Vessel Rupture Complication due to Ballooning of the Distal Segment of a JET 7 Xtra Flex Reperfusion Catheter during Angiogram

Objective

We present a case of intraprocedural device malfunction related to the JET 7 Xtra Flex reperfusion catheter during mechanical thrombectomy.

Case Presentation

A 92-year-old man presented with sudden right hemiparesis with a National Institutes of Health Stroke Scale score of 22. His left middle cerebral artery (M1) was occluded, and emergency mechanical thrombectomy was performed. After partial recanalization was achieved, angiography through a JET 7 Xtra Flex was attempted. After manual injection of contrast media via a 10-mL syringe through the JET 7 Xtra Flex, the catheter moved, jumping forward, and the distal tip of the catheter expanded and ruptured. This resulted in intracranial vessel damage and subsequent patient death.

Conclusion

Contrast media must not be injected through the JET 7 Xtra Flex. If contrast media needs to be injected for angiography during mechanical thrombectomy with a reperfusion catheter, it should always be through the guide catheter.

In-hospital Ischemic Stroke Treated by Mechanical Thrombectomy

Objective

We investigated in-hospital stroke (IHS) treated by mechanical thrombectomy in comparison with out-of-hospital stroke (OHS) to clarify the points of concern in IHS at our institution.

Methods

Between September 2015 and June 2018, 19 patients with IHS who underwent mechanical thrombectomy (IHS group) were enrolled, and compared with 154 patients with OHS (OHS group) regarding patient characteristics, technical results, and outcome. In this study, we set the detection time in the IHS group as patient arrival time, termed "Door" in the OHS group.

Results

Cardiology and gastroenterology were the two main admitting departments, including four (21%) patients of IHS group. In all, 15 (79%) patients had atrial fibrillation; however, less than one-third of them was taking anticoagulant drugs at onset. There were only two cases of direct consultation to the stroke specialists, although IHS onset was mainly recognized by nurses. The median age in the IHS group was 81 (interquartile range (IQR), 76-86.5) versus 80 in the OHS group (IQR, 73-85; p = 0.43), and the median initial National Institutes of Health Stroke Scale score was 21 (IQR, 16-23) versus 21 (IQR, 14-26; p = 0.92), respectively. Sex, Alberta Stroke Program Early CT Score, etiology, and occlusion site did not differ between groups. The rate of use of intravenous tissue plasminogen activator (IV-tPA) was 26% in the IHS group versus 49% in the OHS group (p = 0.065). The median time of detection to imaging, detection to needle for IV-tPA, and detection to puncture were 32, 69, and 87 minutes, respectively, in the IHS group, being significantly longer than those in the OHS group (11, 30, and 50 minutes; p <0.01, p <0.01, and p <0.01, respectively). The median time of puncture to reperfusion was 39 minutes, being significantly shorter than that in the OHS group (82 minutes; p <0.01). Successful reperfusion defined as thrombolysis in cerebral infarction (TICI) 2b-3 was obtained in 94.7% of the IHS group versus 83.1% of the OHS group (p = 0.19). A favorable outcome (modified Rankin Scale score 0-2) at 90 days was achieved by 36.8% (IHS) versus 35.1% (OHS) of patients (p = 0.88). The rate of symptomatic procedural complications was 0% (IHS) versus 7.1% (OHS; p = 0.23). The rate of death at 90 days was 15.8% (IHS) versus 12.3% (OHS; p = 0.67).

Conclusion

The times of detection to imaging and of detection to puncture in the IHS group were longer than those in the OHS group; however, patients in the IHS group had shorter reperfusion. The outcome of the IHS group did not differ from that of OHS group. Our study suggests that the time course of treatment should be improved and rapid stroke pathways involved in consultation with the stroke specialists for IHS should be organized.

Hemodynamic characteristics of hyperplastic remodeling lesions in cerebral aneurysms

Background & purpose

Hyperplastic remodeling (HR) lesions are sometimes found on cerebral aneurysm walls. Atherosclerosis is the results of HR, which may cause an adverse effect on surgical treatment for cerebral aneurysms. Previous studies have demonstrated that atherosclerotic changes had a correlation with certain hemodynamic characteristics. Therefore, we investigated local hemodynamic characteristics of HR lesions of cerebral aneurysms using computational fluid dynamics (CFD).

Methods

Twenty-four cerebral aneurysms were investigated using CFD and intraoperative video recordings. HR lesions and red walls were confirmed on the intraoperative images, and the qualification points were determined on the center of the HR lesions and the red walls. The qualification points were set on the virtual operative images for evaluation of wall shear stress (WSS), normalized WSS (NWSS), oscillatory shear index (OSI), relative residence time (RRT), and aneurysm formation indicator (AFI). These hemodynamic parameters at the qualification points were compared between HR lesions and red walls.

Results

HR lesions had lower NWSS, lower AFI, higher OSI and prolonged RRT compared with red walls. From analysis of the receiver-operating characteristic curve for hemodynamic parameters, OSI was the most optimal hemodynamic parameter to predict HR lesions (area under the curve, 0.745; 95% confidence interval, 0.603–0.887; cutoff value, 0.00917; sensitivity, 0.643; specificity, 0.893; P<0.01). With multivariate logistic regression analyses using stepwise method, NWSS was significantly associated with the HR lesions.

Conclusions

Although low NWSS was independently associated with HR lesions, OSI is the most valuable hemodynamic parameter to distinguish HR lesions from red walls.

A Case of Vertebral Artery Fusiform Aneurysm Treated by Flow Alteration: Successful Prediction of Therapeutic Effects Using Computational Fluid Dynamics

The treatment of intracranial complicated aneurysms remains challenging. In patients with complicated aneurysms that are neither clippable nor coilable, flow alteration treatment (FAT) with a combined procedure of proximal/distal occlusion or trapping of an aneurysm with bypass surgery has been reported. However, it is difficult to predict whatever FAT can achieve aneurysmal obliteration without ischemic complications. A 69-year-old female was incidentally diagnosed with a left vertebral artery (VA) fusiform aneurysm distal to the left posterior inferior cerebellar artery (PICA). Because one-year follow-up three-dimensional computed tomography angiography showed that the aneurysm grew significantly, surgical management was considered the therapy of choice. For determining treatment strategies, we assumed left VA occlusion at the proximal to the left PICA as a FAT model and performed computational fluid dynamics (CFD) analyses. The FAT model had much lower wall shear stress and shear rate at the aneurysm dome than presumed thresholds necessary to thrombus formation, while those at the PICA were obviously higher than the thresholds, and streamlines into the left PICA from the distal VA were preserved. These findings theoretically meant that surgical occlusion of the left VA proximal to the left PICA and aneurysm would induce intra-aneurysmal thrombus formation with preservation of the left PICA flow. The treatment was performed successfully and achieved the predicted results. CFD simulations may be useful to predict effects of FAT for complicated aneurysms.

