Intratumoral dendritic cell-CD4+ T helper cell niches enable CD8+ T cell differentiation following PD-1 blockade in hepatocellular carcinoma

Despite no apparent defects in T cell priming and recruitment to tumors, a large subset of T cell rich tumors fail to respond to immune checkpoint blockade (ICB). We leveraged a neoadjuvant anti-PD-1 trial in patients with hepatocellular carcinoma (HCC), as well as additional samples collected from patients treated off-label, to explore correlates of response to ICB within T cell-rich tumors. We show that ICB response correlated with the clonal expansion of intratumoral CXCL13+CH25H+IL-21+PD-1+CD4+ T helper cells ("CXCL13+ TH") and Granzyme K+ PD-1+ effector-like CD8+ T cells, whereas terminally exhausted CD39hiTOXhiPD-1hiCD8+ T cells dominated in nonresponders. CD4+ and CD8+ T cell clones that expanded post-treatment were found in pretreatment biopsies. Notably, PD-1+TCF-1+ (Progenitor-exhausted) CD8+ T cells shared clones mainly with effector-like cells in responders or terminally exhausted cells in nonresponders, suggesting that local CD8+ T cell differentiation occurs upon ICB. We found that these Progenitor CD8+ T cells interact with CXCL13+ TH within cellular triads around dendritic cells enriched in maturation and regulatory molecules, or "mregDC". These results suggest that discrete intratumoral niches that include mregDC and CXCL13+ TH control the differentiation of tumor-specific Progenitor exhasuted CD8+ T cells following ICB.

Neoadjuvant cemiplimab for resectable hepatocellular carcinoma: a single-arm, open-label, phase 2 trial

BACKGROUND

Surgical resection of early stage hepatocellular carcinoma is standard clinical practice; however, most tumours recur despite surgery, and no perioperative intervention has shown a survival benefit. Neoadjuvant immunotherapy has induced pathological responses in multiple tumour types and might decrease the risk of postoperative recurrence in hepatocellular carcinoma. We aimed to evaluate the clinical activity of neoadjuvant cemiplimab (an anti-PD-1) in patients with resectable hepatocellular carcinoma.

METHODS

For this single-arm, open-label, phase 2 trial, patients with resectable hepatocellular carcinoma (stage Ib, II, and IIIb) were enrolled and received two cycles of neoadjuvant cemiplimab 350 mg intravenously every 3 weeks followed by surgical resection. Eligible patients were aged 18 years or older, had confirmed resectable hepatocellular carcinoma, an Eastern Cooperative Oncology Group performance status of 0 or 1, and adequate liver function. Patients were excluded if they had metastatic disease, if the surgery was not expected to be curative, if they had a known additional malignancy requiring active treatment, or if they required systemic steroid treatment or any other immunosuppressive therapy. After resection, patients received an additional eight cycles of cemiplimab 350 mg intravenously every 3 weeks in the adjuvant setting. The primary endpoint was significant tumour necrosis on pathological examination (defined as >70% necrosis of the resected tumour). Secondary endpoints included delay of surgery, the proportion of patients with an overall response, change in CD8+ T-cell density, and adverse events. Tumour necrosis and response were analysed in all patients who received at least one dose of cemiplimab and completed surgical resection; safety and other endpoints were analysed in the intention-to-treat population. Patients underwent pre-treatment biopsies and blood collection throughout treatment. This trial is registered with ClinicalTrials.gov (NCT03916627, Cohort B) and is ongoing.

FINDINGS

Between Aug 5, 2019, and Nov 25, 2020, 21 patients were enrolled. All patients received neoadjuvant cemiplimab, and 20 patients underwent successful resection. Of the 20 patients with resected tumours, four (20%) had significant tumour necrosis. Three (15%) of 20 patients had a partial response, and all other patients maintained stable disease. 20 (95%) patients had a treatment-emergent adverse event of any grade during the neoadjuvant treatment period. The most common adverse events of any grade were increased aspartate aminotransferase (in four patients), increased blood creatine phosphokinase (in three), constipation (in three), and fatigue (in three). Seven patients had grade 3 adverse events, including increased blood creatine phosphokinase (in two patients) and hypoalbuminaemia (in one). No grade 4 or 5 events were observed. One patient developed pneumonitis, which led to a delay in surgery by 2 weeks.

