The impact of rare cancer and early-line treatments on the benefit of comprehensive genome profiling-based precision oncology

BACKGROUND

Comprehensive genome profiling (CGP) serves as a guide for suitable genomically matched therapies for patients with cancer. However, little is known about the impact of the timing and types of cancer on the therapeutic benefit of CGP.

MATERIALS AND METHODS

A single hospital-based pan-cancer prospective study (TOP-GEAR; UMIN000011141) was conducted to examine the benefit of CGP with respect to the timing and types of cancer. Patients with advanced solid tumors (>30 types) who either progressed with or without standard treatments were genotyped using a single CGP test. The subjects were followed up for a median duration of 590 days to examine therapeutic response, using progression-free survival (PFS), PFS ratio, and factors associated with therapeutic response.

RESULTS

Among the 507 patients, 62 (12.2%) received matched therapies with an overall response rate (ORR) of 32.3%. The PFS ratios (≥1.3) were observed in 46.3% (19/41) of the evaluated patients. The proportion of subjects receiving such therapies in the rare cancer cohort was lower than that in the non-rare cancer cohort (9.6% and 17.4%, respectively; P = 0.010). However, ORR of the rare cancer patients was higher than that in the non-rare cancer cohort (43.8% and 20.0%, respectively; P = 0.046). Moreover, ORR of matched therapies in the first or second line after receiving the CGP test was higher than that in the third or later lines (62.5% and 21.7%, respectively; P = 0.003). Rare cancer and early-line treatment were significantly and independently associated with ORR of matched therapies in multivariable analysis (P = 0.017 and 0.004, respectively).

CONCLUSION

Patients with rare cancer preferentially benefited from tumor mutation profiling by increasing the chances of therapeutic response to matched therapies. Early-line treatments after profiling increase the therapeutic benefit, irrespective of tumor types.

Topological charge transport by mobile dielectric-ferroelectric domain walls

The concept of topology has been widely applied in condensed matter physics, leading to the identification of peculiar electronic states on three-dimensional (3D) surfaces or 2D lines separating topologically distinctive regions. In the systems explored so far, the topological boundaries are built-in walls; thus, their motional degrees of freedom, which potentially bring about new paradigms, have been experimentally inaccessible. Here, working with a quasi-1D organic material with a charge-transfer instability, we show that mobile neutral-ionic (dielectric-ferroelectric) domain boundaries with topological charges carry strongly 1D-confined and anomalously large electrical conduction with an energy gap much smaller than the one-particle excitation gap. This consequence is further supported by nuclear magnetic resonance detection of spin solitons, which are required for steady current of topological charges. The present observation of topological charge transport may open a new channel for broad charge transport-related phenomena such as thermoelectric effects.

Evidence for solitonic spin excitations from a charge-lattice-coupled ferroelectric order

Topological defects have been explored in different fields ranging from condensed matter physics and particle physics to cosmology. In condensed matter, strong coupling between charge, spin, and lattice degrees of freedom brings about emergent excitations with topological characteristics at low energies. One-dimensional (1D) systems with degenerate dimerization patterns are typical stages for the generation of topological defects, dubbed "solitons"; for instance, charged solitons are responsible for high electrical conductivity in doped trans-polyacetylene. Here, we provide evidence based on a nuclear magnetic resonance (NMR) study for mobile spin solitons deconfined from a strongly charge-lattice-coupled spin-singlet ferroelectric order in a quasi-1D organic charge-transfer complex. The NMR spectral shift and relaxation rate associated with static and dynamic spin susceptibilities indicate that the ferroelectric order is violated by dilute solitonic spin excitations, which were further demonstrated to move diffusively by the frequency dependence of the relaxation rate. The traveling solitons revealed here may promise the emergence of anomalous electrical and thermal transport.

Safety and efficacy of nivolumab and standard chemotherapy drug combination in patients with advanced non-small-cell lung cancer: a four arms phase Ib study

In this phase Ib study, four combination therapies of nivolumab 10 mg/kg and standard chemotherapy (cisplatin/gemcitabine, cisplatin/pemetrexed, carboplatin/paclitaxel/bevacizumab, or docetaxel) showed acceptable toxicity profiles in patients with advanced non-small-cell lung cancer. Furthermore, these combination therapies presented encouraging antitumor activities.

Background

The human IgG4 monoclonal antibody nivolumab targets programmed cell death-1 (PD-1) and promotes antitumor response by blocking the interaction of PD-1 with its ligands. This single-center phase Ib study investigated the tolerability, safety, and pharmacokinetics of nivolumab combined with standard chemotherapy in patients with advanced non-small-cell lung cancer (NSCLC).

Patients and methods

Patients who had stage IIIB without indication for definitive radiotherapy, stage IV, or recurrent NSCLC were eligible. Regimens were nivolumab 10 mg/kg + gemcitabine/cisplatin (arm A), pemetrexed/cisplatin (arm B), paclitaxel/carboplatin/bevacizumab (arm C), or docetaxel (arm D). Regimens A, B, and D were repeated every 3 weeks for up to four cycles and regimen C was repeated for up to six cycles; nivolumab alone (arm A), with pemetrexed (arm B), bevacizumab (arm C), or docetaxel (arm D) was continued every 3 weeks as maintenance therapy until disease progression or unacceptable toxicity. Dose-limiting toxicity (DLT) was evaluated during the first treatment cycle.

Results

As of March 2014, six patients were enrolled in each arm. The combination of nivolumab 10 mg/kg and chemotherapy was well tolerated. DLT was observed in only one patient in arm A (alanine aminotransferase increased). Select adverse events (those with a potential immunologic cause) of any grade were observed in six, four, six, and five patients in arms A, B, C, and D, respectively. Three, three, six, and one patient achieved partial response while median progression-free survival was 6.28, 9.63 months, not reached, and 3.15 months in arms A, B, C, and D, respectively.

Conclusions

Combination of nivolumab 10 mg/kg and chemotherapy showed an acceptable toxicity profile and encouraging antitumor activity in patients with advanced NSCLC.

Clinical trials number

Japanese Pharmaceutical Information Center Clinical Trials Information (JapicCTI)-132071.

