Breast cancer dermal lymphatic invasion recurrence and contralateral axillary lymph nodes metastasis after complete response to neoadjuvant therapy: A case report

INTRODUCTION AND IMPORTANCE

Non-luminal type breast cancer patients with pathological complete response (pCR) by neoadjuvant chemotherapy (NAC) usually have a good prognosis, but occasionally recurrence occurs.

CASE PRESENTATION

A 61-year-old woman was diagnosed with breast cancer T2N2aM0 stage IIIA and its intrinsic type was non-luminal type. After NAC, the patient achieved pCR and underwent breast-conserving surgery and axillary lymph node dissection (ALND). Radiotherapy and trastuzumab of one-year duration was added. However, six years and two months later, local recurrence and contralateral axillary lymph node (CLALN) metastasis were identified. After resection, anti-human epidermal growth factor receptor 2 (HER-2) therapy was done, however, six months after operation, purpura was observed on the right chest and tended to increase. One and a half years after re-operation, dermal lymphatic invasion (DLI) recurrence without clinical inflammatory signs was diagnosed. A skin resection was performed >1.5 cm away from the purpura, and the surgical margins were negative but four months later, a recurrence re-emerged.

CLINICAL DISCUSSION

CLALN metastasis is considered distant metastasis based on the current TNM classification. However, as previous ALND or radiotherapy can change lymphatic flow, the resulting CLALN may not be distant metastasis. DLI recurrence without clinical inflammatory signs is likely to be resistant to anti-HER2 even in non-luminal type, and even a 2-cm margin for skin surgical lines may result in positive margins.

CONCLUSION

There are cases where CLALN after ALND should also be considered possible metastasis. In DLI recurrence, the skin excision margin line should be set very generously.

Study of cytochrome P4502E1 mRNA level of mononuclear cells in patients with alcoholic liver disease

BACKGROUND

Cytochrome P-4502E1 (CYP2E1) is an important enzyme because of its unique ability to convert many substrates to cytotoxins. The increased production of reactive intermediates by elevated enzyme concentrations leads to various pathological conditions. Therefore, it is important to detect induced CYP2E1 levels in alcoholic individuals to avoid xenobiotic-promoted liver injury. In the present investigation, we detected CYP2E1 mRNA levels of mononuclear cells obtained from 10 ml of blood by using competitive polymerase chain reaction (PCR) method.

METHODS

Mononuclear cells were obtained from healthy individuals who did and did not drink habitually and patients with alcoholic liver disease (ALD). Complementary DNA synthesis was performed with RNA obtained from mononuclear cells by reverse transcription-PCR. Competitive PCR of CYP2E1 was performed with the sense (5'-CTGCAACGTCATA-GCCGACA-3') and antisense (5'-TCCATTTCCACGAGCAGGCA-3') primer and competitor DNA. Competitive PCR of beta-actin also was performed. Electrophoresis was scanned, and each band was digitized. The concentration of CYP2E1 and beta-actin mRNA was calculated from the ratio of competitor DNA.

RESULTS

In healthy individuals who did and did not drink habitually, CYP2E1 mRNA levels were 103.3 copies/microl RNA and 101.7 copies/microl RNA, respectively. In actively drinking patients with ALD, CYP2E1 mRNA levels were 103.5 copies/microl RNA, but those levels decreased to 101.7 copies/microl RNA after 4 days of abstinence. No significant difference was observed in CYP2E1 mRNA levels between alcoholic fibrosis and cirrhosis. As control, we measured beta-actin mRNA levels in mononuclear cells in all samples. The mean value of beta-actin mRNA was 104.3 copies/microl RNA in all cases, which included patients with ALD.

CONCLUSIONS

The results demonstrated that it is possible to measure the CYP2E1 mRNA levels of mononuclear cells in a 10 ml blood sample. The CYP2E1 mRNA level in mononuclear cells increases during drinking and decreases in abstinence for a short period of 3 to 4 days. It is concluded that CYP2E1 mRNA level may be used as an effective marker for alcoholic intake.

Study of mitochondrial DNA deletion in alcoholics

BACKGROUND

Recently, it has been reported that single or multiple mitochondrial DNA (Mt-DNA) deletions have been observed frequently in liver tissue and white blood cells (WBC) obtained from patients with alcoholic liver disease (ALD). In this study, we investigated the deletion of the Mt-DNA encoding adenosine triphosphatase (ATPase) region in WBC to clarify whether Mt-DNA heteroplasmy caused by alcohol drinking is reversible.

METHODS

Blood samples were obtained from 4 healthy volunteers, 56 patients with ALD, and 106 nonalcoholic healthy controls. The Mt-DNA encoded ATPase region was amplified by polymerase chain reaction (PCR) by using two primers: forward primer, 5'-AACCAACACCTCTTACAGTGA; and reverse primer; 5'-TTGGTGGGTCATTATGTGTTGT.

