the type II intermediate, and it might be associated with gastric carcinogenesis.

Haemorrhagic low-grade fibromyxoid sarcoma: MR findings in two young women

Low-grade fibromyxoid sarcoma (LGFMS) is a rare soft-tissue sarcoma characterised by a deceptively bland histological appearance and a paradoxically aggressive behaviour. LGFMS usually presents in young-to-middle-aged adults as a painless, slow-growing mass with the potential for local recurrence and metastasis despite low-grade histology. Several case reports have described variable MR findings of LGFMS without haemorrhage or necrosis. We report here on the MR findings in two young women with haemorrhagic LGFMS in the thigh.

Noninvasive investigation of asymmetrically conjoined tripus twins with features of rachipagus, parapagus dicephalus, and cephalopagus

A hypothetical mechanism for conjoined twinning postulated by Spencer ([2003] Developmental Malformations and Clinical Implications, Baltimore: Johns Hopkins University Press, p 1-476) suggests that, after separation, monovular twins fuse in one of eight predictable homologous sites. The tripus fetal specimen under study embodies characteristics of three types therefore preventing it from classification into a simple variant of any one of the eight twin types described by Spencer. The aim of this study was to reveal internal structural anomalies of the fetal specimen by using magnetic resonance imaging and computerized tomography. Dorsally appended to the primary twin is a secondary head mass (brain tissue and ocular globe) and two spinal columns converging at T4/T5, suggesting rachipagus twinning. The ventral orientation of the secondary twin's (right lateral) lower limb suggests parapagus twinning. The caudal divergence of the spinal columns and the presence of a secondary hemipelvis, separate from the primary pelvis, suggest cephalopagus twinning. Measurements of the long bones indicate a gestational age of ∼20-23 weeks. Secondary malformations of the primary fetal body include anencephaly, cleft palate, renal agenesis, decreased left ventricular outflow, and a prematurely terminating descending aorta. This study demonstrates the possibility of using current imaging techniques to study very old, formalin-preserved human material for documentation and scientific discussion without destroying the specimen, thus keeping it intact for posterity.

Parovarian tumors of borderline malignancy

The incidence of a parovarian tumor is 10-20% of all uterine adnexal masses, however, it is benign in most cases, and a borderline or malignant tumor is extremely rare. The classification of disease stage and treatment is still controversial owing to its scarcity. We have managed one mucinous and two serous cystadenomas of borderline malignancy originating from paraovarian cysts in our institute over ten year. We report and discuss the cases herein.

Familial amyloid precursor protein mutants cause caspase-6-dependent but amyloid β-peptide-independent neuronal degeneration in primary human neuron cultures

Although familial Alzheimer disease (AD)-associated autosomal dominant mutants have been extensively studied, little is known about the underlying molecular mechanisms of neurodegeneration induced by these mutants in AD. Wild-type, Swedish or London amyloid precursor protein (APP) transfection in primary human neurons induced neuritic beading, in which several co-expressed proteins, such as enhanced green fluorescent protein, red fluorescent protein (RFP)-tau and RFP-ubiquitin, accumulated. APP-induced neuritic beading was dependent on caspase-6 (Casp6), because it was inhibited with 5 μM z-VEID-fmk or with dominant-negative Casp6. Neuritic beading was independent from APP-mediated amyloid β-peptide (Aβ) production, because the APPM596V (APP(MV)) mutant, which cannot generate Aβ, still induced Casp6-dependent neuritic beading. However, the beaded neurons underwent Casp6- and Aβ-dependent cell death. These results indicate that overexpression of wild-type or mutant APP causes Casp6-dependent but Aβ-independent neuritic degeneration in human neurons. Because Casp6 is activated early in AD and is involved in axonal degeneration, these results suggest that the inhibition of Casp6 may represent an efficient early intervention against familial forms of AD. Furthermore, these results indicate that removing Aβ without inhibiting Casp6 may have little effect in preventing the progressive dementia associated with sporadic or familial AD.

Vascular risk factors for central retinal artery occlusion

PURPOSE

To determine the proportion of patients presenting with thromboembolic central retinal artery occlusion (CRAO) who had undiagnosed vascular risk factors amenable to modification.

METHODS

A retrospective audit of consecutive patients with non-arteritic/thromboembolic CRAO presenting between 1997 and 2008 in a single tertiary teaching hospital.

RESULTS

Thirty-three patients with non-arteritic CRAO were identified. Twenty-one patients (64%) had at least one new vascular risk factor found after the retinal occlusive event, with hyperlipidemia being the most common undiagnosed vascular risk factor at the time of the sentinel CRAO event (36%). Nine patients (27%) had newly diagnosed hypertension or previous diagnosis of hypertension but not optimally controlled. To better control their vascular risk factors 18 patients (54%) were given a new or altered medication. Nine patients had more than 50% of ipsilateral carotid stenosis ; six of these proceeded with carotid endarterectomy or stenting. One patient had significant new echocardiogram finding. Systemic ischaemic event post CRAO occurred in two patients with stroke and acute coronary syndrome.

CONCLUSIONS

Patients presenting with CRAO often have a previously undiagnosed vascular risk factor that may be amenable to medical or surgical treatment. As this population is at a high risk of secondary ischaemic events, risk factor modification is prudent.