CD5-positive diffuse large B-cell lymphoma: a retrospective study in 337 patients treated by chemotherapy with or without rituximab

BACKGROUND

CD5-positive (CD5+) diffuse large B-cell lymphoma (DLBCL) shows poor prognosis and frequent central nervous system (CNS) relapses under anthracycline-containing chemotherapy. The aim of this study was to determine the prognosis and CNS relapse incidence of CD5+ DLBCL in the rituximab era.

PATIENTS AND METHODS

We analyzed 337 patients with CD5+ DLBCL who received chemotherapy with (R-chemotherapy group; n = 184) or without (chemotherapy group; n = 153) rituximab.

RESULTS

No significant difference was found in clinical background comparisons between the two groups. In the R-chemotherapy group, 60% of the patients were older than 65 years at diagnosis. Both the complete response rate and overall survival (OS) were significantly better in the R-chemotherapy group (P = 0.0003 and P = 0.002, respectively). Multivariate analysis confirmed that chemotherapy without rituximab was associated with unfavorable OS. However, the probability of CNS relapse did not differ between the two groups (P = 0.89). The CNS relapse was strongly associated with short OS (P < 0.0001). In the R-chemotherapy group, 83% of patients who experienced CNS relapse had parenchymal disease.

CONCLUSIONS

Our results indicate that rituximab improves the OS of patients with CD5+ DLBCL but does not decrease the CNS relapse rate. More effective treatments with CNS prophylaxis are needed for CD5+ DLBCL patients.

MRI of ectopic posterior pituitary bright spot with large adenomas: appearances and relationship to transient postoperative diabetes insipidus

MRI of large pituitary adenomas has revealed that a posterior pituitary bright spot (PPBS), comprising ADH-containing neurosecretory granules, is commonly ectopic before surgery and attached to the tip of the pituitary stalk late after surgery. Although the PPBS indicates functional integrity of the posterior lobe, transient diabetes insipidus (DI), caused by deficiency of ADH, is frequent early after surgery. We attempted to clarify how the shape, signal intensity and site of the PPBS before surgery are related to transient DI in the early postoperative period. We carried out MRI on 15 patients with a large adenoma and an ectopic PPBS before surgery and then within 1 week (early), 1-2 months (intermediate) and 6 or more months (late) after the operation. There were nine who had transient DI, which subsided by the intermediate study; none had permanent DI. Regardless of transient DI, the PPBS was visible, and its signal intensity was similar, on all postoperative studies. Although 11 did not change in shape, four showed a remarkable change from a flat shape before surgery to a rounded one postoperatively. On the intermediate MRI, the PPBS had descended to the level of the diaphragma as mass effect disappeared.

Demonstration of the optic pathway in large pituitary adenoma on heavily T2 weighted MR images

The objective of the investigation was to understand preoperatively the detailed anatomical relationship of large pituitary adenomas to surrounding structures, using the heavily T2-weighted reversed (T2R) MR images. This study consisted of 28 patients with pituitary adenoma, presenting with visual disturbance. The MRI scanner used was a Gyroscan ACSNT 1.5T and the slice thickness of the image was 3 mm with 0.5 mm interslice gap. The relation of pituitary adenoma to optic pathway and to the degree of visual field defect was assessed. Relations of the optic chiasm to adenoma were classified into three types: anterior, superior and posterior. The optic chiasm was directly visualized and identifiable in all patients studied. It was located anterior in four cases, superior in 22 and posterior in two in relation to the adenoma. Its location was further confirmed by the anatomical delineation of surrounding structures such as anterior commissure and lamina terminalis. Optic nerve or tract was unidentifiable in one case, for each category. Detectability of each optic component was higher on T2R images than on conventional T1-weighted images. The adenoma extended into and in front of the third ventricle in anterior and posterior types, respectively. The anterior communicating artery complex and the optic pathway were relocated together in anterior and superior types, and were separated in the posterior type. In a case of the posterior type, the complex was sectioned to obtain a wider surgical field during anterior interhemispheric approach. While degrees of visual field defect were proportional to tumour size in the superior type, they were unrelated in the anterior and posterior types. On choosing a transcranial approach, the transcallosal route is unsuitable for an adenoma of posterior type, which extends in front of the third ventricle. This preoperative MRI information makes it possible to visualize directly the optic pathway even in huge adenomas, and is useful in predicting surgical anatomy and selecting a proper surgical approach.

Treatment of asymptomatic unruptured intracranial aneurysms. A clinical decision analysis

SUMMARY

The indication of preventive surgery for patients who harbor asymptomatic un ruptured intracranial aneurysms remains controversial. To evaluate the benefit of this treatment, we investigated the management outcome in 128 patients with 157 unruptured aneurysms. Surgery was planned in patients 70 years old or younger without serious systemic complications. A total of 77 patients underwent surgery including four endovascular interventions, and conservative management was chosen in 51 patients. There was no mortality and 6.5% morbidity as postoperative results, and no complication was found after endovascular treatment. Among the patients in conservative management, four patients suffered from subsequent rupture during the total follow-up period of 148 person-years. The annual rupture rate was estimated at 2.7%. According to the clinical decision analysis based on our data, preventive surgery is beneficial for a Japanese 70 years old or younger. However, the expected utility decreases if the rupture rate is set at 0.5% or 0.05%, posing a doubt about the benefit of the surgery. Decision analysis provides an aid for logical and objective choice in the management of unruptured aneurysms. The actual risk of rupture has a major impact on decision making in therapeutic strategy.

Heavily T2 weighted MR assessment of fornical injury after anterior interhemispheric approach for large suprasellar tumors

Fornical injury in transforaminal approach is well known. Its injury in the anterior interhemispheric approach (AIA) has been rarely highlighted. We report 2 cases with a large suprasellar tumor who underwent AIA. Postoperative heavily T2 weighted reversed (T2R) MR images demonstrated its unilateral injury. The clinical significance of symptom-free fornical injury after AIA is discussed. Cases 1 and 2 were a 15 year-old girl with a meningioma and a 49-year-old woman with a craniopharyngioma, respectively. They underwent AIA. Postoperative T2R images revealed unilateral fornical crus atrophy. They did not present associated memory deficits. Case 1 had the injury of both fornical column and anterior commissure. They were speculatively torn by intra-operative lateral retraction of the frontal lobes. Case 2 had unilateral atrophy of the mammillary body and postcommissural fornix, which were probably caused by ischemic damage related to surgical manipulation, since case 2 had an associated anterior thalamic infarct. During the operation for large suprasellar tumors, excessive laterally directed brain retraction should be avoided, since such manipulation may easily tear the overstretched anterior commissure and fornical column. Once we notice or suspect fornical injury on MR studies in cases of re-operation, we have to choose a surgical approach and operative manipulation to preserve an intact fornix. The MR evaluation of fornix should be included in the perioperative radiological assessment, since patients with unilateral fornical injury were free of memory disturbance, and T2R imaging is a useful MR sequence for depicting the anatomy related to the fornix.