INTERPRETATION

This report is, to our knowledge, the largest clinical trial of a neoadjuvant anti-PD-1 monotherapy reported to date in hepatocellular carcinoma. The observed pathological responses to cemiplimab in this cohort support the design of larger trials to identify the optimal treatment duration and definitively establish the clinical benefit of preoperative PD-1 blockade in patients with hepatocellular carcinoma.

FUNDING

Regeneron Pharmaceuticals.

Taraxasterol inhibits TGF-β1-induced epithelial-to-mesenchymal transition in papillary thyroid cancer cells through regulating the Wnt/β-catenin signaling

Taraxasterol (TAR) is a kind of active compound extracted from dandelion and its molecular structure resembles steroid hormones. Recently, TAR has been reported to show an anti-tumor activity. However, the specific role of TAR in papillary thyroid cancer (PTC) has not been clarified. In this study, we investigated the effect of TAR on PTC cell migration, invasion and epithelial-to-mesenchymal transition (EMT) induced by TGF-β1. PTC cells were exposed to TGF-β1 (5 ng/mL) and then treated with different concentrations of TAR. We found that TAR showed no obvious cytotoxicity below 10 μg/mL but notably reduced migration and invasion of TGF-β1-treated PTC cells. Moreover, TAR treatment decreased MMP-2 and MMP-9 levels, and obviously affected the expression of EMT markers. We also observed that Wnt3a and β-catenin levels were significantly increased in TGF-β1-treated PTC cells while TAR inhibited these effects in a concentration-dependent manner. Additionally, activation of the Wnt pathway by LiCl attenuated the suppressive effect of TAR on TGF-β1-induced migration, invasion and EMT in PTC cells. Taken together, we highlighted that TAR could significantly suppress TGF-β1-regulated migration and invasion by reversing the EMT process via the Wnt/β-catenin pathway, suggesting that TAR may be a potential anti-cancer agent for PTC treatment.

Exploration of effect of Odanacatib on inhibiting orthodontic recurrence in rats and on CatK and IGF-1 mRNA

OBJECTIVE

This study aimed to investigate the inhibitory effect of Odanacatib on orthodontic recurrence in rats.

MATERIALS AND METHODS

Forty rats were selected to establish a planting anchorage molar movement model, and 50 g of force was used for the mesial movement of the right maxillary first molar. Forty rats were randomly divided into the observation group (n=20) and control group (n=20). Odanacatib (60 μl, 1.25 μM) was locally injected into the mucoperiosteum around the right maxillary first molar of rats in the experimental group, and an equal amount of normal saline was injected into rats in the control group. A Vernier caliper was used for measuring the recurrence movement distance and recurrence rate of rats, Micro-CT for scanning the bone mineral density (BMD) and bone volume fraction (BVF) of the alveolar bone, TRAP special staining for observing changes in osteoclasts and quantitative Real Time-Polymerase Chain Reaction (qRT-PCR) for detecting the mRNA expressions of cathepsin K (CatK) and insulin-like growth factor 1 (IGF-1) in periodontal tissues.

RESULTS

After 3 weeks of modeling, the movement distance of the first molar of rats in the two groups was 1.16±0.19 mm. The molar movement distance and recurrence rate of rats were significantly higher in the control group than those in the observation group (p<0.05). The BMD and BVF of the alveolar bone of rats were markedly lower in the control group than those in the observation group (p<0.05). There was no statistically significant difference in the number of osteoclasts between the observation group (26.15±3.92) and the control group (27.01±2.74) (t=0.882, p=0.383). The CatK mRNA expression of rats was remarkably lower in the observation group than that in the control group (p<0.05). The IGF-1 mRNA expression of rats was significantly higher in the observation group than that in the control group (p<0.05).

CONCLUSIONS

By promoting the IGF-1 mRNA expression and increasing the BMD and BVF of the alveolar bone, Odanacatib inhibits orthodontic recurrence and has no effect on osteoclast activity.

