Clinical Determinants Affecting Indications for Surgery and Chemotherapy in Recurrent Ovarian Granulosa Cell Tumor

Background: Because reports on the management of recurrent granulosa cell tumor have been sparse, a consensus as to which patients should undergo surgical resection and which patients should be considered for chemotherapy has not been established. Methods: A total of 21 tumor recurrences in eight patients with granulosa cell tumor were reviewed. Results: Surgery was performed as the main treatment for 13 recurrences, while chemotherapy was chosen as the main treatment for eight recurrences. Complete tumor resection could be accomplished in 13 of 16 surgeries (81.3%), which include all the ten recurrences without involvement of liver or diaphragm and without ascites. The number of recurrent masses was significantly higher in the early recurrence group (progression free survival < 2 years) than in the late recurrence (progression free survival > 2 years). All cases with a solitary recurrent tumor at an extra-peritoneal site presented a significantly longer progression free survival. Conclusions: For patients with recurrent granulosa cell tumor, surgery may provide the best disease control. In cases with complete resection, the number of recurrent masses was the predictive factor for the next recurrence, and adjuvant chemotherapy might be considered in such cases.

Erythropoietin Receptor Antagonist Suppressed Ectopic Hemoglobin Synthesis in Xenografts of HeLa Cells to Promote Their Destruction

The aim of this study is to explore a cause-oriented therapy for patients with uterine cervical cancer that expresses erythropoietin (Epo) and its receptor (EpoR). Epo, by binding to EpoR, stimulates the proliferation and differentiation of erythroid progenitor cells into hemoglobin-containing red blood cells. In this study, we report that the HeLa cells in the xenografts expressed ε, γ, and α globins as well as myoglobin (Mb) to produce tetrameric α2ε2 and α2γ2 and monomeric Mb, most of which were significantly suppressed with an EpoR antagonist EMP9. Western blotting revealed that the EMP9 treatment inhibited the AKT-pAKT, MAPKs-pMAPKs, and STAT5-pSTAT5 signaling pathways. Moreover, the treatment induced apoptosis and suppression of the growth and inhibited the survival through disruption of the harmonized hemoprotein syntheses in the tumor cells concomitant with destruction of vascular nets in the xenografts. Furthermore, macrophages and natural killer (NK) cells with intense HIF-1α expression recruited significantly more in the degenerating foci of the xenografts. These findings were associated with the enhanced expressions of nNOS in the tumor cells and iNOS in macrophages and NK cells in the tumor sites. The treated tumor cells exhibited a substantial number of perforations on the cell surface, which indicates that the tumors were damaged by both the nNOS-induced nitric oxide (NO) production in the tumor cells as well as the iNOS-induced NO production in the innate immune cells. Taken together, these data suggest that HeLa cells constitutively acquire ε, γ and Mb synthetic capacity for their survival. Therefore, EMP9 treatment might be a cause-oriented and effective therapy for patients with squamous cell carcinoma of the uterine cervix.

Long-term survival in metastatic malignant struma ovarii treated with oral chemotherapy: A case report

Malignant struma ovarii is a rare type of ovarian tumor. Metastasis from malignant struma ovarii is rare and has only been documented in 5–6% of cases. The natural history and optimal treatment strategy for malignant struma ovarii remains controversial due to its rarity. The current report presents the case of a 45-year-old female who presented with a tumor of the rib bone. Following resection, the postoperative diagnosis was a metastasizing thyroid carcinoma. No abnormality was detected in the thyroid gland, however, computed tomography revealed a tumor in the left ovary. The patient underwent a left salpingo-oophorectomy and a wedge resection of the right ovary. The postoperative diagnosis was determined as a mature cystic teratoma with malignant struma ovarii (thyroid type, follicular carcinoma) of the left ovary and mature cystic teratoma of the right ovary. Four years subsequent to the initial diagnosis, multiple lung metastases were detected. The following chemotherapies were administered sequentially and intermittently: Tegafur-uracil, paclitaxel/carboplatin and oral etoposide. During this period, the metastatic lesions extended into the bone and progressed slowly. The patient continues to survive with the disease and 24 years have passed since the initial diagnosis, 20 years following the diagnosis of multiple lung metastates. The present report describes a rare case of malignant struma ovarii in which surgical resection and pathological examination of a metastatic rib tumor resulted in the identification of the primary ovarian lesion. The clinical behavior of malignant struma ovarii does not necessarily indicate a histological malignancy, therefore, prediction of future metastasis is difficult and the optimal treatment strategy for malignant struma ovarii is controversial. The present case indicates that the long-term use of oral anticancer agents may facilitate the maintenance of tumor dormancy.

