Impact of controlled blood pressure and pulse rate at discharge on clinical outcomes in patients with ST-segment elevation myocardial infarction

BACKGROUND

Although major guidelines recommend the routine introduction of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) and beta-blockers for patients with ST-segment elevation myocardial infarction (STEMI), evidence regarding the target blood pressure (BP) or pulse rate (PR) at hospital discharge is sparse. This retrospective study aimed to compare the clinical outcomes in patients with STEMI between those with good BP and PR control and those with poor BP or PR control.

METHODS

We included 748 patients with STEMI who received both ACE inhibitors/ARBs and beta-blockers at hospital discharge, and divided them into a good control group (systolic BP ≤140 mmHg and PR ≤80 bpm, n = 564) and a poor control group (systolic BP >140 mmHg or PR >80 bpm, n = 184). The primary endpoint was major cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction, and re-admission for heart failure.

RESULTS

During the median follow-up duration of 568 days, a total of 119 MACE were observed. The Kaplan-Meier curves showed that MACE were more frequently observed in the poor control group (p = 0.009). In the multivariate Cox hazard analysis, the good control group was inversely associated with MACE (HR 0.656, 95 % CI: 0.444-0.968, p = 0.034) after controlling for multiple confounding factors.

CONCLUSIONS

The good control of systolic BP and PR at discharge was inversely associated with long-term adverse events in STEMI patients treated with both ACE inhibitors/ARBs and beta blockers. This study suggests the importance of titration of ACE inhibitors/ARBs and beta-blockers for better clinical outcomes in patients with STEMI.

Association of Increased Inter-arm Blood Pressure Difference with Long-term Clinical Outcomes in Patients with Acute Myocardial Infarction Who Underwent Percutaneous Coronary Intervention

Objective Patients with acute myocardial infarction (AMI) often have peripheral artery disease (PAD). It is well known that the long-term clinical outcomes of AMI are worse in patients with a low ankle-brachial index (ABI) than in patients with a preserved ABI. Unlike ABI, the association between the inter-arm blood pressure difference (IABPD) and clinical outcomes in patients with AMI has not yet been established. This retrospective study examined whether or not the IABPD is associated with long-term clinical outcomes in patients with AMI. Methods We included 979 patients with AMI and divided them into a high-IABPD group (IABPD ≥10 mmHg, n=31) and a low-IABPD group (IABPD <10 mmHg, n=948) according to the IABPD measured during hospitalization for AMI. The primary endpoint was the all-cause mortality rate. Results During a median follow-up duration of 694 days (Q1, 296 days; Q3, 1,281 days), 82 all-cause deaths were observed. Kaplan-Meier curves showed that all-cause death was more frequently observed in the high-IABPD group than in the low-IABPD group (p<0.001). A multivariate Cox hazard analysis revealed that a high IABPD was significantly associated with all-cause death (hazard ratio 2.061, 95% confidence interval 1.012-4.197, p=0.046) after controlling for multiple confounding factors. Conclusion A high IABPD was significantly associated with long-term all-cause mortality in patients with AMI. Our results suggest the usefulness of the IABPD as a prognostic marker for patients with AMI.

Development of a simple prediction model for mechanical complication in ST-segment elevation myocardial infarction patients after primary percutaneous coronary intervention

Mechanical complication (MC) is a rare but serious complication in patients with ST-segment elevation myocardial infarction (STEMI). Although several risk factors for MC have been reported, a prediction model for MC has not been established. This study aimed to develop a simple prediction model for MC after STEMI. We included 1717 patients with STEMI who underwent primary percutaneous coronary intervention (PCI). Of 1717 patients, 45 MCs occurred after primary PCI. Prespecified predictors were determined to develop a tentative prediction model for MC using multivariable regression analysis. Then, a simple prediction model for MC was generated. Age ≥ 70, Killip class ≥ 2, white blood cell ≥ 10,000/µl, and onset-to-visit time ≥ 8 h were included in a simple prediction model as "point 1" risk score, whereas initial thrombolysis in myocardial infarction (TIMI) flow grade ≤ 1 and final TIMI flow grade ≤ 2 were included as "point 2" risk score. The simple prediction model for MC showed good discrimination with the optimism-corrected area under the receiver-operating characteristic curve of 0.850 (95% CI: 0.798-0.902). The predicted probability for MC was 0-2% in patients with 0-4 points of risk score, whereas that was 6-50% in patients with 5-8 points. In conclusion, we developed a simple prediction model for MC. We may be able to predict the probability for MC by this simple prediction model.

