Analgesic efficacy and safety of percutaneous thermal ablation plus cementoplasty for painful bone metastases: a systematic review and meta-analysis

PURPOSE

To conduct a systematic review and meta-analysis of publications to evaluate the analgesic efficacy and safety of percutaneous thermal ablation (PTA) plus percutaneous cementoplasty (PCP) (PTA + PCP) for painful bone metastases.

METHODS

We searched PubMed, Cochrane Library and Embase for articles published up to October 2022. Outcomes were a 10-point pain scale, morphine equivalents daily dose (MEDD) and complications. A subgroup confined to spinal bone metastases was analyzed.

RESULTS

Twenty-one articles were selected for the analysis. The 21 selected articles involved a total of 661 cases. The pooled pain scales at pre-PTA + PCP, 1 day, 1 week and 1-, 3-, and 6 months post-PTA + PCP were 7.60 (95% confidence interval [CI], 7.26-7.95, I2 = 89%), 3.30 (95% CI, 2.25-4.82, I2 = 98%), 2.58 (95% CI, 1.99-3.35, I2 = 94%), 2.02 (95% CI, 1.50-2.71, I2 = 93%), 1.78 (95% CI, 1.26-2.53, I2 = 95%), and 1.62 (95% CI, 1.14-2.31, I2 = 88%), and in the subgroup, 7.97 (95% CI, 7.45-8.52, I2 = 86%), 3.01 (95% CI, 1.43-6.33, I2 = 98%), 2.95 (95% CI, 1.93-4.51, I2 = 95%), 2.34 (95% CI, 1.82-3.01, I2 = 68%), 2.18 (95% CI, 1.57-3.03, I2 = 78%), and 2.01 (95% CI, 1.16-3.48, I2 = 86%). Mean MEDD decreased up to 3 months post-PTA + PCP in 4 articles. The overall pooled major complication rate was 4% (95% CI, 2-6%, I2 = 2%).

CONCLUSIONS

The updated systematic review and meta-analysis indicates that PTA + PCP for painful bone metastases is safe, and can lead to rapid and sustained pain reduction.

Difference in arterial FDG accumulation in healthy study participants between digital PET/CT and standard PET/CT

OBJECTIVE

To evaluate the differences in FDG accumulation in arteries throughout the body between digital and standard PET/CT.

METHODS

Forty-six people who had FDG-PET examinations with a digital PET/CT scanner for health screening between April 2020 and March 2021 and had previous examinations with a standard PET/CT scanner were the study participants. FDG accumulation in arteries throughout the body was visually assessed in each segment. Scan was considered positive when arterial FDG accumulation was equal to or greater than that of the liver. The positivity rates for general arteries and each arterial segment were compared between the two kinds of scanners. If any one of the arterial segments was considered positive, the general arteries were classified as positive. Moreover, the rate of change in results from the standard PET/CT to the digital scanner in the same individual (negative to positive, positive to negative) was examined.

RESULTS

In the evaluation of general arteries, the positivity rates were 21.7% (10 cases) for the standard PET/CT, whereas positive rates were 97.8% (45 cases) for the digital PET/CT (p < 0.001). In all arterial segments, the positivity rate was significantly higher with the digital PET/CT compared to the standard PET/CT; those with the digital PET/CT were, respectively, 95.7%, 87.0%, 73.9%, 37.0%, 34.8%, and 21.7% in the femoral, brachial, aortic, subclavian, iliac, and carotid arteries. On the other hand, those with the standard PET/CT were 13.0%, 13.0%, 19.6%, 2.2%, 0%, and 4.4% in segments in the above order. Changes from negative to positive were shown in many cases; 35 cases (76.0%) of general arteries, 38 cases (82.6%) for the femoral artery, and 34 cases (73.9%) for the brachial artery. The exception was one case in which a change from positive to negative was confirmed in the carotid artery. In all arteries considered to be positive, FDG accumulation was not greater than but was equal to that in the liver with both scanners.

CONCLUSIONS

Arterial FDG accumulation was significantly higher with digital PET/CT compared to conventional PET/CT. With digital PET/CT, an arterial FDG accumulation equal to the liver may not to be considered as abnormal accumulation.

Spontaneous regression of small cell lung cancer associated with Lambert-Eaton Myasthenic Syndrome: Case report

Spontaneous regression (SR) of cancer is very rare, especially of small cell lung cancer (SCLC). Recently, an association of paraneoplastic neurological syndrome (PNS) has been reported as a cause of SR of cancer, and onconeural antibodies are a possible factor in the SR of cancer associated with PNS. We herein report the first case of SR of SCLC combined with anti-P/Q-type of voltage-gated calcium channel (VGCC) antibody-positive Lambert-Eaton myasthenic syndrome (LEMS), a subtype of PNS. This case report suggests that SCLC may be spontaneously reduced by an autoimmune response induced by VGCC antibodies associated with LEMS. Our finding may help elucidate the mechanisms that inhibit tumor growth and cause the regression of tumors.

A case of pulmonary pleomorphic carcinoma associated with cystic airspace

Lung cancer associated with a cystic airspace is frequently misdiagnosed or overlooked. Adenocarcinoma, followed by squamous cell carcinoma, is the most typical histologic type of lung cancer connected to a cystic airspace. Here we present the rare case of lung pleomorphic carcinoma associated with a cystic airspace. We encountered a 74-year-old Japanese man diagnosed by computed tomography (CT) as having a nodule outside a cystic airspace in the lung. Several previous CT images showed that the cystic airspace preceded the nodule. Postsurgery, pathology indicated a diagnosis of pleomorphic carcinoma. Since pulmonary pleomorphic carcinomas pursue an aggressive clinical course, their early detection may contribute to an improved prognosis. Our case demonstrated that pleomorphic carcinoma can arise with cystic airspaces. For early diagnosis of those aggressive lung cancers, chest physicians should carefully examine the walls of cystic airspaces on CT.

Percutaneous splanchnic nerve neurolysis analgesic efficacy and safety for cancer-related pain: a systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis of publications to evaluate the analgesic efficacy and safety of percutaneous splanchnic nerve neurolysis (SNN) for cancer-related pain.

METHODS

We searched PubMed, Cochrane Library, and Ichushi-Web for English or Japanese articles published up to July 2022 and reporting patients who underwent percutaneous SNN for cancer-related pain. The outcome measures assessed in the systematic review and meta-analysis were the pain measurement scales and morphine equivalents daily dose (MEDD) before and after the intervention and the rate of complications.

