Percutaneous Transluminal Angioplasty for Intracranial Arteriosclerotic Lesions

Recent developments of the interventional neuroradiological technique made percutaneous transluminal angioplasty (PTA) possible even for intracranial arteries1.

We report our experiences of 17 cases treated by PTA including 9 intracranial internal carotid (ICA), 4 middle cerebral (MCA) and 4 vertebro-basilar arterial (VBA) stenoses and discuss the problems of the procedure.

All patients had cerebral ischemic symptoms and stenoses more than 60% calculated angiographically. Three of them were treated by PTA for residual stenoses after thrombolytic therapy for acute occlusion. We used PTA balloon catheters 2.0 mm to 3.5 mm in diameter (Stealth, Target therapeutics) for all PTA procedures. A PTA balloon was inflated for 1 min at 6 atm as a rule. All were successfully dilated (stenosis less than 50%) except one treated by PTA for residual MCA stenosis after thrombolytic therapy.

The patient died from massive infarction due to MCA re-occlusion caused by MCA dissection. Restenosis appeared in 4 of 16 patients. Repeated PTA was successfuly carried out for the 4 patients.

However, restenosis appeared in one of them but the patient is now on follow-up because of asymptomatic course.

PTA for intracranial arteries is an effective treatment but its indication should be determined strictly because of potential risk such as acute occlusion derived from dissection.

The Strategy of Dural Arteriovenous Fistula with Isolated Sinus

We treated 7 cases of dural arteriovenous fistulas (dAVF) with isolated sinus by transvenous direct embolization.

The fistulas located in the transverse-sigmoid sinus in 5 cases, superior sagittal sinus in 1 case and transverse-sigmoid and superior sagittal sinus in 1 case.

The initial symptoms were generalized convulsion in 2 cases, disturbed consciousness in 1 case, tinnitus in 2 cases and transient ischemic attack in 2 cases. We performed sinus packing with coils in all cases following transarterial embolization.

All patients improved neurologically after the treatments and AVFs completely disappeared in all cases.

Endovascular Treatment for Internal Carotid Stenoses

Seventy four cases of internal carotid stenoses greater than 60% were treated by PTA and/or stenting 86 times. Sixty one cases of cervical ICA stenosis were treated 71 times. 11 cases of high cervical - intracranial ICA stenosis were treated 13 times. Two cases of ICA dissection were treated by stent deployment.

Stenotic ratio reduced from 79% to 29% in cervical ICA stenosis and 71 % to 32% in high cervical to intracranial ICA stenosis in average. Morbidity related to PTA and/or stenting was 2/74 (2.7%) and mortality was 0%. One was an ischemic complication and the other was a hemorrhagic complication due to hyperperfusion. Restenosis (stenosis greater than 70%) rate was 32%. Asymptomatic cerebral embolism were found in three cases (4.2%) on angiogram immediately after PTA and/or stenting. The complication rate related to PTA and/stenting was low but asymptomatic emboli were found in three cases.

Considering these results, the indication for PTA and/stenting should be restricted to patients with high risk group, such as cases with high medical risks or difficult CEA cases, if appropriate protective systems for cerebral emboli were not available.

Preoperative routine evaluation of bilateral adrenal glands by endoscopic ultrasound and fine-needle aspiration in patients with potentially resectable lung cancer

BACKGROUND AND STUDY AIMS

The aim of the current study was to assess the detection rate of the right adrenal gland and the diagnostic ability of endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) for the diagnosis of adrenal metastasis in potentially resectable lung cancer.

PATIENTS AND METHODS

This retrospective cohort study included a consecutive series of 150 patients undergoing EUS/EUS - FNA for staging of lung cancer. The detection rate of the right adrenal gland by EUS and the diagnostic accuracies of computed tomography (CT), positron emission tomography-CT (PET-CT), and EUS/EUS - FNA for the diagnosis of adrenal metastasis were evaluated.

RESULTS

The right adrenal gland was visualized by EUS in 131 patients (87.3 %); the left adrenal gland was visualized in all patients. Findings suggestive of metastasis in either one of the adrenal glands or in both were observed in 6 patients (4.0 %) by CT, in 5 patients (3.3 %) by PET-CT, and in 11 patients (7.3 %) by EUS. EUS - FNA was performed simultaneously in the 11 patients, and in 4 patients the diagnosis of metastasis was established. The accuracy for the diagnosis of adrenal metastasis was 100 % for EUS/EUS - FNA, 96.0 % for CT, and 97.0 % for PET-CT (P = 0.1146).

CONCLUSIONS

As well as the left adrenal gland, the right adrenal gland was also usually visible by EUS. EUS/EUS - FNA provided an accurate diagnosis of adrenal metastasis, although the prevalence of adrenal metastasis was relatively low in these patients with potentially resectable lung cancer.

P5-02-05: Real-Time Subcellular Imaging of Breast Cancer Cell Attachment in Blood Vessels Using GFP-Labeled Paxillin in Live Mice

Background: Paxillin is involved in the assembly of focal adhesions. We wish to visualize paxillin behavior in breast cancer cells in vivo, as well as in vitro.