Identification and Characterization of Single-Chain Antibodies that Specifically Bind GI Noroviruses

Norovirus infections commonly lead to outbreaks of acute gastroenteritis and spread quickly, resulting in many health and economic challenges prior to diagnosis. Rapid and reliable diagnostic tests are therefore essential to identify infections and to guide the appropriate clinical responses at the point-of-care. Existing tools, including RT-PCR and enzyme immunoassays, pose several limitations based on the significant time, equipment and expertise required to elicit results. Immunochromatographic assays available for use at the point-of-care have poor sensitivity and specificity, especially for genogroup I noroviruses, thus requiring confirmation of results with more sensitive testing methods. Therefore, there is a clear need for novel reagents to help achieve quick and reliable results. In this study, we have identified two novel single-chain antibodies (scFvs)—named NJT-R3-A2 and NJT-R3-A3—that effectively detect GI.1 and GI.7 virus-like particles (VLPs) through selection of a phage display library against the P-domain of the GI.1 major capsid protein. The limits of detection by each scFv for GI.1 and GI.7 are 0.1 and 0.2 ng, and 6.25 and 25 ng, respectively. They detect VLPs with strong specificity in multiple diagnostic formats, including ELISAs and membrane-based dot blots, and in the context of norovirus-negative stool suspensions. The scFvs also detect native virions effectively in norovirus-positive clinical stool samples. Purified scFvs bind to GI.1 and GI.7 VLPs with equilibrium constant (K_D) values of 27 nM and 49 nM, respectively. Overall, the phage-based scFv reagents identified and characterized here show utility for detecting GI.1 and GI.7 noroviruses in multiple diagnostic assay formats with strong specificity and sensitivity, indicating promise for integration into existing point-of-care tests to improve future diagnostics.

Replication of human noroviruses in stem cell-derived human enteroids

The major barrier to research and development of effective interventions for human noroviruses (HuNoVs) has been the lack of a robust and reproducible in vitro cultivation system. HuNoVs are the leading cause of gastroenteritis worldwide. We report the successful cultivation of multiple HuNoV strains in enterocytes in stem cell-derived, nontransformed human intestinal enteroid monolayer cultures. Bile, a critical factor of the intestinal milieu, is required for strain-dependent HuNoV replication. Lack of appropriate histoblood group antigen expression in intestinal cells restricts virus replication, and infectivity is abrogated by inactivation (e.g., irradiation, heating) and serum neutralization. This culture system recapitulates the human intestinal epithelium, permits human host-pathogen studies of previously noncultivatable pathogens, and allows the assessment of methods to prevent and treat HuNoV infections.

Detection of human norovirus in intestinal biopsies from immunocompromised transplant patients

Human noroviruses (HuNoVs) can often cause chronic infections in solid organ and haematopoietic stem cell transplant (HSCT) patients. Based on histopathological changes observed during HuNoV infections, the intestine is the presumed site of virus replication in patients; however, the cell types infected by HuNoVs remain unknown. The objective of this study was to characterize histopathological changes during HuNoV infection and to determine the cell types that may be permissive for HuNoV replication in transplant patients. We analysed biopsies from HuNoV-infected and non-infected (control) transplant patients to assess histopathological changes in conjunction with detection of HuNoV antigens to identify the infected cell types. HuNoV infection in immunocompromised patients was associated with histopathological changes such as disorganization and flattening of the intestinal epithelium. The HuNoV major capsid protein, VP1, was detected in all segments of the small intestine, in areas of biopsies that showed histopathological changes. Specifically, VP1 was detected in enterocytes, macrophages, T cells and dendritic cells. HuNoV replication was investigated by detecting the non-structural proteins, RdRp and VPg. We detected RdRp and VPg along with VP1 in duodenal and jejunal enterocytes. These results provide critical insights into histological changes due to HuNoV infection in immunocompromised patients and propose human enterocytes as a physiologically relevant cell type for HuNoV cultivation.