Stagnation and complex flow in ruptured cerebral aneurysms: a possible association with hemostatic pattern

OBJECT

Histopathological examination has revealed that ruptured cerebral aneurysms have different hemostatic patterns depending on the location of the clot formation. In this study, the authors investigated whether the hemostatic patterns had specific hemodynamic features using computational fluid dynamics (CFD) analysis.

METHODS

Twenty-six ruptured middle cerebral artery aneurysms were evaluated by 3D CT angiography and harvested at the time of clipping. The hemostatic patterns at the rupture points were assessed by means of histopathological examination, and morphological parameters were obtained. Transient analysis was performed, and wall shear stress–related hemodynamic parameters and invariant Q (vortex core region) were calculated. The morphological and hemodynamic parameters were compared among the hemostatic patterns.

RESULTS

Hematoxylin and eosin staining of the aneurysm wall showed 13 inside-pattern, 9 outside-pattern, and 4 other-pattern aneurysms. Three of the 26 aneurysms were excluded from further analysis, because their geometry models could not be generated due to low vascular CT values. Mann-Whitney U-tests showed that lower dome volume (0.04 cm3 vs 0.12 cm3, p = 0.014), gradient oscillatory number (0.0234 vs 0.0289, p = 0.023), invariant Q (−0.801 10−2/sec2 vs −0.124 10−2/sec2, p = 0.045) and higher aneurysm formation indicator (0.986 vs 0.963, p = 0.041) were significantly related to inside-pattern aneurysms when compared with outside-pattern aneurysms.

CONCLUSIONS

Inside-pattern aneurysms may have simpler flow patterns and less flow stagnation than outside-pattern aneurysms. CFD may be useful to characterize the hemostatic pattern of ruptured cerebral aneurysms.

Inflammatory biomarkers in atherosclerosis: pentraxin 3 can become a novel marker of plaque vulnerability

Inflammation is crucially involved in the development of carotid plaques. We examined the relationship between plaque vulnerability and inflammatory biomarkers using intraoperative blood and tissue specimens. We examined 58 patients with carotid stenosis. Following carotid plaque magnetic resonance imaging, 41 patients underwent carotid artery stenting (CAS) and 17 underwent carotid endarterectomy (CEA). Blood samples were obtained from the femoral artery (systemic) and common carotid artery immediately before and after CAS (local). Seventeen resected CEA tissue samples were embedded in paraffin, and histopathological and immunohistochemical analyses for IL-6, IL-10, E-selectin, adiponectin, and pentraxin 3 (PTX3) were performed. Serum levels of IL-6, IL-1β, IL-10, TNFα, E-selectin, VCAM-1, adiponectin, hs-CRP, and PTX3 were measured by multiplex bead array system and ELISA. CAS-treated patients were classified as stable plaques (n = 21) and vulnerable plaques (n = 20). The vulnerable group showed upregulation of the proinflammatory cytokines (IL-6 and TNFα), endothelial activation markers (E-selectin and VCAM-1), and inflammation markers (hs-CRP and PTX3) and downregulation of the anti-inflammatory markers (adiponectin and IL-10). PTX3 levels in both systemic and intracarotid samples before and after CAS were higher in the vulnerable group than in the stable group. Immunohistochemical analysis demonstrated that IL-6 was localized to inflammatory cells in the vulnerable plaques, and PTX3 was observed in the endothelial and perivascular cells. Our findings reveal that carotid plaque vulnerability is modulated by the upregulation and downregulation of proinflammatory and anti-inflammatory factors, respectively. PTX3 may thus be a potential predictive marker of plaque vulnerability.

Changes in hemodynamics after placing intracranial stents

Stent-assisted coil embolization has enabled the endovascular treatment of wide-necked cerebral aneurysms. Moreover, recent reports demonstrated that stent-assisted coil embolization was associated with a significant decrease in angiographic recurrences of coiled cerebral aneurysms. One of the possible explanations for this adjunctive effect of stent-assisted coil embolization is changes in the local hemodynamics caused by placing intracranial stents. This study investigated the hemodynamic effect of intracranial stents using computational fluid dynamics (CFD) analysis. The geometry of the intracranial stent, Enterprise(TM) VRD, was acquired by using micro computed tomography and virtually placed across the aneurysm orifice of a saccular aneurysm model (saccular model) and a blister-like aneurysm model (blister-like model) constructed from patient-specific three-dimensional (3D) rotational angiography data. Transient CFD analysis was performed with these models with and without stents. Stent placement induced no significant changes in the 3D streamline in the saccular model and slight changes in the blister-like model. Both saccular and blister-like models with stents had lower wall shear stress (WSS) and flow velocity, and higher oscillatory shear index, WSS gradient, and relative residence time than the equivalent models without stents, indicating the possibility that stent placement induced stagnant and disturbed blood flow. Cross-sectional vector velocity around the stent strut revealed complex blood flow patterns with variable direction and velocity. Although this study was a simulation under limited conditions, similar hemodynamic changes might be induced in the neck remnants treated with stent-assisted coil embolization.

Low Wall Shear Stress Is Independently Associated With the Rupture Status of Middle Cerebral Artery Aneurysms

Background and Purpose—

We determined which hemodynamic parameter independently characterizes the rupture status of middle cerebral artery (MCA) aneurysms using computational fluid dynamics analysis.

Methods—

In 106 patient-specific geometries of MCA aneurysms (43 ruptured, 63 unruptured), morphological and hemodynamic parameters were compared between the ruptured and unruptured groups. Multivariate logistic regression analysis was performed to determine parameters that independently characterized the rupture status of MCA aneurysms.