RESULTS

Pooled pain measurement scores at pre-intervention, 1-2 weeks, and at 1, 2, 3, and 6 months post-intervention were 6.65 (95% confidence interval [CI], 5.77-7.67, I² = 97%), 2.79 (95% CI, 2.00-3.88, I² = 88%), 2.82 (95% CI, 2.49-3.20, I² = 55%), 2.86 (95% CI, 2.64-3.10, I² = 0%), 2.99 (95% CI, 2.56-3.46, I² = 82%), and 3.09 (95% CI, 1.44-6.65, I² = 70%), respectively. Mean MEDD was described in 8 of the 11 included articles. In all 8 articles, MEDD decreased up to 3 months post-intervention. The pooled minor complication rates for diarrhea and hypotension were 28% (95% CI, 13-49%, I² = 85%) and 31% (95% CI, 16-51%, I² = 80%), respectively. The pooled major complication rate was 2% (95% CI, 1-2%, I² = 0%).

CONCLUSIONS

Analysis indicates that percutaneous SNN for cancer-related pain can be performed safely with sustained reduction of pain measurement scales while reducing the administration of opioids.

Predicting the pathological invasiveness of early lung adenocarcinoma prior to surgery using Deauville criteria: reliability and validity

PURPOSE

This retrospective study aimed to investigate the validity and reliability of FDG-PET/CT visual assessment using Deauville criteria to predict pathological invasiveness of early lung adenocarcinoma prior to surgery.

MATERIALS AND METHODS

Between April 2020 and January 2022, 51 patients who underwent surgery for pathological stage 0/I lung adenocarcinoma were enrolled. The pulmonary lesions were divided into two groups according to pathological invasiveness: less invasive (including adenocarcinoma in situ and minimally invasive adenocarcinoma and invasive adenocarcinoma. We compared CT size (total and solid size), SUVmax, and Deauville score between the two groups. Furthermore, we investigated inter-rater and intra-rater agreements regarding the Deauville score. Receiver operating characteristic (ROC) curve analysis was performed to identify the diagnostic performance of each method.

RESULTS

Based on pathologic diagnoses, 51 lesions in the 51 patients were divided into 6 less invasive and 45 invasive adenocarcinoma lesions. According to quadratic-weighted Kappa statistics, inter-rater (k = 0.93) and intra-rater (k = 0.97) agreements among all five components of the Deauville score indicated high agreement. There was a statistically significant difference in CT solid size, SUVmax, and Deauville score between the two groups. There were no significant differences between CT solid size and FDG-PET/CT assessments (AUC = 0.93 for Deauville score and SUVmax, AUC = 0.84 for CT solid size).

CONCLUSION

FDG-PET/CT visual assessment using the Deauville score could assist in deciding upon minimally invasive surgery for early lung adenocarcinoma.

Removal of central venous port-catheter by the combination of interventional radiological procedures

We encountered a patient with an infection related to an implanted central venous port-catheter that necessitated removal of the system. As the catheter had tightly adhered to the venous wall, removal was impossible with standard methods. After trial and error, we used a guiding catheter that was advanced over the implanted catheter to detach the fibrin sheath on the implanted catheter that had adhered to the vessel wall. At that time, a pull-through technique was used. After we succeeded in detaching the adhesion with the guiding catheter, we were able to withdraw the implanted catheter.

Computed tomography-guided single celiac plexus neurolysis analgesic efficacy and safety: a systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis of published studies to evaluate the analgesic efficacy and safety of computed tomography (CT)-guided single celiac plexus neurolysis (CPN) with the injection of a neurolytic agent into the celiac plexus in one session (CT-guided single CPN).

METHODS

PubMed, the Cochrane Library, and Ichushi-Web were searched for English or Japanese articles published up to February 2022, which reported findings about patients who underwent CT-guided single CPN. The outcome measures assessed in the systematic review and meta-analysis were the pain measurement scales from 0 to 10 before and after the intervention and the rate of minor and major complications.

RESULTS

The pooled pain measurement scales at pre-intervention and 1- or 2-, 7-, 30-, 60-, 90-, and 180-day post-intervention was 6.72 (95% confidence interval [CI], 4.77-9.46, I² = 98%), 2.31 (95% CI 2.31-4.44, I² = 92%), 2.84 (95% CI 1.39-5.79, I² = 95%), 3.36 (95% CI 1.66-6.77, I² = 98%), 3.19 (95% CI 1.44-7.08, I² = 59%), 3.87 (95% CI 1.88-7.97, I² = 0%), and 3.40 (95% CI 3.02-3.83, I² = not applicable), respectively. The pooled minor complication rates of diarrhea, hypotension, nausea or vomiting, and pain associated with the procedure were 18% (95% CI 8-37%, I² = 45%), 16% (95% CI 2-58%, I² = 76%), 6% (95% CI 2-16%, I² = 1%), and 7% (95% CI 2-21%, I² = 17%), respectively. There was no major complication in the included studies.

CONCLUSION

CT-guided single CPN can be performed safely and provides immediate analgesic efficacy although the amount of heterogeneity is characterized as large. Further investigation of its long-term analgesic efficacy is required.

18FDG PET-Positive Congenital Pulmonary Airway Malformation Mimicking Lung Cancer

ABSTRACT

Adult cases of type 2 congenital pulmonary airway malformation (CPAM) are extremely rare, and no PET/CT findings have been reported for CPAM. We encountered a case of 18FDG PET-positive CPAM mimicking lung cancer in a 45-year-old asymptomatic man. CT revealed a large cavitary mass in the left lower lobe. SUVmax measured by 18FDG PET was 3.5. The patient underwent video-assisted thoracoscopic lobectomy on suspicion of CPAM with/or lung cancer. Histologically, no neoplastic cells were present, and the lesion was consistent with type 2 CPAM. An adenomatoid proliferative pattern and granulomatous lesions may have contributed to a PET/CT false-positive result.

Inhibition of fibrotic changes in infrapatellar fat pad alleviates persistent pain and articular cartilage degeneration in monoiodoacetic acid-induced rat arthritis model

OBJECTIVE

We have reported that fibrotic changes in infrapatellar fat pad (IFP) after acute joint inflammation are closely associated with persistent pain in rats. In this study, to examine the effects of anti-fibrotic treatment on persistent pain, we used C-type natriuretic peptides (CNP) at the recovery phase after acute joint inflammation.