Erythropoietin is involved in hemoprotein syntheses in developing human decidua

Before establishment of feto-placental circulation, decidua can synthesize hemoproteins to maintain oxygen homeostasis in situ. Using the human decidua of induced abortions ranging from 5 to 8 weeks of gestation, we determined the expression levels of erythropoietin, erythropoietin receptor, cytoglobin, myoglobin, embryonic-, fetal- and adult hemoglobin mRNA by quantitative RT-PCR analysis and identified their proteins by Western blot and immunohistochemical analyses. Erythropoietin signaling was demonstrated in phosphatidylinositol-3-kinase/protein kinase B pathway by Western blot, and the transcriptional factors for erythroid and non-erythroid heme synthesis were examined by RT-PCR analysis. In decidua, erythropoietin and its receptor mRNAs, erythropoietin receptor protein and phosphatidylinositol-3-kinase, were expressed with a peak at 6 weeks of gestation. Moreover, the decidua during 5 to 8 weeks of gestation expressed embryonic, fetal and adult hemoglobins additionally cytoglobin and myoglobin at transcriptional and protein levels. The heme portion of these hemoproteins is considered to be synthesized by non-erythroid δ-aminolevulinate synthase. These hemoproteins were discernible especially in decidual cells concomitant with cytotrophoblast cells and macrophage in these developing decidua. Considering the different capacity for oxygen binding and dissociation among hemoglobins with the oxygen storage capacity for cytoglobin and myoglobin, these hemoproteins appear to play a role in oxygen demand in decidua in situ before development of feto-placental circulation under the control of erythropoietin signaling.

Exposure to ethinyl estradiol prenatally and/or after sexual maturity induces endometriotic and precancerous lesions in uteri and ovaries of mice

Unrecognizable exposure to estrogenic substance may cause estrogen-dependent diseases, endometriosis and cancer. Pregnant mice (ICR/Jcl, CLEA) were exposed to 0.01 mg ethinyl estradiol (EE2 )/kg per day or vehicle (olive oil) through oral intubation from day 11 to 17 of gestation. They delivered their offspring and raised them. When the experimental female F1 mice were at 8 weeks of age, they were not exposed to EE2 or to the same dose of EE2 or to vehicle twice a week until 20 weeks of age. The control female F1 mice were exposed to the same dose of EE2 or vehicle alone, similarly. All mice were killed at 28 weeks of age. The resected uteri and ovaries were processed for microscopic examinations and for determination of the aromatase mRNA levels and aromatase protein through quantitative RT-PCR and Western blotting, respectively. Adenomyosis and adenocarcinomatous changes were significantly discernible in the EE2 -exposed uteri, and incidence of ectopic glands and serous cysts were significantly increased in the prenatally EE2 -exposed ovaries as compared with respective controls. Significant upregulation of the aromatase mRNA was seen in the prenatally EE2 -exposed uteri and in the EE2 -exposed ovaries. The aromatase protein was identified in all ovaries examined, and in EE2 -exposed uteri but not in controls and confirmed its localization in eutopic and ectopic glands, abnormally proliferated lesions and the lining of the cysts. Taken together, continuous EE2 exposure may cause endometriotic and precancerous lesions due to excessive estrogen synthesis in both target organs.

Size Effects of Polystyrene Nanoparticles on Atopic Dermatitis-like Skin Lesions in NC/NGA Mice

Nano-sized particles are diffusing in the environment with the development of nanotechnology. Polystyrene (PS) nanoparticles are modified industrial products and pharmaceutical agents, however, adverse effects of PS nanoparticles remain to be elucidated. In the present study, we investigated the effects of PS nanoparticles with different sizes on the atopic dermatitis (AD)-like skin lesions in NC/Nga mice assumed to show the skin barrier defect/dysfunction in the presence or absence of mite allergen. Male NC/Nga mice were injected intradermally with three different-sized PS nanoparticles (25, 50, or 100 nm) and/or mite allergen into their right ears. We evaluated clinical scores, ear thickening, histological findings and the local protein expression of inflammatory molecules in the ear and Ig production in serum. PS nanoparticles aggravated AD-like skin lesions related to mite allergen, which was paralleled by the local protein levels of interleukin-4, CCL2/monocyte chemotactic protein-1, CCL3/macrophage inflammatory protein-1 alpha, and CCL4/macrophage inflammatory protein-1 beta. In contrast, PS nanoparticles decreased interferon-γ expression. Furthermore, exposure to PS nanoparticles induced ear swelling and CC-chemokine expression in the absence of allergen. These effects were greater with the smaller PS nanoparticles than with the larger ones regarding overall trend. These results suggest that exposure to PS nanoparticles under skin barrier defect/dysfunction can exacerbate AD-like skin lesions related to mite allergen in a size-dependent manner. The enhancing effects may be accounted for by T helper 2-biased immune responses. Furthermore, PS nanoparticles can evoke skin inflammation via the overexpression of CC-chemokines even in the absence of allergen in atopic subjects.