Characterization of cross-reactive norovirus-specific monoclonal antibodies

Noroviruses (NoVs) commonly cause acute gastroenteritis outbreaks. Broadly reactive diagnostic assays are essential for rapid detection of NoV infections. We previously generated a panel of broadly reactive monoclonal antibodies (MAbs). We characterized MAb reactivities by use of virus-like particles (VLPs) from 16 different NoV genotypes (6 from genogroup I [GI], 9 from GII, and 1 from GIV) coating a microtiter plate (direct enzyme-linked immunosorbent assay [ELISA]) and by Western blotting. MAbs were genotype specific or recognized multiple genotypes within a genogroup and between genogroups. We next applied surface plasmon resonance (SPR) analysis to measure MAb dissociation constants (Kd) as a surrogate for binding affinity; a Kd level of <10 nM was regarded as indicating strong binding. Some MAbs did not interact with the VLPs by SPR analysis. To further assess this lack of MAb-VLP interaction, the MAbs were evaluated for the ability to identify NoV VLPs in a capture ELISA. Those MAbs for which a Kd could not be measured by SPR analysis also failed to capture the NoV VLPs; in contrast, those with a measurable Kd gave a positive signal in the capture ELISA. Thus, some broadly cross-reactive epitopes in the VP1 protruding domain may be partially masked on intact particles. One MAb, NV23, was able to detect genogroup I, II, and IV VLPs from 16 genotypes tested by sandwich ELISA, and it successfully detected NoVs in stool samples positive by real-time reverse transcription-PCR when the threshold cycle (CT) value was <31. Biochemical analyses of MAb reactivity, including SPR analysis, identified NV23 as a broadly reactive ligand for application in norovirus diagnostic assays.

Metastasis from endometrial carcinoma to bilateral breasts presenting as inflammatory breast lesions

BACKGROUND

Endometrial carcinoma rarely metastasizes to the bilateral breasts and presents as an inflammatory breast lesion. In this paper, we report a case of bilateral breast metastatic endometrial carcinoma and describe the clinical and pathological features. It is the second case of this kind of disease and the first case report with full clinical data.

CASE REPORT

A 56-year-old Chinese woman (G3, P3) with endometrial carcinoma received cytoreductive surgery and chemotherapy. Approximately 22 months later, she presented with pain in the right axillary region and edema of the right breast. The pathology report confirmed multifocal invasive papillary adenocarcinoma of the right mammary gland, consistent with endometrial carcinoma metastasis. Although she received many lines of chemotherapy, the disease still progressed and metastasized to the contralateral breast. Gefitinib (Iressa) improved symptoms temporarily.

CONCLUSIONS

Bilateral breasts metastasis of endometrial carcinoma is rare and difficult to treat. Molecular targeted therapy may be an effective treatment for breast metastasis.

Effects of cyclic strain on endothelial cell apoptosis and tubulogenesis are dependent on ROS production via NAD(P)H subunit p22phox

OBJECTIVE

Vascular endothelial cells (ECs) are constantly exposed to blood flow associated forces such as cyclic strain due to blood pressure, which affects ECs survival and angiogenesis by producing ROS via NAD(P)H oxidase. NAD(P)H oxidase subunit p22phox is reported to be related to the development of atherosclerosis and increased levels of p22phox mRNA are correlated to ECs proliferation. However, the importance and signaling mechanism of p22phox on ECs survival and angiogenesis under cyclic strain are unclear.

METHODS

5%-20% cyclic strain were applied by the Flexercell system to simulate in vivo environment of human ECs; the effect of p22phox on mechanical ECs survival mechanism and tubulogenesis was determined by western blot and 3-D tissue culture by knocking down p22phox expression via shRNA plasmid.

RESULTS

Knockdown of p22phox induced expression of cleaved caspase-3 and decreased cell viability ratio (CVR). 5% strain increased and 20% strain decreased CVR of shp22phox cells. There were complex biphasic effects of cyclic strain on ECs survival signaling. 5% strain continuously increased Akt phosphorylation; 20% strain increased after 10min stimulation and decreased Akt phosphorylation lately. 5% strain increased and 20% strain decreased eNOS phosphorylation. Knockdown of p22phox decreased Akt and eNOS phosphorylation with or without cyclic strain. ROS production was increasingly stimulated progressively by strain via the p22phox pathway. 5% strain increased and 20% strain decreased total NO production and vascular tubulogenesis via p22phox pathway.

CONCLUSION

ROS production is pivotal to responses to physiological or pathological strain. Physiological strain increases but pathological strain decreases ECs survival and tubulogenesis, and these effects occur via the NAD(P)H subunit p22phox pathway.