DESIGN

Thirty-two male Wistar rats were used in this study. Monoiodoacetic acid (MIA) was injected intra-articularly to induce IFP fibrosis and persistent pain. CNP was injected after acute inflammatory phase in the same knee joint. Time-course pain-avoidance behavior tests and histological analyses were performed to examine the effects of CNP.

RESULTS

Histological evaluations indicated that intra-articular injection of CNP inhibited fibrotic changes in IFP after acute inflammation. Incapacitance tests indicated that MIA injection into rat knee joint quickly decreased the percent weight on ipsilateral limb. In the vehicle group, the decrease was maintained up to day 28, suggesting that pain persistence occurred after acute inflammation (Day 0/Day 28, Est Dif -8.15, CI -10.78∼-5.53, Linear mixed-effect model). In contrast, the pain was alleviated in the CNP group after day 14 (Day0/Day 14, -0.51, -2.62-1.59). In addition, we observed significant improvement in the degree of articular cartilage degeneration at day 14 in the CNP group (OARSI score: vehicle 16.14 ± 4.37 vs CNP 6.87 ± 3.44, P < 0.01; Wilcoxon rank sum test).

CONCLUSION

Fibrotic changes in IFP may play important roles in both persistent pain and articular cartilage degeneration.

Pancreatic FDG uptake on follow-up PET/CT in patients with cancer

To evaluate the breakdown of unexpected pancreatic ¹⁸F-fluorodeoxyglucose (FDG) uptake and the proportion of secondary primary pancreatic cancer on follow-up, patients with cancer underwent positron emission tomography/computed tomography (PET/CT). The participants consisted of 4,473 consecutive patients with cancer who underwent follow-up PET/CT between January 2015 and March 2019 at Kochi Medical School. Among the participants, 225 with a history of pancreatic cancer were excluded from the present study. Retrospective and blinded PET/CT evaluations of 4,248 patients were performed. In patients with pancreatic FDG uptake, the distribution of FDG uptake in the pancreas was evaluated. The final diagnosis was determined pathologically. A total of 14 (0.3%) of the 4,248 patients exhibited FDG uptake in the pancreatic area. Pancreatic abnormalities were detected in 14 patients, and included five cases of pancreatic metastases (36%), four cases of secondary primary pancreatic cancer (29%), two cases of lymph node metastases (14%), one case of malignant lymphoma (7%), one case of autoimmune pancreatitis (7%) and one case of pseudolesion (7%). One patient with early-stage secondary primary pancreatic cancer had a maximum standardized uptake value (SUV_max) <3.0. The remaining 13 patients had a SUV_max >3.0 in the pancreas. Of the 14 patients, two had multiple foci of FDG uptake in the pancreas. Patients with multiple foci of FDG uptake exhibited pancreatic metastasis from renal cell carcinoma and malignant lymphoma. In conclusion, the majority of patients with unexpected pancreatic FDG uptake on follow-up PET/CT exhibited malignancies; furthermore, ~30% of the malignancies detected in patients with pancreatic FDG uptake were secondary primary pancreatic cancers. In patients with unexpected pancreatic FDG uptake on follow-up PET/CT, primary cancer should be considered as well as metastatic tumors.

Evaluation of pleural lesions after pleurodesis with OK-432 by fluorodeoxyglucose-positron emission tomography/CT

OBJECTIVE

This study aimed to determine changes in FDG-PET/CT after pleurodesis with OK-432 and to investigate differences in the changes between non-malignant and malignant lesions.

METHODS

Study participants were 17 patients with a history of malignant chest disease who underwent FDG-PET/CT after pleurodesis using OK-432 and in whom pleural lesions were determined to be non-malignant (n = 8) or malignant (n = 9). FDG uptake (SUV_max) was counted on all pleural lesions. CT findings (CT attenuation, shape) of pleural lesions with increased FDG uptake were evaluated.

RESULTS

The number of patients with increased FDG uptake in the pleura differed significantly between the non-malignant group (3/8) and malignant group (9/9) (p < 0.01) The mean SUV_max of non-malignant lesions with increased FDG uptake was 2.3 ± 0.7 vs. 6.2 ± 2.2 in malignant lesions, for a significant difference (p < 0.01). The mean CT attenuation of lesions was 36 ± 11 HU in the non-malignant group and 34 ± 14 HU in the malignant group, a difference that was not significant (p = 0.91). There was a significant difference in nodular and linear shapes between non-malignant and malignant lesions (p < 0.01). All non-malignant lesions were linear.

CONCLUSIONS

Positive FDG uptake was shown in non-malignant pleural lesions as well as in malignant pleural lesions after pleurodesis using OK-432. Combined analysis of FDG accumulation and CT morphology is helpful to distinguish between benign and malignant lesions.

Remote effects in the ipsilateral thalamus and/or contralateral cerebellar hemisphere using FDG PET in patients with brain tumors

PURPOSE

To evaluate reduced metabolism in the ipsilateral thalamus (TH) and/or contralateral cerebellum (CE) according to tumor localization and cortical metabolism around the tumor in patients with brain tumors based on FDG uptake.

METHODS

This study investigated 48 consecutive patients with solitary cerebral hemisphere parenchymal brain tumors who underwent PET/CT and MRI. Patients were divided into 4 groups (A: reduced uptake in ipsilateral TH and contralateral CE, B: reduced uptake in ipsilateral TH only, C: reduced uptake in contralateral CE only, and D: no reduced uptake in ipsilateral TH or contralateral CE). FDG uptake and MRI findings were compared among these groups.

RESULTS

Of 48 patients, group A included 24 (50%), group B included 10 (21%), group C included 0, and group D included 14 (29%). No significant tendencies were observed between the groups regarding tumor localization. However, reduced cortical metabolism around the tumor was observed in 22 patients in group A, 7 patients in group B, and 1 patient in group D. All patients in group B showed reduced metabolism from around the tumor up to the ipsilateral TH.

CONCLUSION

Reduced FDG uptake in ipsilateral TH and contralateral CE usually occur simultaneously in patients with solitary brain tumors.