Heavily T2 weighted MR images of anterior optic pathways in patients with sellar and parasellar tumours - prediction of surgical anatomy

OBJECTIVE

Location of anterior optic pathways in sellar and parasellar tumours was preoperatively evaluated, by use of heavily T2 weighted MR images.

METHODS

Heavily T2 and conventional T1 weighted images were studied in 20 patients with sellar and parasellar tumours who underwent craniotomy. Pathology revealed pituitary adenoma in 5 patients, craniopharyngioma in 8 and parasellar meningioma in 7. Maximum sizes ranged from 15 mm to 58 mm. Sequence parameters of TR/TE for heavily T2 weighted and T1 weighted images were 5800/220 msec and 600/20 msec, respectively, and slice thickness was 3 mm for both.

RESULTS

The anterior optic pathway was detected in 95% on heavily T2 weighted images and 50% on T1 weighted images. All preoperative heavily T2 weighted images were compatible with operative findings. The optic chiasms were most commonly supero-posterior in pituitary adenomas, anterior (prefixed) in craniopharyngiomas and posterior in meningiomas. The optic nerves were commonly located superior or lateral to the tumours. However, parasellar meningiomas, off the midline, revealed the optic nerves in various locations, depending on the tumour origin. In such tumours, heavily T2 weighted images provided surgical information on the width of the working space through prechiasmal and/or optico-carotid spaces in the pterional approach. Spatial relation of the tumours to the lamina terminalis, anterior commissure and anterior communicating artery complex was clearly shown in craniopharyngioma patients, who underwent the anterior interhemispheric approach.

CONCLUSION

Heavily T2 weighted MR images are useful in determining the location of optic pathways and surgical approach and in individual prediction of the anatomy for even large sellar and parasellar tumours.

High-dose chemotherapy with hematopoietic stem cell transplantation is effective for nasal and nasal-type CD56+ natural killer cell lymphomas

CD56+ natural killer (NK) cell lymphomas occur frequently in the nasal and nasopharyngeal regions and carry a poor prognosis. We have studied seven cases with NK-cell lymphomas. These lymphomas showed the following immunophenotype: CD56+, CD2+, sCD3- and Epstein-Barr virus-encoded small RNAs (EBERs)+. Six patients had localized (stage I or II) disease involving the nasopharyngeal region, while one had stage III disease. One patient with stage I disease achieved a complete remission (CR) after treatment with involved-field irradiation, but subsequently relapsed and died. The remaining six patients received combination chemotherapy as primary treatment: five patients with localized stage I or II disease and one patient with advanced stage III disease. Responses to initial chemotherapy were generally poor. These six patients received a variety of salvage chemotherapy regimens, but never achieved a CR. Subsequently, four of six patients showed a highly aggressive clinical course and died of disseminated disease within 1 year from the diagnosis. Three of six patients received high-dose chemotherapy supported by syngeneic, autologous or allogeneic peripheral blood stem cell transplantation. Two of the three transplant patients achieved a CR and are now surviving in continuous CR. Our clinical experience suggests that myeloablative high-dose chemotherapy and bone marrow rescue by hematopoietic stem cell transplantation may be an effective salvage treatment modality for refractory NK-cell lymphomas and could be considered as a part of the initial therapy for these patients.

Heavily T2-weighted MR imaging of white matter tracts in the hypothalamus: normal and pathologic demonstrations

BACKGROUND AND PURPOSE

The MR appearance of white matter tracts in the hypothalamus and the role of the hypothalamus as a memory mechanism have not been sufficiently described in clinical settings. Heavily T2-weighted black-and-white reversed (T2R) images were assessed to reveal their visualization and clinical significance.

METHODS

One hundred healthy subjects and three patients with hypothalamic lesions underwent fast spin-echo MR imaging to reveal the postcommissural fornix (PF) and mammillothalamic tract (MT).

RESULTS

The PF was identifiable in axial and/or coronal sections in all healthy subjects. No remarkable asymmetry of its size or course was evident. Both anteroposterior and vertical dimensions ranged from 10.5 to 14 mm. The MT was visible in one or two axial sections above the mammillary body in 64% of healthy subjects and in a coronal section in 36%. Two patients with glioblastoma multiforme and lacunar infarct at the hypothalamus presented with anterograde amnesia; T2R imaging revealed involvement of both the PF and MT. The third patient had a suprasellar craniopharyngioma with PF injury sparing the MT resulting from surgical manipulation and was free of memory deficit. Anterograde amnesia was evident only when both the PF and MT were injured.

CONCLUSION

T2R images have made a high rate of detection of the PF and MT possible and could provide a more detailed correlation of hypothalamic neuroanatomy and memory mechanism in clinical settings.

Administration of granulocyte colony-stimulating factor induces hyporesponsiveness to lipopolysaccharide and impairs antigen-presenting function of peripheral blood monocytes

OBJECTIVE

The incidence and severity of acute graft-vs-host disease after allogeneic transplantation of granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood stem cells (PBSC) are not greater than those after conventional bone marrow transplantation despite infusion of more than one log greater number of donor T cells in PBSC. It has been postulated that monocytes from G-CSF-mobilized donors suppress alloreactivity of donor T cells.

MATERIALS AND METHODS

We investigated the phenotype and function of monocytes in normal individuals receiving 10 microg/kg of G-CSF for 4 days.

RESULTS

Monocytes were phenotypically and functionally different after G-CSF administration from steady-state monocytes. They were characterized by an increased CD14(+)CD16(+) subpopulation, reduced expression of HLA-DR, and diminished ability to produce tumor necrosis factor-alpha and interleukin-10 to lipopolysaccharide, compared with steady-state monocytes. These alterations were not replicated by culturing monocytes with G-CSF in vitro, suggesting an indirect effect of G-CSF. In addition, the antigen-presenting function of G-CSF-mobilized monocytes was impaired.