Materials and Methods: Dual-photon confocal microscopy was used to image paxillin behavior by linking it to GFP. MDA-MB-231 human breast cancer cells expressing paxillin-GFP were imaged in vitro and in vivo adhering and trafficking in blood vessels in mice. 106 paxillin-GFP expressing breast cancer cells were injected in the epigastric cranialis vein.

Results: In vitro, round breast cancer cells had greater paxillin movement than stretched cancer cells as seen by fluorescence imaging. Paxillin-GFP breast cancer cells in the epigastric cranialis vein were initially rounded and had GFP-expressing protrusions. At later timepoints, many paxillin-GFP-expressing breast cancer cells stretched. The breast cancer cells then extravasated and subsequently grew around the outer surface of the blood vessel after one week. Two weeks after injection, paxillin-GFP expressing breast cancer cells were imaged migrating along the vessel wall. Most of the paxillin-GFP expressing breast cancer cells were stretched and were not mobile. With anti-VEGF treatment, paxillin was observed in round structures within the cells rather than stretched structures and paxillin movement within the cell was arrested.

Discussion: These results demonstrate that breast cancer cells brightly expressing paxillin-GFP and two-photon confocal microscopy can allow the visualization of the behavior of paxillin within breast cancer cells during adhesion and migration along the walls of blood vessels, as well as during anti-angiogenesis therapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-02-05.

Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal nodal staging of lung cancer

BACKGROUND

Recently, transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been evaluated for mediastinal nodal staging (N staging) of lung cancer, as this technique is less invasive than mediastinoscopy and possibly more accurate than 18F-fluorodeoxyglucose positron emission tomography with computed tomography (PET-CT). However, EUS-FNA does not provide access to pretracheal and hilar lymph nodes. More recently, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been introduced as a novel technique for accessing pretracheal and hilar lymph nodes. Although the combined endoscopic approach of EUS-FNA and EBUS-TBNA is presumably more accurate than PET-CT, only a few reports have quantitatively evaluated its diagnostic ability. Therefore, we prospectively assessed the diagnostic yield of this combined endoscopic approach for mediastinal N staging of lung cancer.

METHODS

A consecutive series of 120 patients with suspected resectable lung cancer on CT findings underwent PET-CT and combined EUS-FNA/EBUS-TBNA. The accuracy and other diagnostic indices of the combined approach in mediastinal N staging were compared with those of PET-CT.

RESULTS

Among the enrolled patients, a final pathological N stage was established in 110 patients. The accuracy of the combined approach using EUS-FNA and EBUS-TBNA was significantly higher than that of PET-CT (90.0 % vs. 73.6 %; P < 0.0001). The sensitivity, specificity, and positive and negative predictive values were respectively 71.8 %, 100 %, 100 %, and 86.6 % for the combined approach vs. 47.4 %, 87.5 %, 66.7 %, and 75.9 % for PET-CT.

CONCLUSIONS

The combined endoscopic approach using EUS-FNA and EBUS-TBNA provided excellent diagnostic performance. Therefore, this approach is strongly recommended before surgery or mediastinoscopy to avoid futile thoracotomy and surgical intervention.

Carbon dioxide insufflation vs. conventional saline irrigation for peroral video cholangioscopy

BACKGROUND AND STUDY AIMS

Recent studies have evaluated the efficacy of peroral cholangioscopy (POCS) for diagnosis of biliary diseases. In order to obtain clear images with POCS, saline irrigation, which is performed to replace yellow bile, is carried out for an extended duration. The aim of this study was to evaluate the feasibility of replacing saline irrigation with CO₂ insufflation during POCS.

PATIENTS AND METHODS

A total of 36 patients who had bile duct lesions and were due to undergo POCS were enrolled in the study. Of these patients, 18 underwent POCS using saline irrigation followed by CO₂ insufflation, and 18 patients underwent the reverse approach. The two methods were compared with regard to the time required to obtain a clear endoscopic image and the quality of the images.

RESULTS

The median time required to obtain a clear endoscopic image using CO₂ insufflation (5.0 min) was significantly shorter than that required for saline irrigation (22.5 min; P < 0.001). The quality of the endoscopic images obtained was similar in 27 cases. However, CO₂ insufflation provided better images in four cases that showed an abundance of mucin or biliary sludge, and saline irrigation was superior to CO₂ insufflation in five cases that showed severe stricture with bleeding and tall papillary lesions.

CONCLUSIONS

CO₂ insufflation during POCS can reduce procedure time and simplify cholangioscopy. The overall image quality was similar to that obtained with conventional saline irrigation.