Pulmonary exposure to soluble cell wall beta-(1, 3)-glucan of aspergillus induces proinflammatory response in mice

Compared to the significant immunomodulation of cell wall component(s) of bacterium such as lipopolysaccharide (E. Coli), that of pathogenic fungi has not been well elucidated, especially in vivo. Furthermore, although it has been implied that beta-(1, 3)-glucan of fungi possesses various biological activities, the impacts of the component have not been properly clarified, possibly due to its insolubility in water and alkali solutions. Previously, we isolated a soluble type of beta-(1, 3) -glucan from Aspergillus (referred to as ASBG). The present study investigated the effects of a single pulmonary exposure to ASBG on the immune (proinflammatory) responses in naïve mice. ASBG (12.5-100micorg/animal) exposure Induced neutrophilic lung inflammation with an enhanced local expression of proinflammatory cytokines such as interleukin (IL)-1beta and chemokines such as macrophage inflammatory protein -1a, and keratinocyte-derived chemoattractant in a dose-dependent fashion with overall trends. On the other hand, ASBG at relatively lower doses significantly amplified the lung expression of IL-2, IL-6, and IL-12 as compared with vehicle. ASBG significantly induced pulmonary edema. Furthermore, ASBG augmented the nuclear translocation of nuclear factor (NF)-kB and its binding capacity to the promoter site of DNA in the lung homogenate. These results suggest that pulmonary exposure to ASBG confers lung inflammation, at least partly, via the enhanced local expression of proinflammatory cytokines, likely through NF-kB-dependent pathway.

Laparoscopic mucin removal in patients with pseudomyxoma peritonei

BACKGROUND AND OBJECTIVES

Pseudomyxoma peritonei results from ovarian and appendiceal mucinous tumors. Cyst rupture results in intraabdominal mucin accumulation, leading to abdominal distension. No effective treatment has yet been established. Pseudomyxoma peritonei is generally associated with a poor prognosis. In a recent Mayo Clinic report, the 5-year survival rate for this disease was 53% and the 10-year survival rate was 32%, while the Memorial Sloan-Kettering Cancer Center reported 5- and 10-year survival rates of 75% and 10%.

METHODS AND RESULTS

In this report, we describe 4 patients with a laparoscopically confirmed recurrence of pseudomyxoma peritonei who subsequently underwent repeated laparoscopic mucin removal.

CONCLUSION

Because laparoscopic surgery can be performed frequently, it appears that laparoscopic surgery, a minimally invasive procedure, greatly improves the quality of life of patients with pseudomyxoma peritonei.

Phase II study of single-agent gemcitabine in heavily pretreated Japanese patients with recurrent ovarian cancer

BACKGROUND

Gemcitabine has been recommended as an active agent for salvage chemotherapy in patients with recurrent epithelial ovarian cancer, but no clinical study of this agent has been conducted for Japanese women with ovarian cancer. To evaluate the efficacy and feasibility of gemcitabine for heavily pretreated Japanese patients with recurrent epithelial ovarian cancer, we conducted a single-institute phase II clinical trial.

METHODS

All patients had received a minimum of two previous chemotherapy regimens, In this study, gemcitabine was administered at 1000 mg/m(2) on days 1, 8, and 15 of a 28-day cycle.

RESULTS

A total of 28 patients participated in this study. Although 5 patients (17.9%) needed dose reduction to 800 mg/m(2) because of thrombocytopenia and granulocytopenia, all patients completed an average of 6.7 courses (range, 2-24 courses). The overall response rate, including five partial responses, was 17.9% (95% confidence interval [C I], 6.0-36.9). The median time to progression was 8.8 months and the median survival period was 11.2 months. Grade 3/4 hematological toxicities included leucopenia, 35.7%; granulocytopenia, 39.3%; anemia, 46.4%; and thrombocytopenia, 10.7%. However, no grade 3/4 nonhematological toxicity was observed. The mean delay in treatment was 5.0 +/- 7.7 days (range, 0-15 days) in a total of 562 cycles.

CONCLUSION

Single-agent gemcitabine is an effective salvage chemotherapy regimen in heavily pretreated Japanese patients with recurrent epithelial ovarian cancer.