Results—

Univariate analyses showed that the aspect ratio, wall shear stress (WSS), normalized WSS, oscillatory shear index, WSS gradient, and aneurysm-formation index were significant parameters. The size of the aneurysmal dome and the gradient oscillatory number were not significantly different between the 2 groups. With multivariate analyses, only lower WSS was significantly associated with the rupture status of MCA aneurysms.

Conclusions—

WSS may be the most reliable parameter characterizing the rupture status of MCA aneurysms.

Abstract 64: Mechanism Of Carotid Plaque Vulnerability: Associations Of Pro-and Anti-inflammatory Molecules

Background: Inflammation plays an important role in the development, progression, and rupture of carotid plaques. We examined the relationship between plaque vulnerability and inflammatory molecules using blood samples and histological specimens.

Methods: We examined 58 patients with symptomatic or asymptomatic carotid stenosis, among which 41 underwent carotid artery stenting (CAS) and 17 underwent carotid endarterectomy (CEA). All of these patients were recruited in Mie University Hospital from Sept. 2009 to Mar. 2012 and underwent carotid plaque imaging with MRI. In the 41 patients with CAS, blood samples were obtained in the femoral artery as controls and in the carotid artery just before and after the operation. Emboli attached to the distal protection devices in CAS, or resected tissues after CEA were embedded in paraffin. The serum concentrations of IL-6, IL-10, E-selectin, adiponectin, hs-CRP and pentraxin 3 (PTX3) levels were measured by ELISA. Paraffin-embedded tissues were subjected to histopathologic and immunohistochemical analysis on IL-6, IL-10, E-selectin, PTX3.

Results: The patients with CAS were classified to 22 with stable plaque (stable group) and 19 with vulnerable plaque (vulnerable group). The values of IL-6, E-selectin, hs-CRP and PTX3 in the vulnerable group were higher than those in the stable group, whereas adiponectin and IL-10 were decreased in the vulnerable group as compared to the stable group. The values of PTX3 in the control and intracarotid samples before and after CAS were higher from the vulnerable group than those from the stable group. Pathologically, IL-6 was immunostained in the vulnerable plaques with infiltration of inflammatory cells, and PTX3 was expressed in the endothelial and perivascular cells in the unstable plaques.

Conclusions: The vulnerability of carotid plaques was modulated by upregulation of pro-inflammatory factors and downregulation of anti-inflammatory ones. In addition, PTX3 may be a novel determinant for plaque vulnerability.

Multicenter phase II study of FOLFOX for metastatic colorectal cancer (mCRC) in Japan; SWIFT-1 and 2 study

BACKGROUND/AIMS

This study assessed the efficacy and toxicity of the FOLFOX4 (SWIFT1) and mFOLFOX6 (SWIFT2) regimens in Japanese patients with metastatic colorectal cancer (mCRC).

METHODOLOGY

Patients with mCRC were required to have ECOG performance status of 0 to 1, and to have adequate organ function. Two multicenter Phase II studies (SWIFT1/SWIFT2) were conducted in chemotherapy naive patients with mCRC.

RESULTS

112 patients were enrolled in these studies (SWIFT1: 54 patients / SWIFT2: 58 patients). The disease sites for each study were the colon in 27 patients and 28 patients, and the rectum in 27 patients and 30 patients, respectively. All patients received a median of 8 courses. After a median follow-up period of 35 months, 54 patients and 58 patients were evaluable in the respective studies, and the overall response rate was 50.0% (CR:31 PR:53). The response rate according to the sites of metastasis were as follows: liver, 54.1% (46/85); lung, 17.4% (4/23); and lymph node, 23.3% (7/30). Grade 3/4 neutropenia occurred in 14 patients (12.5%), while Grade 3/4 non-hematological toxicities were observed in 16 patients (31.0%) and Grade 3 neurotoxicity was observed in 6patients (5.4%) and 5 patients (4.5%), respectively.

CONCLUSIONS

FOLFOX4 (SWIFT1) and mFOLFOX6 (SWIFT2) regimens complying with the international standard dosage and schedule can also be administered safely and effectively in Japan.

A phase II study of preoperative chemotherapy (CX) with S-1 and cisplatin followed by gastrectomy for clinically resectable type 4 and large type 3 gastric cancer: JCOG 0210

4609

Background: Prognosis of both linitis plastica (type 4) and large ulcero-invasive type (type 3) gastric cancer is poor even after curative resection. We conducted a phase II study to evaluate the safety and efficacy of preoperative CX with S-1 and cisplatin followed by gastrectomy in patients (pts) with these tumors. Methods: Eligibility criteria included histologically proven adenocarcinoma of the stomach; clinically resectable gastric cancer of type 4 or type 3 of =8 cm; cN0–2; cM0; PS 0–1; 20–75 years old. Pts received two 28-day cycles of induction CX of S-1 (80–120 mg/body, po, day 1–21) and cisplatin (60mg/m2, iv, day 8). Gastrectomy with D2/3 dissection was performed within 3 to 5 weeks after CX. No adjuvant therapy was added until recurrence after the curative gastrectomy. Primary endpoints were the proportion of protocol achievement and incidence of treatment related death (TRD). Sample size was determined to reject the rate of 45% under the expectation of 60% with power of 80% and alpha of 10%. Results: Fifty pts, 29 males and 21 females with a median age of 61 years (range: 32–75), were entered in this study between 03/2003 and 12/2003. Type 3/4 ratio was 20/30. Surgical exploration was carried out in 48 pts (96%). Among 49 eligible pts, 36 pts (73%; 95% CI, 59–85%) received two cycles of induction CX and R0 resection. One TRD was observed during the first course of CX due to uncontrollable hemorrhage from the primary tumor. Median survival time and the 3- year OS were 1.44 years (95% CI, 1.26–1.98) and 26.0% (95% CI, 14.9–38.6%), respectively. Pathological response, defined as disappearance of more than one third of the primary tumor, was confirmed in 24 pts (48%) and pathological complete response was seen in 1 pts (2%). During the CX, grade 3/4 neutropenia and anorexia occurred in 7 pts (14%), respectively. Postoperative morbidity included pneumonia in 2 pts, pancreatic leakage in 4, and intraperitoneal abscess in 3, without any mortality. Conclusions: Preoperative CX with S-1 and cisplatin followed by gastrectomy was safe and promising for type 4 and large type 3 gastric cancer. The results of ongoing phase III study to evaluate this treatment are awaited.