Determinants of serious in-hospital complications in patients with Killip class 1/2 ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention

Killip classification has been used to stratify the risk of patients with acute myocardial infarction (AMI). There were many reports that Killip class 3 or 4 is closely associated with poor clinical outcomes. In other words, Killip class 1 or 2 is associated with favorable clinical outcomes in patients with AMI, especially when patients received primary percutaneous coronary intervention (PCI). However, some patients with Killip class 1/2 suffer from serious in-hospital complications. This study aimed to identify factors associated with serious in-hospital complications of ST-segment elevation myocardial infarction (STEMI) in patients with Killip class 1/2. The primary endpoint was serious in-hospital complications defined as the composite of in-hospital death and mechanical complications. We included 809 patients with STEMI, and divided them into the non-complication group (n = 791) and the complication group (n = 18). In-hospital death was observed in 14 patients (1.7%), and mechanical complications were observed in 4 patients (0.5%). Final TIMI flow ≤ 2 was more frequently observed in the complication group (33.3%) than in the non-complication group (5.4%) (p < 0.001). Multivariate logistic regression analysis revealed that serious in-hospital complication was associated with final TIMI flow grade ≤ 2 (Odds ratio 6.040, 95% confidence interval 2.042-17.870, p = 0.001). In conclusion, serious in-hospital complication of STEMI was associated with insufficient final TIMI flow grade in patients with Killip class 1/2. If final TIMI flow grade is suboptimal after primary PCI, we may recognize the potential risk of serious complications even when patients presented as Killip class 1/2.

Clinical Impact of In-Stent Calcification in Coronary Arteries: Optical Coherence Tomography Study

In-stent restenosis with neoatherosclerosis has been known as the predictor of target lesion revascularization (TLR) after percutaneous coronary intervention. However, the impact of in-stent calcification (ISC) alone on clinical outcomes remains unknown since neoatherosclerosis by optical coherence tomography includes in-stent lipid and calcification. We aimed to assess the effect of ISC on clinical outcomes and clinical differences among different types of ISC. We included 126 lesions that underwent optical coherence tomography-guided percutaneous coronary intervention and divided those into the ISC group (n = 38) and the non-ISC group (n = 88) according to the presence of ISC. The cumulative incidence of clinically driven TLR (CD-TLR) was compared between the ISC and non-ISC groups. The impact of in-stent calcified nodule and nodular calcification on CD-TLR was evaluated using the Cox hazard model. The incidence of CD-TLR was significantly higher in the ISC group than in the non-ISC group (p = 0.004). In the multivariate Cox hazard model, ISC was significantly associated with CD-TLR (hazard ratio [HR] 3.58, 95% confidence interval [CI] 1.33 to 9.65, p = 0.01). In-stent calcified nodule/nodular calcification and in-stent nodular calcification alone were also the factors significantly associated with CD-TLR (HR 3.34, 95%CI 1.15 to 9.65, p = 0.03 and HR 5.21, 95%CI 1.82 to 14.91, p = 0.002, respectively). ISC without in-stent calcified nodule/nodular calcification, which was defined as in-stent smooth calcification, was not associated with CD-TLR. In conclusion, ISC was associated with a higher rate of CD-TLR. The types of calcifications that led to a high rate of CD-TLR were in-stent calcified nodule/nodular calcification and in-stent nodular calcification alone but not in-stent smooth calcification. In-stent calcified nodule and nodular calcification should be paid more attention.

Determinants of successful parallel wire technique in percutaneous coronary intervention to coronary chronic total occlusion

BACKGROUND

Many techniques and concepts have been developed in the field of percutaneous coronary intervention to chronic total occlusion (CTO). Parallel wire technique (PWT) is still an important technique in antegrade approach. The purpose of this study was to identify the determinants of successful PWT in coronary CTO.

METHODS

We reviewed consecutive 451 CTO lesions that were treated with PCI in our medical center. The overall success rate of PCI to CTO during the study period was 92.2 % (416/451). Of 451 CTO lesions, we excluded 333 CTO lesions in which PTW was not performed. We included 118 CTO lesions in which PWT was performed, and divided them into the successful PWT group (n = 65) and the unsuccessful PWT group (n = 53) according to the procedure success of PWT. Multivariate logistic regression analysis were performed to find the determinants of successful PWT.

RESULTS

The prevalence of the sufficient clarity of CTO exit site was significantly higher in the successful PWT group (46.2 %) than in the unsuccessful PWT group (11.3 %) (p < 0.01). Multivariate logistic regression analysis revealed that the J-CTO score was inversely associated with successful PWT (OR 0.66, 95 % CI 0.44-0.99, P = 0.04), whereas the sufficient clarity of CTO exit site was associated with successful PWT (OR 5.16, 95 % CI 1.75-15.20, P < 0.01).