Crossed cerebellar diaschisis in acute stroke detected by dynamic susceptibility contrast MR perfusion imaging

BACKGROUND AND PURPOSE

Crossed cerebellar diaschisis (CCD), the decrease in blood flow and metabolism in the cerebellar hemisphere contralateral to a supratentorial stroke, is frequently reported on positron-emission tomography (PET) and single-photon emission CT (SPECT) but is rarely described with MR perfusion techniques. This study was undertaken to determine the frequency of CCD observed in acute stroke by retrospective review of a research data base of patients with acute stroke evaluated by diffusion-weighted (DWI) and dynamic contrast susceptibility perfusion MR imaging (PWI).

MATERIALS AND METHODS

PWI scans of 301 consecutive patients with acute stroke and positive DWI abnormality from a research data base were reviewed. Contralateral cerebellar hypoperfusion was identified by inspection of time-to-peak (TTP) maps for asymmetry with an absence of cerebellar abnormalities on T2-weighted scans, DWI, or disease of the vertebrobasilar system on MR angiography. In a subset of the cases, quantitative analysis of perfusion scans was performed using an arterial input function and singular value decomposition (SVD) to generate cerebral blood flow (CBF) maps.

RESULTS

A total of 47 of 301 cases (15.61%) met the criteria of CCD by asymmetry of cerebellar perfusion on TTP maps. On quantitative analysis, there was corresponding reduction of CBF by 22.75 +/- 10.94% (range, 7.45% to 52.13%) of the unaffected cerebellar hemisphere).

CONCLUSIONS

MR perfusion techniques can be used to detect CCD, though the frequency presented in this series is lower than that commonly reported in the PET/SPECT literature. Nevertheless, with its role in acute stroke and noninvasive nature, MR perfusion may be a viable alternative to PET or SPECT to study the phenomenon and clinical consequences of supratentorial stroke with CCD.

Hormone effects on specific and global brain functions

The first demonstration of how biochemical changes in neurons in specific parts of the brain direct a complete mammalian behavior derived from the effects of estrogens in hypothalamic neurons that facilitate lordosis behavior, the primary reproductive behavior of female quadrupeds (Pfaff. Estrogens and Brain Function. 1980; Pfaff. Drive: Neurobiological and Molecular Mechanisms of Sexual Motivation. 1999). Sex behaviors depend on sexual arousal that in turn depends on a primitive function: generalized CNS arousal (Pfaff. Brain Arousal and Information Theory. 2006). Here we summarize one of the ways in which a generalized arousal transmitter, norepinephrine, can influence the electrical excitability of ventromedial hypothalamic cells in a way that will foster female sex behavior.

Voltage-dependent calcium channels in ventromedial hypothalamic neurones of postnatal rats: modulation by oestradiol and phenylephrine

Oestradiol actions in the hypothalamus play an important role in reproductive behaviour. Oestradiol treatment in vivo induces alpha(1b)-adrenoceptor mRNA and increases the density of alpha(1B)-adrenoceptor binding in the hypothalamus. Oestradiol is also known to modulate neuronal excitability, in some cases by modulating calcium channels. We assessed the effects of phenylephrine, an alpha(1)-adrenergic agonist, on low-voltage-activated (LVA) and high-voltage-activated (HVA) calcium channels in ventromedial hypothalamic (VMN) neurones from vehicle- and oestradiol-treated female rats. Whole-cell and gramicidin perforated-patch recordings were obtained, with barium as the charge carrier. In the absence of phenylephrine, oestradiol treatment increased the magnitude of LVA currents compared to controls, but had no effect on HVA currents. Phenylephrine enhanced HVA currents in a significantly greater proportion of neurones from oestradiol-treated rats (76%) than from vehicle-treated (41%) rats. The L-channel blocker nifedipine abolished this oestradiol effect on phenylephrine-enhanced HVA currents. Preincubating slices with the N-type channel blocker omega-conotoxin GVIA completely blocked the phenylephrine response, suggesting that the N-type channel is essential. Phenylephrine also stimulated LVA currents in approximately two-thirds of neurones in slices from both vehicle- and oestradiol-treated rats. Our data show that oestradiol increases LVA currents in the VMN. Oestradiol also amplifies alpha(1)-adrenergic signalling by increasing the proportion of neurones showing phenylephrine-stimulated HVA currents mediated by N- and L-type calcium channels. In this way, oestradiol may increase excitatory responses to arousing adrenergic inputs to VMN neurones governing oestradiol-dependent reproductive behaviour.

Anterior ischemic optic neuropathy in moyamoya disease: a first case report

Neuro-ophthalmological manifestations in moyamoya disease are usually the result of cerebrovascular involvement of the visual pathways. We report a case of ischemic optic neuropathy due to ocular hypoperfusion as a result of moyamoya disease, despite a prior internal to external carotid artery bypass with normal hemisphere perfusion. The blood supply of the optic nerve, a proposed pathogenesis of an anterior ischemic optic neuropathy and complications of the ocular ischemic syndrome are discussed.

Wyburn-Mason syndrome associated with thyroid arteriovenous malformation: a first case report

A 31-year-old woman with a prior history of Wyburn-Mason syndrome, complicated previously by a left thalamic intracerebral hemorrhage at age 21, complained of sudden left vision loss due to a central retinal vein occlusion. Angiography revealed a left thyroid arterio-venous malformation (AVM) in addition to ones found intracerebrally. The pathogenesis and embryogenesis of this finding including the management of AVMs in Wyburn-Mason syndrome are discussed.