Therapeutic results of a novel enzyme-targeting radiosensitization treatment, Kochi oxydol-radiation therapy for unresectable carcinomas II, in patients with stage I primary breast cancer

Linac-based stereotactic radiotherapy has little effect on the majority of advanced neoplasms. Therefore, the novel radiosensitizer Kochi oxydol-radiation therapy for unresectable carcinomas (KORTUC) II, which contains hydrogen peroxide and sodium hyaluronate, was developed. The effectiveness of KORTUC II for the treatment of chemotherapy-resistant supraclavicular lymph node metastases, recurrent breast cancer and stage IV primary breast cancer has previously been demonstrated. The present study evaluated the safety and efficacy of KORTUC II for patients with stage I primary breast cancer. A total of 15 patients (age range, 40–76 years) were enrolled. The injection of 3 ml of KORTUC II agent was initiated from the sixth radiotherapy fraction and was performed twice a week, under ultrasonographic guidance. The therapeutic effects were evaluated by PET-CT and/or MRI examinations prior to and following KORTUC II treatment. All patients exhibited complete responses and the overall survival rate was 100% after a follow-up period of five years. The mean duration of follow-up at the end of March 2015 was 53 months. Based on these results, KORTUC II treatment exhibited marked therapeutic effects with satisfactory treatment outcomes and an acceptable extent of adverse events.

Comparison of wear rate and osteolysis between second-generation annealed and first-generation remelted highly cross-linked polyethylene in total hip arthroplasty. A case control study at a minimum of five years

BACKGROUND

There is no previous report that directly compared wear resistance of second-generation annealed highly cross-linked polyethylene with that of first-generation remelted highly cross-linked polyethylene. We therefore performed a retrospective study at a minimum of 5-year follow-up comparing second-generation annealed and first-generation remelted highly cross-linked polyethylene in order to: (1) assess wear rates and (2) compare the incidence of osteolysis between, (3) identify the frequency of complication related to the two types of highly cross-linked polyethylene.

HYPOTHESIS

There is a difference in the linear wear rate and the incidence of osteolysis between the two types of highly cross-linked polyethylene in total hip arthroplasty.

MATERIALS AND METHODS

In a single centre study, we reviewed 123 primary cementless total hip arthroplasties between 2010 and 2011 that were performed with 32mm alumina ceramic on second-generation annealed (X3) or first-generation remelted (Longevity) highly cross-linked polyethylene liner. There was no specific reason for the choice of the type of highly cross-linked polyethylene. There were no significant differences between the two groups in respect of gender, diagnosis, body mass index, pre- and post-operative functional and activity score, cup size, and cup orientation except the younger age in the X3 group. The mean wear rate and the incidence of osteolysis were evaluated at the latest follow-up.

RESULTS

One hundred nine cases followed over 5 years post-operatively (88.6% in all consecutive cases) were evaluated. X3 and Longevity were used in 54 and 55 cases, respectively. The mean follow-up was 5.3 years in both groups. The mean linear wear rate of X3 and Longevity group was 0.045±0.023mm/year and 0.076±0.031mm/year, respectively (P<0.001). No osteolysis was found on plain X-rays in both groups and no specific complication was related to these highly cross-linked components.

DISCUSSION

Excellent wear resistance of both types of highly cross-linked polyethylene liner was revealed in our study. The difference of wear rate between two materials should be monitored in a longer follow-up.

LEVEL OF EVIDENCE

Level III retrospective case control study.

Efficiency of genomic selection for breeding population design and phenotype prediction in tomato

Genomic selection (GS), which uses estimated genetic potential based on genome-wide genotype data for a breeding selection, is now widely accepted as an efficient method to improve genetically complex traits. We assessed the potential of GS for increasing soluble solids content and total fruit weight of tomato. A collection of big-fruited F1 varieties was used to construct the GS models, and the progeny from crosses was used to validate the models. The present study includes two experiments: a prediction of a parental combination that generates superior progeny and the prediction of progeny phenotypes. The GS models successfully predicted a better parent even if the phenotypic value did not vary substantially between candidates. The GS models also predicted phenotypes of progeny, although their efficiency varied depending on the parental cross combinations and the selected traits. Although further analyses are required to apply GS in an actual breeding situation, our results indicated that GS is a promising strategy for future tomato breeding design.

Therapeutic response to a novel enzyme-targeting radiosensitization treatment (KORTUC II) for residual lesions in patients with stage IV primary breast cancer, following induction chemotherapy with epirubicin and cyclophosphamide or taxane

Linac-based radiotherapy has a negligible effect on the majority of advanced neoplasms. Therefore, a novel radiosensitization treatment Kochi Oxydol Radiation Therapy for Unresectable Carcinomas II (KORTUC II), which utilizes hydrogen peroxide and sodium hyaluronate was developed. The effectiveness of KORTUC II for the treatment of chemotherapy-resistant supraclavicular lymph node metastases and recurrent breast cancers has previously been demonstrated. The present study evaluated the safety and efficacy of KORTUC II in patients with stage IV primary breast cancer. Seven patients (age range, 36–65 years) were enrolled. All patients received induction chemotherapy prior to KORTUC II treatment and underwent positron emission tomography-computed tomography (PET-CT) examinations prior to and 2–7 months following KORTUC II treatment, and every six months thereafter where possible. The radiotherapy regimen (x-ray irradiation) was 2.75 gray (Gy)/fraction, 5 fractions/week for 16–18 fractions with a total radiation dose of 44–49.5 Gy. Administration of the KORTUC II agent (3–6 ml: 3 ml for a lesion <3 cm in diameter and 6 ml for a lesion ≥3 cm) was initiated from the sixth radiotherapy fraction, and was conducted twice a week under ultrasonographic guidance. The therapeutic effects were evaluated by PET-CT examinations prior to and following KORTUC II treatment. Of the seven lesions from the seven patients, five exhibited complete responses, two exhibited partial responses and none exhibited stable disease or progressive disease. The overall survival rate was determined to be 100% at 1 and 86% at 2 years post-treatment. The mean duration of follow-up by December 2014 was 51 months. The results of the PET-CT studies indicated that KORTUC II treatment demonstrated marked therapeutic effects with satisfactory treatment outcomes and acceptable adverse effects.