CONCLUSIONS

The J-CTO score was inversely associated with successful PWT, whereas the sufficient clarity of CTO exit site was associated with successful PWT. The low J-CTO score and the sufficient clarity of CTO exit site may be the determinants of successful PWT.

Impact of Excessive Increase in Systolic Blood Pressure after Exercise on Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction

OBJECTIVE

Although the clinical outcomes for patients with ST-elevation myocardial infarction (STEMI) have improved significantly, some patients still experience poor clinical outcomes. The available risk classifications focus on the short-term outcomes, and it remains important to find high-risk features among patients with STEMI. In Japan, the 200 m walk electrocardiogram (ECG) test is widely performed before discharge. The purpose of this study was to investigate the association between the excessive increase in systolic blood pressure (SBP) following a 200 m walk and the long-term clinical outcomes in patients with STEMI.

METHODS

We included 680 patients with STEMI and divided those into an excessive increase in SBP group (n = 144) and a non-excessive increase in SBP group (n = 536) according to the SBP increase after a 200 m walk ECG test. We defined an excessive increase in SBP as SBP ≥ 20 mmHg either just after or 3 min after a 200 m walk ECG test. The primary endpoint consisted of major cardiovascular events (MACE), defined as the composite of all-cause death, non-fatal myocardial infarction, readmission for heart failure, and ischemia-driven target vessel revascularization.

RESULTS

The median follow-up duration was 831 days. MACE was more frequently observed in the excessive increase in SBP group (24.3%) than in the non-excessive increase in SBP group (15.1%). Multivariate Cox hazard analysis revealed that the excessive increase in SBP was significantly associated with MACE (HR 1.509, 95% CI: 1.005-2.267, p = 0.047) after controlling for multiple confounding factors.

CONCLUSION

An excessive increase in SBP after the 200 m walk ECG test was significantly associated with MACE in patients with STEMI. The 200 m walk ECG test is simple and low-cost, but may help to identify high-risk patients with STEMI.

Appetite Predicts Long-Term Clinical Outcomes in Patients with Acute Myocardial Infarction

BACKGROUND

Recently, the nutritional status of patients has drawn attention in an aging society. Early studies have reported that nutritional status is related to long-term outcomes in patients with acute myocardial infarction (AMI). However, it is not necessarily simple to evaluate the nutritional status of patients with AMI. We hypothesized that appetite before discharge can be a predictor for long-term adverse cardiovascular events in patients with AMI. This retrospective study aimed to investigate whether appetite is related to long-term adverse outcomes in patients with AMI.

METHODS

This study included 1006 patients with AMI, and divided them into the good appetite group (n = 860) and the poor appetite group (n = 146) according to the percentage of the dietary intake on the day before discharge. Major adverse cardiac events (MACE), which were defined as a composite of all-cause death, non-fatal MI, and re-admission for heart failure, were set as the primary outcome.

RESULTS

The median follow-up duration was 996 days, and a total of 243 MACE was observed during the study period. MACE was more frequently observed in the poor appetite group than in the good appetite group (42.5% versus 21.0%, p < 0.001). In the multivariate COX hazard model, poor appetite was significantly associated with MACE (Hazard ratio 1.698, 95% confidence interval 1.243-2.319, p < 0.001) after controlling for multiple confounding factors.

CONCLUSION

Appetite at the time of discharge was significantly associated with long-term clinical outcomes in patients with AMI. Patients with poor appetite should be carefully followed up after discharge from AMI.

Factors Associated with In-Hospital Death in Patients with Killip Class 3 Acute Myocardial Infarction

The clinical outcomes in acute myocardial infarction (AMI) patients with Killip class 3 are often inconsistent with those in the literature, and the factors associated with poor outcomes have not been sufficiently investigated. The purpose of this study was to identify factors associated with in-hospital death in AMI patients with Killip class 3. We included 205 AMI patients with Killip class 3, and divided them into a survived group (n = 189) and in-hospital death group (n = 16). The primary objective was to identify factors associated with in-hospital death using multivariate analysis. Age was significantly younger in the survived group than in the in-hospital death group (73.1 ± 11.2 versus 83.2 ± 6.2 years, P < 0.001). Systolic blood pressure (SBP) was significantly higher in the survived group than in the in-hospital death group (150.0 ± 31.2 versus 124.8 ± 25.3 mmHg, P = 0.002). The prevalence of TIMI thrombus grade ≥ 2 was significantly greater in the in-hospital death group than in the survived group (56.3 versus 22.2%, P = 0.005). In multivariate logistic regression analysis, in-hospital death was significantly associated with age [odds ratio (OR) 1.168, 95% confidence interval (CI) 1.061-1.287, P = 0.002] and TIMI thrombus grade ≥ 2 (versus ≤ 1: OR 5.743, 95% CI 1.717-19.214, P = 0.005), and inversely associated with SBP on admission (per 10 mmHg increase: OR 0.764, 95% CI 0.613-0.953, P = 0.017). In conclusion, in-hospital death was associated with age and coronary thrombus burden, and was inversely associated with SBP on admission in patients with Killip class 3. It may be important to recognize these high risk features to improve the clinical outcomes of patients with Killip class 3.