Sonographic findings in a patient with cystic hypersecretory duct carcinoma of the breast

In this report, we describe a case of a rare form of intraductal carcinoma of the breast known as cystic hypersecretory duct carcinoma in a 49-year-old woman with a palpable mass and no history of breast disease. Mammography showed heterogeneous dense breast tissue with no definite abnormally increased density or microcalcifications. Gray-scale sonography detected multiple small aggregated, anechoic cysts with good through-transmission in the upper outer quadrant of the left breast, corresponding to the location of the palpable mass. The patient underwent an excision biopsy, and histopathologic examination of the surgical specimen revealed multiple cysts of different size containing an eosinophilic material resembling thyroid colloid. The locations of the cysts corresponded to those of the anechoic cysts detected on sonography. The epithelium lining the cysts showed micropapillary growth consistent with a diagnosis of cystic hypersecretory duct carcinoma. The mammographic and sonographic findings in this case differed somewhat from those reported previously for this rare form of breast carcinoma. Because the imaging findings and low-power microscopic appearance of the mass in our patient's case closely resembled those of some benign breast lesions, we recommend careful differentiation of this type of lesion using high-power microscopy during histopathologic evaluation.

Marked differences in olfactory sensitivity and apparent speed of forebrain neuroblast migration in three inbred strains of mice

In the adult forebrain, new neuroblasts constantly migrate from the subventricular zone along the rostral migratory stream to the olfactory bulb, where many become neurons. It is unclear whether this process is different in commonly used mouse strains and whether it is related to olfactory function. Adult male BALB/c, C57BL/6, and 129/S1 (formerly 129SV) mice were tested for olfactory sensitivity plus discrimination, using male mouse urine from the two other strains. BALB/c mice had the greatest olfactory sensitivity, followed by 129/S1, and C57BL/6 mice, by an order of magnitude each. Newly formed cells were pulse-labeled for 3 h with i.p. 5-bromo-2'-deoxyuridine (BrdU) injections and the animals analyzed 24 h later. In 129/S1 mice, a greater proportion of neuroblasts were present closer to the olfactory bulb than in BALB/c mice, followed by C57BL/6 mice. The total number of BrdU-labeled cells did not differ, suggesting differences in migration and not proliferation. The impaired olfactory function in C57BL/6 mice might be caused by the reduced number of neuroblasts that reach the olfactory bulbs. However, olfactory function in BALB/c and 129/S1 mice did not correlate with their putative migration speed, suggesting a more complex nature of cellular processes that contribute to olfactory function. These results caution against comparing studies of olfactory function or neural precursors that use different strains of mice, and question the use of C57BL/6 mice as a "normal" strain or as transgenic background. Perhaps more importantly, the results point to an opportunity to identify genes that regulate olfactory function and neuroblast behavior.

Association of globular beta-actin with intracellular lipid droplets in rat adrenocortical cells and adipocytes

Proteins located on the surface of lipid droplets may mediate intracellular lipid metabolism. In the present study, immunofluorescent staining and polyacrylamide gel electrophoresis demonstrated that actin (43 kD) is associated with isolated intracellular lipid droplets of rat adrenocortical cells and adipocytes. Two-dimensional gel electrophoresis and immunoblot analysis further confirmed that the lipid droplet-associated actin is the beta isoform. In cultured adrenocortical cells, stress fibers and the surface of intracellular lipid droplets were labeled with anti-beta-actin monoclonal antibody, whereas FITC-phalloidin staining did not mark the rim of lipid droplets. The present results provide the first morphological evidence that globular beta-actin is associated with intracellular lipid droplets. This significant association of actin with the surface of lipid droplets suggests that beta-actin might be involved in the regulation of intracellular lipid metabolism, particularly providing insight into the important transport of lipid constituents.

Use of coisogenic host blastocysts for efficient establishment of germline chimeras with C57BL/6J ES cell lines

Gene targeting in embryonic stem (ES) cells allows the production of mice with specified genetic mutations. Currently, germline-competent ES cell lines are available from only a limited number of mouse strains, and inappropriate ES cell/host blastocyst combinations often restrict the efficient production of gene-targeted mice. Here, we describe the derivation of C57BL/6J (B6) ES lines and compare the effectiveness of two host blastocyst donors, FVB/NJ (FVB) and the coisogenic strain C57BL/6-Tyr(c)-2J (c2J), for the production of germline chimeras. We found that when B6 ES cells were injected into c2J host blastocysts, a high rate of coat-color chimerism was detected, and germline transmission could be obtained with few blastocyst injections. In all but one case, highly chimeric mice transmitted to 100% of their offspring. The injection of B6 ES cells into FVB blastocysts produced some chimeric mice. However; the proportion of coat-color chimerism was low, with many more blastocyst injections required to generate chimeras capable of germline transmission. Our data support the use of the coisogenic albino host strain, c2J, for the generation of germline-competent chimeric mice when using B6 ES cells.

MRI of the hypothalamus and pituitary gland in patients with hyperprolactinaemia following radiotherapy for nasopharyngeal carcinoma

PURPOSE

Neuroendocrine dysfunction is a known complication of cranial radiation. While growth hormone deficiency is the most common laboratory finding, hyperprolactinaemia is one of the most common symptomatic dysfunction in adult female patients with nasopharyngeal carcinoma (NPC) following radiotherapy. This analysis aims to study the magnetic resonance imaging (MRI) features of the hypothalamus and the pituitary gland in affected patients.