CONCLUSION

Hyporesponsiveness of G-CSF-treated monocytes to lipopolysaccharide with regard to tumor necrosis factor-alpha production, together with impaired antigen-presenting function, may be responsible for the unexpectedly low incidence of graft-vs-host disease after G-CSF-mobilized PBSC transplantation.

Hepatic graft-versus-host disease presenting as an acute hepatitis after allogeneic peripheral blood stem cell transplantation

Hepatic graft-versus-host disease (GVHD) generally presents as cholestatic jaundice, and increased serum alkaline phosphatase (ALP) is followed by hyperbilirubinemia and clinical jaundice. Currently accepted standards for evaluating the clinical severity of GVHD are based not on serum aminotransferase levels but on the serum bilirubin level. We describe a 17-year-old Japanese female who had increased aminotransferases without cholestasis on day 23 after allogeneic peripheral blood stem cell transplantation (allo-PBSCT). Liver biopsy revealed lymphocytic infiltration of the portal tracts and pericentral necrosis of the lobuli. The limiting plates were not clearly defined due to cellular infiltrates. There was periductal lymphocytic infiltration and vacuolization of the biliary epithelial cells with exocytosis, compatible with GVHD of cholangiohepatitic type. These findings indicate that acute hepatic GVHD may present as acute hepatitis and this should be included in the differential diagnosis for patients with increased aminotransferases after allogeneic stem cell transplantation.

Temporal profiles of the levels of endogenous antioxidants after four-vessel occlusion in rats

Although it is known that development of lipid peroxidation after ischemia occurs predominantly in vulnerable regions, temporal profiles of antioxidants after ischemia have not been regionally elucidated. After reperfusion periods of 0, 3, 24, and 72 hours following 20 minutes of four-vessel occlusion (n = 6 in each group), the concentration of total glutathione (GSH) and the activities of superoxide dismutase (SOD), catalase, and glutathione peroxidase (GSH-Px) were assayed in the hippocampus, parietal cortex, striatum, thalamus, and brain stem. The levels of all antioxidants were unchanged in all regions without reperfusion; however, the concentration of total GSH significantly decreased in the hippocampus at 3 hours after the onset of reperfusion, and showed a maximum decrease in the hippocampus (68% of the sham-control level), parietal cortex (78% of the sham-control level), and striatum (76% of the sham-control level) after 24 hours of reperfusion. After 72 hours of reperfusion, these regions and the thalamus showed restoration and an increase in the total GSH concentration, respectively. The activities of SOD, GSH-Px, and catalase were stable during the reperfusion period, but the hippocampus showed significant increases in these enzyme activities and the parietal cortex and striatum showed significant increases in SOD activities at 72 hours after the onset of reperfusion. These results indicate that endogenous antioxidants take 72 hours for restoration in vulnerable regions after 20 minutes of four-vessel occlusion in rats.

Successful engraftment of allogeneic peripheral blood stem cell transplant after nonmyeloablative preparative regimen with cytarabine and cyclophosphamide: report of 2 cases

We report our experience with allogeneic peripheral blood stem cell transplantation (allo-PBSCT) following a nonmyeloablative conditioning regimen consisting of cytarabine (8 g/m2) and cyclophosphamide (120 mg/kg) in the treatment of 2 patients aged 50 and 55 years with refractory chronic myelomonocytic leukemia and chronic myeloid leukemia in accelerated phase, respectively. Our nonmyeloablative regimen was well tolerated by older patients at high risk of regimen-related toxicity by the conventional conditioning regimen but was immunosuppressive enough to achieve mixed chimerism. After allo-PBSCT, we monitored chimerism in these patients by fluorescence in situ hybridization using X- and Y-specific probes and polymerase chain reaction-based analysis of a variable number of tandem repeats. We found that full chimerism and graft-versus-leukemia (GVL) effects could be induced in these patients by donor lymphocyte infusions and withdrawal of posttransplantation immunosuppressive therapy. Our observations suggest that a nonmyeloablative conditioning regimen can establish mixed chimerism and that donor lymphocyte infusion may induce GVL effects in older patients at high risk of regimen-related toxicity.

Allogeneic peripheral blood stem cell transplantation for the treatment of chronic active Epstein-Barr virus infection

The prognosis of chronic active Epstein-Barr virus infection (CAEBV) is very poor. We describe a 24-year-old male with severe CAEBV who was treated with allogeneic peripheral blood stem cell transplantation (allo-PBSCT). On admission, EBER-1 in lymphocytes infiltrating the liver, EBV-DNA in peripheral blood mononuclear cells (PBMC) and monoclonal NK cell proliferation were confirmed. After unsuccessful chemotherapy, he received an allo-PBSCT from his HLA-identical sister. Although he died of pulmonary hemorrhage on day +19, EBV-DNA was undetectable by PCR in PBMC, and the post-mortem liver showed no EBER-1-positive lymphocytes. This experience suggests that EBV-positive lymphocytes in CAEBV may be eradicated by allo-PBSCT, thereby raising the possibility of a new treatment modality. Bone Marrow Transplantation (2000) 26, 805-808.

Allogeneic peripheral blood stem cell transplantation in 23 adult patients with hematologic malignancies: a single-center experience

We describe a single-center experience of 23 consecutive patients (median age, 35 years) with hematologic malignancies who received allogeneic peripheral blood stem cell transplants (alloPBSCTs) from HLA-identical siblings. Ten patients had standard-risk disease and 13 had high-risk disease. Twenty-one patients received alloPBSCT as a primary transplant, and the remaining 2, with high-risk disease, as a second transplant after posttransplantation relapse. All donors received daily subcutaneous injections of granulocyte colony-stimulating factor at a dose of 10 microg/kg, and peripheral blood stem cells were collected by 1 to 3 aphereses. Median numbers of CD34+ and CD3+ cells infused were 5.8 x 10(6)/kg (range, 1.3-19.7 x 10(6)/kg) and 4.9 x 10(8)/kg (range, 1.9-8.6 x 10(8)/kg), respectively. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A (CyA) and methotrexate (18 patients) or CyA and methylprednisolone (5 patients). Rapid hematologic engraftment was observed in 20 of the 23 patients. Median days to absolute neutrophil counts >0.5 x 10(9)/L and platelet counts >20 x 10(9)/L were 12 (range, 9-18 days) and 14 (range, 10-128 days), respectively. Acute GVHD of grade 2-4 was observed in 6 of 20 evaluable patients (30%) and extensive chronic GVHD in 8 of 15 evaluable patients (53%). Ten of the 23 patients (44%) were surviving in continuous complete remission 191 to 1492 days (median, 643 days) posttransplantation. Treatment-related death within 100 days posttransplantation was observed in 6 of the 23 patients (26%). Six of the 23 patients (26%) developed relapse at a median 81 days (range, 38-160 days) posttransplantation. Further study is needed to assess the precise benefits of alloPB-SCT compared with allogeneic bone marrow transplantation.