Pulmonary exposure to carbon black nanoparticles increases the number of antigen-presenting cells in murine lung

Particulate matters can enhance antigen-related airway inflammation and immunoglobulin production. The present study was designed to determine the effects of different sizes of nanoparticles on the antigen-presenting cells (APC) in the lung. ICR mice were exposed to vehicle, carbon black (CB) nanoparticles (14 nm or 56 nm), ovalbumin (OVA), or OVA + nanoparticles intratracheally. The expression of major histocompatibility complex (MHC) class II, costimulatory molecules (CD80, CD86, CD11c), and DEC205 (dendritic cell marker), F4/80 (macrophage marker), and CD19 (B-cell marker) in the lung cells was measured by flow cytometry. 14 nm nanoparticles, but not 56 nm nanoparticles, increased the number of the total lung cells. Combination of OVA and 14 nm or 56 nm nanoparticles increased the total lung cells. The expression of MHC class II and/or costimulatory molecules and the number of APC in the lung were increased by 14 nm nanoparticles in the presence or absence of OVA. The increases were more prominent with combination of OVA and 14 nm nanoparticles. 56 nm nanoparticles did not show any significant effects. 14 nm CB nanoparticles can increase the expression of MHC class II and costimulatory molecules and the number of APC in the lung, especially in the presence of antigen, which can result in subsequent antigen-related airway inflammation and immunoglobulin production.

A change in promoter methylation of hMLH1 is a cause of acquired resistance to platinum-based chemotherapy in epithelial ovarian cancer

BACKGROUND

Acquired resistance to platinum-based chemotherapy (Pt-chemo) is a major problem for improving the prognosis for patients with advanced epithelial ovarian cancer (EOC). However, the molecular mechanism of acquired resistance to Pt-chemo is not well understood.

MATERIALS AND METHODS

hMLH1 promoter methylation (hMLH1 MET) and hMLH1 protein expression was examined in 36 paired samples of primary and secondary resected tumors by methylation-specific polymerase chain reaction (PCR).

RESULTS

No primary tumors exhibited hMLH1 MET, while 56.3% of secondary tumors showed hMLH1 MET. Moreover, no significant correlation was observed between hMLH1 MET and histological subtype, while hMLH1 MET was significantly greater (p < 0.001) in partially responsive secondary tumors compared with no change or progressive disease, and hMLH1 MET also occurred more frequently (p = 0.059) in tumors treated with four or more courses of Pt-chemo.

CONCLUSION

A change in hMLH1 MET is a major molecular cause of acquired resistance to Pt-chemo in EOC.

Successful Pregnancy in a Patient With Double Outlet Left Ventricle After a Rastelli Operation Using a Prosthetic Valve

A woman with double outlet left ventricle (DOLV) had undergone a Rastelli operation using a prosthetic Björk Shiley valve and who was receiving anticoagulant drug delivered a healthy male infant. Oral warfarin was replaced by heparin from the 5th to the 13th week of gestation and for the last 5 weeks of gestation. Successful pregnancy in patients with DOLV after a Rastelli operation using a prosthetic valve is possible with careful maintenance.

Endoscopic ultrasonography in patients with thyroid cancer: its usefulness and limitations for evaluating esophagopharyngeal invasion

BACKGROUND AND STUDY AIMS

Although computed tomography (CT) and magnetic resonance imaging (MRI) are useful for detecting esophagopharyngeal invasion by thyroid cancer, they cannot assess the depth of invasion, which is important for the surgical planning. In the present study, endoscopic ultrasonography (EUS) of the esophagus was used to assess esophagopharyngeal invasion by thyroid cancer, and the value of this technique was assessed prospectively.

PATIENTS AND METHODS

Between 1 December 1998 and 31 December 2000, EUS examinations were carried out in 59 patients in whom esophagopharyngeal invasion by thyroid cancer was suspected due to large tumors or tumors with poor mobility. The EUS findings were evaluated in 52 patients (10 men, 42 women; mean age 62.4 years; mean tumor size 39.5mm) with complete resections, and compared with the pathological results.

RESULTS

The diagnostic specificity and accuracy of EUS in assessing invasion into the muscularis propria (82.9 %, 82.7 %) were greater than those of MRI (60 %; P = 0.034, 65.4 %; P = 0.044) and esophagography (58.8 %; P = 0.034, 60 %; P = 0.028). The accuracy for detecting cancer invasion located in the upper part of the lobe was less than for invasion in the middle and/or lower parts of the lobe ( P = 0.020). Conclusions. EUS is useful for assessing esophagopharyngeal invasion by thyroid cancer, although its effectiveness may be limited in thyroid lesions located in the upper part of the lobe.

Aggressive NK cell lymphoma/leukemia with clonal der(3)t(1;3) (q12;p25), del(6)(q13) and del(13)(q12q14)

We describe a 54-year-old man with CD2, CD7, and CD56-positive but CD3, CD4, and CD8-negative aggressive NK cell lymphoma/leukemia. Chromosome analysis of the peripheral blood cells showed clonal aberration consisting of 46,XY,dup(3)(p21p25),der(3)t(1;3)(q12;p25),del(5)(q13q22), del(6)(q13),del(13)(q12q14). The peripheral blood lymphoma cells contained clonal EBV-DNA by Southern blot analysis. The disease was refractory to chemotherapy and the clinical course was aggressive and rapid. Deletion 6q and deletion 13q have been frequently reported in NK cell lymphoma/leukemia. Thus, some tumor suppressor genes involving NK cell malignancies may be present in these regions.