Ossification of the Achilles Tendon - A Case Report

Ossification of the Achilles tendon is a very unusual condition. We report a case with bilateral Achilles tendon ossification followed up for twelve years, treated twice surgically on the left side and conservatively on the right side. At the age of 51, the patient's plain radiogram showed bilateral ossifications of the Achilles tendon (right 55 mm, left 15 mm in length). The left side small mass was removed. The right side mass was decided to be followed up because of its large size. At the age of 61, ossification recurred on the left side. Conservative treatment with etidronate disodium for two years failed to prevent ossification from progressing. At the age of 63, the mass on the right and left sides increased to 70 mm and 45 mm in length, respectively. The mass of the left side was excised again, and dull pain disappeared postoperatively on the left side.

S-1 mediates the inhibition of lymph node metastasis in oral cancer cells

S-1, an oral fluorouracil antitumor drug, is composed of three agents: tegafur (FT), 5-chloro-2,4-dihydroxypyridine (CDHP), and potassium oxonate (Oxo). Approximately 50% of oral squamous cell carcinomas (OSCC) exhibit cervical lymph node metastasis. The extent of lymph node involvement is a major determinant in both staging and prognosis of the majority of OSCC. The purpose of this study was to examine the effect of S-1 on the metastatic potential of OSCC cells. We used orthotopic green fluorescence protein (GFP) SAS-L1, in BALB/c nu/nu mice. Mice received oral doses of either 5% hydroxypropylmethylcellulose (HPMC) for control or S-1 (20 mg/kg) and were autopsied at 2 weeks. We also performed in vitro experiments using concomitant 5-fluorouracil (5-FU) and CDHP as a drug model of S-1 to determine the effect of S-1 on OSCC invasion and metastasis. Although 100% (11 of 11) of mice not treated with S-1 showed cervical lymph node metastasis, only 54.4% (6 of 11) of S-1 treated mice demonstrated metastasis. In in vitro experiments, OSCC cells treated with 5-FU and CDHP showed a marked reduction in invasiveness and in adhesion to laminin coated plates. Western blot analysis revealed that treatment with 5-FU and CDHP suppressed expression of integrins alphav, alpha3, alpha6, beta1, beta3, beta4, beta5, and beta6. These results suggest that S-1 inhibits tumor proliferation and lymph node metastasis in OSCC cells. Moreover, expression of integrin subunits and the integrin signal transduction pathway may be closely related to metastasis suppression.

Telomerase-specific virotheranostics for human head and neck cancer

PURPOSE

Long-term outcomes of patients with squamous cell carcinoma of the head and neck (SCCHN) remain unsatisfactory despite advances in combination of treatment modalities. SCCHN is characterized by locoregional spread and it is clinically accessible, making it an attractive target for intratumoral biological therapies.

EXPERIMENTAL DESIGN

OBP-301 is a type 5 adenovirus that contains the replication cassette in which the human telomerase reverse transcriptase promoter drives expression of the E1 genes. OBP-401 contained the replication cassette and the green fluorescent protein (GFP) gene. The antitumor effects of OBP-301 were evaluated in vitro by the sodium 30-[1-(phenylaminocarbonyl)-3,4-tetrazolium]-bis(4-methoxy-6-nitro)benzene sulfonic acid hydrate assay and in vivo in an orthotopic xenograft model. Virus spread into the lymphatics was also orthotopically assessed by using OBP-401.

RESULTS

Intratumoral injection of OBP-301 resulted in the shrinkage of human SCCHN tumors orthotopically implanted into the tongues of BALB/c nu/nu mice and significantly recovered weight loss by enabling oral ingestion. The levels of GFP expression following ex vivo infection of OBP-401 may be of value as a positive predictive marker for the outcome of telomerase-specific virotherapy. Moreover, whole-body fluorescent imaging revealed that intratumorally injected OBP-401 could visualize the metastatic lymph nodes, indicating the ability of the virus to traffic to the regional lymphatic area and to selectively replicate in neoplastic lesions, resulting in GFP expression and cell death in metastatic lymph nodes.