Therapeutic response to a novel enzyme-targeting radiosensitization treatment (Kochi Oxydol-Radiation Therapy for Unresectable Carcinomas) in patients with recurrent breast cancer

Linear accelerator-based radiotherapy has little effect on the majority of locally advanced neoplasms. Thus, the novel radiosensitizer Kochi Oxydol Radiation Therapy for Unresectable Carcinomas, Type II (KORTUC II), which contains hydrogen peroxide and sodium hyaluronate, was developed. The effectiveness of KORTUC II for the treatment of chemotherapy-resistant supraclavicular lymph node metastases has been previously demonstrated. The present study evaluated the safety and effectiveness of KORTUC II in patients with recurrent breast cancer. A total of 20 patients (age range, 39–84 years) were enrolled in the study. The majority of patients underwent positron emission tomography (PET)-computed tomography (CT) examinations prior to and 1–7 months following KORTUC II treatment, and every 6 months thereafter when possible. The radiotherapy regimen was 2.75 Gy/fraction, 5 fractions/week, for 16–18 fractions, with a total radiation dose of 44.00–49.50 Gy (X-ray irradiation), or 4.00 Gy/fraction, 3 fractions/week, for 10–12 fractions, with a total radiation dose of 40.00–48.00 Gy (electron beam irradiation). The injection of 3–6 ml of the KORTUC II agent was initiated at the fifth radiotherapy fraction, and was performed twice/week under ultrasonographic guidance. The therapeutic effects were evaluated by PET-CT examinations prior and subsequent to KORTUC II treatment, which was observed to be well tolerated with minimal adverse effects. Of the 24 lesions presented by the 20 patients, 18 exhibited complete response, 5 partial response, 0 stable disease and 1 progressive disease. The overall survival rate was 100% at 1 year and 95% at 2 years. The mean duration of follow-up at the end of June 2014 was 51 months. Based on the results of the PET-CT studies conducted, KORTUC II treatment demonstrated marked therapeutic effects, with satisfactory treatment outcomes and acceptable adverse events.

Safety and efficacy of image-guided enzyme-targeting radiosensitization and intraoperative radiotherapy for locally advanced unresectable pancreatic cancer

A novel radiosensitization treatment involving the injection of hydrogen peroxide and sodium hyaluronate, using ultrasonic guidance, into a tumor immediately prior to intraoperative radiotherapy (IORT) was established for patients with stage IVa locally advanced unresectable pancreatic cancer. The aim of the present study was to assess the safety and efficacy of this novel treatment, termed Kochi Oxydol-Radiation Therapy for Unresectable Carcinomas-IORT (KORTUC and IORT). In total, 12 patients were treated with KORTUC-IORT, external-beam radiotherapy and systemic chemotherapy using gemcitabine hydrochloride and S-1. For evaluation of the therapeutic and adverse effects, contrast-enhanced computed tomography was conducted prior to the treatment, and one and six months following KORTUC-IORT. Medical examinations were performed every month at the regularly scheduled follow-up visits. The one- and two-year survival rates were 75 and 25%, respectively, and the median survival time was 16 months. All treatments associated with KORTUC-IORT were well-tolerated by the patients, with a small number of adverse effects and no serious complications. It was identified that the delivery of KORTUC-IORT is safe and effective, in combination with external-beam radiotherapy and systemic chemotherapy, for patients with locally advanced unresectable pancreatic cancer.

Choline by magnetic spectroscopy and dynamic contrast enhancement curve by magnetic resonance imaging in neoadjuvant chemotherapy for invasive breast cancer

This study investigated the relationship between choline by magnetic resonance spectroscopy (MRS) and late enhancement curves by dynamic magnetic resonance imaging (DMRI) in determining therapeutic response to neoadjuvant chemotherapy (NAC) among invasive breast cancer patients. Subjects comprised 21 women (22 breasts) with biopsy-confirmed invasive breast cancer (mean age 54 years) who underwent MRS with choline and gadolinium-enhanced DMRI at 1.5 T before and after NAC. Choline signals on MRS were classified into 2 patterns: choline-positive or choline-negative, while late enhancement curves were classified as 'plateau' or 'washout' (type A), or 'persistent' (type B) according to the consensus of 2 radiologists. Maximum tumor diameters and clinical tumor reduction rates were assessed by MRI. Before NAC, choline-positive results were found in all 22 tumors, 21 of which were type A and 1 of which was type B. After NAC, a change from choline-positive to choline-negative was observed with MRS in 11 tumors, while another 11 remained choline-positive. According to DMRI, enhancement curves changed from type A to type B in 14 tumors, remained type A in 7 tumors, and remained type B in 1 tumor. Tumor reduction rates were significantly greater for choline-negative tumors than for choline-positive tumors after NAC (p=0.0115). Following NAC, no significant correlation was noted between enhancement curves and reduction rates (p=0.1210), although a significant correlation was noted between enhancement curves and choline signals (p=0.0014). Changes in choline signals as noted using MRS might offer advantages over changes in enhancement curves by DMRI when evaluating response to NAC in terms of the tumor reduction rate in invasive breast cancer.

Non-surgical care for locally advanced breast cancer: radiologically assessed therapeutic outcome of a new enzyme-targeting radiosensitization treatment, Kochi Oxydol-Radiation Therapy for Unresectable Carcinomas, Type II (KORTUC II) with systemic chemotherapy

We have previously developed a new enzyme-targeting radiosensitization treatment named Kochi Oxydol-Radiation Therapy for Unresectable Carcinomas, Type II (KORTUC II), which markedly enhances radiotherapeutic effects on various types of locally advanced malignant neoplasms. KORTUC II was approved by our local ethics committee for use against various types of malignant neoplasms. A maximum of 6 ml of radiosensitizer was injected into tumor tissue under ultrasonographic guidance just before each administration of radiotherapy. Seventeen patients with locally advanced breast cancer were enrolled to receive KORTUC II with systemic chemotherapy without surgical care. Patients were eligible if they had declined surgical treatment. Median observation period was 13.4 months (range, 1-26 months). This therapy was well tolerated. Contrast-enhanced magnetic resonance imaging revealed complete response in all primary breast tumors, and no patients displayed local recurrence during the follow-up period. Ultrasonography depicted tumor-like findings in 9 of 17 cases after therapy. The existence rate of posterior shadow artifacts behind the tumor was 2/17 before therapy, increasing to 8/17 after therapy. Intratumoral flow signals on color Doppler sonography were seen in 16/17 cases before therapy, but had disappeared from all cases after therapy. The increased rate of posterior shadow artifacts and absence of flow signals after therapy suggest that the tumor-like finding on ultrasonography represents scar tissue. Computed tomography revealed positive axillary nodes metastases in 16/17 and 2/17 cases before and after therapy, respectively. Nodal metastatic failure affected only 1 patient, who refused adjuvant systemic chemotherapy at the end of the observation period. Abnormal lymph node findings on computed tomography remained stable in the other patient. Excellent locoregional control based on accurate radiological evaluation implies that KORTUC II with chemotherapy has the potential to replace surgery in therapy for locally advanced breast cancer.