Bronchoscopic diagnosis of thyroid cancer with laryngotracheal invasion

HYPOTHESIS

Some controversy exists concerning the appropriate surgical management for patients with thyroid cancer invading the laryngotracheal wall. We have used shaving of the wall when cancer invasion was confined to the perichondrium, and extensive resection when it invaded further. Preoperative assessment of the depth and length of laryngotracheal invasion is important when choosing an appropriate surgical procedure.

DESIGN

Prospective study.

SETTING

A Japanese center for thyroid diseases, where about 1400 thyroid operations are performed each year.

PATIENTS

Of 171 patients with thyroid cancer who were surgically treated between January 1, 2000, and July 30, 2000, 37 were suspected to have laryngotracheal invasion on preoperative magnetic resonance imaging or ultrasonography.

INTERVENTION

We used bronchoscopy to examine the 37 patients suspected to have laryngotracheal invasion.

MAIN OUTCOME MEASURE

Bronchoscopic findings (localized mucosal redness, telangiectasia, mucosal elevation, mucosal edema, and mucosal erosion) were compared with pathological results in the 30 patients who underwent curative resections. Seven patients were excluded because of palliative resections.

RESULTS

Of the 18 patients without localized mucosal changes, we performed shaving of the laryngotracheal wall in 4 patients because we found laryngotracheal invasion during surgery. Shaving of the laryngotracheal wall was performed successfully in terms of obtaining a cancer-free margin. Twelve patients with localized mucosal redness required extensive resections. Other mucosal changes were found depending on the depth of cancer invasion.

CONCLUSION

Surgeons should perform extensive resections when encountering localized mucosal redness on bronchoscopy.

Usefulness of endoscopic ultrasonography (EUS) in diagnosing esophageal infiltration of thyroid cancer

Pre-operative evaluation of esophageal infiltration is sometimes difficult in patients with advanced thyroid cancer even with recent imaging modalities. We evaluated the accuracy of endoscopic ultrasonography (EUS) in diagnosing esophageal infiltration of thyroid cancer. Twenty-nine patients with advanced thyroid cancer underwent EUS and other imaging examinations before surgery. The diagnostic accuracy of EUS was compared with that of magnetic resonance imaging (MRI) and esophagography based on pathologic findings in 27 of the 29 cases. EUS clearly demonstrated the 5-layer structure of the esophageal wall. EUS detected cancer invasion into the muscularis propria of the esophagus correctly in 8 of 10 patients diagnosed pathologically with muscular infiltration. EUS was significantly more accurate than MRI and esophagography (88.9% vs 63.0% and 66.7%, respectively). The specificity of EUS was also significantly better than the specificities of MRI or esophagography (94.1% vs 58.8% and 64.7%, respectively). The sensitivity, positive predictive value and negative predictive value of EUS tended to be better than those of MRI and esophagography. EUS is useful in evaluating the esophageal infiltration of thyroid cancer. This method has the further advantage of detecting the exact depth of cancer invasion into the esophageal wall.

Effect of combining ultrasonography and ultrasound-guided fine-needle aspiration biopsy findings for the diagnosis of thyroid nodules

OBJECTIVE

To assess the accuracy of ultrasonography and cytology in predicting malignancy in thyroid nodules.

DESIGN

Prospective open study.

SETTING

Thyroid centre, Japan.

SUBJECTS

329 nodules in 309 patients examined by a new ultrasound scanner and ultrasound-guided fine-needle aspiration biopsy.

INTERVENTIONS

Comparison of ultrasonographic, cytological, and combined diagnosis with the histological diagnosis.

MAIN OUTCOME MEASURES

Sensitivity, specificity, and accuracy of each diagnostic method.

RESULTS

The sensitivity, specificity, accuracy were 84%, 87%, 85% for cytological diagnosis, and 82%, 91%, and 87% for ultrasonographic diagnosis. By using ultrasonographic diagnosis when cytological specimens were inadequate or gave false negative results, the sensitivity, specificity, and accuracy went up to 89%, 91%, and 90%, respectively. We could not diagnose follicular carcinomas accurately by combined cytology and ultrasonography.

CONCLUSION

The combination of ultrasonography and cytology improves the accuracy of diagnosis of thyroid nodules, but is less effective with follicular tumours.