METHODS

MRI was performed in 24 patients NPC with hyperprolactinaemia detected 10-52 months following one course of radical radiotherapy. The region of study included the nasopharynx, the hypothalamus and the pituitary gland in 20 patients, while in the remaining four patients, this was limited to the pituitary gland. The estimated radiation dose to the hypothalamus and the pituitary gland was 66 Gy, and six patients also had adjuvant chemotherapy. There was no clinical evidence of tumour recurrence in all 24 patients when hyperprolactinaemia was detected.

RESULTS

None of the 24 patients showed any MRI evidence of structural abnormality in the hypothalamic-pituitary region.

CONCLUSION

MRI did not reveal any structural abnormality in the hypothalamic-pituitary region of patients who developed hyperprolactinaemia following radiotherapy for NPC.

Comparative treatability of Moso bamboo and southern pine with CCA preservative using a commercial schedule

The United States Department of Agriculture introduced several bamboo species into the southern United States in the 1920s. One of the species included was Moso bamboo (Phyllostachys pubescens), a species native to China. This species grows well in South Carolina. In rural areas, bamboo splits are frequently used for fences and stakes for supporting crop plants. However, the decay resistance of bamboo is very low. In this study, Moso bamboo splits and southern pine lumber were treated in a commercial wood-treating plant using a full-cell process with Chromated Copper Arsenate (CCA) preservative to target retentions of 4.0 and 6.4kg/m3. Results indicate that bamboo is much more difficult to treat than southern pine. Using the same treatment procedures for southern pine, bamboo could only achieve approximately 22% of the target CCA retention.

Retrospective analysis on treating nasopharyngeal carcinoma with accelerated fractionation (6 fractions per week) in comparison with conventional fractionation (5 fractions per week): report on 3-year tumor control and normal tissue toxicity

BACKGROUND AND PURPOSE

To assess the therapeutic gain achieved by accelerated fractionation for non-keratinizing/undifferentiated nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

During January 1994 to October 1997, 325 patients were treated to a total dose of 66 Gy in 33-37 fractions: 167 (irradiated before mid-January 1996) with 5 daily fractions (CF) and subsequent 158 with 6 daily fractions (AF) per week. Their median treatment times were 46 and 39 days, respectively. Additional boost to parapharyngeal extension had been given to 181 and Cisplatin-based chemotherapy to 57 patients (24 concurrent with radiotherapy).

RESULTS

The AF group had significantly higher progression-free rate than the CF group (74 vs. 63% at 3 years, P=0.02 by the log-rank test). However, the difference in disease-specific survival (86 vs. 80%, P=0.39) and overall survival (81 vs. 78%, P=0.9) did not reach statistical significance. Strongly significant improvement in local failure-free rate was achieved for patients with T3-4 tumors (87 vs. 62%, P<0.01). Multivariate analyses showed that fractionation was an independent significant factor for overall progression: hazard ratio=0.63, 95% confidence interval: 0.41-0.98, P=0.04. Among the 268 patients treated with radiotherapy alone, those treated by AF had significantly higher incidence of acute reaction grade > or=3 (72 vs. 13%, P<0.01). However, all patients completed the scheduled dose without excessive prolongation, and no significant increase in late complications was observed (20 vs. 15% at 3 years, P=0.19).

CONCLUSIONS

The current analyses suggested that acceleration to 6 daily fractions per week could significantly improve the progression-free rate for NPC without excessive late toxicity. Improvement in local control was confined to T3-4 tumors.

PEG adsorption of autoantibodies and detection of alloantibodies in warm autoimmune hemolytic anemia

BACKGROUND

The purpose of this study was to evaluate the effectiveness of PEG in the adsorption of autoantibodies and the detection of alloantibodies in patients with warm autoimmune hemolytic anemia (WAIHA).

STUDY DESIGN AND METHODS

The study was divided into three parts. First, the effectiveness of antibody removal by a conventional adsorption procedure and that by the PEG adsorption method were compared by using commercial antisera adsorbed with antigen-positive RBCs. Second, patients' sera with known weak alloanti-E were used to test against screening cells after allogeneic adsorption to show nonspecific coating of antibodies and the dilution effect on the PEG adsorption procedure. Third, conventional and PEG one-cell sample allogeneic adsorptions of WAIHA patients' sera with and without alloantibodies were performed and compared.

RESULTS

In the first part, seven of the eight polyclonal antisera gave a lower titer and score when tested against antigen-positive RBCs in the indirect antiglobulin test; this indicated that PEG is more efficient in removing antibodies. In the second part, similar reaction patterns were observed in antibody screening tests on unadsorbed sera and on sera after the first, second, and third adsorptions, which indicated that there was no alloantibody loss, nonspecific antibody coating, or dilution effect when PEG was added in the allogeneic adsorption procedures. In the third part, a 40-percent increase in efficiency in reducing the number of adsorptions and an 85-percent decrease in completion time of the adsorption procedures were obtained when PEG was used for adsorbing sera from 16 patients with WAIHA. Both conventional and PEG procedures were capable of removing autoantibodies to identify the specificities of alloantibodies.

CONCLUSION

The PEG adsorption method is an effective, sensitive, and efficient method of enhancing auto- antibody adsorption and alloantibody detection. It can reduce the processing time and minimize the delay of urgent transfusions to patients with WAIHA and can indirectly enhance cost-effectiveness and decrease the labor-intensive testing required by these cases.