Role of diffusion-weighted imaging in evaluating therapeutic efficacy after transcatheter arterial chemoembolization for hepatocellular carcinoma

The decision to repeat transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) is based on correct evaluation of response to therapy. The purpose of this study was to investigate whether apparent diffusion coefficient (ADC), a quantitative parameter of diffusion-weighted imaging (DWI), can predict early HCC recurrence after TACE. Results obtained using this method were compared with those using iodized-oil computed tomography (CT). DWI was performed on 25 patients with 36 HCCs before and 5-7 days after TACE to calculate the ADC of HCC. Patients were also evaluated with iodized-oil CT immediately after TACE. Contrast-enhanced CT was performed 3 months after TACE to confirm early relapse of HCC lesion. After TACE, the percent change in ADC (%ADC) from before to after therapy was significantly increased in non-relapsed lesions (85.2+/-12.4%) compared to relapsed lesions (8.0+/-56.7%, p=0.0004). However, no difference in area under the curve was seen for receiver operating characteristic analysis to predict early relapse after TACE between %ADC from DWI (95% confidence interval, 0.743-1.026) and iodized-oil CT (95% confidence interval, 0.703-1.016). ADC from DWI can evaluate the efficacy of TACE for HCC as effectively as iodized-oil CT, and may help in deciding whether to repeat TACE.

Professional Oral Health Care Reduces the Number of Oropharyngeal Bacteria

Silent aspiration of oropharyngeal pathogenic organisms is a significant risk factor causing pneumonia in the elderly. We hypothesized that regular oral hygiene care will affect the presence of oropharyngeal bacteria. Professional cleaning of the oral cavity and/or the gargling of a disinfectant liquid solution was performed over a five-month period in three facilities for the dependent elderly. Total oropharyngeal bacteria, streptococci, staphylococci, Candida, Pseudomonas, and black-pigmented Bacteroides species were monitored. The levels of these oropharyngeal bacteria decreased or disappeared after weekly professional oral health care, i.e., cleaning of teeth, dentures, tongue, and oral mucous membrane by dental hygienists. After lunch, gargling with povidone iodine was shown to be less effective than professional oral care. These findings indicate that weekly professional mechanical cleaning of the oral cavity, rather than a daily chemical disinfection of the mouth, can be an important strategy to prevent aspiration pneumonia in the dependent elderly.

New radiosensitization treatment (KORTUC I) using hydrogen peroxide solution-soaked gauze bolus for unresectable and superficially exposed neoplasms

We developed a new radiosensitization treatment using a hydrogen peroxide solution (Oxydol)-soaked gauze named KORTUC I (Kochi Oxydol-Radiation Therapy for Unresectable Carcinomas) for superficially exposed and unresectable neoplasms, such as malignant melanoma and malignant fibrous histiocytoma (MFH), based on our experimental results which demonstrated hydrogen peroxide as a strong radiosensitizer for the highly radioresistant osteosarcoma cell line, HS-Os-1. Five patients entered our clinical trial, one of whom had unresectable malignant melanoma; one, unresectable MFH; one, unresectable extramammary Paget's disease; one, locally advanced breast cancer and one with locally recurrent skin cancer. These patients were treated with radiation therapy using a high-energy electron beam from a linear accelerator. The total dose was 48 Gy, and each fraction size was 4 Gy. Radiation therapy for these patients was performed three times per week. Each time the radiation therapy was carried out, the superficially exposed tumors of these patients were covered with hydrogen peroxide solution (Oxydol)-soaked gauze, and the lesion was gently massaged for several minutes so as to allow the hydrogen peroxide solution to soak deeply into the tumor. In the treatment results, two of these five patients showed a clinically complete response (cCR) two to three months following the end of the KORTUC I radiosensitization treatment. The other three patients showed a clinically partial response (cCR) showing a decrement of more than half of the pretreatment volume. KORTUC I was completed without any severe complications, excluding mild radiation-induced dermatitis/mucositis (Grade I). In conclusion, this newly developed radiosensitization treatment using hydrogen peroxide solution (Oxydol)-soaked gauze for superficially exposed unresectable/radioresistant neoplasms appears to be an effective and valuable method of radiosensitization in terms of the blockade of anti-oxidative enzymes such as peroxidases, resulting in local oxygen production. Moreover, the KORTUC I radiosensitization treatment is relatively inexpensive and the method can therefore be utilized worldwide for many patients suffering from superficially exposed and locally advanced radioresistant neoplasms such as malignant melanoma, malignant fibrous histiocytoma (MFH) and various types of sarcomas.

Sentinel lymph node detection using computed tomography lymphography is accurate after neoadjuvant chemotherapy for breast cancer

For breast cancer patients who have undergone neoadjuvant chemotherapy (NAC), a sentinel lymph node biopsy (SLNB) has not been recommended until recently. This is due to the possible lymph-flow interruption caused by fibrotic changes following chemotherapy and possible increases in false-negative cases. We investigated the changes in the lymph-flow and the detection of sentinel lymph nodes (SLNs) using computed tomography (CT) lymphography before and after NAC. We enrolled 53 patients with breast cancer who had undergone CT lymphography between May 2004 and April 2006. In total, 75 examinations were performed; 44 before NAC and 31 just after NAC. The CT lymphography procedures were approved by the medical ethics committee of our university. After a comprehensive explanation, written informed consent was obtained from all the patients, prior to enrollment in the study. Differences in changes in the lymph-flow, detection of SLNs, and changes in the number of detected SLNs were examined before and after NAC. Differences in the categoric variables were analyzed using the Chi-square test or Fisher's exact test. The identification rate (90.5%) of the SLNs following NAC was higher than the one before NAC (79.5%). However, no statistically significant difference was noted. No interruptions to the lymph-flow prevented the detection of SLNs by NAC. By performing CT lymphography before and after NAC, the interruption to the lymph-flow can be checked and the site of SLNs can be identified prior to surgery. We found that SLNB is recommended for breast cancer patients with or without NAC.

Preoperative assessment of vascular anatomy of inferior mesenteric artery by volume-rendered 3D-CT for laparoscopic lymph node dissection with left colic artery preservation in lower sigmoid and rectal cancer

AIM: To determine the distance between the branching point of the left colic artery (LCA) and the inferior mesenteric artery (IMA) by computed tomography (CT) scanning, for preoperative evaluation before laparoscopic colorectal operation.

METHODS: From February 2004 to May 2005, 100 patients (63 men, 37 women) underwent angiography performed with a 16-scanner multi-detector row CT unit (Toshiba, Aquilion 16). All images were analyzed on a workstation (AZE Ltd, Virtual Place Advance 300). The distance from the root of the IMA to the bifurcation of the LCA was measured by curved multi-planar reconstruction on a workstation.