No significant financial relationships to disclose.

Diffusion-weighted MR imaging in carotid angioplasty and stenting with protection by the reversed carotid arterial flow

BACKGROUND AND PURPOSE

Distal embolism during carotid angioplasty with stent (CAS) can be protected by a flow-reversal device. Diffusion-weighted MR imaging was used to evaluate this protective procedure and perform a comparison with the control.

METHODS

Cases of CAS with protection procedures were included in this study. Sixty-five men (68 procedures) and 5 women (5 procedures), with an average age of 68.8 years, having severe carotid stenosis were treated in our department between 2002 and 2004. Eleven cases were treated with the Parodi Anti-Emboli System, with which the internal carotid blood flow is reversed by simultaneous occlusion of the proximal common carotid artery and external carotid artery. Diffusion-weighted MR imaging was performed within 1-3 days after CAS. As controls, data from diffusion-weighted MR imaging in 26 patients who had diagnostic angiography were included.

RESULTS

Diffusion-weighted MR imaging in diagnostic angiography showed 11.5% appearance of ischemic spots after procedures. In the Parodi Anti-Emboli System, this value was 18.2%. In the CAS group, ischemic lesions appeared only in the hemisphere ipsilateral to carotid stenosis. There were no ischemic lesions in the opposite carotid or vertebrobasilar territory. The appearance rate of new ischemic spots was not significantly different between the control group and the group of CAS with Parodi Anti-Emboli System (chi2 test, P = .6227, Fisher exact method).

CONCLUSIONS

Protection results obtained with the Parodi system were excellent and comparable with conventional angiography.

Diffusion-weighted magnetic resonance imaging in carotid angioplasty and stenting with balloon embolic protection devices

We compared the results of two procedures to protect against distal embolism caused by embolic debris from carotid angioplasty with stent deployment (CAS) using diffusion-weighted magnetic resonance imaging (MRI). The study group comprised 39 men and 3 women (42 and 3 CAS procedures, respectively) with severe carotid stenosis (average age 70.0 +/- 6.6 years). During 20 CAS procedures the internal carotid artery was protected with a single balloon. A PercuSurge GuardWire was used for temporary occlusion. During 25 CAS procedures the internal and external carotid arteries were simultaneously temporarily occluded with a PercuSurge GuardWire and a Sentry balloon catheter, respectively. Diffusion-weighted MRI was performed 1 to 3 days after CAS. Data from 26 patients undergoing conventional angiography for diagnosis of cerebral ischemic disease, cerebral aneurysm or brain tumors were included as controls. Diffusion-weighted MRI after conventional diagnostic angiography showed ischemic spots in 3 of the 26 controls (11.5%). Ischemic spots were observed during 11 of 20 CAS procedures with the internal carotid artery protected with a single balloon (55.0%), and were observed during 9 of 25 CAS procedures with both the internal and external carotid arteries protected (36.0%). This difference was significant (P = 0.0068). Ischemic lesions appeared not only ipsilateral to the carotid stenosis but also in the contralateral carotid artery (31.9%) and vertebrobasilar territory (25.3%). Better protection was obtained with simultaneous double occlusion of both the internal and external carotid artery than with single protection of the internal carotid artery during CAS.

Angioscopic observation during carotid angioplasty with stent placement

This clinical report is the first to describe angioscopy during carotid angioplasty with stent placement. The average observation time was 3 minutes 43 seconds in 18 cases. The view was clear in 67% of cases. Lesions in the endothelium, rupture of the fibrous cap, clots, debris detaching from plaque, and stent struts were observed. No symptomatic ischemic complications occurred. Diffusion-weighted MR imaging after angioscopy showed asymptomatic ischemic lesions in 47% of cases.

[A case of multiple liver metastases from sigmoid colon cancer effectively treated by hepatic intra-arterial administration of levoforinate and 5-fluorouracil]

A 62-year-old female patient, who was diagnosed with sigmoid colon cancer with multiple liver metastases, was admitted to our hospital. She underwent sigmoidectomy with D3 lymph node dissection on January 31, 2000. In addition to that, she received hepatic intra-arterial infusion of levoforinate (l-LV) 250 mg and 5-fluorouracil (5-FU) 500 mg for combined multiple hepatic metastases starting on postoperative day 14, and these medications were administered over 48 hours once weekly by infuser pump. The tumor diminished by 59% 2 months after the start of administration and further diminished at 4 months. PR was achieved. Cancer metastasis to the cerebellum and metastasis to the lung were detected at month 9 and month 11, respectively, but the liver metastatic tumor continued to diminish in size, ultimately becoming undetectable by CT scan at month 10. Surgery and radiotherapy were performed for the cerebellar metastasis, and intravenous administration of a combination of l-LV and 5-FU was performed systemically for the pulmonary metastatic tumor. At present, the patient receives regular outpatient treatment continuously. To our knowledge, there has been no report on the combination therapy with l-LV and 5-FU through the hepatic artery. Since good antitumor efficacy was demonstrated in the present patient, this case is described in this report together with four other cases of hepatic metastasis from colorectal cancer.

[A case report: disappearance of cancer cells confirmed by surgical resection after transcatheter hepatic artery embolization (TAE) for ruptured hepatocellular carcinoma]

The patient was a 74-year-old man. He had received medical treatment for liver cirrhosis (C types) and elevated AFP. Abdominal ultrasonography (US) revealed a 150 mm size tumor in the right lobe of the liver. After admission, anemia progressed rapidly, and we recognized bloody ascites by abdominal punction. Thus, diagnosis was a tumor rupture. Emergency angiography was performed. Farmorubicin and Lipiodol were injected, and complete TAE was added. After two TAE treatments CT-scan showed a remarkable decrement of the tumor and hypertrophy of the left lobe in the liver. Right lobectomy of the liver was then done because reserve function of the liver was good. Cancer cells changed into hyaline body and mecrotic focus. In the pathological examination of the extirpated sample, no viable tumor cells were detected.