Clinical benefit of peretinoin for the suppression of hepatocellular carcinoma (HCC) recurrence in patients with Child-Pugh grade A (CP-A) and small tumor: A subgroup analysis in a phase II/III randomized, placebo-controlled trial

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Background: HCC has a high recurrence rate and poor prognosis; however, no effective treatment has been established for preventing recurrence after resection or ablation. Peretinoin, an acyclic retinoid, of 600 mg/day reduced HCC recurrence and a strong effect after two years suggested that it mainly suppressed de novo carcinogenesis (ASCO2010). Liver impairment causes non- HCC-related deaths or adverse events, and can potentially mask drug efficacy. The size of the main HCC nodule associates vascular invasion and intrametastasis. To evaluate peretinoin efficacy and assess its mechanism of action, we performed subgroup analysis in CP-A patients who had undergone curative therapy for a small tumor.

Methods: Eligibility criteria included HCV positive, CP-A or B, and prior curative resection or ablation for conventional HCC. The patients were randomized into groups to receive peretinoin 600 mg/day (high dose, H), peretinoin 300 mg/day (low dose, L), or placebo (P). The patients were grouped according to the CP grade and the size of the major tumor <20mm at the time of diagnosis. Cumulative recurrence-free survival rates were calculated. Hazard ratio (HR) was calculated using Cox regression analysis.

Results: Of the 401 patients, 310 showed CP-A, and 144 showed CP-A and tumor size <20 mm. In the CP-A subgroup, the HR of H group (100) vs. P group (106) was 0.603 (95% CI, 0.408-0.891); in the CP-A and tumor size <20 mm subgroup, the HR of H group (49) vs. P group (49) was 0.376 (95% CI, 0.200-0.705). The common treatment-related adverse events in the CP-A subgroup were albuminuria, hypertension, and headache, which were tolerated.

Conclusions: Subgroup analysis with CP-A reinforced the peretinoin efficacy in preventing HCC recurrence. In addition, the CP-A and tumor size <20mm subgroup results strongly suggested that peretinoin inhibited de novo carcinogenesis. The subgroup analyses results of our phase II/II study supported the efficacy and safety of peretinoin and showed that it has early benefits for patients with well-preserved liver function and undergone curative therapy for a small tumor.

[Table: see text]

"Transmural air leak": a computed tomographic finding following endoscopic submucosal dissection of gastric tumors

BACKGROUND AND STUDY AIMS

A small amount of free air, visible on CT but not on plain chest radiography, which appeared following endoscopic submucosal dissection (ESD) of a gastric neoplasm without endoscopically visible perforation, was defined as a "transmural air leak", and a prospective, consecutive entry study was performed to determine its incidence and clinical significance.

PATIENTS AND METHODS

Between January 2006 and September 2008, ESD was performed for 246 gastric lesions in 246 consecutive patients. Abdominal CT scan was performed 1 day after ESD. In addition, chest radiography and blood biochemistry tests were performed at different time points before and after ESD.

RESULTS

Two hundred and nineteen lesions (89 %) were curatively removed by ESD. Among the total of 246 patients, we encountered endoscopically visible perforation during ESD in 2 patients (0.8 %), and clinically suspected perforation diagnosed by the presence of free air on chest radiography but invisible during ESD in 3 patients (1 %), while transmural air leak was observed in another 33 (13 %). Air leak occurred in cases where resection size was larger, procedure time longer, and the muscularis propria on the ulcer base was exposed at the end of ESD. Patients with air leaks developed pyrexia at a higher rate than those without (36 % vs. 16 %, P = 0.018). These patients recovered with antibiotics and required no endoscopic or surgical intervention. The presence of an air leak did not affect the duration of hospital stay.

CONCLUSIONS

A transmural air leak was observed in 13 % of the patients undergoing ESD. Larger resection size, prolonged procedure time, and exposure of the muscularis propria on the ulcer base were risk factors for transmural air leak, but the outcome of patients with this complication was good.

Clinical trial: extended treatment duration of peginterferon-alpha2b plus ribavirin for 72 and 96 weeks in hepatitis C genotype 1-infected late responders

BACKGROUND

The benefits of prolonging peginterferon and ribavirin after 48 weeks of treatment to maximize sustained virological responses (SVR) in hepatitis C virus (HCV) genotype 1-infected patients remain to be understood.

AIM

To investigate whether extended treatment longer than 72 weeks may be superior to 72-week treatment.

METHODS

A total of 120 treatment-naïve or retreated patients with HCV genotype 1 were treated with peginterferon-alpha-2b (1.5 microg/kg/week) plus weight-based ribavirin. We had 34 late responders, in whom HCV RNA first became undetectable at week 12-48, and randomized them into three groups receiving standard-dose peginterferon-alpha-2b plus low-dose ribavirin (200 mg/day) for extended 24 weeks (group A), receiving low-dose peginterferon-alpha-2b (0.75 microg/kg/week) plus low-dose ribavirin for extended 48 weeks (group B) or no extended treatment (group C), and evaluated the outcome according to their virological response.

RESULTS

Multivariate analysis showed that the treatment for 96 weeks was identified as a significant, independent factor associated with SVR in HCV genotype 1-infected late responders in comparison with group A [odds ratio (OR), 10.002; P = 0.080] and group C (OR, 17.748; P = 0.025).