Ozone exposure enhances expression of cell-surface molecules associated with antigen-presenting activity on bronchoalveolar lavage cells in rats

In this study, we investigated the effects of ozone (O3) exposure on expression of cell-surface molecules associated with antigen presentation and on accessory activity of bronchoalveolar lavage cells (BAL cells). Rats were exposed to 1 ppm O3 for 3 days. Expression of cell-surface molecules was measured by flow cytometry. Accessory activity of BAL cells was assessed by the allogeneic mixed lymphocyte reaction (MLR) and specific antigen-presenting activity. O3 exposure increased the expression of Ia, B7.1, B7.2, and CD11b/c on BAL cells. Morphological and immunological studies showed the Ia-positive cells to have monocyte-like features. Peripheral blood monocytes expressed Ia, B7.1, B7.2, and CD11b/c. The Ia expression on the monocytes was further increased by treatment of them with BAL fluid from O3-exposed rats (O3-BALF). Resident alveolar macrophages, however, did not express Ia antigen, and the Ia expression was not increased by O3-BALF. Neutrophils, which also infiltrated in response to O3 exposure, did not express Ia, B7.1, and B7.2. Therefore, infiltrating monocytes may have caused the increased expression of Ia and B7 molecules on BAL cells exposed to O3. The accessory activity of BAL cells in terms of MLR and specific antigen-presenting activity was also enhanced by O3 exposure. The present study suggests that monocytes infiltrating in response to O3 exposure caused enhancements of the expression of Ia and costimulatory molecules on and the accessory activity of BAL cells.

Effect of exposure to nitrogen dioxide on alveolar macrophage-mediated immunosuppressive activity in rats

Nitrogen dioxide (NO2), a major component of air pollutants, induces inflammatory responses in the lungs. Resident alveolar macrophages (AM) play an immunosuppressive role in the lungs via suppression of lymphocyte proliferation, and nitric oxide (NO) plays a crucial role in this immunosuppressive activity. Microenvironmental changes within the alveoli during inflammatory responses, however, can inhibit this immunosuppressive activity of AM. The present study was designed to clarify the effect of NO2 exposure on the immunosuppressive activity of and NO production by AM in rats. Wistar rats were exposed to 10 ppm NO2 for 3, 14 or 28 days, after which bronchoalveolar lavage fluid (BALF) was taken as a sample of the alveolar microenvironment. Suppression of concanavalin A-induced lymphocyte proliferation and NO production by AM were markedly inhibited by BALF from NO2-exposed rats (NO2-BALF). The inhibitory effect of NO2-BALF at 28-days exposure was stronger than that of NO2-BALF at 3 or 14 days exposure. In conclusion, AM-mediated immunosuppressive activity was inhibited by the NO2-induced changes of the alveolar microenvironment through the inhibition of NO production.

Ultrasonographic characteristics of thyroid nodules: prediction of malignancy

BACKGROUND

High-resolution real-time ultrasonography (US) can detect characteristics of thyroid nodules, but the US differentiation between malignant nodules and benign nodules is not well described.

HYPOTHESIS

Ultrasonography is useful for predicting malignancy of thyroid nodules.

DESIGN

A retrospective study of 329 thyroid nodules (> or =5 mm) in 309 patients comparing US characteristics and pathological results.

SETTING

A center for the treatment of thyroid diseases where about 1400 thyroid operations are performed per year.

PATIENTS

Between January 1 and June 30, 1999, 309 patients were examined by US before thyroidectomy.

MAIN OUTCOME MEASURE

The US characteristics to predict malignancy for both follicular and nonfollicular neoplasms by means of multiple logistic regression analysis.

RESULTS

The sensitivity of preoperative US diagnosis was 86.5% for nonfollicular neoplasms and 18.2% for follicular neoplasms. The specificity was 92.3% and 88.7%, respectively. According to multiple logistic regression analysis, margin, shape, echo structure, echogenicity, and calcification were reliable indication of malignancy in nonfollicular neoplasms. According to a receiver operating characteristic curve constructed from this multiple logistic regression analysis, the best point not to overlook malignancy is the point at which sensitivity is 94% and specificity is 87%. The probability of malignancy at this point is greater than 0.2. For follicular neoplasms, ultrasonographic diagnosis was unreliable, even when multiple logistic regression analysis was applied.

CONCLUSION

We can predict malignancy of nonfollicular neoplasms of the thyroid by using multiple logistic regression analysis based on only 5 features: margin, shape, echo structure, echogenicity, and calcification.