[Long partial response (PR) in a case of multiple liver metastasis from colon cancer effectively treated by continuous hepatic intra-arterial infusion chemotherapy]

The patient was a 69-year-old man who had undergone a sigmoidectomy for cancer of the sigmoid colon on March 25, 1993. We detected the elevation of CEA after the operation. Computed tomography revealed multiple metastasis of the liver on September 3, 1996. After beginning 48-hour continuous hepatic arterial infusion using 5-FU 1,000 mg and Leucovorin 30 mg, we recognized a decrement of metastatic liver tumor. We could not detect cancer cells by needle biopsy for liver tumors on February 19, 1998. This case is maintaining good quality of life by hepatic artery infusion using 5-FU and Leucovorin, showing a long PR for about two years. We think that this case shows ideal clinical progress from chemotherapy for cancer of the digestive organs.

Mechanism of oxidative DNA damage induced by quercetin in the presence of Cu(II)

Quercetin, one of flavonoids, has been reported to be carcinogenic. There have been no report concerning carcinogenicity of kaempferol and luteolin which have structure similar to quercetin. DNA damage was examined by using DNA fragments obtained from the human p53 tumor suppressor gene. Quercetin induced extensive DNA damage via reacting with Cu(II), but kaempferol and luteolin induced little DNA damage even in the presence of Cu(II). Excessive quercetin inhibited copper-dependent DNA damage induced by quercetin. Bathocuproine, a Cu(I)-specific chelator, catalase and methional inhibited the DNA damage by quercetin, whereas free hydroxyl radical scavengers did not. Site specificity of the DNA damage was thymine and cytosine residues. The site specificity and the inhibitory effects suggested that DNA-copper-oxygen complex rather than free hydroxyl radical induced the DNA damage. Formation of 8-oxodG by quercetin increased extensively in the presence of Cu(II), whereas 8-oxodG formation by kaempferol or luteolin increased only slightly. This study suggests a good relationship between carcinogenicity and oxidative DNA damage of three flavonoids. The mechanism of DNA damage by quercetin was discussed in relation to the safety in cancer chemoprevention by flavonoids.

Somatic alterations of the SMAD-2 gene in human colorectal cancers

The SMAD-2 gene, which is located at 18q21, has been identified as a candidate tumour-suppressor gene from work on colorectal cancers. The aim of the present study was to determine the clinical alterations and the significance of its mutations in a series of colorectal cancers previously examined for SMAD-4/DPC-4 gene. Mutation analyses of the SMAD-2 gene were carried out on cDNA samples from 36 primary colorectal cancer specimens using a combination of the polymerase chain reaction (PCR), single-strand conformation polymorphism (SSCP) and DNA sequencing. Only one missense mutation (2.8%), producing an amino acid substitution in the highly conserved region, and two homozygous deletions (5.5%) of the total coding region of the SMAD-2 gene were detected in the 36 cancers. The SMAD-2 gene may play a role as a candidate tumour-suppressor gene in a small fraction of colorectal cancers. However, allelic loss at 18q21 is very often seen in this type of tumour. Even in combination with changes in SMAD-4, the observed frequency was not sufficient to account for all 18q21 deletions in colorectal cancers. Thus, another tumour-suppressor gene, such as DCC, discovered as the first tumour-suppressor candidate in the region may also exist in this chromosome region.

[Results of combination therapy of UFT-E with low-dose CDDP for patients with advanced recurrent breast cancer]

CDDP, as a modulator for 5-FU, has already been described as a very effective treatment for gastrointestinal tract cancer. We administered a dose of 400 mg of UFT-E orally every day, and 10 mg of CDDP by drip infusion twice weekly, for more than 10 weeks to 12 outpatients with metastatic local, pulmonary, hepatic, osteal or multiple-organ cancer which showed a poor response to the pretreatment, and assessed its efficacy and drug toxicity. In terms of the clinical efficacy of this therapy, CR was noted in one patient and PR in 2 patients with a response rate of 25%. The incidence of drug toxicity was low. Complications included temporal transient nausea and anorexia in two patients and leukopenia grade 2 as bone marrow suppression in 3 patients. From the standpoint of QOL, as well as in terms of both antitumor effect and drug toxicity, the therapy mentioned above was believed to be effective for outpatients with advanced recurrent breast cancer.

[A randomized controlled trial with methotrexate (MTX), 5-fluorouracil (5-FU) and pirarubicin (THP) vs 5-FU alone in advanced or recurrent gastric carcinoma. Tokai Hokuriku THP Study Group]

A randomized controlled trial was designed to investigate the therapeutic benefit of a combination chemotherapy consisting of MTX, 5-FU and THP in patients with advanced or recurrent gastric carcinoma. The patients were randomized into two groups; Group A patients (n = 37) underwent our combined chemotherapy, whereas Group B (n = 34) underwent chemotherapy with 5-FU alone as a control. There were no significant differences in various background factors between the groups. The median survival time was roughly 170 days after the randomization for the patients with advanced cancer (n = 26 for Group A and n = 25 for Group B), with no significant difference between the groups. Two long survivors, however, belonged to Group A. The median survival time of 161 days for Group A (n = 11) was longer than that of Group B (84 days, n = 9), but the difference was not statistically significant. The incidence of toxicities (leukopenia in particular) exceeding JCOG grade 3 was significantly higher for Group A, but no morbidity was observed. These results imply that patients with advanced or recurrent gastric carcinoma may benefit from a regimen of MTX, 5-FU and THP.

Spread of colorectal cancer micrometastases in regional lymph nodes by reverse transcriptase-polymerase chain reactions for carcinoembryonic antigen and cytokeratin 20

BACKGROUND AND OBJECTIVES

Lymph node metastasis is known as a significant predictor of prognosis in colorectal cancer patients. Recently, reverse transcriptase polymerase chain reaction (RT-PCR) has been applied to detecting micrometastasis. To assess the risk of recurrence and accurately determine the spread of tumor cells, we examined lymph node micrometastases in a series of colorectal cancer patients.

METHODS

We examined 202 lymph nodes obtained from 13 colorectal cancer patients who underwent curative operation and were histologically diagnosed to be node-negative, using RT-PCR to amplify mRNAs for two epithelial markers, carcinoembryonic antigen (CEA) and cytokeratin 20 (CK-20).

RESULTS

All the cases, including early stage patients, had micrometastases. A total of 102 among 202 lymph nodes (50.5%) were positive for either CEA or CK-20, or both (47.0, 40.1, and 36.6% respectively). Positive lymph nodes were spread along the courses of vascular trunks as well as being located in more distant regions.