RESULTS: The IMA could be visualized in all the cases, but the LCA was missing in two patients. The mean distance from the root of the IMA to the root of the LCA was 42.0 mm (range, 23.2-75.0 mm). There were no differences in gender, arterial branching types, body weight, height, and body mass index.

CONCLUSION: Volume-rendered 3D-CT is helpful to assess the vascular branching anatomy for laparoscopic surgery.

Heart-type fatty acid binding protein is a novel prognostic marker in patients with non-ischaemic dilated cardiomyopathy

OBJECTIVE

To determine whether concentrations of heart-type fatty acid binding protein (H-FABP) measured before hospital discharge predict critical cardiac events in patients with idiopathic dilated cardiomyopathy (DCM).

PATIENTS

92 consecutive patients with DCM were enrolled and followed up for four years.

MAIN OUTCOME MEASURES

Serum concentrations of H-FABP, brain natriuretic peptide (BNP), cardiac troponin T before hospital discharge and survival rate.

RESULTS

23 patients died of cardiac causes, received a left ventricular assist device or underwent heart transplantation during the four-year follow up. Univariate analyses showed that New York Heart Association functional class, heart rate, ejection fraction, serum H-FABP and plasma BNP were significant variables. According to multivariate analysis, serum H-FABP and plasma BNP concentrations were independent predictors of critical cardiac events. Cardiac troponin T before hospital discharge was not a predictor. The area under the receiver operating characteristic curve for death from critical cardiac events was similar between H-FABP and BNP. Patients with an H-FABP concentration at or above the median (> or = 5.4 ng/ml) had a significantly lower survival rate than those below the median, according to analysis by log rank test (p < 0.0001). When combined with BNP concentration at or above the median (> or = 138 pg/ml), H-FABP below the median predicted the worst prognosis among the combinations.

CONCLUSIONS

The concentration of serum H-FABP before discharge from hospital may be an independent predictor for critical cardiac events in DCM.

Recovery, morphological quality, and in vitro maturation of follicular oocytes from bitches with pyometra

The objective of this study was to collect oocytes from ovaries of bitches with pyometra and to characterize the quality of the oocytes recovered. In 10 of 12 cases of pyometra, follicles with a diameter of 500 microm to 1mm were observed in the ovaries. A total of 710 oocytes were collected from 10 bitches by puncturing individual follicles after slicing the ovarian tissues. Oocyte recovery was successful from a bitch with severe clinical signs of pyometra. Of the oocytes collected, 53.5% were surrounded by > or =2 layers of cumulus cells, and 55.0% of these cumulus-oocyte complexes (COCs) had a darkly pigmented ooplasm >110 microm in diameter (large-dark COCs). The number of large-dark COCs per bitch varied from 1 to 72. A germinal vesicle with fine filaments of chromatin (Type A) was observed in 51.8% (range 21.1-100%) of the oocytes of large-dark COCs. Out of 50 oocytes cultured for 72 h, 6.0% developed to Metaphase II. In conclusion, there were many follicles with a diameter of 500 microm to 1mm in ovaries of bitches with pyometra, and many oocytes recovered from these follicles underwent meiotic maturation in vitro. The number of oocytes and COCs, and the morphological quality of the germinal vesicles varied among individual bitches.

Identifying patterns of spatial current dispersion that characterise and separate the Brugada syndrome and complete right-bundle branch block

The aim of the study was to detect patterns of spatial-current distribution in the late QRS and early ST-segments that distinguish Brugada-syndrome cases from complete right-bundle branch block (CRBBB). Magnetocardiograms (MCGs) were recorded from Brugada-syndrome patients (n = 6), CRBBB patients (n = 4) and the members of a control group (n = 33). The current distributions at six time points from Q-onset were estimated by producing current-arrow maps (CAMs). The angle of the current arrow of maximum amplitude at each time point was calculated. In the Brugada cases, the characteristic ST elevation was seen above the upper right chest, and abnormal currents appeared to be present in the right-ventricular outflow tract (RVOT). The angles of the abnormal arrows were -78 degrees +/- 51 degrees at 100 ms and -50 degrees +/- 61 degrees at 110 ms. In the cases of CRBBB, wide S- and R-waves were recorded above the upper right and lower right chest, respectively. The angles of the abnormal arrows for CRBBB were 152 degrees +/- 19 degrees at 100 ms, 159 degrees +/- 20 degrees at 110 ms, and 157 degrees +/- 19 degrees at 120 ms. The findings suggest that an abnormal current from the RVOT to the upper left chest may be a feature of the Brugada syndrome, and that the direction of this current is completely different from that seen in CRBBB.

Mechanism of improvement in exercise capacity after the maze procedure combined with mitral valve surgery

OBJECTIVE

To clarify the mechanism of improvement in exercise capacity after the maze procedure.

DESIGN

Retrospective study.

SETTING

Tertiary referral centre.

PATIENTS

26 patients (mean (SD) age 57 (9) years) with atrial fibrillation (AF) and mitral valve disease were studied with echocardiography and cardiopulmonary exercise testing before and after the maze procedure combined with mitral valve surgery. Of these, eight had persistent AF and 18 had restored sinus rhythm (SR) by the surgery. Six patients (mean (SD) age 59 (12) years) with AF undergoing mitral valve surgery without the maze procedure who had cardiopulmonary exercise testing before and after the surgery formed the control group.

MAIN OUTCOME MEASURES

Echocardiographic parameters of atrial function were measured from transmitral flow recordings. Peak oxygen uptake (VO2) and the slope of the relation between VO2 and workload (ratio of DeltaVO2 to Delta work) were determined as indices of exercise capacity.

RESULTS

The degree of improvements in peak VO2 and the ratio of DeltaVO2 to Delta work after the mitral valve surgery was comparable between the maze and control group. It was also comparable between patients with and those without successfully restored SR after the maze procedure. The degree of the increase in peak VO2 correlated with the change in left atrial diameter (r = -0.40, p = 0.047) but atrial contraction did not correlate with the increase.

CONCLUSIONS

Improvement in exercise capacity may not be caused by restored SR and atrial contraction but may at least partly relate to the reduction of left atrial size and improvement of haemodynamic variables by the surgery.