CONCLUSIONS

These results illustrate the potential of telomerase-specific oncolytic viruses for a novel therapeutic and diagnostic approach, termed theranostics, for human SCCHN.

Antitumor activity of suberoylanilide hydroxamic acid against human oral squamous cell carcinoma cell lines in vitro and in vivo

It has been reported recently that histone deacetylase inhibitors (HDACIs) can block the growth of a variety of malignant tumor cells by reversing the silencing of the tumor suppressor genes; these will be the anticancer agents of the next generation. In this study, we evaluated the antitumor effects of the HDACI suberoylanilide hydroxamic acid (SAHA) on oral squamous cell carcinoma (OSCC) and investigated its molecular mechanism. SAHA suppressed the in vitro proliferation of OSCC cell lines in a dose- and time-dependent manner. Flow cytometric analyses showed that treatment with SAHA led to G1 phase cell-cycle arrest of OSCC cells, accompanying a decrease in the percentage of S-phase cells. Western blot analyses demonstrated that the expression of p21 protein was remarkably augmented and hyperacetylation of p53 was induced after SAHA treatment. These results suggest that administration of SAHA suppresses OSCC growth through G1 phase arrest. Additionally, we observed that the growth of xenograft SAS tumors in nude mice was significantly blocked by the administration of SAHA without major adverse effects.

Inhibition of TGF-beta1 suppresses motility and invasiveness of oral squamous cell carcinoma cell lines via modulation of integrins and down-regulation of matrix-metalloproteinases

Transforming growth factor (TGF)-beta1 is a multifunctional polypeptide that regulates a variety of cellular processes. Several studies have indicated that it is associated with epithelial-mesenchymal transition, angiogenesis, migration and metastases in many types of malignant tumors. We have used a wound-healing assay and a Matrigel invasion assay to evaluate the effects of TGF-beta1 and TGF-beta receptor I kinase inhibitor (TRI) on the cell motility and invasiveness of the human oral squamous cell carcinoma (OSCC) cell lines SAS-L1 and HSC-3. While TGF-beta1 enhanced the migration and invasion of OSCC cells, TRI significantly suppressed the migration and invasion of these cells. Exogenous TGF-beta1 up-regulated the activity of type IV collagenase (gelatinase A and gelatinase B), whereas TRI down-regulated the activity of these matrix metalloproteinases. Western blot analysis revealed that TGF-beta1 enhanced the expression of alpha5, alphav, beta1, beta6 and alphavbeta3 integrin subunits, and these enhanced integrins were down-regulated by treatment with TRI. These results suggest that the inhibition of TGF-beta1 suppresses motility and invasiveness of OSCC cells via modulation of integrins and matrix-metalloproteinases. Therefore, targeting the TGF-beta1 signaling pathway could be beneficial in the treatment of patients with OSCC.

Hypoxia induces resistance to 5-fluorouracil in oral cancer cells via G(1) phase cell cycle arrest

Malignant tumors are exposed to various levels of hypoxic condition in vivo. It has been known that tumor cells under hypoxia are resistant to chemotherapies. To clarify the mechanism of the hypoxia-induced chemoresistance, we evaluated the effects of hypoxia on the resistance of oral squamous cell carcinoma (OSCC) cell lines to 5-fluorouracil (5-FU). OSCC cells were divided to two groups by the proliferation activity under hypoxic condition; hypoxia-resistant (HR) and hypoxia-sensitive (HS) cells. Growth of HS cells were inhibited by hypoxia and introduced to G(1) arrest in cell cycle. 5-FU effect on HS cell viability was markedly reduced in hypoxic condition without an induction of chemoresistant related protein, P-glycoprotein. However, proliferation, cell cycle, and 5-FU sensitivity of HR cells were not affected by hypoxia. Hypoxia-inducible factor (HIF)-1alpha was induced by hypoxia in all OSCC cell lines, but diminished in HS cells within 48h. Expression of p21 and p27 was strongly augmented and CyclinD expression was reduced by hypoxia in HS cells. However, the expression of these proteins was constitutive in HR cells during 48h hypoxic culture. Phosphorylation of mammalian target of rapamycin (mTOR) was reduced by hypoxia in HS cells. From these findings, we concluded that HS OSCC cells acquire 5-FU resistance under hypoxia by G(1)/S transition through an upregulation of cell cycle inhibitors.