RESULTS

Heteroplasmy was observed in one volunteer on day 3 and in the remaining persons on day 4 after the start of alcohol consumption. Heteroplasmy was observed for another 6 days after alcohol consumption stopped, but on the 7th day it had disappeared in all volunteers. In WBC Mt-DNA obtained from ALD patients within 3 days of abstinence, heteroplasmy was observed in 38 of the 56 patients (67.9%), whereas heteroplasmy was not detected in any healthy subjects. In 10 of the 18 ALD patients (56%) who had heteroplasmy within 3 days of abstinence, heteroplasmy disappeared after 4 weeks of abstinence.

CONCLUSION

An acquired mutation of Mt-DNA, at least in the encoding ATPase region, may result from alcohol drinking and may be reversed by stopping drinking.

Immunohistochemical study of hyaluronate receptor (CD44) in alcoholic liver disease

BACKGROUND

It has been suggested that the elevation of serum hyaluronate (HA) levels in liver diseases may be due to increased synthesis of HA by hepatic stellate cells or decreased degradation by sinusoidal endothelial cells. The increase in serum HA levels in patients with cirrhosis is thought to be a response to a reduction in HA receptors (CD44) in hepatic sinusoidal endothelial cells. To learn more about how alcohol affects the number and distribution of HA receptors of hepatic sinusoidal endothelial cells, we immunohistochemically studied CD44 levels in liver biopsy obtained from patients with alcoholic liver disease (ALD patients) and also from patients with nonalcoholic liver disease (non-ALD); ALD patients were evaluated when they were currently drinking and again after they became abstinent. Normal liver tissue obtained from three autopsy cases served as a control.

METHODS

Liver biopsy specimens were obtained from 18 ALD patients and 12 non-ALD patients. In ALD patients, liver biopsy was performed twice within 3 days and 4 to 8 weeks after abstinence when serum levels of aspartate aminotransferase and alanine aminotransferase became normal. CD44 in liver specimens was stained with anti-CD44 antibody by streptavidine-biotin-peroxidase complex. The intensity of the staining of CD44 in liver tissue was determined by a computer-assisted imaging analyzer. We also measured serum levels of CD44 in both ALD and non-ALD patients.

RESULTS

The intensity and the number of CD44 staining increased in both ALD and non-ALD patients compared with those in normal liver, which was negative. The staining intensity of CD44 in liver specimens obtained from patients with ALD who were active in alcohol consumption were significantly higher when compared with patients with ALD after abstinence. Serum levels of CD44 in patients with liver disease increased compared with those of healthy subjects.

CONCLUSIONS

The results suggest that HA receptors may increase to degrade the increased HA in serum and/or liver.

Effects of a new orally active dopamine prodrug, docarpamine, on refractory ascites: a pilot study

OBJECTIVE

Refractory ascites is a debilitating condition in patients with cirrhosis. Recently, docarpamine, an orally active dopamine prodrug, was reported to increase renal blood flow, glomerular filtration, and sodium excretion. This suggests docarpamine may be useful for the treatment of refractory ascites.

METHODS

In this study, we investigated docarpamine metabolism in cirrhotic patients and its effect on refractory ascites.

RESULTS

Blood samples were obtained from seven cirrhotic patients and six healthy subjects after administration of 750 mg docarpamine, and plasma levels of free dopamine were measured. In healthy subjects, maximum plasma concentration (Cmax), time taken to reach Cmax (Tmax), elimination half-life (T(1/2)), and area under the plasma concentration-time curve (AUC) of plasma free dopamine were 76.8 +/- 24.1 ng/ml, 1.3 +/- 0.2 h, 0.8 +/- 0.1 h, and 97.5 +/- 21.1 ng x h/ml, respectively. In patients with cirrhosis, Cmax (53.1 +/- 24.9 ng/ml), T(1/2) (0.8 +/- 0.1 h), and AUC (100.6 +/- 45.6 ng x h/ml) were no different from healthy subjects when comparing each parameter, whereas Tmax (2.7 +/- 0.2) was significantly longer than that of healthy subjects. We treated 10 cirrhotic patients with refractory ascites with docarpamine or placebo and the same dose of diuretics used before hospitalization. After 8 wk of docarpamine treatment, ascites disappeared completely in three of the five patients and decreased in the remainder. However, in five patients treated with placebo, ascites was not changed or increased. Side effects were not observed in any case.

CONCLUSIONS

Docarpamine was found to metabolize in cirrhotic patients as well as in normal subjects and may be an effective treatment for refractory ascites.