A chitinase with high activity toward partially N-acetylated chitosan from a new, moderately thermophilic, chitin-degrading bacterium, Ralstonia sp. A-471

A moderately thermophilic bacterium, strain A-471, capable of degrading chitin was isolated from a composting system of chitin-containing waste. Analysis of the 16S rDNA sequence revealed that the bacterium belongs to the genus Ralstonia. A thermostable chitinase A ( Ra-ChiA) was purified from culture fluid of the bacterium grown in colloidal chitin medium. Purification of the enzyme was achieved mainly by exploiting its binding to the colloidal chitin. The molecular mass of the enzyme was estimated to be 70 kDa and the isoelectric point approximately 4.7. N-terminal amino acid sequencing revealed a sequence of ADPYLKVAYYP, which had high homology (66% identity) with that of chitinase A1 from Bacillus circulans WL-12. The pH and temperature optima were determined to be 5.0 and 70 degrees C, respectively. The enzyme was classified as a retaining glycosyl hydrolase and was most active against partially N-acetylated chitosans. Its activities towards the partially N-acetylated chitosans, i.e. chitosan 7B, chitosan 8B, and chitosan 9B, were about 11-fold, 9-fold, and 5-fold higher than towards colloidal chitin, respectively. Ra-ChiA cleaved (GlcNAc)6 almost exclusively into (GlcNAc)2. Activation of Ra-ChiA was observed by the addition of 1 mM Cu2+, Mn2+, Ca2+, or Mg2+. Degradation of the partially N-acetylated chitosan produced oligosaccharides with a degree of polymerization ranging from 1-8; these are products that offer potential application for functional oligosaccharide production.

Oral beraprost sodium improves exercise capacity and ventilatory efficiency in patients with primary or thromboembolic pulmonary hypertension

OBJECTIVE

To investigate the effect of beraprost sodium, an orally active prostacyclin analogue, on exercise capacity and ventilatory efficiency in patients with primary pulmonary hypertension and chronic thromboembolic pulmonary hypertension.

PATIENTS AND DESIGN

Symptom limited cardiopulmonary exercise testing was performed before and 3 (1) months (mean (SEM)) after beraprost treatment in 30 patients with precapillary pulmonary hypertension (14 with primary pulmonary hypertension and 16 with chronic thromboembolic pulmonary hypertension).

RESULTS

Long term treatment with beraprost resulted in significant increases (mean (SEM)) in peak workload (87 (4) W to 97 (5) W, p < 0.001) and peak oxygen consumption (peak VO2, 14.9 (0.7) ml/kg/min to 16.8 (0.7) ml/kg/min, p < 0.001). Beraprost decreased the ventilatory response to carbon dioxide production during exercise (VE-VCO2 slope, 42 (2) to 37 (1), p < 0.001). No significant difference in the responses of these variables to beraprost treatment was observed between patients with primary pulmonary hypertension and chronic thromboembolic pulmonary hypertension.

CONCLUSIONS

Oral administration of beraprost sodium may improve exercise capacity and ventilatory efficiency in patients with both primary and chronic thromboembolic pulmonary hypertension.

Cobalamin deficiency results in severe metabolic disorder of serine and threonine in rats

Dietary cobalamin (vitamin B12; Cbl) deficiency caused significant increases in plasma serine, threonine, glycine, alanine, tyrosine, lysine and histidine levels in rats. In particular, the serine and threonine levels were over five and eight times, respectively, higher in the Cbl-deficient rats than those in the sufficient controls. In addition, some amino acids, including serine and threonine, were excreted into urine at significantly higher levels in the deficient rats. When Cbl was supplemented into the deficient rats for 2 weeks, in coincidence with the disappearance of the urinary excretion of methylmalonic acid (an index of Cbl deficiency), the plasma serine and threonine levels were normalized. These results indicate that Cbl deficiency results in metabolic disorder of certain amino acids, including serine and threonine. The expression level of hepatic serine dehydratase (SDH), which catalyzes the conversion of serine and threonine to pyruvate and 2-oxobutyrate, respectively, was significantly lowered by Cbl deficiency, even though Cbl does not participate directly in the enzyme reaction. The SDH activity in the deficient rats was less than 20% of that in the sufficient controls, and was normalized 2 weeks after the Cbl supplementation. It is thus suggested that the decrease of the SDH expression relates closely with the abnormalities in the plasma and urinary levels of serine and threonine in the Cbl-deficient rats.

Hemodynamic, renal, and hormonal effects of ghrelin infusion in patients with chronic heart failure

Ghrelin is a novel GH-releasing peptide that may also induce vasodilation and a positive energy balance through GH-independent mechanisms. However, the hemodynamic, renal, and hormonal effects of ghrelin in patients with chronic heart failure (CHF) remain unknown. Accordingly, 12 patients with CHF were given an iv infusion of human ghrelin (0.1 microg/kg.min) or placebo. Ghrelin significantly decreased mean arterial pressure (-9 mm Hg, P < 0.05) without a significant change in heart rate. Ghrelin significantly increased cardiac index (+25%, P < 0.05) and stroke volume index (+30%, P < 0.05), although it did not significantly alter mean pulmonary arterial pressure or pulmonary capillary wedge pressure. Infusion of ghrelin induced a marked increase in serum GH level (15-fold), associated with slight increases in circulating epinephrine, ACTH, cortisol, and PRL. Infusion of ghrelin did not significantly alter urine volume, urinary sodium excretion, or creatinine clearance. These hemodynamic, renal and hormonal parameters remained unchanged during placebo infusion. In summary, iv infusion of ghrelin, a potent GH-releasing peptide, had beneficial hemodynamic effects in patients with CHF in the absence of renal effects.

Comparative left ventricular functional and neurohumoral effects of chronic treatment with carvedilol versus metoprolol in patients with dilated cardiomyopathy

The efficacy of treating dilated cardiomyopathy with metoprolol was compared with that of carvedilol. Metoprolol was administered to 29 patients, and carvedilol to 62. Patients who could not be dosed with up to 40 mg daily of metoprolol or 20 mg daily of carvedilol were defined as intolerant. As well as the tolerability of these beta-blockers, the effects on left ventricular end-diastolic dimension (LVDd), fractional shortening (FS), plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) concentrations, the delayed heart and mediastinum (H/M) ratio determined from metaiodobenzylguanidine imaging were compared. Drug intolerance occurred in 24% of patients in the metoprolol group and 19% in the carvedilol group. Among the drug-tolerant patients, LVDd, FS and plasma BNP concentration improved in both groups and to the same degree. Only 25% of drug-tolerant patients in the metoprolol group had a delayed H/M ratio below 1.9 compared with 57% in the carvedilol group. Both metoprolol and carvedilol, when tolerated, improve cardiac function and neurohumoral factors to the same degree. However, carvedilol is preferable to metoprolol for patients with a low delayed H/M ratio.