CONCLUSION

Extending the treatment duration from 48 weeks to 96 weeks improves SVR rates in genotype 1-infected patients with late virological response to peginterferon-alpha-2b and ribavirin.

Endoscopic ultrasound-guided fine needle aspiration biopsy for splenic tumor: a case series

Splenic tumors are occasionally found in clinical practice but the diagnosis is often difficult if only serologic and imaging tests are used. Therefore, pathologic sampling is required in such cases. Endoscopic ultrasonography (EUS) provides a good image of the spleen through the gastric wall, and a transgastric EUS-guided fine needle aspiration (EUS-FNA) biopsy may be easier than the percutaneous approach. Furthermore, a large-gauge needle may raise the capability of EUS-FNA for the histopathologic diagnosis. The aim of this study was to evaluate the yield of EUS-FNA using a large-gauge needle for a splenic tumor. Five patients with splenic tumor were subjected to EUS-FNA with a 19-gauge needle to obtain histopathologic materials. A pathologic sample was obtained in all cases, and the diagnoses were lymphoma (n = 2), sarcoidosis (n = 2), and inflammatory pseudotumor (n = 1). EUS-FNA using a 19-gauge needle is safe and useful for the diagnosis of splenic tumors.

Influence of sodium benzoate on the metabolism ofo-xylene in the rat

The main metabolites of o-xylene in urine are o-methylhippuric acid, o-toluic acid, o-toluic acid glucuronide, 3,4-dimethylphenol, 3,4-dimethylphenol conjugates and o-xylylmercapturic acid. The urinary excretion of o-toluic acid, o-toluic acid conjugates and o-xylene were increased by the prior administration of sodium benzoate. Conversely, the amounts of o-methylhippuric acid, 3,4-dimethylphenol conjugates and o-xylylmercapturic acid decreased by sodium benzoate pretreatment. In addition, the urinary excretion of o-methylhippuric acid was delayed by the pretreatment. The percentages of urinary excretion of the o-xylene metabolites were substantially changed by the pretreatment with sodium benzoate. These results therefore highlight a potential interaction of an air pollutant with a food additive, an interaction that remains to be established in man.

Detection of Pb-LIII edge XANES spectra of urban atmospheric particles combined with simple acid extraction

Pb-LIII edge XANES spectra of atmospheric particles are directly obtained by fluorescent XAFS spectroscopy using a 19-element solid state detector (SSD). Particulate sample was collected on a quartz fiber filter using a high-volume air sampler, and the filter was cut into small pieces (25x25 mm). Then, surface layer of the filter piece was scaled and accumulated in order to enhance the particle density per filter unit. Use of 10 pieces of the surface layer enables the measurement of Pb-LIII edge XANES spectra on beamline BL01B1 at SPring-8, Hyogo, Japan. The shape of the Pb-LIII edge XANES spectra of the particulate sample is similar to the shapes of the spectra for PbS, PbCO(3), PbSO(4) and/or PbCl(2). Additionally, the filter sample is also divided into water-soluble, 0.1 M HCl-extractable, and residual fractions of Pb compounds by a simple acid extraction procedure. We discuss the possibility of Pb speciation in the particulate samples with combination of highly sensitive XANES spectroscopy and simple acid extraction.

The yield of endoscopic ultrasound-guided fine needle aspiration for histological diagnosis in patients suspected of stage I sarcoidosis

BACKGROUND AND STUDY AIM

Sarcoidosis is a systemic disorder of unknown cause that is characterized by a pathological hallmark, noncaseating granuloma. Bilateral hilar lymphadenopathy (BHL) is a major clinical feature, but it is sometimes difficult to exclude other diseases, especially in cases where there are no pulmonary abnormalities (stage I). Bronchoscopic transbronchial biopsy is currently a popular method by which to obtain pathological material, but its diagnostic power is insignificant. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), also attempted recently, makes the sampling of pathological material easier and better, but the diagnoses are still based on cytological findings. Our study aimed to evaluate the yield of transesophageal EUS-FNA for histological confirmation of stage I sarcoidosis.

METHODS

The study was a prospective comparative study to investigate the diagnostic sensitivities of FNA cytology and FNA histology. Subjects were consecutive patients with BHL without lung lesions on chest radiographs or chest CT who were referred to our hospitals between December 2003 and April 2006. Transesophageal EUS-FNA was performed with 19-gauge needles instead of the conventional 22-gauge needles.

RESULTS

Forty-one patients were included in this study, and both histological and cytological materials were obtained successfully by EUS-FNA in all patients. Histopathological examination of the FNA sample showed noncaseating granuloma in 34 (94.4%) of the 36 patients with a final diagnosis of sarcoidosis. In contrast, only 28 of the 36 (77.8%) were diagnosed as having sarcoidosis on the basis of cytological findings. The difference was statistically significant (P = 0.0444).

CONCLUSION

FNA histology is better suited than FNA cytology to establishing the diagnosis of stage I sarcoidosis, and EUS-FNA with a 19-gauge needle plays a important role in this process.