Rathke's cleft cyst with large frontal extension: unusual shape and pathomechanism of its formation

The patient was a 62 year old woman who presented with a visual field defect. Magnetic resonance images showed an intra-and supra-sellar low intensity mass on T1 weighted images. The preoperative diagnosis was craniopharyngioma, Rathke's cleft cyst (RCC) or arachnoid cyst. The patient underwent transsphenoidal surgery & the pathological diagnosis was RCC. We conclude that although RCC has a round, ovoid or dumb-bell shaped configuration, it may present a unusual shape in cases with preconditions, as were seen in our patient.

[Prevention of hepatitis B flare-up using lamivudine in a patient with non-Hodgkin's lymphoma after allogeneic bone marrow transplantation]

A 22-year-old man with non-Hodgkin's lymphoma (B-cell lymphoblastic lymphoma, Stage IVA) received chemotherapy and radiation therapy and achieved complete remission. He was admitted for allogeneic bone marrow transplantation (BMT) using a graft from his completely HLA-matched mother. Although he had HBV infection, allogeneic BMT was performed because he still had normal liver function and strongly requested the procedure. He developed both acute and chronic GVHD after the procedure, but showed no liver damage related to HBV. Treatment with lamivudine (150 mg/day) was started because the HBV-DNA level increased gradually after allogeneic BMT. Although the HBV-DNA then decreased gradually and there was no evidence of severe liver damage, the patient died following relapse of NHL. It seems that in this case, treatment of HBV with lamivudine may have prevented serious liver damage after allogeneic BMT. Therefore, allogeneic BMT may be done safely in patients with HBV infection if lamivudine is administered.

Hyperbaric oxygen reduces infarct volume in rats by increasing oxygen supply to the ischemic periphery

OBJECTIVE

Hyperbaric oxygen (HBO) increases oxygen supply to anoxic areas. To examine the therapeutic effect of HBO on ischemic stroke, we measured infarct volume as well as cerebral blood flow (CBF), oxygen supply, and lipid peroxidation in the ischemic periphery.

DESIGN

Prospective experimental study in rats.

SETTING

Experimental laboratory in a university teaching hospital.

SUBJECTS

Thirty-eight adult rats.

INTERVENTION

The rats were anesthetized (1% halothane) and intubated. Focal ischemia was induced by ligating the right middle cerebral and right common carotid arteries. Nineteen animals were exposed to 2 hrs of HBO (100% oxygen, 3 atmospheres absolute), initiated 10 mins after the onset of ischemia. The remaining animals were kept at ambient pressure and used as controls.

MEASUREMENTS AND MAIN RESULTS

At the initiation of ischemia, CBF measured by a laser-Doppler flow probe placed in the ischemic periphery was reduced to 47%+/-11% and 51%+/-15% of normal levels in animals exposed or not to HBO, respectively. These altered values were not affected further by administration of HBO and remained stable throughout a 2-hr observation period. Arterial oxygen pressure and content were significantly increased to 1571+/-130 torr (209.41+/-17.32 kPa; p < .0001) and 1.03+/-0.04 mmol/dL (p < 0.0001), respectively, in HBO-treated animals compared with nontreated animals (139+/-14 torr [18.53+/-1.87 kPa] and 0.86+/-0.04 mmol/dL, respectively). The calculated increase in the oxygen supply to the ischemic periphery was 20%. The infarct volume of HBO-treated animals measured 24 hrs after the onset of focal cerebral ischemia was significantly reduced by 18% (HBO-treated, 132+/-13 mm3 vs. nontreated, 161+/-29 mm3; p = .02). Lipid peroxidation was unchanged after 120 mins of HBO administration in the cerebral cortex where the laser-Doppler flow probe was placed.

CONCLUSIONS

HBO at 3 atmospheres absolute reduced infarct volume by increasing oxygen supply to the ischemic periphery without aggravating lipid peroxidation, suggesting that HBO can be useful in treating stroke victims.

Neuroradiological characteristics of pineocytoma and pineoblastoma

We reviewed neuroradiological images in two histologically proven cases of pineocytoma and three of pineoblastoma to delineate the characteristic features of these rare tumours. CT revealed isodense or slightly hyperdense masses with central or peripheral calcification; enhancement with contrast medium tended to be homogeneous in pineocytomas and heterogeneous in pineoblastomas. In the pineocytomas, T1-weighted images revealed rounded, sometimes or slightly lobulated low-signal masses with strong, homogeneous contrast enhancement. Their margin was clear, without invasion of adjacent structures. In the pineoblastomas, however, T1-weighted images revealed multilobulated tumours with heterogeneous contrast enhancement. All three pineoblastomas had poorly defined margins with adjacent structures such as the posterior thalamus or corpus callosum, suggesting a more invasive nature. T2-weighted images revealed nonspecific high signal lesions in all five cases.

Bilateral ptosis with pupil sparing because of a discrete midbrain lesion: magnetic resonance imaging evidence of topographic arrangement within the oculomotor nerve

The topographic arrangement within the midbrain oculomotor nerve is not adequately elucidated in humans. Two patients with a partial oculomotor palsy because of a localized infarction or hematoma were treated. Both patients had bilateral ptosis, impaired adduction, and supraduction. One patient had impaired infraduction and pupillary involvement on one side. Results of computed tomography and magnetic resonance imaging revealed discrete lesions at the dorsal midbrain tegmentum that spared the rostral midbrain. The authors' cases elucidate that pupillary components take the most rostral course. This report provides indirect magnetic resonance imaging evidence to prove the course of pupillary fibers. Based on the different neuro-ophthalmologic findings in the authors' cases (sparing or affecting pupillary component and infraduction), the nerves of the inferior rectus and inferior oblique for infraduction pass more rostrally than those of medial rectus, superior rectus, and levator palpebrae. The nuclear and fascicular arrangement within the midbrain oculomotor nerve is speculated to be pupillary, extraocular, and eyelid elevation in the rostro-caudal order, based on the neuro-ophthalmologic impairment and magnetic resonance imaging findings in the authors' patients and in previous animal experiments. Knowing the fascicular and nuclear arrangement within the midbrain in detail will offer diagnostic clues for differentiation of causes for partial oculomotor palsy.