CONCLUSIONS

Even in histologically negative lymph nodes, there is a considerable possibility that micrometastases may exist. Their detection by RT-PCR may improve clinical staging and indications for cancer therapy. We should also take care in the choice of surgical approach.

Spread of colorectal cancer micrometastases in regional lymph nodes by reverse transcriptase-polymerase chain reactions for carcinoembryonic antigen and cytokeratin 20

BACKGROUND AND OBJECTIVES

Lymph node metastasis is known as a significant predictor of prognosis in colorectal cancer patients. Recently, reverse transcriptase polymerase chain reaction (RT-PCR) has been applied to detecting micrometastasis. To assess the risk of recurrence and accurately determine the spread of tumor cells, we examined lymph node micrometastases in a series of colorectal cancer patients.

METHODS

We examined 202 lymph nodes obtained from 13 colorectal cancer patients who underwent curative operation and were histologically diagnosed to be node-negative, using RT-PCR to amplify mRNAs for two epithelial markers, carcinoembryonic antigen (CEA) and cytokeratin 20 (CK-20).

RESULTS

All the cases, including early stage patients, had micrometastases. A total of 102 among 202 lymph nodes (50.5%) were positive for either CEA or CK-20, or both (47.0, 40.1, and 36.6% respectively). Positive lymph nodes were spread along the courses of vascular trunks as well as being located in more distant regions.

CONCLUSIONS

Even in histologically negative lymph nodes, there is a considerable possibility that micrometastases may exist. Their detection by RT-PCR may improve clinical staging and indications for cancer therapy. We should also take care in the choice of surgical approach.

Somatic alterations of the DPC4 gene in human colorectal cancers in vivo

BACKGROUND & AIMS

The chromosome region 18q21 has been shown to be frequently deleted in colorectal cancers, and such frequent allelic loss is a hallmark of the presence of a tumor-suppressor gene. The DPC4 gene, which is located at 18q21, has been identified as a tumor-suppressor gene from examination of pancreatic cancers. The aim of the present study was to determine if it might also be altered in colorectal cancers.

METHODS

Mutation analyses of the DPC4 gene were performed on complementary DNA samples from 31 primary colorectal cancer specimens using a combination of polymerase chain reaction, single-strand conformation polymorphism, and DNA sequencing.

RESULTS

Four missense mutations producing amino acid substitutions and a somatic 12-base pair deletion in the coding region of the DPC4 gene were detected in the 31 cancers (16%; 5 of 31).

CONCLUSIONS

The DPC4 gene may play a role as a tumor-suppressor gene in a fraction of colorectal cancers; however, while allelic loss at 18q21 is very often seen in colorectal cancers, only a minority show DPC4 mutations, suggesting that there might be another tumor-suppressor gene in this chromosome region.

[Effect of leucovorin and 5-FU for advanced colorectal cancer patients]

In 17 cases of advanced colorectal carcinoma with accessible metastatic lesions, a low dose of leucovorin (LV, 30 mg/body) + 5-fluorouracil (5-FU 500 - 750 mg/body) was administered intravenously as a bolus injection, or by injection into the hepatic artery from a reservoir. Two of the 12 patients (16.7%) who received intravenous injection, and one of the five cases who received intra-hepatic artery injection showed partial response (PR). The side effect of this treatment was mild, and the performance status of the patients was excellent. This article deals with 3 PR cases. Case 1 had a bipulmonary multiple metastasis. When LV + 5-FU was administered intravenously, a reduction rate of 87% was obtained, and the patient survived for 27 more months. Case 2 had paraaortic lymph node metastasis. When LV + 5-FU was administered intravenously, a reduction rate of 59% was obtained, but the patient died after 9 months. Case 3 had a multiple liver metastasis. LV + 5-FU was administered intravenously in the liver, and a reduction rate of 69% was achieved. The patient survived for 30 months from the administration. LV + 5-FU is an effective treatment for advanced colorectal cancer. In the future, more research should be conducted to study the amount and method of administration, and combined treatment, to increase the response rate and to extend the period of good health.

[A case of postoperative pulmonary metastasis of colon cancer which responded to treatment with leucovorin and 5-FU]

A 72-year-old man underwent a radical operation for sigmoid colon cancer (well-differentiated adenocarcinoma, stage III) in 1989. Chest X-ray examination performed in September 1992 showed multiple nodular shadows in the lungs. A diagnosis of pulmonary metastasis was made from abnormally increased CEA and CA 19-9 and findings by chest tomography and CT scanning. There was no evidence of metastasis or recurrence in the liver, bone, brain or large intestine. He received three courses of bolus injections of leucovorin (30 mg/body) and 5-FU (500 mg/body), each over five consecutive days with a two-week rest period, and subsequently weekly at the same doses. CEA and CA 19-9 levels started to decrease after completion of the second course of consecutive treatment. In week 18 of chemotherapy, CEA and CA 19-9 levels dropped to 5.6 ng/ml and 32 U/ml from 66 ng/ml and 130 U/ml, respectively. Chest tomography and chest CT showed the disappearance or reduction in size of the nodules, with a reduction rate of 87.1%. Twenty-two weeks later, at this writing, there was no evidence of disease progression, and the patient was thus judged to be PR. He continues to receive chemotherapy at our outpatient clinic.

[A case of secondary leukemia induced by chemotherapy with a CDDP-based regimen for gastric cancer 5 years following radical resection]

Cisplatin, mitomycin C and 5-fluorouracil were given a 55-year-old woman for an unresectable gastric cancer, and successful radical gastrectomy was performed. Postoperative adjuvant immunochemotherapy using UFT and PSK was continued for about 4 years and 4 months. Pancytopenia was observed at 5 years after the treatment and then marked leucocytosis was noted. She also showed complications of general fatigue, appetite loss etc. A secondary acute leukemia associated with eosinophilia was diagnosed by peripheral blood examinations, showing WBC, 122,400: blast, 37.5 % and eosinophil, 41%. Results also showed atypia and pseudo-Pelger nuclear abnormality of eosinophil, high positive stain of cell myelogenic cell surface marker, many numeral and structural abnormalities of chromosomal analysis, etc. From the above results, it was suggested that the leukemia might be induced by previously performed chemotherapy. The patient died about 2 months following its onset.