High prevalence of vitamin D deficiency in Japanese female patients with Graves' disease

We reported previously that vitamin D deficiency is a causal mechanism of postoperative tetany in patients with Graves' disease. The aim of the present study was to determine the prevalence of vitamin D deficiency by reviewing serum 25(OH)D levels in 208 patients with Graves' disease (146 women, 62 men) during a 1 year period. Serum 25(OH)D levels were significantly lower (p < 0.001) in female Graves' patients (31.8 +/- 13.3 nmol/l) than in male patients (41.3 +/- 15.0 nmol/l). Vitamin D deficiency (defined as a serum 25(OH)D value below 25 nmol/l) was found in 40% of female patients and in 18% of male patients (p < 0.005). There was a significant seasonal variation in the 25(OH)D concentrations in female patients [amplitude 6.38 (95% CI, 5.42-7.56)], with values below 25 nmol/l found in 58% of female patients during the winter months. There were significant (p < 0.001) differences in serum 25(OH)D levels between age groups in the female patients. The concentrations were lowest in patients in their twenties (25.1 +/- 8.2 nmol/l) and highest in patients in their fifties and sixties (43.2 +/- 13.7 nmol/l). Serum 25(OH)D concentrations might be monitored in patients with Graves' disease during antithyroid drug therapy, and vitamin D and/or calcium supplements are recommended for patients with vitamin D deficiency.

Indications for bilateral modified radical neck dissection in patients with papillary carcinoma of the thyroid

HYPOTHESES

After subtotal thyroidectomy with modified radical neck dissection of the affected side, nodal recurrence at the contralateral cervical side indicates a poor prognosis for patients with papillary thyroid cancer. Bilateral modified radical neck dissection is beneficial for patients at high risk for contralateral nodal recurrence.

DESIGN AND SETTING

Retrospective study of patients with papillary cancer who were treated surgically from January 1, 1970, through December 31, 1995, at the Noguchi Thyroid Clinic and Hospital Foundation, Beppu, Japan.

PATIENTS

Patients (N = 1776) had primary tumors greater than 10 mm in maximum diameter and underwent thyroidectomy and ipsilateral modified radical neck dissection with curative intent.

RESULTS

Thirty-two patients (1.8%) developed contralateral lymph node metastases during the mean follow-up period of 12.1 years. The risk factors for contralateral nodal recurrence were male sex, large primary tumor, tumor extension over the isthmus, extracapsular adhesion or invasion to surrounding tissues, and the presence of gross nodal metastasis at initial surgery. These patients had a greater number of distant metastases (31.1% vs 0.7%; P<.001) and a lower 10-year survival rate (83.7% vs 99.3%; P<.001) than patients without nodal recurrence.

CONCLUSION

Bilateral modified radical neck dissection should be considered for patients with papillary carcinoma who show risk factors for contralateral nodal recurrence, as it could prevent a second operation and may improve their outcome.

Screening of the Men1 gene and discovery of germ-line and somatic mutations in apparently sporadic parathyroid tumors

Hyperparathyroidism is the first manifestation in a majority of multiple endocrine neoplasia (MEN1) patients. To discriminate between sporadic and hereditary parathyroid tumors and characterize MEN1 somatic mutations, we examined MEN1 gene mutations in patients who had undergone surgery for sporadic parathyroid tumors. DNA was extracted from fresh frozen parathyroid tumor specimens from 112 patients as well as from peripheral blood leukocytes from 64 of the 112 patients. Sequence analysis was performed to examine exons 2-10 of the MEN1 gene for mutations. Loss of heterozygosity (LOH) was also examined by an analysis of codon 418 and 541, which lie within a polymorphic region of MEN1. Somatic MEN1 mutations were found in 25 of the 112 patients (22%). Two patients had two point mutations (508del33 and Y341X and 363insT and 1767delT, respectively). A total of 27 mutations were characterized, 20 of which have not been reported previously. There were 7 nonsense mutations, 10 frameshift mutations, 2 splice site deletions, 5 missense mutations, and 3 in-frame mutations. Nineteen mutations (70%) predicted truncation of the menin protein. Germ-line MEN1 mutations were found in 3 of 64 patients (5%) who had no family history of endocrine tumors associated with MEN1, and these patients were identified as MEN1 gene probands. LOH at the MEN1 locus was detected in three parathyroid tumors showing germ-line mutation. LOH was significantly frequent in parathyroid tumors with somatic MEN1 mutations (15 of 22 tumors, 68%) but not in those without germ-line or somatic MEN1 mutations (14 of 51 tumors, 28%; P = 0.0011). Our findings suggest that alterations of both alleles of the MEN1 gene may be associated not only with endocrine tumors of affected MEN1 patients but also with sporadic parathyroid tumors. Germ-line MEN1 gene analysis can distinguish heritable from nonheritable parathyroid tumors, and MEN1 gene evaluation of patients with apparently sporadic parathyroid tumor is recommended before parathyroid surgery.