Metastatic tumour of the tunica vaginalis testis from carcinoma of the stomach

A 50-year-old man with advanced inoperable gastric adenocarcinoma and diffuse peritoneal metastasis received six cycles of palliative chemotherapy and responded clinically with weight gain. Two months after the completion of chemotherapy, however, he developed a left hydrocele. Aspiration yielded 70 ml of yellowish hydrocele fluid, which contained metastatic adenocarcinoma cells, consistent with a gastric primary tumour. A diagnosis of malignant hydrocele was made. Two weeks later, he developed a painful recurrent left hydrocele with increasing pain and swelling. Left orchidectomy was performed. Tiny white mural nodules measuring 1 mm in size were noted on the tunica vaginalis. No focal lesion was noted in the testis. On microscopic examination, the tunica vaginalis showed reactive mesothelial hyperplasia and extensive lymphatic permeation by poorly differentiated adenocarcinoma, consistent with a gastric primary tumour.

Both src-dependent and -independent mechanisms mediate phosphatidylinositol 3-kinase regulation of colony-stimulating factor 1-activated mitogen-activated protein kinases in myeloid progenitors

Colony-stimulating factor 1 (CSF-1) supports the proliferation, survival, and differentiation of bone marrow-derived cells of the monocytic lineage. In the myeloid progenitor 32D cell line expressing CSF-1 receptor (CSF-1R), CSF-1 activation of the extracellular signal-regulated kinase (ERK) pathway is both Ras and phosphatidylinositol 3-kinase (PI3-kinase) dependent. PI3-kinase inhibition did not influence events leading to Ras activation. Using the activity of the PI3-kinase effector, Akt, as readout, studies with dominant-negative and oncogenic Ras failed to place PI3-kinase downstream of Ras. Thus, PI3-kinase appears to act in parallel to Ras. PI3-kinase inhibitors enhanced CSF-1-stimulated A-Raf and c-Raf-1 activities, and dominant-negative A-Raf but not dominant-negative c-Raf-1 reduced CSF-1-provoked ERK activation, suggesting that A-Raf mediates a part of the stimulatory signal from Ras to MEK/ERK, acting in parallel to PI3-kinase. Unexpectedly, a CSF-1R lacking the PI3-kinase binding site (DeltaKI) remained capable of activating MEK/ERK in a PI3-kinase-dependent manner. To determine if Src family kinases (SFKs) are involved, we demonstrated that CSF-1 activated Fyn and Lyn in cells expressing wild-type (WT) or DeltaKI receptors. Moreover, CSF-1-induced Akt activity in cells expressing DeltaKI is SFK dependent since Akt activation was prevented by pharmacological or genetic inhibition of SFK activity. The docking protein Gab2 may link SFK to PI3-kinase. CSF-1 induced Gab2 tyrosyl phosphorylation and association with PI3-kinase in cells expressing WT or DeltaKI receptors. However, only in DeltaKI cells are these events prevented by PP1. Thus in myeloid progenitors, CSF-1 can activate the PI3-kinase/Akt pathway by at least two mechanisms, one involving direct receptor binding and one involving SFKs.

Alloimmunization in Chinese with warm autoimmune haemolytic anaemia - incidence and characteristics

We perform a retrospective study to determine the incidence and characteristics of alloimmunization in Chinese patients with warm autoimmune haemolytic anaemia. Among 67 patients studied, clinically significant alloantibodies were found in only eight patients, giving a rate of alloimmunization of 11.3%. The latter contrasts with the much higher rate reported in the Western population. This probably reflects the genetic homogeneity in Chinese with respect to the red cell phenotype. The alloimmunization rate, however, is still significant and therefore comprehensive pretransfusion testing is required for Chinese patients with warm autoantibodies so as to safeguard patient's safety.

Analysis of released products from oxidized ultra-high molecular weight polyethylene incubated with hydrogen peroxide and salt solutions

The wear of ultra-high molecular weight polyethylene (UHMWPE) implants generates polymeric and metallic particulate, which can be phagocytosed by human macrophages. The generation of these UHMWPE particles has been attributed to wear mechanisms and oxidation of the material. Many cell/particle studies have focused specifically on investigating particles of virgin materials themselves (i.e. virgin UHMWPE), while in fact, there is a strong likelihood that the oxidation processes encountered by the materials will yield particles with very different surface chemistries. Therefore, it is conceivable that chemical changes in the material would lead to altered cellular responses, as measured in the various cell study models. This paper has focused on the characterization of UHMWPE particulates that have been exposed to various conditions simulating processing steps and some of the oxidative and hydrolytic agents related to inflammatory responses. These include gamma-irradiation, thermal treatment and chemical oxidation by H2O2 and saline solutions. Oxidation of the particles was measured using Fourier transform infrared spectroscopy (FTIR). Degradation products were isolated from the incubation solutions using high-performance liquid chromatography (HPLC). UHMWPE particulates underwent extensive oxidation after gamma-irradiation and thermal treatments. There were marked differences following treatments of film samples taken from bar stock and the virgin particle samples. Polymer-related products, containing alkenes, alkanes and hydroxyl groups, were found in the incubation solutions. The study concluded that future work must consider both the particulates' surface chemistry and the possibility of soluble degradation products when assessing UHMWPE/cellular interactions.