Enhanced susceptibility to apoptosis of oral squamous cell carcinoma cells subjected to combined treatment with anticancer drugs and phosphatidylinositol 3-kinase inhibitors

The purpose of this study was to determine whether phosphatidylinositol 3-kinase (PI 3-K) inhibitors could modulate the apoptotic activity of the anticancer drugs cisplatin, 5-fluorouracil or docetaxel in an oral squamous cell carcinoma (OSCC) cell line, HSC-2. In preliminary experiments, cisplatin, 5-fluorouracil and docetaxel inhibited the proliferation of OSCC cells in a dose-dependent manner. We found that two PI 3-K inhibitors, wortmannin and LY294002, markedly suppressed the phosphorylation of Akt in OSCC cells. Treatment of OSCC cells with PI 3-K inhibitors significantly enhanced cisplatin-, 5-fluorouracil- or docetaxel-induced apoptosis. Caspase-3 and -9 inhibitors, but not a caspase-8 inhibitor, reduced anticancer drug-mediated apoptosis in PI 3-K inhibitor-treated OSCC cells, suggesting that the apoptotic pathway induced by the combination of anticancer drug therapy and PI 3-K inhibition may be functionally related to the intrinsic apoptotic pathway in OSCC cells. Expression of Bcl-2, cellular inhibitor of apoptosis protein-1 (cIAP-1), and X-linked IAP was down-regulated, and expression of Bax was up-regulated by PI 3-K inhibitors, while that of Bcl-xL, Bak and cIAP-2 was not attenuated. We also found that Bad phosphorylation was down-regulated by PI 3-K inhibitors. These results suggested that inhibition of PI 3-K enhances the susceptibility of OSCC cells to anticancer drug-mediated apoptosis through regulation of expression and post-translational modification of both pro- and anti-apoptotic proteins. These findings could potentially lead to new strategies for improving the efficacy of anticancer drugs in OSCC cells.

Radiological and histological features of tumoral calcinosis of the dorsum of the foot

Tumoral calcinosis is a rare condition characterized by large calcific masses occurring predominantly in the juxta-articular regions of the extremities. To our knowledge, occurrences in the foot, particularly in association with bone erosion, have been very rare. A 52-year-old Japanese man presented with a mass in the foot, the size of which increased over a period of 27 years. CT scan and MRI demonstrated a 6 cm x 3 cm x 2.5 cm sized mass. There was bone erosion of the dorsal side of the third metatarsal head. Marginal excision was made. Histopathologically, the mass was composed of amorphous calcification with inflammatory cell infiltration. X-ray diffraction method revealed that the pattern of the mass coincided with hydroxyapatite. The patients had no local recurrence at 5 years after operation.

Comparison of methods to stimulate ovarian follicular growth in cynomolgus and African green monkeys for collection of mature oocytes

The objective was to compare various gonadotropin-based methods to stimulate ovarian follicular growth in female cynomolgus (n=16) and African green monkeys (n=8) for collection of mature oocytes. On the 1st day of menstruation, the monkeys were treated with 3.75 mg leuprorelin acetate (a GnRH agonist). Starting 2-3 weeks later, ovarian follicular growth was stimulated as follows: (a) 25 IU/kg of human FSH (hFSH) in a glycerol solution given once daily for 9 d; (b) 200 IU of eCG given six times during a 9-d interval; (c) 75 IU/kg hFSH in a glycerol solution given three times (72 h intervals) during a 6-d interval. In addition, the monkeys were given 1200 or 4000 IU of hCG 36 h (Methods A and B) or 60 h (Method C) after the last gonadotropin treatment, and oocyte collection was attempted 36-38 h after hCG. Although there were no significant differences among methods in the number of oocytes collected, in cynomolgus monkeys, hFSH (Methods A and C) was better than eCG (Method B; 12 and 10 versus 7 mature oocytes, respectively), whereas in African green monkeys, eCG (Method B) was more effective than hFSH (Method A; 12 versus 7 mature oocytes). Furthermore, in cynomolgus monkeys, Method C was nearly as effective as Method A; using a glycerol solution as a solvent decreased the frequency of hFSH administration from nine to three times. In conclusion, in cynomolgus and African green monkeys, ovarian response depended on the species and on the individual, and in cynomolgus monkeys, hFSH in a glycerol solvent was effective.

Inguinal endometriosis attaching to the round ligament

We report a case of endometriosis in the right inguinal region, attached to the right round ligament in a 28-year-old woman. At the age of 20, laparoscopic left ovarian cystectomy and pelvic adhesiolysis for endometriosis was carried out. She noticed a right tender groin mass 7 months previously, and the tumour size fluctuated with the menstrual cycle. A poorly circumscribed elastic hard mass, measuring 3 cm in diameter, was palpated in her right inguinal region. Magnetic resonance imaging showed a 2.5 cm x 2.5 cm mass in the right inguinal canal and a 5.4 cm x 6.8 cm mass was seen in the left ovary. The mass enlarged during menstruation. The groin mass was removed, in addition to carrying out laparoscopic ovarian cystectomy. At operation, the groin mass was found to be in continuity with the round ligament of extraperitoneal portion. Histological diagnosis of endometriosis was made in both ovarian and inguinal tumours. After surgery, the pain disappeared completely. Worth mentioning is that MRI clearly showed the change of tumour size depending on the menstrual cycle, which aided in arriving at the correct diagnosis of endometriosis in an unusual location.