Baseline NIH Stroke Scale Score predicting outcome in anterior and posterior circulation strokes

OBJECTIVE

The NIH Stroke Scale (NIHSS) may not appropriately assess the spectrum of posterior circulation (PC)-related neurologic deficits. We determined the cutoff baseline NIHSS score that predicts independent daily life activity during the chronic stage in anterior circulation (AC) vs PC ischemic strokes.

METHODS

A total of 310 consecutive patients hospitalized within 3 days after the onset of an ischemic stroke were prospectively enrolled in the study. Patients on thrombolytic therapy were excluded. In all patients, infarcts and vascular lesions were identified primarily using magnetic resonance techniques. A favorable outcome was defined as a modified Rankin Scale score of < or =2 at 3 months poststroke.

RESULTS

In 101 patients with PC stroke, the total baseline NIHSS score was lower (p < 0.001), and the subscores of ataxia (p < 0.001) and visual fields (p = 0.043) were higher than in 209 patients with AC stroke. Multivariate-adjusted OR for the favorable outcome in patients with PC vs AC stroke was 2.339 (95% CI 1.331-4.109, p = 0.003). A low baseline NIHSS score was independently predictive of a favorable outcome in both patients with PC (OR 1.547, 95% CI 1.232-1.941) and AC (1.279, 1.188-1.376) stroke. The optimal cutoff scores of the baseline NIHSS for the favorable outcome were < or =5 for patients with PC stroke (sensitivity, 84%; specificity, 81%) and < or =8 for patients with AC stroke (sensitivity, 80%; specificity, 82%).

CONCLUSIONS

The cutoff score of the baseline NIH Stroke Scale (NIHSS) for a favorable chronic outcome was relatively low in patients with PC stroke compared to patients with AC stroke. The NIHSS appears to have limitations with respect to its use when comparing the neurologic severity of PC and AC stroke.

Endoscopic ultrasound-guided fine-needle aspiration biopsy for lymphadenopathy of unknown origin

BACKGROUND AND STUDY AIMS

The diagnosis of mediastinal and intra-abdominal lymphadenopathy is sometimes difficult, especially in patients who have no other primary lesions. Lymphoma is one of the main causes of this condition. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe and accurate diagnostic procedure for lesions surrounding the gastrointestinal tract. However, diagnosing lymphoma using the EUS-FNA technique remains a diagnostic challenge, due to limitations in the amount of material sampled. The aim of the present study was to evaluate the yield of EUS-FNA biopsy (EUS-FNAB) using a large-gauge needle in patients with mediastinal and intra-abdominal lymphadenopathy of unknown origin, especially in relation to subclassification of the lymphomas.

PATIENTS AND METHODS

Consecutive patients with mediastinal and intra-abdominal lymphadenopathy of unknown origin who were referred between October 2003 and March 2005 were enrolled in the study. EUS-FNAB was carried out using a 19-gauge needle, passing through the esophageal, gastric, and duodenal walls. Pathological diagnoses were made on the basis of histological findings, including immunopathological staining.

RESULTS

A total of 104 patients were included in the study. The locations of the lymph nodes were mediastinal in 50 patients, intra-abdominal in 48 patients, and both mediastinal and intra-abdominal in six patients. The diagnoses made using EUS-FNAB were lymphoma (n = 48), metastasis (n = 16), and benign/reactive (n = 40). The overall accuracy of EUS-FNAB for unknown lymphadenopathy was 98 %, and it was possible to classify the lymphomas in accordance with the World Health Organization classifications in 88 % of cases. No serious complications occurred with the procedure.

CONCLUSIONS

Open thoracic surgery, laparotomy, and other invasive diagnostic procedures such as mediastinoscopy and laparoscopy can now be avoided, as EUS-FNAB is potentially a safe and accurate tool for diagnosing unknown lymphadenopathy, including lymphoma.

Expansion of genetically corrected neutrophils in chronic granulomatous disease mice by cotransferring a therapeutic gene and a selective amplifier gene

Hematopoietic stem cell gene therapy has not provided clinical success in disorders such as chronic granulomatous disease (CGD), where genetically corrected cells do not show a selective advantage in vivo. To facilitate selective expansion of transduced cells, we have developed a fusion receptor system that confers drug-induced proliferation. Here, a 'selective amplifier gene (SAG)' encodes a chimeric receptor (GcRER) that generates a mitotic signal in response to estrogen. We evaluated the in vivo efficacy of SAG-mediated cell expansion in a mouse disease model of X-linked CGD (X-CGD) that is deficient in the NADPH oxidase gp91phox subunit. Bone marrow cells from X-CGD mice were transduced with a bicistronic retrovirus encoding GcRER and gp91phox, and transplanted to lethally irradiated X-CGD recipients. Estrogen was administered to a cohort of the transplants, and neutrophil superoxide production was monitored. A significant increase in oxidase-positive cells was observed in the estrogen-treated mice, and repeated estrogen administration maintained the elevation of transduced cells for 20 weeks. In addition, oxidase-positive neutrophils were increased in the X-CGD transplants given the first estrogen even at 9 months post-transplantation. These results showed that the SAG system would enhance the therapeutic effects by boosting genetically modified, functionally corrected cells in vivo.