Effects of Angiotensin II on human endothelial cells survival signalling pathways and its angiogenic response

Reduced capillary density (rarefaction) is an early event of cardiovascular disease. The PI-3K-Akt pathway is a key player in anti-endothelial cells (ECs) apoptosis. VEGF is a key growth factor for angiogenesis. We investigated the effect of Angiotensin II (Ang II) on ECs survival signalling and angiogenesis in vitro. We found that Ang II had a biphasic effect on Akt phosphorylation by western blotting analysis. Low concentration Ang II caused a dose-dependent increase in Akt phosphorylation, while high concentration of Ang II led to a decrease of Akt phosphorylation. This effect was negative regulated by its type II receptor. Ang II 10(-4) M induced ECs apoptosis by its type II receptor was completely blocked by VEGF. Cell viability was increased by Ang II 10(-6) M and decreased by Ang II 10(-4) M. It was further decreased by pre-treatment with PI-3K/Akt inhibitor LY294002, but unaffected by p38-MAPK inhibitor SB202190. Ang II 10(-4) M reduced ECs' proliferation and vascular tube length, which were in part regulated by type II receptor. Our findings support a dose-dependent role of Ang II in effect on ECs survival and angiogenesis by PI-3K/Akt pathway. The anti-angiogenic effect of Ang II was mediated by its type II receptor.

Gene Therapeutic Exploration: Retrovirus-Mediated Soluble Vascular Endothelial Growth Factor Receptor-2 (sFLK-1) Inhibits the Tumorigenicity of S180, MCF-7, and B16 Cells In Vivo

Inhibition of tumor angiogenesis is an anticancer strategy in which neovasculature is targeted because tumor progression relies on neovascularization. The soluble, truncated form of vascular endothelial growth factor receptor-2 (VEGFR-2), sFLK-1, is a well-known inhibitor of endothelial cells. This kind of soluble receptor retains its high-affinity binding to VEGF, but cannot work with the receptor tyrosine transphosphorylation and activation of downstream signal transduction to induce endothelial proliferation due to the lack of the tyrosine kinase domain. Therefore, we tried to use this sFLK-1 as an inhibitor for malignant tumor gene therapy. In this study we transferred a soluble VEGFR-2 (sFLK-1) from embryo mouse liver by RT-PCR to PA317 cells through retroviral vector (pLXSN) and obtained stable expression. NIH3T3 cells were used for measuring the virus titer. The virus titer in this experiment was 2 x 10(7) CFU/ml. After 7 days of preparing subcutaneous tumor models bearing S180, MCF-7, and B16 cells in mice, respectively, 2 x 10(7) PFU of recombinant retroviruses were injected locally into the tumors the treatment groups. After treatment, the tumor size and weight were significantly smaller than that of control (p < 0.05). After autopsy, the metastasic focus numbers in the treatment groups were also less than control groups. We also measured VEGFR-2 expression in tumor tissues by Western blot to check if sFLK-1 had been integrated into the cells of tumor tissues. Expression in the treatment groups was significantly greater than that of control groups (p < 0.001). Microvessel density (MVD) and proliferative cell nuclear antigen (PCNA) were investigated to determine whether the Re-sFLK-1 fragment had the ability to inhibit tumor angiogenesis and proliferation in mice bearing S180 and MCF-7 cells. The results showed that MVD and PCNA in th e treatment groups werelower than in control groups. There were significant difference between treatment groups and control groups (p < 0.0001). The results indicated that retroviral-mediated sFLK-1 gene therapy in animal tumor models has significant therapeutic effect.

In vivo inhibition of tumor angiogenesis by a soluble VEGFR-2 fragment

The interaction of vessel endothelial cell growth factor (VEGF) and its receptors (flt-1, FLK-1/KDR) regulates tumor angiogenesis. Therefore, blocking the binding of VEGF and the corresponding receptor has become critical for antitumor angiogenesis biological therapy. Our study extracted sFLK-1 fragment from embryo mouse liver using RT-PCR, recombined it to retrovirus vector, and transfected it to tumor cell lines (S180 and B16) by the liposome mediated method, then we observed the biological behavior of transgenic cells in vivo. The results are: (1) Fragment (1034 bp) was extracted from E9, E11 embryo mouse liver tissue, which was identified by sequence analysis. (2) This fragment was cloned to retrovirus vector (PLXSN vector), which was further transfected to tumor cells lines (S180 and B16). SDS-PAGE indicated the suspension of transgenic cells present sVEGFR-2(sFLK-1) fragment; Western blot identified it. (3) In vivo study showed that the weight and size of tumor in the group of transgenic cells were smaller than in control groups. Microvessel density (MVD) and FLK-1 expression were obviously different between transgenic and control groups, but there were no differences in VEGF expression between transgenic and control groups. In short, the isolated soluble VEGFR2 fragment transfected to tumor cells can be secreted to extracellular suspension and can inhibit tumor angiogenesis in vivo.