Clinicopathological study of chronic hepatitis induced by alcohol with or without hepatitis G virus

The concept of chronic hepatitis induced by alcohol (AL-CH) has not been widely accepted, because AL-CH may be due to non-A-E hepatitis virus in heavy drinkers. Recently, hepatitis G virus (HGV) was identified as a positive-strand RNA virus related to members of the Flaviviridae family. In this study, we determined serum HGV in patients with AL-CH and analyzed the clinicopathological changes after abstinence to evaluate whether AL-CH is caused by alcohol or not. Serum samples were obtained from 16 patients with AL-CH who had neither hepatitis B nor C virus. The diagnosis was confirmed histologically. In eight patients, liver biopsy was performed twice, within 3 days and 4 to 8 weeks after abstinence. The NS3 region of the HGV genome was detected using an reverse transcriptase-polymerase chain reaction method. Serum levels of AST, ALT and gamma-glutamyltranspeptidase were measured once a week sequentially after admission. Serum HGV-RNA was detected in only one patient with AL-CH (6.3%). In all patients, including one patient with HGV, serum levels of AST, ALT and gamma-glutamyltranspeptidase clearly decreased to normal levels after abstinence. Inflammatory activity in the periportal area of patients with actively drinking decreased or disappeared after abstinence for 4 to 8 weeks. These results suggest that HGV may not play an important role for development of AL-CH, and that AL-CH may be caused by alcohol itself, although a more larger number of patients with AL-CH are needed to obtain definitive conclusions.

Histochemical study of hyaluronate in alcoholic liver disease

Recently, it has been reported that serum hyaluronate (hyaluronic acid; HA) concentrations increase in various liver diseases, especially in alcoholic liver disease (ALD), and serum HA concentration has been used as a marker for hepatic fibrosis. However, it is unknown whether hepatic HA contents in ALD increase by alcohol or not. In this study, we histochemically stained HA in liver biopsy specimens obtained from ALD patients while actively drinking and after abstinence to clarify the effects of alcohol on hepatic HA contents. Liver biopsy specimens were obtained from 13 patients with ALD and 10 patients with non-ALD. In ALD patients, liver biopsy was performed twice within 3 days, and 4 to 8 weeks after abstinence when serum levels of AST and ALT normalized. HA in biopsy specimens was stained histochemically with biotinylated HA binding protein. Staining intensity of HA in liver tissue was also determined by computer-assisted imaging analyzer. HA staining was clearly observed in sinusoidal wall and fibrous regions around the portal tract and central vein in liver diseases. HA staining intensities in patients actively drinking with ALD increased markedly, compared with those in patients with non-ALD, and these intensities decreased with abstinence. These results clearly suggest that hepatic HA contents in ALD may be increased by alcohol in addition to hepatic fibrosis, and, therefore, increased HA deposition in the liver may be reversible by abstinence of alcohol.

Characteristics of serum hyaluronate concentrations in patients with alcoholic liver disease

It has been reported that serum hyaluronate [hyaluronic acid (HA)] concentrations are increased in liver diseases, especially in alcoholic liver disease (ALD). However, the characteristics of serum HA concentration in patients with ALD have not been studied. In this study, first, we measured serum HA concentrations in patients with different stages of both ALD and non-ALD to clarify the characteristics of serum HA concentration in patients with ALD. Second, we measured serum HA concentrations in patients with ALD sequentially after abstinence. We also measured serum HA concentrations in patients with chronic type C hepatitis before and after treatment with interferon. Finally, we analyzed the relationship between serum HA concentrations and the contents of type IV collagen and laminin in the livers of both ALD and non-ALD patients. Serum HA concentrations in liver disease were higher than the cut-off value, and increased significantly (p < 0.001) in parallel with the progression of hepatic fibrosis in both ALD and non-ALD patients. Serum HA concentrations in patients actively drinking with ALD were significantly higher (p < 0.001) than those in non-ALD. After 4 weeks of abstinence, these concentrations fell to the levels of non-ALD. Although serum ALT levels were decreased in 80% of patients treated with interferon, serum HA concentrations were not changed or increased. A significant correlation between serum HA concentrations and hepatic type IV collagen and laminin content was present in ALD, but not in non-ALD. These results clearly suggest that the increase of serum HA concentrations in ALD may be associated with not only hepatic fibrosis, but also alcohol drinking.