Losartan, an angiotensin II (AT1) receptor antagonist, preserves cerebral blood flow in hypertensive patients with a history of stroke

In patients with severe hypertension, chronic heart failure or a history of stroke, the lower limit of autoregulation of cerebral blood flow (CBF) is shifted to higher levels of blood pressure (BP) than those observed in healthy subjects. The aim of pharmacotherapy for hypertensive patients with an impaired autoregulation of CBF should be to reduce BP while preserving an appropriate CBF. In the present study, 16 hypertensive patients who had had an episode of stroke more than 4 weeks previously were administered the angiotensin II (AT1) receptor antagonist losartan at daily doses of 25-100 mg for 4 weeks. Systolic and diastolic blood pressures were recorded for 24 h using an ambulatory BP monitoring system. CBF in both hemispheres of the cerebrum and cerebellum was quantified using single photon emission tomography with N-isopropyl-p-[123I]iodoamphetamine. At baseline, CBF was 29.7 +/- 6.7 ml/min/100 g in the cerebrum and 31.5 +/- 7.5 ml/min/100 g in the cerebellum. At the end of treatment, BP was lower, while CBF increased by 7.7% in the cerebrum, and remained at the baseline level in the cerebellum. Thus, CBF was preserved despite the reduction in BP. We consider the use of losartan is advantageous for hypertensive patients with a history of stroke in whom autoregulation of CBF is potentially impaired.

Clinical results of stenting for cervical internal carotid stenoses

SUMMARY

Total 89 patients with cervical ICA stenosis were treated by stenting. In 74 cases of stenting, we used our blocking balloon systems to prevent distal embolism. The morbidity and the mortality rate was 4.5% and 0%, respectively.Two(3%) of 74 cases showed distal embolism when blocking balloon catheter systems(BBCS) were used, while distal embolism occurred in four (27%) of 15 cases of stenting without BBCS. On diffusion- weighted MRI (DWI), hyperintense areas were detected in seven (47%) of 15 lesions when we used BBCS only during postdilatation. On the other hand, use of BBCS during predilatation as well as postdilatation reduced hyperintense areas on DWI, which were detected in three (25%) of 12 patients. Our blocking balloon catheter system is a useful device to reduce the risk of distal embolism, especially when we use it during not only postdilatation but predilatation.

Lymphoid blast crisis of chronic myelogenous leukemia occurring more than 11 years after receiving an allogeneic bone marrow transplant for chronic myelogenous leukemia in myeloid blast crisis at onset

A 25-year-old male developed lymphoid blast crisis (BC) of chronic myelogenous leukemia (CML) more than 11 years after receiving an allogeneic bone marrow transplant (alloBMT) for CML with myeloid BC at presentation from his HLA-identical brother. The lymphoid BC of CML probably occurred without a preceding chronic phase of CML. This case illustrates the difficulties involved in determining the appropriate length of follow-up after alloBMT.

The enzymatic basis for the conversion of nonfucosylated to fucosylated alpha-fetoprotein by acyclic retinoid treatment in human hepatoma cells: activation of alpha1-6 fucosyltransferase

The purpose of the present study was to investigate the mechanism by which nonfucosylated alpha-fetoprotein (AFP) is converted to fucosylated AFP in human hepatoma cell lines exposed to acyclic retinoid (AR), an effective drug for the secondary prevention of hepatocellular carcinoma. AR treatment (100 microM) of HepG2 and Hep3B cells significantly increased the activity and mRNA levels of alpha1-6 fucosyltransferase (alpha1-6 FucT), the enzyme responsible for the fucosylation of AFP, leading to an increase in fucosylated glycoproteins as evidenced by lectin binding measurements. Lectin immunoelectrophoresis of AFP obtained from culture media indicated that the relative percentage of nonfucosylated AFP (L1 fraction) was decreased and alpha1-6 fucosylated AFP (L3 fraction) was increased in these hepatoma cell lines after treatment with AR. The total AFP levels were, however, markedly suppressed by AR treatment, and therefore the absolute L3 fraction on the basis of the total AFP present was extremely low. These results demonstrate that AR enhances the conversion of the L1 to the L3 fraction due to the activation of alpha1-6 FucT in human hepatoma cell lines despite clinical outcome with AR treatment and the L3 fraction of AFP. Even though the dramatic decrease in AFP is the limiting factor in the synthesis of the L3 fraction and, therefore, the absolute value of fucosylated AFP is extremely low, the conversion from L1 to L3 as judged by lectin immunoelectrophoresis represents a good marker for the progress of AR treatment.