378 INTRACYTOPLASMIC SPERM INJECTION AND ESTABLISHMENT OF EMBRYONIC STEM CELLS IN AFRICAN GREEN MONKEYS (CERCOPITHECUS AETHIOPS)

There has been little embryological research in African green monkeys (Cercopithecus aethiops), although Vero and Cos7 cell lines derived from the kidney of the green monkey are used as valuable resources for testing viral infections and introducing foreign genes. Embryological research would not only contribute to medical science but would also help to maintain and propagate other monkeys, including those in the wild. We examined intracytoplasmic sperm injection (ICSI) and in vitro culture of green monkey embryos and attempted to establish embryonic stem (ES) cells, which would be precious resources. We collected mature oocytes from females treated with eCG + hCG or human FSH + hCG to induce follicular growth stimulation and oocyte maturation. Of 61 oocytes from eCG-treated females and of 44 oocytes from FSH-treated females, 41 (67.2%) and 27 (61.4%) fertilized oocytes with 2 pronuclei and a second polar body were produced with ICSI, respectively. We cultured fertilized oocytes from eCG-treated and FSH-treated females in CMRL-1066 medium containing 10% fetal bovine serum (FBS), with or without a buffalo rat liver (BRL) cell monolayer. Of 28 zygotes from eCG-treated females, 9 were cultured without a monolayer, and 3 (33.3%) developed into blastocysts; none of 19 cultured with a monolayer did. Of 22 zygotes from FSH-treated females, 18 were cultured without a monolayer, and 5 (27.8%) developed into blastocysts; none of 4 cultured with a monolayer did. Thus, there were no differences in the fertilization rates and development into blastocysts between the oocytes from eCG- and FSH-treated females. On the other hand, BRL cells did not support development into blastocysts [0/23 (0%) with a monolayer vs. 8/27 (29.6%) without a monolayer; P &lt; 0.01]. The other embryos were used for experiments such as embryo transfer. Parts of the inner cell mass (ICM), isolated by removing trophectoderm and the zona pellucida (ZP) with a 27-gauge needle (5 blastocysts) or by dissolving the ZP with an enzyme (3 blastocysts) were transferred to DMEM/F12 (1 : 1) medium containing 20% FBS or knockout serum replacement with a mitomycin C-treated STO cell or mouse embryonic fibroblast cell monolayer. Only 3 ICMs formed extended colonies; the others, including the 3 blastocysts from which the ZP was dissolved, did not. When the 3 colonies were subcultured with collagenase or divided into small clusters with a needle, 2 flat colonies, as in primate ES cells, appeared. At the next subculture, the flat colonies disappeared. However, we confirmed the formation of ES-like cell colonies. These results show that it is possible to produce blastocysts with ICSI and that ES cells may be established in African green monkeys.

Thalidomide suppresses melanoma growth by activating natural killer cells in mice

Although thalidomide (Thd) is being extensively investigated for its effects on cytokine production and T cell costimulation, it is poorly understood whether it is capable of modulating the activities of natural killer (NK) cells. In this study, Thd effects on NK cell activity were examined with a murine model of melanoma, which is mostly rejected by NK cell-dependent mechanism. Administration of Thd significantly (p<0.01 on Day 21) suppressed the growth of subcutaneous B16F1 melanoma. In Thd-treated mice, marked splenomegaly and augmented splenocyte count were observed. Additionally, the percentage of splenic NK1.1+ cells was elevated to approximately 2.5-fold within 10 days after Thd treatment. The expression of interferon inducible protein (IP)-10, interferon (IFN)-gamma, interleukin (IL)-12 and IL-18 was remarkably upregulated. Production of the cytotoxic molecule perforin was also augmented. These data suggest that Thd strongly activates NK cell activity in mice, possibly resulting in enhanced tumor surveillance defense.