Measuring quality of life of Chinese cancer patients: A validation of the Chinese version of the Functional Assessment of Cancer Therapy-General (FACT-G) scale

BACKGROUND

Few cancer specific quality-of-life (QoL) measures from the West have been translated for use with Chinese-speaking patients, and no substantial validation of these translations with adequately large cohorts has been published previously, to the authors' knowledge. The Functional Assessment of Cancer Therapy-General (FACT-G) is a well-validated QoL instrument that is specific to cancer patients. The scale was translated into Chinese and the psychometric properties of this translated scale (FACT-G [Ch]) were tested with a Chinese sample in Hong Kong, China.

METHODS

A total of 1262 Chinese cancer patients were selected in 3 samples from 5 Hong Kong regional hospitals. Quantitative and qualitative data were used to assess the cultural equivalence, factor structure, reliability, and validity of the FACT-G (Ch).

RESULTS

Focus group discussions indicated that the FACT-G was seen as covering QoL domains identified as important and relevant to Chinese cancer patients, though in some respects it was seen as having limited scope in this sample. Psychometrically, the factor structure of the FACT-G deviated from that of the original work. The FACT-G (Ch) had acceptable reliability (Cronbach alpha 0.85). The convergent validity of the FACT-G (Ch) with a generic QoL measure (WHOQOL-BREF[HK]) was 0.72 (P < 0.001), and divergent validity showed low correlations of less than 0.15 (P < 0.05) with non-QoL measures.

CONCLUSIONS

Focus group data indicated that the FACT-G translation into Chinese was seen as a conceptually relevant and moderately sufficient QoL measure. Psychometrically, the instrument had acceptable properties, but conceptual differences from the original version were suggested. Although more work is needed to increase its adequacy, the translated scale has reasonable utility for use with Chinese populations in clinical settings.

"Hypotyrosinemia" in phenylketonuria

It has been postulated that the significant incidence of learning disabilities in well-treated patients with phenylketonuria (PKU) may be due, in part, to reduced production of neurotransmitters as a result of deficient tyrosine transport across the neuronal cell membrane. Hypotyrosinemia has been reported in treated and untreated PKU but virtually no data are available. We decided to examine this in our patient population and to compare it with the published norms, patient data from our hospital clinical biochemical laboratory database, and a group of normal children and adolescents in a private pediatric practice. We found that the mean nonfasting plasma tyrosine in 99 classical PKU patients was 41.1 micromol/L, in 26 mild (atypical) PKU patients 53.3 micromol/L, and in 35 non-PKU mild hyperphenylalaninemia patients 66.6 micromol/L. This compared to nonfasting plasma tyrosine levels in 102 non-PKU subjects of 64.0 micromol/L in our hospital biochemistry database, 69.1 micromol/L in 58 volunteers in the private office practice, and 64-78.8 micromol/L in infants, children, and adolescents in the literature review. Our data support the previously undocumented statements in the literature that plasma tyrosine levels are low in PKU.

Total biological effect on late reactive tissues following reirradiation for recurrent nasopharyngeal carcinoma

PURPOSE

To assess the additional damage of normal tissues attributable to reirradiation and the magnitude of partial recovery following the initial course.

METHODS AND MATERIALS

Symptomatic late complication rates (excluding xerostomia) in 3635 patients receiving one course (Group 1) and 487 patients receiving two courses of external radiotherapy (Group 2) for nasopharyngeal carcinoma were retrospectively analyzed and compared.

RESULTS

Group 2 had significantly lower actuarial complication-free survival rates than Group 1: 48% versus 81% at 5 years. The post-retreatment incidence was significantly affected by biologically effective dose (BED) (assuming an alpha/beta ratio of 3 Gy) of the first course: hazard ratio (HR) = 1.04 per Gy(3) (p = 0.01), but only marginally by that of the second course: HR = 1.01 per Gy(3) (p = 0.06). If the summated BED was taken as the dose unit, it was estimated that a total BED of 143 Gy(3) would induce a 20% incidence at 5 years, while the corresponding dose projected from Group 1 was 111 Gy(3). The gap effect was insignificant in the overall analyses, but a trend of decreasing risk with increasing interval was observed in patients with gap > or = 2 years: HR = 0.86 per year (p = 0.07).

CONCLUSION

The major determinant of post-retreatment complication is the severity of damage during the initial course. The sum of total doses tolerated is higher than that expected with a single-course treatment, suggesting occurrence of partial recovery (particularly in those reirradiated after an interval of 2 years or more).

Quadruple primary neoplasms in a 27-year-old woman

A27-year-old woman was referred to our department on 3 February 1998 with a diagnosis of malignant melanoma associated with cystic teratoma of ovary. She had had a laparotomy and bilateral salphingo-oophorectomy on 5 January 1998. Pathology revealed tumour involvement of left ovary, left parametrium and malignant ascites, the right ovary showed polycystic disease, the uterus showed simple hyperplasia of endothelium, the omentum had no tumour and subdiaphragmatic scrapping was negative. On histological examination of the tumour, the cystic portion was basically a cystic teratoma with presence of skin, glial and bony tissue, the solid portion consisted of sheets of undifferentiated tumour cells, which on immunohistochemical staining shown strong positivity to HMB 45 and S-100. Ultrastructual examination confirmed melanocytic differentiation.

Her chest X-ray was clear. Computed tomography of abdomen and pelvis suggested bilobar liver metastasis and significant para-aortic lymphadenopathy. The alpha-fetoprotein (αFP) and beta-human chorionic gonadotrophin (β-hCG) were within normal limits. The diagnosis was a malignant melanoma arising in cystic teratoma of ovary, stage IV disease.