Silent cerebral infarction and cognitive function in middle-aged neurologically healthy subjects

We sought to clarify whether apparently silent cerebral infarcts and periventricular hyperintensities are associated with depressed cognitive function in middle-aged subjects. Subjects were 84 middle-aged neurologically normal adults who wished to undergo a screening examination of the brain. We performed magnetic resonance imaging (MRI) of the brain and neuropsychologic tests in all subjects. Silent cerebral infarcts and periventricular hyperintensities, respectively, were detected in 21 and 14 of 84 subjects. Mini-mental state (MMS) and Raven's colored progressive matrices (RCPM) scores were significantly lower in subjects with than without silent cerebral infarcts. By two-factor analysis of variance, MMS score was affected by silent cerebral infarcts or periventricular hyperintensities, with interactions between the two lesion types (P < 0.05). Silent cerebral infarcts may be an independent factor in the pathogenesis of intellectual dysfunction, but truly independent analysis is difficult because many subjects with silent cerebral infarcts also have periventricular hyperintensities.

Transcortical mixed aphasia due to cerebral infarction in left inferior frontal lobe and temporo-parietal lobe

We present a case of transcortical mixed aphasia caused by a cerebral embolism. A 77-year-old right-handed man was admitted to our hospital with speech disturbance and a right hemianopia. His spontaneous speech was remarkably reduced, and object naming, word fluency, comprehension, reading and writing were all severely disturbed. However, repetition of phonemes and sentences and reading aloud were fully preserved. Although magnetic resonance imaging (MRI) showed cerebral infarcts in the left frontal and parieto-occipital lobe which included the inferior frontal gyrus and angular gyrus, single photon emission CT revealed a wider area of low perfusion over the entire left hemisphere except for part of the left perisylvian language areas. The amytal (Wada) test, which was performed via the left internal carotid artery, revealed that the left hemisphere was dominant for language. Hence, it appears that transcortical mixed aphasia may be caused by the isolation of perisylvian speech areas, even if there is a lesion in the inferior frontal gyrus, due to disconnection from surrounding areas.

Clinical results and problems of percutaneous transluminal angioplasty and stenting for extracranial internal carotid stenoses. Is the blocking balloon catheter system useful for prevention of distal embolism?

SUMMARY

110 patients with extracranial ICA stenosis were treated by PTA or stenting. In 21 of 55 cases of only PTA and in 40 of 55 cases of stenting, we used our blocking balloon systems to prevent distal embolism. The morbidity and the mortality rates were 5.4% and 0%, respectively. There was only one embolic complication in cases of PTA or stenting where blocking balloon systems were used. In contrast, distal embolism occurred in 3 of 34 cases of PTA without blocking balloon systems (one symptomatic case) and in 4 of 15 cases of stenting without blocking balloon systems (3 symptomatic cases). Our blocking balloon catheter system is a useful device to reduce the risk of symptomatic distal embolism.

[Prevention of recurrent hepatocellular carcinoma with retinoid]

The annual rate of recurrent hepatocellular carcinoma (HCC) after curative treatment of the initial tumor is reportedly as high as 20-25%. Such a high recurrence rate is responsible for the poor prognosis of patients with HCC. One third of the recurrent HCC arises from intrahepatic metastasis of the initial tumor, one third from multicentric carcinogenesis, and one third from unknown origin. In any type of recurrence, elimination of the transformed cell clone from the remnant liver is essential to prevent the recurrence of HCC. A retinoid analog, acyclic retinoid, induces differentiation and apoptosis of HCC cell lines in vitro. An early clinical trial showed a preventive effect of the compound on recurrent HCC. A further trial of acyclic retinoid is now under way.

Role of oxidized LDL in atherosclerosis

A critical event in the early stages of atherosclerosis is the focal accumulation of lipid-laden foam cells derived from macrophages. In various cholesterol-fed animal models of atherosclerosis, localized attachment of circulating monocytes to arterial endothelial cells appeared to precede the formation of foam cells. It is suggested that monocyte recruitment into early lesions depends on the endothelial adhesiveness for monocytes and lymphocytes. In vivo and in vitro experiments have identified molecules, such as ICAM-1, VCAM-1, and P-selectin, that can support the adhesion of monocytes and lymphocytes. Moreover, oxidized LDL, lysophosphatidyl-choline, and oxidized fatty acids induce the expression not only of these adhesion molecules but also of scavenger receptors, such as CD-36, SR-A, and LOX-1. Recently, we isolated and characterized the novel receptors for oxidized LDL, namely, LOX-1 and SR-PSOX. Expression of LOX-1 is found on endothelial cells, smooth muscle cells, and macrophages, whereas SR-PSOX is expressed on macrophages. In this paper the significance of oxidized LDL and its receptors, LOX-1 and SR-PSOX, in terms of atherogenesis is discussed.