Granulocyte colony-stimulating factor and lineage-independent modulation of VLA-4 expression on circulating CD34+ cells

Although the use of allogeneic transplants of peripheral blood stem/progenitor cells (PBSCs) is increasing, the precise mechanism of PBSC mobilization has not yet been fully clarified. We examined the expression of some adhesion molecules on CD34+ cells from steady-state bone marrow (BM), granulocyte colony-stimulating factor (G-CSF)-mobilized PBSCs, and cytotoxic drugs plus G-CSF-mobilized PBSCs. Irrespective of mobilization method, very late antigen (VLA)-4 expression on circulating CD34+ cells was significantly lower than on steady-state BM CD34+ cells. To elucidate the influence of lineage commitment on VLA-4 expression of circulating CD34+ cells, we analyzed VLA-4 expression on different subsets of CD34+ cells with or without CD33, CD38, CD5, or CD10 antigens, or Glycophorin A in G-CSF-mobilized PBSCs and steady-state BM from related donors, using 3-color flow cytometry. VLA-4 on circulating CD34+ subsets was less expressed than on each corresponding subset of steady-state BM CD34+ cells. Furthermore, VLA-4 positive rates showed no significant difference among the CD34+ subsets. Finally, the data comparing CD34+ cells from steady-state and G-CSF-mobilized PBSCs revealed no differences in terms of VLA-4 expression. These data suggest that reduced expression of VLA-4 may be a result of peripheralization of CD34+ cells from bone marrow, which occurs in a G-CSF- and lineage-independent fashion.

G-CSF reduces IFN-gamma and IL-4 production by T cells after allogeneic stimulation by indirectly modulating monocyte function

Despite a 10-fold increase of T cell dose, the incidence and severity of acute GVHD following allogeneic transplantation of G-CSF-mobilized PBSC is not increased compared to BMT. Experimental murine studies demonstrate that G-CSF polarizes donor T cells toward a type 2 cytokine response. To determine whether G-CSF alters T cell cytokine responses, we investigated the effects of G-CSF administration on T cell proliferative and cytokine responses to alloantigen and Con A in nonadherent PBMC (NAC) and CD3+ T cells obtained from normal individuals before and after G-CSF administration (10 microg/kg x 4 days). Although T cell proliferative and cytokine (IFN-gamma and IL-4) responses to alloantigen stimulation and Con A were significantly reduced in post-G-CSF NAC, they were restored by the removal of non-T cells from post-G-CSF NAC. Furthermore, there was less T cell alloreactivity in MLR in the presence of autologous post-G-CSF monocytes than in the presence of pre-G-CSF monocytes. This alteration was not replicated in vitro by culturing PBMC with G-CSF. These results suggest that G-CSF administration suppresses T cell proliferative and cytokine (IFN-gamma and IL-4) responses to allogeneic stimulation by indirectly modulating monocyte function. Bone Marrow Transplantation (2000).

Bone CT evaluation of nasal cavity of acromegalics--its morphological and surgical implication in comparison to non-acromegalics

PURPOSE

In order to numerically compare the morphological differences of the nasal cavity and nasal sinus between acromegalics and non-acromegalics, bone window CT scans sliced parallel to the transsphenoidal surgical route were performed. MATERIAL AND CASES: Acromegalic patients had small or large macroadenomas and were 13 (7 men and 6 women) in number, aged 53.2 +/- 16.1 years. Non-acromegalic patients had pituitary tumors and were 44 (21 men and 23 women) in number, aged 52.1 +/- 12.5 years.

RESULTS

The results of acromegalics are described in comparison to non-acromegalics in parentheses. a) The width of the surgical corridor: piriform aperture, 27.6 +/- 2.7 (25.9 +/- 2.6) mm; origin of inferior nasal concha, 29.4 +/- 9.4 (26.6 +/- 4.0) mm; and origin of middle nasal concha, 29.8 +/- 3.2 (26.2 +/- 4.2) mm. b) The depth of the surgical corridor: the upper lip thickness, 18.1 +/- 2.7 (13.3 +/- 1.4) mm; the distances between piriform aperture and sphenoid wall, 52.9 +/- 4.6 (49 +/- 4.2) mm; sphenoid wall and sellar floor, 17.3 +/- 4.1 (18.7 +/- 4.1) mm; and sellar floor to dorsum sellae, 17.6 +/- 3.4 (15.6 +/- 4.0) mm. c) Marked carotid prominence: 7/13=53.4% (8/44=18.25%). d) Sinusitis: 8/13=61.5% (12/44=27.3%).

DISCUSSION & CONCLUSION

The data presented above show that morphological differences in bony nasal cavity and soft tissue may be responsible for a deeper and narrower surgical field for acromegalics. Acromegalics had a marked carotid prominence more frequently, which needs special attention to avoid carotid injury, when enlarging the surgical field. Knowing these morphological differences will provide useful information for peri- and intra-operative care.

Growth hormone secreting adenoma with unusual extension: coexisting pituitary cyst and its clinical significance

A 58 year old man showed acromegalic features. The serum growth hormone (GH) level was 7.3 ng/ml and SMC (somatomedin-C) 637 U/ml. Triple stimulation test showed abnormal response compatible with a GH secreting tumour. The conventional enhanced MRI revealed a less enhanced hemisphere-shaped lesion at the right corner of the sella turcica. In addition, dynamic MRI demonstrated an elongated lesion extending to the left beyond the midline. The patient underwent transsphenoidal surgery. Besides the soft and suckable tumour at the right corner, we entered into a small cavity loosely filled with the tumour, which was subsequently also removed. The operative finding corresponded to the lesion shown in dynamic MRI. Postoperative GH and SMC levels became 2.3 ng/ml and 326 U/ml respectively. Incidental pituitary cystic lesions in autopsied cases have been reported to be 6-33%. This case had a GH secreting adenoma with coexisting pituitary cyst. The coexisting pituitary cyst supposedly influenced the unusual shape and extension of the pituitary adenoma. Coexistence of such lesion should be kept in mind for microadenoma on neuroradiological evaluation and on intraoperative inspection surrounding the tumour.