Her past medical history included multiple primary neoplasms. She had right thigh cutaneous histiocytoma at the age of 20 years, with complete excision performed. She developed poorly differentiated invasive ductal carcinoma of left breast (stage pT2N0M0) at the age of 21 years and had a left mastectomy and left axillary clearance; no postoperative adjuvant treatment was given. She also recently had multiple thyroid nodules which shown atypical cells, suggestive of a follicular neoplasm, and total thyroidectomy was contemplated.

Evaluation of her family revealed a strong family history of malignancy. Her twin sister died of a primary brain tumour at the age of 8 years. Her father died of lung cancer at the age of 45 years. Her paternal grandfather died of lung cancer in his 60s. Her paternal grandmother died of primary liver cancer in her 60s. One of her paternal half-uncles (mutual grandfather, different grandmothers) died of a primary brain tumour in his 50s while another died of lung cancer in his 70s. There was no positive family history of malignancy on her maternal side (Figure 1).

She was treated with combination chemotherapy using cisplatin (75 mg/m2) and cyclophosphamide (750 mg/m2). However, she deteriorated rapidly after the first cycle of chemotherapy and died on 16 March 1998.

Structural adaptation to selective pressure for altered ligand specificity in the Pseudomonas aeruginosa amide receptor, amiC

The AmiC protein in Pseudomonas aeruginosa is the negative regulator and ligand receptor for an amide-inducible aliphatic amidase operon. In the wild-type PAC1 strain, amidase expression is induced by acetamide or lactamide, but not by butyramide. A mutant strain of P. aeruginosa, PAC181, was selected for its sensitivity to induction by butyramide. The molecular basis for the butyramide inducible phenotype of P.aeruginosa PAC181 has now been determined, and results from a Thr-->Asn mutation at position 106 in PAC181-AmiC. In the wild-type PAC1-AmiC protein this residue forms part of the side wall of the amide-binding pocket but does not interact with the acetamide ligand directly. In the crystal structure of PAC181-AmiC complexed with butyramide, the Thr-->Asn mutation increases the size of the ligand binding site such that the mutant protein is able to close into its 'on' configuration even in the presence of butyramide. Although the mutation allows butyramide to be recognized as an inducer of amidase expression, the mutation is structurally sub-optimal, and produces a significant decrease in the stability of the mutant protein.

CSF-1 activates MAPK-dependent and p53-independent pathways to induce growth arrest of hormone-dependent human breast cancer cells

The CSF-1 receptor (CSF-1R) is expressed in >50% of human breast cancers. To investigate the consequence of CSF-1R expression, hormone-dependent human breast cancer cell lines, MCF-7 and T-47D, were transfected with CSF-1R. Unexpectedly, CSF-1 substantially inhibited estradiol (E2) and insulin-dependent proliferation of MCF-7 transfectants (MCF-7fms) and prevented cyclin E/cdk2 and cyclin A/cdk2 activation, consistent with a G1 arrest. In contrast, CSF-1 increased DNA synthesis in T-47D transfectants (T-47Dfms) alone and with E2 or insulin. In response to CSF-1, there was a marked and sustained upregulation of the cyclin-dependent kinase inhibitor, p21Waf1/Cip1, in MCF-7fms but not T-47Dfms. CSF-1 also markedly upregulated cyclin D1 in MCF-7fms. The coordinate increase in cyclin D1 and p21 had the effect of decreasing the specific but not absolute activity of cyclin D1/cdk4. p53 was not involved since CSF-1 induction of p21 was unaffected by dominant-negative p53 expression. ERK activation by CSF-1 was robust and sustained in MCF-7fms and to a much lesser extent in T-47Dfms. Using pharmacological and transient transfection approaches, we showed that ERK activation was necessary and sufficient for p21 induction in MCF-7fms. Moreover, activated MEK inhibited E2-stimulated cdk2 activity. Our findings indicate that the consequence of CSF-1R-mediated signals in human breast cancer cells is dependent on the genetic background of the particular tumor.

New approaches to virtual environment surgery

This research focused on two main problems: 1) low cost, high fidelity stereoscopic imaging of complex tissues and organs; and 2) virtual cutting of tissue. A further objective was to develop these images and virtual tissue cutting methods for use in a telemedicine project that would connect remote sites using the Next Generation Internet. For goal one we used a CT scan of a human heart, a desktop PC with an OpenGL graphics accelerator card, and LCD stereoscopic glasses. Use of multiresolution meshes ranging from approximately 1,000,000 to 20,000 polygons speeded interactive rendering rates enormously while retaining general topography of the dataset. For goal two, we used a CT scan of an infant skull with premature closure of the right coronal suture, a Silicon Graphics Onyx workstation, a Fakespace Immersive WorkBench and CrystalEyes LCD glasses. The high fidelity mesh of the skull was reduced from one million to 50,000 polygons. The cut path was automatically calculated as the shortest distance along the mesh between a small number of hand selected vertices. The region outlined by the cut path was then separated from the skull and translated/rotated to assume a new position. The results indicate that widespread high fidelity imaging in virtual environment is possible using ordinary PC capabilities if appropriate mesh reduction methods are employed. The software cutting tool is applicable to heart and other organs for surgery planning, for training surgeons in a virtual environment, and for telemedicine purposes.