Different mutation status of the beta-catenin gene in carcinogen-induced colon, brain, and oral tumors in rats

Mutations in the region corresponding to the N-terminal phosphorylation sites (codons 1-51) of the rat beta-catenin gene (Ctnnb1) were investigated in rat colon tumors induced by 1-hydroxyanthraquinone (1-HA) plus methylazoxymethanol (MAM) acetate, by using polymerase chain reaction (PCR)-single-strand conformation polymorphism (SSCP) analysis. The beta-catenin gene was also screened for mutations in rat brain and oral tumors induced by ethyl nitrosourea (ENU) and 4-nitroquinoline 1-oxide (4-NQO), respectively. In colon tumors, beta-catenin gene mutations were found in two of three adenomas (67%) and 26 of 28 adenocarcinomas (93%), with a total incidence of 90% (28 of 31 adenomas plus adenocarcinomas). Eight (29%) were (34)G-->T (second position), eight (29%) were (32)G-->A (first position), five (18%) were (34)G-->A (first position), five (18%) were (41)C-->T (second position), one (4%) was (34)G-->A (second position), and one (4%) was (32)A-->G (second position), mutations, resulting in the substitutions of Gly(34)-->Val, Asp(32)-->Asn, Gly(34)-->Arg, Thr(41)-->Ile, Gly(34)-->Glu, and Asp(32)-->Gly, respectively. The (34)G-->T (second position) mutations found in this study were unique compared to those found in other carcinogen-induced rat colon carcinogenesis models. In contrast, beta-catenin gene mutations were not found in either the brain or oral tumors. These results suggest that mutations in the beta-catenin gene in rat tumors occur in specific tissues or organ sites and in a carcinogen-specific manner. Thus, the mutation spectrum in the beta-catenin gene is organ- and chemical carcinogen-specific.

Intrahepatic cholangiocarcinoma arising 10 years after the excision of congenital extrahepatic biliary dilation

A 52-year-old woman was found to have a liver tumor during treatment for a liver abscess. The tumor was diagnosed as intrahepatic cholangiocarcinoma by closer examinations, including a percutaneous needle biopsy. Ten years previously, she had undergone excision of a choledochal cyst, with reconstruction by Roux-en-Y hepaticojejunostomy, as treatment for Todani's type Ia congenital biliary dilation, which had been confined only to the extrahepatic bile duct. The significant association between congenital biliary dilation and hepatobiliary malignancies is well known. Some patients have been reported to develop biliary cancer long after the excision of the entire extrahepatic bile duct and hepaticoenterostomy. However, in these patients, the development mostly took place in the remnant choledochal cyst, the anastomotic site, or in the dilated intrahepatic bile duct of Todani's type IV-A congenital biliary dilation. The development of intrahepatic cholangiocarcinoma after operation has not been reported previously in a patient with Todani's type I congenital biliary dilation. This case suggests that the entire biliary tree may have a high risk of field cancerization, even in extrahepatic congenital biliary dilation.

Chemoprevention of hepatocellular carcinoma: concept, progress and perspectives

Hepatocellular carcinoma (HCC) often develops in patients with chronic liver diseases associated with hepatitis B (HBV) and hepatitis C (HCV) virus infections with high incidences. Particularly, post-therapeutic recurrence encountered after the curative treatment of the preceding HCC may limit the prognosis. Thus, prevention of HCC is of great significance. In the present review, immunopreventions with alpha-interferon and glycyrrhizin, as well as chemoprevention with acyclic retinoid, are discussed. alpha-Interferon prevents the development of HCC not only in patients with a long-term elimination of HCV (sustained virological responders), but in ones with normalized serum aminotransferases (sustained biochemical responders). Glycyrrhizin also suppresses serum aminotransferases and thereby prevents the tumor development, even though the compound does not have antiviral activity for HBV or HCV by itself. Therefore, suppression of hepatic necroinflammation by these drugs may serve to prevent hepatocarcinogenesis. In contrast, acyclic retinoid suppresses the post-therapeutic recurrence in cirrhotic patients who underwent curative treatment of preceding tumors. The retinoid induces the disappearance of serum lectin-reactive alpha-fetoprotein (AFP-L3), a tumor marker indicating the presence of unrecognizable tumors in the remnant liver, suggesting a deletion of such minute (pre)malignant clones (clonal deletion). As a molecular mechanism of the clonal deletion, a novel mechanism of apoptosis induction by the retinoid via tissue transglutaminase is implicated. In future, a combination of immunopreventive and chemopreventive therapies may give a clue to the further advances of cancer prevention, and thereby to the improvement of the prognosis of cirrhotic patients.

[Hypereosinophilic syndrome with DIC treated successfully with a combination of high-dose methylprednisolone and cyclosporin A]

A 47-year-old man was admitted to our hospital with subcutaneous nodules on the bilateral lower legs and disseminated intravascular coagulation (DIC). Peripheral blood examination revealed leukocytosis with an increase of mature eosinophils, thrombocytopenia and abnormal coagulation. Bone marrow aspiration revealed an increased eosinophil count, and a diagnosis of hypereosinophilic syndrome (HES) was made. Prednisolone (PSL) therapy was not effective. Subsequent methylPSL pulse therapy followed by PSL brought about a transient improvement of the HES and DIC, but after reduction of the PSL, the HES worsened. After addition of cyclosporin A to the PSL, however, the HES improved and did not worsen.