Incidence of malignant tumors in patients with acromegaly

Neoplasms may be one of the systemic complications to which we attribute high mortality in acromegaly. The present study was designed to investigate the incidence of malignant tumors in patients with acromegaly in the Japanese population. In this report, 44 patients (25 men and 19 women) with biochemically proven acromegaly were studied retrospectively and had a total 670 patient years of the duration of acromegaly. We investigated the incidence of malignant tumors. There were 5 patients with malignant tumors (5 in men) in this study (11%). Male patients with acromegaly had nearly a 3.5 times higher ratio of malignancy than expected and this increased cancer incidence was considered significant (P=0.01). There was no significant increase in cancer incidence of either the total patient population or female patients. The malignant tumors were two thyroid cancers and one colon, one gastric and one bladder cancer. It is of note that the colon cancer of one patient was diagnosed 2 years after transsphenoidal surgery even though the levels of serum GH and insulin-like growth factor (IGF-1) were reduced to normal after operation. This preliminary study has suggested that male patients with acromegaly might have a high risk of malignancy and that careful screening for tumors is needed both before and after surgical and medical treatment, even in patients with normalized serum GH and IGF-1 levels.

Cystine protects cochlear outer hair cells against glutamate toxicity

We previously reported that long-term exposure to glutamate (Glu) induced death of cochlear outer hair cells (OHCs). However, the mechanisms of OHC death induced by Glu were unclear. In the central nervous system, Glu is known to interfere with a cystine-Glu antiporter, leading to a decrease in cystine uptake and reducing the intracellular glutathione level. We therefore investigated the effect of cystine supplementation on degeneration of OHCs caused by long-term exposure to Glu. Supplementation of cystine significantly decreased the number of dying OHCs. These findings suggest that a cystine-Glu interaction may be involved in the mechanism of OHC degeneration caused by Glu.

MRI findings and clinical manifestations in Rathke's cleft cyst

We retrospectively analysed patients with histologically proven Rathke's cleft cyst (RCC) in relation to the clinical manifestations and MRI findings, in particular, of cyst size and intensity in order to obtain an insight into their growing mechanisms, clinical presentations and their management. Eleven patients with RCC were divided into two groups based on T1 weighted images(WI). The A group consisted of 4 patients with cyst of low intensity in T1 WI. The age averaged 64.5 years. Their initial complaints were visual field defects(VFD). Their complaints were rather insidious. The maximum cyst size averaged 27.8+/-2.4 mm. The B group consisted of 7 patients with cyst of iso- or high-intensity in T1 WI. Two patients in the B group showed mixture of low and high and iso- and high-intensity, suggesting the presence of bleeding at the onset of symptoms or growing mechanism of the cysts. In the B group the age averaged 39.9 years, being lower than that in the A group. (P=0.0140 with Mann-Whitney's U test) The 5 patients out of 7 showed headache of insidious type or acute onset and the 3 showed a fluctuation of the VFD. The average size was 21.7+/-3.5 mm and smaller than that of the A group. (P=0.0298 with Mann-Whitney's U test) Our study has shown that the cyst with iso-to high intensity on T1 WI may cause clinical symptoms with a smaller size than cysts of the low intensity. In the former cyst pattern the onset and growing mechanism may be related to bleeding. The patients with this pattern are more likely to have acute and/or fluctuation of clinical presentations. Knowing these various clinical manifestations based on MRI pattern will be of help in following and managing patients with RCC.

Glutamate toxicity induced degeneration of outer hair cells with a temporal increase of nitric oxide production in the guinea pig cochlea

The aim of this study was to examine the roles of glutamate (GLU) toxicity and involvement of nitric oxide (NO) in the pathogenesis of cochlear degeneration. We examined guinea pig cochleae following chronic exposure to GLU. Trypan blue extrusion and transmission electron microscopy were performed to evaluate degeneration in the organ of Corti. In parallel, nitric oxide synthase (NOS) activity was demonstrated by histochemical staining of NADPH diapholase. GLU treatment caused time-dependent degeneration of outer hair cells (OHCs) in conjunction with a temporal increase of NOS activity in the organ of Corti. This suggests that GLU may be involved in OHC degeneration under toxic conditions, with NO production possibly playing a role in this process.

[Stem cell transplantation in multiple myeloma]

High-dose chemotherapy combined with autologous hematopoietic stem cell transplantation (ASCT) has brought about high complete remission rates (about 40%), reduction of transplant-related toxicity in the patients with multiple myeloma, and it has spread rapidly. Moreover, it has demonstrated that overall survival times of high-dose chemotherapy with ASCT are significantly more extended than conventional chemotherapy. The indications of transplantation should be determined on the basis of various prognostic factors and sensitivity of the induction chemotherapy, and it is important that a therapeutic strategy should take the timing of ASCT into consideration before induction therapy. However, some problems of tumor cell contamination in the peripheral stem progenitor graft and its contribution to relapse have arisen. Some new trials including positive selection of CD34+ cells within its grafts and double auto-transplantation are ongoing to solve these problems. If the patient is under 50 years of age and an HLA identical donor is available, an allogeneic bone marrow transplantation (allo-BMT) may be considered. However, the indication of allo-BMT should be carefully selected because the transplant-related mortality is high (about 40%), and allo-BMT is not superior to ASCT in overall survival. New trials with nonablative hematopoietic stem cell transplantation with donor lymphocyte infusions (DLI) to induce a graft-versus-myeloma (GVM) effect are awaited.

Involvement of nitric oxide in aminoglycoside vestibulotoxicity in guinea pigs

Involvement of nitric oxide (NO) has been reported in physiological and pathological conditions in the inner ear. Recently, the presence of nitric oxide synthase (NOS) was demonstrated in the vestibular epithelium. In this study we used nicotinamide adenine dinucleotide phosphate-diapholase staining to monitor NOS activity during degeneration of guinea pig vestibular epithelia affected by streptomycin. Increased NOS activity was observed in affected epithelia in a dose- and time-dependent manner and a NOS inhibitor could protect hair cells from apoptosis. Additionally, cycloheximide significantly reduced NOS activity and the occurrence of apoptosis. These findings suggest that NO is involved in the degenerative process of vestibular epithelia caused by aminoglycosides.