[Recent advance and its problem of postoperative immunotherapy on gastric cancer--with references to effects and host dependent factors]

The effects of immunotherapy such as PSK, Bestatine and OK-432 (oral administration) in combination with various chemotherapy were reviewed in the patients who underwent gastrectomy for gastric cancer from the Japanese references. The immunotherapy might lead to better prognosis about 10% or more, however, if it is administered for such a selected patient who show a lower preoperative serum IAP value (580 micrograms/ml), higher total protein (6.5g/dl), better performance status (0, 1 or 2) and etc, the survival rate could be increased. The usefulness of immunotherapy was also noted in such a case which showed severe side effects of chemotherapy and bad performance status. Moreover, the pre- and post-operative immunotherapy was advisable for prevention of surgical stress and enhancement of tumor metastases.

[Therapeutic effect of transarterial infusion immunochemotherapy for metastatic liver cancer]

In order to improve therapeutic efficacy for metastatic liver cancer, intermittent transarterial administration of BRM in combination with anticancer drugs was performed by use of reservoir apparatus. A total of 22 patients (12 cases of gastric cancer, 6 of colon cancer, 2 of pancreas cancer, 1 of gall bladder cancer and 1 of biliary tract carcinoid) were treated according to the following schedule: both 10 mg of ADM (or MMC) and 0.5 KE (or 1.0 KE) of OK-432 were administered on day 1 and 40 x 10(4) JRU of recombinant interleukin 2 (r-IL 2) on day 4, 7 and 11. The treatment was repeated as many times as possible. In terms of direct antitumor effect and decrease of tumor marker, the response rate was 43% (6 cases out of 14) and 75% (9 cases out of 12), respectively. As for performance status, improvement, no change and deterioration were seen in 4 cases, 8 cases and 3 cases, respectively. Even though 13 patients died, 8 of them survived more than 300 days. In the case of gastric cancer patients with liver metastasis, 50% survival time of 12 cases was 334 days, while that of 30 cases, who were administered anticancer drugs only systemically, was 144 days. In 3 cases the decrease in the size of tumors located in both liver and the other metastases also was seen. Every case developed high grade fever, but an antifebrile was effective. Otherwise severe side effects were not seen. These results indicated that intermittent arterial infusion immunochemotherapy was feasible for the treatment of metastatic liver cancer.

[A long-term survival case of advanced gastric cancer undergoing radical gastrectomy by second-look operation after successful chemotherapy (CDDP, MMC, 5-FU)]

A 55-year-old woman with gastric cancer underwent laparotomy and was found to have an unresectable tumor characterized by S3 (invasion of the pancreas), N3, P0 and H0. She was then treated by combined administration of cisplatinum, mitomycin C and 5-fluorouracil. A remarkable response (CR) was confirmed by upper gastrointestinal roentgenography and endoscopy. Upon reoperation about 8 weeks after chemotherapy, a successful radical total gastrectomy with R2 (partially R3) lymphnode dissection was performed. Histological examination of the specimens, including the stomach and lymphnodes, revealed no cancer cells in any region (pCR). She had been given UFT and PSK for 4 years 4 months after reoperation. She has lived for 5 years 2 months after reoperation without any signs of recurrence or metastases.

[Relationship between the prognosis and nuclear DNA histograms in gastric cancer patients with a synchronous liver metastases who were given a combined gastrectomy and hepatectomy]

Out of 127 gastric cancer cases with a synchronous liver metastases, the relationship between the prognosis and the nuclear DNA contents in the primary and liver metastatic foci has been investigated in 10 relatively noncurative patients who had received a combined gastrectomy and hepatectomy. In 3 out of 5 long-term survival cases, low ploidy patterns were seen in both foci, whereas in 1 out of 5 short-term survival cases, a multiplicity was observed, i.e., a low ploidy in the primary focus and a high ploidy in the liver. In the other 4 short-term survival cases, high ploidy patterns were noted in both foci.

[Intraoperative intraperitoneal administration of mitomycin C and OK-432 for peritoneal dissemination of gastric cancer]

In order to improve the prognosis, intraoperative intraperitoneal administration of both mitomycin C and OK-432 was performed for the peritoneal dissemination of gastric cancer. Some 74 of 469 patients of gastric cancer, who underwent surgical treatment over the last 7 years in our department, had peritoneal dissemination and 24 of them were treated with the drugs described above. However, there was no significant difference between treated group and controlled untreated group. No severe side effects were noted except for moderate pyrexia. It is still too early to determine the effect of this treatment because of both the short duration of follow-up and the small number of analyzed cases. In the future, we are planning to apply this treatment to selected cases, for which a histological diagnosis will be made intraoperatively by use of irrigation cytology and/or stamp biopsy.

[A case of metastatic malignant melanoma of the stomach treated by a surgical operation]

A metastatic malignant melanoma of the stomach is not a disease of rate occurrence, but reports of melanomas that were clinically diagnosed and were treated by a surgical operation are rare. The case presented is a 73-year-old woman, who underwent an excision of a malignant melanoma of the left sole in 1981. Subsequently, she had a subcutaneous metastasis of a melanoma three times and was treated by a resection and immunochemotherapy. In January, 1988, an X-ray examination of stomach revealed a giant elevated lesion, and an endoscopic examination of the stomach revealed a black pigmented tumor with ulceration. A biopsy taken from the tumor confirmed the diagnosis of a malignant melanoma. Thus, she was given a total gastrectomy. Reports in the Japanese literature of metastatic malignant melanomas of the stomach diagnosed while the patient was still living amount to 11 cases. Of this number, 3 patients were given a surgical operation. Further, these 3 patients lived longer than the non-surgically treated cases and had a better quality of remaining life.

[Relationship between the effectiveness of CDDP therapy and the nuclear DNA content in advanced-recurrent gastric cancer cases]

A microspectrophotometric analysis of the DNA content has been performed on 9 advanced recurrent gastric cancer patients with measurable lesions, who has either been treated by CDDP alone or with other chemotherapeutics during a three-year period since, 1984. Histograms of the DNA content were classified into four ploidy patterns. All of the 4 responder cases (CR, PR, MR) showed type, IV, although only one of 5 non-responder cases revealed the same typing. In one of the two CR cases the DNA ploidy pattern, which was examined before and after the therapy, changed from type IV to type II. Thus it appears that an analysis of the DNA content may be useful in evaluating the effectiveness of different chemotherapies.