Effect of aging on nitric oxide production by rat alveolar macrophages

Nitric oxide (NO) plays an important role in alveolar macrophages (AM)-mediated defense against infection. The elderly become highly susceptible to respiratory tract infection. Inhibition of NO production significantly suppresses defense against infections. Therefore, it is necessary to elucidate the effect of senescence on NO production of AM. The alveolar microenvironment and lymphocytes affect NO production by AM. We examined whether changes in the alveolar microenvironment, lymphocytes, or AM brought about by aging affect NO production by AM. Bronchoalveolar lavage fluid was used as a substitute for the alveolar microenvironment. The results showed that NO production by AM activated by lymph node cells in bronchoalveolar lavage fluid from old rats in response to concanavalin A decreased compared with that of young rats. AM from aged rats produced less NO than AM from young rats. Bronchoalveolar lavage fluid and lymph node cells from aged rats had no effect on the amount of NO produced by AM. Therefore, age-associated decrease in the functional capacity of AM plays a central role in the decrease of NO production.

Mechanisms of ozone-induced inhibitory effect of bronchoalveolar lavage fluid on alveolar macrophage-mediated immunosuppressive activity in rats

Resident alveolar macrophages (AM) play an important immunomodulatory role via suppression of lymphocyte proliferation, and nitric oxide (NO) plays a crucial role in this immunosuppression of AM. Our previous report suggested that during ozone (O3)-induced lung inflammation, bronchoalveolar lavage fluid (BALF) inhibited AM-mediated immunosuppression and concanavalin A (Con A)-induced proliferation of lymph node cells (LNC) [E. Koike et al. (1998) Toxicol. Sci. 41, 217-223]. In these studies, we investigated the mechanisms of the inhibition of BALF from O3-exposed rats (O3-BALF). We investigated whether BALF might affect (1) the interferon-gamma (IFN-gamma) production by Con A-stimulated LNC and IFN-gamma-induced NO production by AM, and (2) the interleukin (IL)-2 production by Con A-stimulated LNC and IL-2-induced LNC proliferation. These results demonstrated that O3-BALF inhibited IFN-gamma production by Con A-stimulated LNC, IFN-gamma-induced NO production by AM, and IL-2-induced LNC proliferation. In addition, the major inhibitory factor against AM-mediated immunosuppression in O3-BALF may be a protein of greater than 10 kDa.

[Thoracoscopic repair of diaphragmatic eventration sustained at knife injury: a case report]

A 46-year-old male taxi driver was stabbed onto the left chest while on duty. On arrival soon after, he was hemodynamically stable. Computed tomography showed omental prolapse into the left thorax through the diaphragm. On the 11th day, he underwent thoracoscopy revealing omental prolapse via a 3-cm rent in the left diaphragm, which was reduced manually. The diaphragmatic orifice was lifted and debrided with suturing using a stapling cutter. The post-operative course was uneventful. Finger palpation through the orifice enabled safe suturing of the left diaphragm facing the omentum, the colon, and the stomach, all of which may suffer iatrogenic injury.

Effect of ozone exposure on alveolar macrophage-mediated immunosuppressive activity in rats

Ozone (O3), a major component of photochemical air pollution, is a strong oxidizing agent and highly toxic. Resident alveolar macrophages (AM) play an important immunomodulatory role in the lung via suppression of lymphocyte proliferation, thus limiting the magnitude and duration of local immune responses. Nitric oxide (NO) plays a crucial role in the immunosuppressive activity of AM. However, during immunoinflammatory responses, microenvironmental changes within the alveoli inhibit this AM function, permitting full expression of local T-cell-mediated immune responses. We hypothesize that similar changes in AM function may occur during inflammation induced by exposure to inorganic air pollutants, such as O3. In order to test this hypothesis, in the present study, we investigated (1) whether O3 exposure of rats might affect the immunosuppressive activity and NO production of bronchoalveolar lavage cells (BAL cells) and (2) whether changes in the microenvironment of the alveoli induced by O3 exposure can affect the immunosuppressive activity and NO production of AM. AM-mediated immunosuppressive activity was measured as inhibition of concanavalin A (Con A)-induced proliferation of lymph node cells (LNC). Bronchoalveolar lavage was used to sample the alveolar microenvironment, and the resulting fluid (BALF) was tested for capacity to modulate AM activity in the cultures. BALF and BAL cells from rats exposed to 1 ppm O3 or filtered air for 3 days were used. The present results demonstrate that BAL cells isolated from O3-exposed rats suppressed Con A-induced LNC proliferation and produced NO in the same manner as BAL cells (AM) from air-exposed rats. AM-mediated suppressive activity of LNC proliferation and NO production were markedly inhibited by BALF from O3-exposed but not from air-exposed rats. These results suggested that AM-mediated immunosuppressive activity in vivo may be inhibited by the O3-induced release of soluble factors which inhibit NO production by AM.