Delayed postoperative CSF rhinorrhea of intrasellar arachnoid cyst

CSF rhinorrhea due to a transsphenoidal approach usually follows accidental or intentional arachnoid opening. We report a patient with an intrasellar arachnoid cyst, who developed delayed onset of CSF rhinorrhea. A sixty-two-year-old man presented with bitemporal type visual field defect for the last 3 years. With the diagnosis of arachnoid cyst or Rathke's cleft cyst, based on MRI findings of intra-and supra-sellar cyst with CSF intensity, he successfully underwent transsphenoidal surgery without evidence of intra-operative CSF leakage. He developed CSF rhinorrhea one week later. This needed another operation for sellar floor repair. The pathomechanism of this delayed onset is explained as follows. Incomplete or oneway communication of subarachnoid space to cyst cavity, unrecognized during surgery, might cause delayed onset of CSF rhinorrhea. By using MRI, identification of the residual gland, which was compressed posteriorly, is useful for differentiating an arachnoid cyst from other cystic lesions. In highly suspect cases, even without evidence of intra-operative CSF leakage, peri-operative measures to prevent occurrence of postoperative CSF rhinorrhea are required.

Epithelial-myoepithelial carcinoma: An unusual tumor of the paranasal sinus

A 65-year old woman presented with nasal obstruction and on examination was found to have a huge mass in the maxillary sinus. This was removed, and histological examination revealed a mixture of trabecular structures consisting of inner dark cells, outer clear cells and solid structures consisting of only clear cells. Immunohistochemical examination showed the clear cells to be positive for alpha-smooth muscle actin. Ultrastructural examination confirmed the myoepithelial cell origin. The characteristic morphological, immunohistochemical and ultrastructural features aided in the diagnosis of epithelial-myoepithelial carcinoma.

Assessment of hair cell death using the dye extrusion method

We examined the usefulness of the dye extrusion method for assessing cochlear hair cell death in guinea pigs. Unilateral temporal bones were incubated in sterile Dulbecco modified Eagle's medium for 1-6 h and then perfused with PBS/0.3% trypan blue to determine hair cell viability. Cells with nuclei stained with trypan blue were assumed to have died. The contralateral temporal bones of each animal were incubated with the same medium for 1-6 h and examined by transmission electron microscopy (TEM). This method revealed that hair cell viability under these conditions was maintained for at most 3 h. After incubation for more than 3 h, hair cell injury began and increased. After 6 h incubation, TEM revealed apoptotic death of outer hair cells. The results with this method agreed with the TEM findings. The dye extrusion method is simple, easy and useful for screening hair cell death in the cochlea under pathological conditions.

Apoptotic cell death in Kikuchi's disease: a TEM study

The pathogenesis of Kikuchi's disease (Kikuchi-Fujimoto disease, histiocytic necrotizing lymphadenitis) remains unclear. However, some previous studies have suggested that a disorder in cellular immunity is responsible for this disease, and apoptotic cell death appears to be the principal finding in the histogenesis of this disease. In the present study, a lymph node from a female patient with Kikuchi's disease was examined by transmission electron microscopy (TEM). TEM revealed specific morphological features of apoptotic cells, such as nuclear chromatin condensation and fragmentation along the nuclear membrane with intact organelles, and the presence of histiocytes phagocytosing karyorrhectic debris (apoptotic bodies) in areas affected by Kikuchi's disease. Although neither the role nor the trigger of apoptosis in Kikuchi's disease has been clearly determined, our findings show that apoptotic cell death clearly plays a role in the pathogenesis of Kikuchi's disease.

Time-dependent response of vestibular hair cells of guinea pigs following high-dose applications of streptomycin

Apoptosis has been reported to occur in vestibular hair cells following aminoglycoside treatment and is suggested to play a predominant role in deletion of affected hair cells. However, the type of cell death occurring during an acute phase of vestibular damage following high-dose application of streptomycin has not yet been determined. Hence, in this study we examined the cell death mode of vestibular hair cells during the acute phase. The numbers of hair cell nuclei stained by the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labelling (TUNEL) method and residual hair cells were quantitatively analysed. Hoechst nuclear staining was used for analysis of the nuclear morphology of affected hair cells. TUNEL staining of hair cell nuclei and lost hair cells began to appear 6 h after streptomycin treatment and increased with more exposure time. Apoptotic nuclear features could also be found from 6 h after streptomycin treatment. These findings support the thesis that apoptosis is a predominant cell death mode in degeneration of vestibular hair cells due to streptomycin ototoxicity.

Local substances regulating cochlear blood flow

The regulation of cochlear lateral wall blood flow was investigated in rats using histochemistry, immunohistochemistry and transmission electron microscopy. The contractile protein, tropomyosin (TM) was localized in the pericyte around the vessels of spiral ligament but little was seen around strial capillaries. Prostaglandin I2 (PGI2) is a vasodilatory substance produced by PGI2 synthase (PGI2S), which is present in the endothelium of the vessels of spiral ligament but not much is present around strial capillaries. Endothelial nitric oxide synthase (eNOS) was present in the endothelium of both the vessels of spiral ligament and strial capillaries. These findings indicate that the blood flow of the cochlear lateral wall is regulated mainly in the spiral ligament by locally produced substances and that strial blood flow is not significantly regulated by pericytes responsible for enlargement or constriction of capillaries.

Cycloheximide blocks the toxic effect of streptomycin in guinea pig vestibular hair cells

Apoptosis has been suggested to be a predominant cell death process for streptomycin-induced degeneration of vestibular hair cells. However, the biochemical aspects of this have not been studied. The purpose of this study was to examine the biochemical aspects of apoptosis of vestibular hair cells caused by streptomycin. Cycloheximide is a widely used protein synthesis inhibitor in studies of apoptosis. We therefore investigated cycloheximide effects on degeneration of vestibular hair cells following streptomycin applications. Supplements of cycloheximide significantly prevented DNA fragmentation in hair cell nuclei and reduced the loss of hair cells. This suggests that cycloheximide possibly inhibits apoptosis of hair cells and attenuates streptomycin-induced degeneration of the vestibular epithelium.