[In vivo antitumor effect of LAK cells induced from various lymphocytes--experimental study in rats]

A MRMT-1 was inoculated in the thigh of SD rats. On day 7, regional lymph node lymphocytes (TB-LN), thymus cells (TB-TC) and spleen cells (TB-SC) or non-tumor bearing spleen cells (NB-SC), were obtained. LAK were induced with lug/ml of R-IL2 (TGP-3) using above lymphocytes, and were examined as for their in vivo and in vitro cytotoxic activities. In vitro: Against MRMT-1, cytotoxic activity of LAK increased with lapse of culturing time. Thus on day 4 of culture, it was the highest (46.5%) in TB-SC-LAK, while that of TB-LN-LAK was the lowest (5.8%). Against YAC-1, they also increased except TB-LN-LAK. In vivo: When the mixture of MRMT-1 and LAK was sc inoculation, diameter of the tumor were the smallest in TB-LN-LAK and the largest in TB-SC-LAK. When it was injected intraperitoneally, in non-irradiated rats, the survival prolongation was the best in TB-LN-LAK and the worst in TB-SC-LAK. In pre-irradiated rats; the cytotoxicity was almost the same as the results of in vitro. When it was injected intravenously, number of lung metastatic nodes were the smallest in TB-LN-LAK and the largest in TB-SC-LAK. R-IL2 substitution therapy was also effective. In conclusion, the effectiveness of LAK-AIT was estimated more accurately by in vivo cytotoxic assay. TB-LN was most useful as a source of LAK cells.

Cure of advanced gastric cancer by combined chemotherapy with cisplatinum, mitomycin C, and 5-fluorouracil

A 55-year-old female, in which an unresectable Borrmann II-type gastric cancer (moderately differentiated adenocarcinoma) extending from vicinity of the cardia to the lower portion of the corpus, with direct invasion into the pancreas and extensive lymph node metastases, confirmed by laparotomy, was treated postoperatively by 3 courses of chemotherapy with cisplatinum in combination with mitomycin C and 5-fluorouracil. A complete response was confirmed by roentgenography and endoscopy, and, at 4 months after the first operation, a total gastrectomy with radical lymphadenectomy was performed successfully. Cancer cells were not detectable histologically in the stomach specimen and in all the lymph nodes removed. One year and 5 months after the second operation she is well, showing no sign of recurrence.

[Experience with CDDP therapy in advanced and recurrent gastric cancer cases]

For 3 years beginning in 1984, 14 advanced and recurrent gastric cancer cases with measurable lesions (8 unresected cases, 3 cases of recurrence, 2 cases with non-curative resection, 1 case of no operation) were treated by CDDP therapy alone or in combination with other chemotherapies. CR was obtained in 2 of the 8 non-resected cases, radical gastrectomy being feasible in these 2 cases by second-look operation. Five of the 8 cases showed PD, and in 1 case the effect was rather obscure. One of the 2 non-curative resection cases achieved PR, and the other case was MR. One of the 3 recurrent cases was NC, the remaining cases being PD. The one case given no operation showed PD. Overall effectiveness of CDDP therapy for advanced and recurrent gastric cancer cases was seen in 3 (21.4%) of the 14 cases. All of these 3 cases showing effective CDDP therapy was elevated serum CEA values before the therapy, which was markedly reduced after starting the therapy, the reduction rate being very remarkable.

Advanced gastric cancer successfully resected following cisplatin therapy: report of a case

A case of unresectable advanced gastric cancer was treated with cis-dichlorodiammine platinum (CDDP) at a dosage of 30 mg/day for 5 days every month after operation. After three courses of administration, examinations revealed that the tumor had disappeared, and an evaluation of complete response was made. Four months later, a second-look operation was performed; and it was found that the cancer was smaller than a thumb and could be resected radically. No significant side effects were observed during CDDP therapy.

Heterotopic gastric mucosa accompanied by aberrant pancreas in the duodenum

An operated case of a heterotopic gastric mucosa, accompanied by an aberrant pancreas tissue, in the bulb of the duodenum was reported. A 40-yr-old man complained of epigastralgia and was diagnosed to have a protruding lesion in the duodenum by roentgenological and endoscopic examinations. Partial excision of the duodenal wall including the mass was performed. Cut surface of the specimen showed a yellowish-whitish mass in the submucosal through the subserosal layers, which was covered by a papillary elevated mucous membrane. Histologically the mass was an aberrant pancreas of the Heinrich I-type and the mucous membrane covering the mass was a heterotopic gastric mucosa, consisting of completely developed fundic glands.

[Successful treatment of advanced gastric cancer by combined cisplatinum, mitomycin C and 5-FU administration. A case report]

A 55-year-old woman with gastric cancer underwent laparotomy and was found to have an unresectable tumor at the MC region, characterized by S3 (invasion into the pancreas), N3, P0, H0, Borrmann-II and moderately differentiated tubular adenocarcinoma. She was then treated by combined administration of cis-dichlorodiammine platinum (CDDP), mitomycin C and 5-fluorouracil (5-FU). A complete response was confirmed by upper gastrointestinal roentgenography and endoscopy. Upon reoperation 4 months after the initial laparotomy, a successful total radical gastrectomy with R2 (partially R3) lymph node dissection was performed. Histological examination of the specimens, including the stomach and lymph nodes, revealed no cancer cells in any region.

Clinical studies on serum immunosuppressive acidic protein (IAP) and ferritin in gastric cancer patients: with special reference to preoperative value and influence of surgical stress

Serum IAP and ferritin values were measured preoperatively in 83 resectable gastric cancer patients. IAP was significantly higher in them than in normal subjects, and increased gradually with progression of cancer, and the values at stages III and IV were significantly higher than that at stage I. It was significantly higher in the cases of n(+) than in those of n(-), and in the cases of noncurative resection than in those of curative resection. Ferritin was significantly higher in them than in normal subjects and mammary cancer patients, and in males than in females, and the values at stages I and IV were significantly higher than that at stage III. OK-432 was serially administered pre- and postoperatively in 83 cases and only postoperatively in 33 cases. IAP increased markedly at 1 week postoperatively and was reduced gradually at 2 and 4 weeks. Ferritin increased markedly at 1 week after operation and reached the maximum value at 2 weeks and was reduced toward the value of 1 week at 4 weeks. However, these changes showed no significant difference between the both groups.