Operating theater blood transaction system. A "virtual" blood transfusion service that brings the blood bank to the operating table

We describe an operating theater blood transaction system (OTBTS) that is a novel computer software system incorporating electronic crossmatch and the concept of a "self-service" blood banking system in the operating theater. Through this system, the surgeons and the anesthetists can issue blood units for intraoperative transfusion for the patients with a negative antibody screen without the need for a porter service or pneumatic tube system. Since implementation of the OTBTS, the time for obtaining compatible blood for intraoperative transfusion has been reduced from 20 to 30 minutes to around 1 minute. Furthermore, the crossmatch-transfusion ratio was reduced to 1.05. The 23% of patients who required extra blood units (i.e., more than originally anticipated) during surgery further benefited from the system. The blood stock reserved for patients undergoing surgery was reduced by 20%. Therefore, the OTBTS is a system that can greatly enhance the efficiency and safety of intraoperative transfusion and can also save workforce resources.

Caution on the use of altered fractionation for nasopharyngeal carcinoma

Randomized trials and overviews on the value of altered fractionation for head and neck cancers are reviewed. Attention is drawn to the unexpectedly high incidence of temporal lobe necrosis incurred in patients with nasopharyngeal carcinoma. Preliminary analyses suggest that incomplete repair is likely to be the major factor, even a 6-h interfraction interval may be inadequate if substantial volumes of nervous tissues are included within the target volume.

Staging of nasopharyngeal carcinoma: from Ho's to the new UICC system

The independent significance of different tumor factors in 4,514 patients with undifferentiated or non-keratinizing carcinoma of the nasopharynx irradiated at the Queen Elizabeth Hospital during 1976-1985 were analyzed retrospectively. Multivariate analyses showed that the most significant primary factors included cranial nerve palsy, erosion of base of skull and oropharynx. For tumors within the nasopharynx, there was no difference in survival between those with involvement of 1 site vs. more than 1 sites. Patients with cranial nerve palsy had significantly worse prognosis than those with bony erosion alone. Although the nodal characteristics (size, level of extension, fixation, laterality and multiplicity) were inter-related, their independent impact all reached statistical significance. However, the criteria used currently could be simplified: laterality should be revised to unilateral vs. bilateral, level to upper-mid vs. lower neck, and size to < or =6 cm vs. >6 cm. Grouping of N2 together with N3 into Stage IV was inappropriate as the former had significantly better prognosis. Our findings, together with review of the publications, provided clinical data for developing the current UICC staging system for nasopharyngeal carcinoma. Such major revision resulted not only in better distinction of hazards, but also more even distribution of cases between different stages.

Recurrent nasopharyngeal carcinoma: the puzzles of long latency

PURPOSE

To study the peculiar characteristics of relapses with long latency following radical treatment for nasopharyngeal carcinoma.

METHODS AND MATERIALS

847 patients with nasopharyngeal recurrence were retrospectively studied, focusing on the independent effects of latency on different outcome aspects and its relationship with other prognostic factors.

RESULTS

The proportion of recurrence with latency <2 years (Group A), 2-<5 years (Group B), and 25 years (Group C) were 52%, 39%, and 9%, respectively. A higher proportion of Group C originated from patients with node-negative early primary, but fewer of them were still confined within the nasopharynx at detection of recurrence. There was no significant difference in the choice of salvage modality, but among those reirradiated, more of Group C were treated with external beams to a higher dose. The difference in local salvage rate was not statistically significant, but the 5-year distant failure-free rates of the 3 groups were 57%, 67%, and 83%, respectively; and the corresponding disease-specific survival (DSS) were 14%, 20%, and 35%. Multivariate analysis confirmed the independent significance of latency in predicting distant failure (hazard ratio = 0.81 per year, p < 0.01) and cancer deaths (hazard ratio = 0.90 per year, p < 0.01).

CONCLUSIONS

Nasopharyngeal recurrence with long latency showed different natural behavior: the prognosis was significantly better due to lower risk of distant failure.

Synergistic activation of mitogen-activated protein kinase by cyclic AMP and myeloid growth factors opposes cyclic AMP's growth-inhibitory effects

Colony-stimulating factors (CSFs) promote the proliferation, differentiation, commitment, and survival of myeloid progenitors, whereas cyclic AMP (cAMP)-mediated signals frequently induce their growth arrest and apoptosis. The ERK/mitogen-activated protein kinase (MAPK) pathway is a target for both CSFs and cAMP. We investigated how costimulation by cAMP and colony-stimulating factor-1 (CSF-1) or interleukin-3 (IL-3) modulates MAPK in the myeloid progenitor cell line, 32D. cAMP dramatically increased ERK activity in the presence of CSF-1 or IL-3. IL-3 also synergized with cAMP to activate ERK in another myeloid cell line, FDC-P1. The increase in ERK activity was transmitted to a downstream target, p90(rsk). cAMP treatment of 32D cells transfected with oncogenic Ras was found to recapitulate the superactivation of ERK seen with cAMP and CSF-1 or IL-3. ERK activation in the presence of cAMP did not appear to involve any of the Raf isoforms and was blocked by expression of dominant-negative MEK1 or treatment with a MEK inhibitor, PD98059. Although cAMP had an overall inhibitory effect on CSF-1-mediated proliferation and survival, the inhibition was markedly increased if ERK activation was blocked by PD98059. These findings suggest that upregulation of the ERK pathway is one mechanism induced by CSF-1 and IL-3 to protect myeloid progenitors from the growth-suppressive and apoptosis-inducing effects of cAMP elevations.