[Primary Zweymuller total hip arthroplasty for osteoarthritis secondary to congenital acetabular dysplasia]

OBJECTIVE

To evaluate the effectiveness of Zweymuller prothesis in replacing osteoarthritis secondary to congenital dysplasia of the hip.

METHODS

From January 1996 to June 2000, Zweymuller prothesis was used to reconstruct 32 hips in 29 patients with congenital acetabular dysplasia(3 bilateral cases). All patients were female. According to the classification of Perner, 19 hips belonged to type I, 7 type II, 5 type III, and 1 type IV. The mean follow-up period was 27.5 months (6-53 months). The preoperative Harris hip score ranged from 25 to 59(average 44.5).

RESULTS

The pain was completely relieved, and the Harris hip score ranged from 63 to 97(average 85).

CONCLUSION

We consider that the Zweymuller total hip arthroplasty provides stable fixation of the cup in the presence of moderate acetabular dysplasia without structural bone grafting or cementing.

[Reconstruction of hip, knee, and ankle bony fused in non-functional position of ankylosing spondylitis patients]

OBJECTIVE

To evaluate the reconstruction of hip, knee and ankle joints with bony fusion at non-functional positions for patients with severe late-stage ankylosing spondylitis (AS).

METHODS

From January 1996 to May 1997, simultaneous ipsilateral total hip, knee and ankle replacement was performed under single anesthesia on 2 patients (3 sides) with multiple joint deformity including bony fusion at non-functional positions. They were followed for 29 months on average.

RESULTS

Satisfactory range of motion and function were observed. HSS knee score on average was improved by 45 points and Harris hip score by 37.7 points. There were no wound healing problems or late infection. No aseptic loosening was found.

CONCLUSIONS

Simultaneous ipsilateral total hip, knee and ankle replacement not only reduced cost for hospitalization, but also facilitated early rehabilitation. To our knowledge, this is the first report on this type of surgery, named ipsilateral tri-arthroplasty.

Clinical course of pediatric congenital inner ear malformations

OBJECTIVE

To determine any factors that could improve the early detection and management of congenital inner ear malformations.

STUDY DESIGN

A retrospective review was performed of all patients with a diagnosis of inner ear malformation at Loyola University Medical Center (LUMC) and the Hospital for Sick Children (HSC) between 1987 and 1995. Clinical records and audiometric data were accumulated. One neuroradiologist reviewed every temporal bone computed tomography (CT) scan.

METHODS

Forty-six pediatric patients with congenital inner ear anomalies evaluated at two tertiary care hospitals.

RESULTS

The average patient age at initial assessment was 25.7 months. A family history of hearing loss was noted in only five patients (12.8%). A major nonotological deformity was seen in 41% of patients. The average hearing threshold was 88 dB. All three patients with sudden hearing loss had vestibular aqueduct enlargement. Two of the three patients with common cavity anomalies had a history of recurrent meningitis. Twenty-seven patients had a vestibular aqueduct deformity, the most frequent radiographic abnormality in the series.

CONCLUSIONS

Because inner ear malformation was diagnosed after 24 months of age in a significant percentage of patients, we recommend increased parental education and vigilance by primary care practitioners. Universal newborn screening may be the key to earlier detection of these infants. For children with idiopathic sensorineural hearing loss, we recommend a temporal bone CT scan. Patients with vestibular aqueduct enlargement must be counseled about the risk of progressive sensorineural hearing loss, meningitis, and the need to avoid contact sports. Patients with common cavity abnormalities should be considered for exploratory tympanotomy and also educated about the risk for meningitis.

[The relationship between laminin-receptor and nm23 protein expression and its correlation with interstitial microvascular density and tumor metastasis in breast carcinoma]

OBJECTIVE

To study the relationship between 67,000 laminin, laminin-receptor (LN-R) and nm23 protein expression, interstitial microvascular density (MVD) and tumor metastasis in breast carcinomas.