Clinical significance of hepatitis GB virus C infection in alcoholic liver disease

Recently, hepatitis GB virus C (HGBV-C) has been recovered from patients with non-A-E hepatitis. However, it has been unclear whether HGBV-C may be related to the development of alcoholic liver disease (ALD) or not. In this study, we determined HGBV-C RNA in sera from alcoholic patients without markers for hepatitis C and B viruses to evaluate the role of HGBV-C in ALD. Serum samples were obtained from 68 patients with ALD and 40 nonalcoholic patients with chronic type C liver disease. HGBV-C RNA was detected in only 3 of 68 (4.4%) patients with ALD, in 2 of 27 patients with hepatic fibrosis, and in 1 of 5 patients with chronic hepatitis. There was no HGBV-C RNA in sera from patients with fatty liver, alcoholic hepatitis, or cirrhosis. Serum levels of AST, ALT, and gamma-glutamyltranspeptidase in alcoholic patients with, as well as without, HGBV-C RNA decreased to normal levels after abstinence. In addition, an inflammatory change was not observed in liver biopsy specimens obtained from two HGBV-C-positive patients with alcoholic hepatic fibrosis. Our results clearly suggest that the prevalence of HGBV-C infection in patients with ALD is rare and that HGBV-C may not play an important role in the development of liver disease in alcoholics.

Aldecalmycin, a new antimicrobial antibiotic from Streptomyces. I. Taxonomy, fermentation, isolation, physico-chemical and biological properties

A new antibiotic, aldecalmycin, has been discovered in the culture broth of Streptomyces sp. MJ147-72F6. Aldecalmycin was purified by solvent extraction, Diaion HP-20 chromatography, silica gel chromatography, Sephadex LH-20 chromatography, HPLC and centrifugal partition chromatography. The 1H and 13C NMR spectra of aldecalmycin showed the presence of keto-enol tautomers. Aldecalmycin is equipotent in inhibiting the growth of sensitive and methicillin-resistant Staphylococcus aureus (MRSA).

Novel antibiotics, amythiamicins. II. Structure elucidation of amythiamicin D

The structure of a unique polythiazole-containing cyclic peptide antibiotic, amythiamicin D, was elucidated by chemical degradations and NMR spectral analyses. Acid hydrolysis of amythiamicin D gave one mole of glycine and three new amino acids. Structures of N-acetyl-O-methyl derivatives of these new amino acids were determined by NMR and UV spectral analyses. Connectivities of these amino acids were determined by HMBC experiments.

Novel antibiotics, amythiamicins. III. Structure elucidations of amythiamicins A, B and C

The structures of novel antimicrobial antibiotics, amythiamicins A, B and C, were elucidated by chemical degradations and NMR spectral analyses. The main frame from C-1 to C-41 of these antibiotics was the same as that of amythiamicin D. Amino acid autoanalyses of amythiamicins A, B and C showed that these have another one mole of serine and proline in comparison with amythiamicin D. Stereochemistries of both amino acids were determined to be L by chiral HPLC. These seryl-prolyl residues in amythiamicins A, B and C are attached at C-41 through an oxazoline ring, amide and ester bond, respectively.

Novel antibiotics, amythiamicins. I. Taxonomy, fermentation, isolation, physico-chemical properties, and antimicrobial activity

Novel antibacterial antibiotics, amythiamicins A, B, C and D, have been isolated from the fermentation broth of Amycolatopsis sp. MI481-42F4. In this paper, the taxonomy of the producing strain, fermentation, isolation, physico-chemical properties and biological activities of amythiamicins are reported. Amythiamicins inhibit the growth of Gram-positive bacteria including multi-drug resistant strains.

Aureobasidins, new antifungal antibiotics. Taxonomy, fermentation, isolation, and properties

Aureobasidins A to R were isolated from the fermentation broth of Aureobasidium pullulans R106. Aureobasidins are cyclic depsipeptide antibiotics with MW's ranging from 1.070 to 1,148. Aureobasidins showed high in vitro antifungal activity against Candida albicans.

Effects of ethanol and its metabolites on collagen synthesis by cultured rat liver cells

The effects of ethanol and its metabolites on collagen synthesis in cultured rat Ito cells and hepatocytes were studied. In cultured Ito cells, collagen synthetic ability reached peak values after incubation for 24 h and after 8 h in cultured hepatocytes. The distribution patterns of 14C-activity in each collagen fraction were quite different between the two cell types. About 80% of the activity was found in the degraded collagen fraction in the cultured hepatocytes, indicating a rapid turn-over of collagen protein in this cell type. In the Ito cells, the activity in the intact collagen was about 50%. Ethanol and its metabolites added to the incubation medium did not stimulate collagen synthesis in either cell type; rather, they inhibited it. Collagen metabolism in the cells to which ethanol or its metabolites had been added was slower than in the control medium. These results indicate that the pathogenesis of alcoholic liver fibrosis is not simple and that interaction or modulation of cell function in different types of cells should be considered when examining the mechanisms of fibrogenesis in alcoholic liver fibrosis.