METHODS

The expression of laminin (LN), LN-R, FVIIIRAg and nm23 protein were detected in 73 cases of breast carcinoma with immunohistochemical technique and analyzed.

RESULTS

A significant difference in LN expression was found in breast carcinoma according to their pathological grade. A positive relation exists between LN-R expression and lymph node metastasis. A positive relationship exists between the degree of LN-R and MVD expression. A significant difference in lymph node metastasis cases exists between nm23 protein positive expression group and negative expression group. When the expression of nm23 protein was inhibited, the degree of LN-R, MVD expression increased and positively related with lymph node metastasis.

CONCLUSION

LN-R expression enhancement, microvascular density increase and nm23 expression inhibition may be the reliable markers for predicting tumor metastasis and prognosis.

[Clinical analysis of 13 infected total knee replacements]

OBJECTIVE

To investigate the cause, treatment and its result of infected total knee replacements (TKRs).

METHODS

Between 1987 and 1999, 13 infected TKRs in 13 patients were treated with surgical debridement and one-stage or two-stage reimplantation. The preoperative average ROM of knees was 55 degrees and the average Hospital for Special Surgery (HSS) knee score was 36.5 points. Clinical results were evaluated after average follow-up for 3 years and 5 months. We analyzed the factors for TKR infection.

RESULTS

No recurrent infection was noted, and pain was significantly alleviated in all patients. The average ROM of knees was 85 degrees and the average HSS knee score was 73.5 points.

CONCLUSIONS

The high risk factors for TKR infection are rheumatoid arthritis, steroid administration, associated diabetes mellitus, hinged prosthesis and previous knee surgery. Early surgical debridement with intravenous antibiotics is necessary as soon as deep infection is detected. Two-stage reimplantation is more effective in eradicating deep infection than single debridement or one-stage reimplantation.

[Low-molecular-weight heparin for preventing deep-vein thrombosis after total joint arthroplasty]

OBJECTIVE

To evaluate the efficacy and safety of low-molecular-weight heparin (LMWH) in preventing deep-vein thrombosis (DVT) after total hip and knee replacement (THR, TKR).

METHODS

From November 1997 to March 1999, we performed total joint replacement for 47 control patients (34 knees, 28 hips) and for 31 patients (19 knees, 17 hips) who had been given low-molecular-weight heparin for preventing deep-vein thrombosis. All patients received venography of the operated limbs after operation.

RESULTS

DVT occurred in 19.4% of the LMWH patients (26.3% in TKR, 11.8% in THR) and the reduction was significant (P < 0.05) compared to the control group (48.4%, 55.9%, 39.3% respectively). The incidence of proximal DVT was also reduced significantly (P < 0.05) from 19.4% of the control group to 2.8% of the LMWH group.

CONCLUSION

Low-molecular-weight heparin can significantly reduce the incidence of deep-vein thrombosis after total joint replacement.

[Reinfusion of autologous shed blood after joint replacement]

OBJECTIVE

To evaluate the results of reinfusion of autologous shed blood after joint replacement.

METHODS

From February 1996 to March 1998, we selected 36 patients for 56 joint replacements. Apart from preoperative donation of autologous blood, all patients received transfusion of unwashed autologous drained blood from hips and knees after arthroplasty. The CBCIIConstaVac blood conservation system was used to salvage shed blood. Among the patients, 8 hips and 48 knees were involved. 12 patients had rheumatoid arthritis, 16 osteoarthritis, 5 ankylosing spondylitis, and 3 other arthritis.

RESULTS

36 patients received 24 260 ml (50%) autologous shed blood, 9 700 ml (20%) reserved autologous blood, and 14 600 ml (30%) allogenic blood. 15 patients experienced transient febrile reaction at the time of reinfusion, no other clinic abnormalities were discovered after reinfusion.

CONCLUSIONS

Reinfusion of autologous shed blood is a safe and effective to decrease the use of allogenic blood and avoid the complications of its transfusion.

Toronto's Hospital for Sick Children study of traumatic sudden sensorineural hearing loss

OBJECTIVE

Traumatic sudden sensorineural hearing loss (SHL) is by definition a hearing loss of greater or equal to 30 dB occurring within 3 days of trauma. The objective of this study was to assess the rate of traumatic sudden SHL. Etiology is discussed with statistical references, and appropriate treatment is proposed. A case study of an enlarged vestibular aqueduct illustrates the above.

METHOD

The authors retrospectively studied cases at The Hospital for Sick Children, Toronto, between the years 1980 and 1995. High-resolution CT scans of the temporal bones with bone algorithms and coronal/axial views were performed on all children presenting with SHL after 1988.

RESULTS

Of the 12 children studied, 9 had high-resolution CT scans, revealing a 33% incidence each of inner-ear malformations, temporal bone fractures, and other miscellaneous CT findings.

CONCLUSION

By corollary, the authors recommend a high index of suspicion for congenital temporal bone abnormalities in all cases of sudden sensorineural hearing loss, particularly those associated with trauma.

[One-stage reimplantation for the salvage of total knee arthroplasty complicated by infection]

One-stage reimplantation for the salvage of infected total knee arthroplasty in 8 patients was reviewed at an average follow-up of 20.1 months late infections occurred in 7 (87.5%) patients. The timing of the diagnosis of the infection after knee arthroplasty was of the prosthesis averaged 11.5 months. No one had recurrent infection and pain was relieved significantly in all patients. Our results suggest that one-stage reimplantation is a reasonably reliable procedure for the management of an infected prosthesis. The use of Gentamicin-impregnated bone cement and the Streptomicin bead mixed with Gentamicin improve the success of treating or preventing recurrence of the infection. Early one-stage reimplantation was needed as soon as the deep infection was defined in order to decrease more destruction of the bone.

[Total knee replacement of severe flexion contracture deformities greater than 60 degree]

The technique of total knee arthroplasty for the patients with severe flexion contractures of more than 60 degrees is not clear. Recently, We have performed 37 total knee arthroplasties in 23 patients with flexion contracture of more than 60 degrees (average 77.97 degrees). Among them, 14 knees (37.9%) with flexion contracture of more than 90 degrees, and 7 knees (18.0%) with 90 degrees flexion fusion deformities. Significant improvements occurred after averaged 4.3-year follow-up. Complications occurred in four patients: three had transient peroneal-nerve palsy, and one had temporary circulatory disturbance of the lower extremity. They recovered after conservative therapy. We consider that severe flexion contracture of more than 60 degrees is not a contraindication of TKR. Staged bone resection and thoroughly soft-tissue release of the posterior capsule and collateral ligament balance were the critical procedure. If necessary, additional distal femoral condyle resection with posterior cruciate ligment sacrifice can be considered.

[Simultaneous bilateral total knee replacement for the patients with serious rheumatoid disease]

This retrospective study reviews 57 patients with serious rheumatoid disease who had bilateral total knee arthroplasties simultanneously between 1987 and 1994. The short follow-up results revealed that there was no increase in complications in the patients with simultaneous bilateral procedures, and nearly identical postoperative results to those observed among patients with single joint replacement. Advantage of simultaneous bilateral total arthroplasty include reduction in hospital cost, the need for less invasive surgical event and the ability to rehabilitate the patient symmetrically.

[Clinical evaluation of intermittent administration of CDDP in advanced ovarian cancer]

We examined the effects of intermittent cisplatin therapy (ICDDPT) on advanced ovarian cancer patients (OCP). Most OCPs had received surgical removal of primary lesion, and histopathological analysis indicated epithelial tumors. Four OCPs were stage 3, three were stage 4 and one was stage 2 (n = 8). After surgical treatment and induction chemotherapy, ICDDPT with 20-25 mg/day CDDP was given for 3 or 5 days, every 3 months. During the intervals, maintenance immunochemotherapy with Tegafur and OK-432 was given. Following ICDDPT all patients are alive, the longest survival time being 3 years and 10 months. Three have survived at least 3 years, 1 for at least 2 years and 3 for at least 1 year. Adverse drug reaction (ADR) was analysed with reference to the total dose of CDDP, i.e. under 500 mg, over 500 mg-under 1,000 mg and over 1,000 mg. Abnormal laboratory findings in platelets (thrombocytopenia), Hb, BUN, Creatinine, GOT and GPT were observed at the all doses. These ADR were not increased with the increasing dose so that accumulative toxicity was not observed. Therefore ICDDPT was seen to be effective in treating OCP.