Inhibition of cyclooxygenase-2 suppresses invasiveness of oral squamous cell carcinoma cell lines via down-regulation of matrix metalloproteinase-2 and CD44

Expression of cyclooxygenase-2 (COX-2) in tumors is known to be associated with enhanced angiogenesis, suppression of host immunity, and tumor invasion. In the present study, human oral squamous cell carcinoma (OSCC) cell lines NA and HSC-4 were used to evaluate the effects of NS-398, a selective inhibitor of COX-2, and COX-2 antisense oligonucleotide (COX-2 AS) on the invasion activity of OSCC cells. Matrigel invasion assay revealed that the invasiveness of NA and HSC-4 was suppressed by treatment with either NS-398 or COX-2 AS. These reagents down-regulated the secretion of matrix metalloproteinase-2 (MMP-2) to culture supernatant as well as the expression of MMP-2 mRNA and protein. Membrane-type 1 matrix metalloproteinase (MT1-MMP), an activator of proMMP-2, was also down-regulated by treatment with these reagents. Furthermore, expression of CD44 on the surface of these cells was reduced by treatment with either NS-398 or COX-2 AS. In addition, MMP-2 antisense oligonucleotides reduced the expression of CD44 on the surface of both OSCC cell lines. These findings suggest that NS-398 and COX-2 AS suppress the invasiveness of OSCC cells via down-regulation of MMP-2 and CD44. Genetic or pharmacological inhibition of COX-2 may therefore be a beneficial strategy in the treatment of OSCC patients.

Pilot study of the optimum hematocrit for patients in the predialysis stage after renal transplantation

Anemia is a common complication in patients with chronic kidney diseases including posttransplant patients. Guidelines for the treatment of anemia in chronic kidney disease published by NHF-K/DOQI recommend the target hemoglobin and hematocrit (Hb and Ht) levels to be in the 11 to 12 g/dL and 33% to 36% ranges, respectively, which are somewhat higher than those recommended in Japan (Ht = 30%). However, these guidelines were established mainly from the data on hemodialysis patients with only limited information available as to the impact of anemia control in posttransplant patients. The aim of the present study was to evaluate cardiac function and quality of life (QOL) when the Ht was raised to about 36% by administration of recombinant-human-erythropoietin (rHuEPO) to patients with mild impairment of renal function (s-Cre < 2.0 mg/dL) after renal transplantation. Twenty-five patients were analyzed for cardiac function, blood data, and QOL in a prospective study encompassing 8 months of rHuEPO treatment. Using a once weekly subcutaneous dose of 6000 IU of Epoetin-beta, the Ht became 33% to 36% and Hb was 11 to 12 g/dL. Among the cardiac function tests, left ventricular end-diastolic diameter and left ventricular mass index decreased significantly. QOL did not show any significant changes after administration of rHuEPO. In conclusion, we demonstrated a potential benefit of using rHuEPO to maintain the Hb between 11 and 12 g/dL and the Ht between 33% and 36% in posttransplant patients with regard to the prevention of cardiovascular complications. Further study is required to establish the benefits of correcting anemia by rHuEPO on the outcome of posttransplant patients.

Recombinant human bone morphogenetic protein-2 promotes Indian hedgehog-mediated osteo-chondrogenic differentiation of a human chondrocytic cell line in vivo and in vitro

We examined osteo-chondrogenic differentiation of a human chondrocytic cell line (USAC) by rhBMP-2 in vivo and in vitro. USAC was established from a transplanted tumor to athymic mouse derived from an osteogenic sarcoma of the mandible. USAC usually shows chondrocytic phenotypes in vivo and in vitro. rhBMP-2 up-regulated not only the mRNA expression of types II and X collagen, but also the mRNA expression of osteocalcin and Cbfa1 in USAC cells in vitro. In vivo experimental cartilaginous tissue formation was prominent in the chamber with rhBMP-2 when compared with the chamber without rhBMP-2. USAC cells implanted with rhBMP-2 often formed osteoid-like tissues surrounded by osteoblastic cells positive for type I collagen. rhBMP up-regulated Ihh, and the expression of Ihh was well correlated with osteo-chondrogenic cell differentiation. These results suggest that rhBMP-2 promotes chondrogenesis and also induces osteogenic differentiation of USAC cells in vivo and in vitro through up-regulation of Ihh.

Effect of 5-fluorouracil on G1 phase cell cycle regulation in oral cancer cell lines

5-fluorouracil (5-FU) has been widely used for chemotherapy of head and neck cancer, and is known to affect the cell cycle and induce apoptotic death of cancer cells. However, the molecular actions of 5-FU on the cell cycle regulatory mechanism have not been fully explained. Herein we analyzed the effects of 5-FU on the expression of G1/S-related cell cycle regulators in oral cancer cell lines. In vitro 5-FU treatment of oral cancer cells resulted in an increase in G1/S phase cells. p21 expression was augmented by 5-FU without any notable changes in p53 expression. A remarkable up-regulation of cyclin E and a concomitant down-regulation of cyclin D were observed after 24 h 5-FU treatment. Our results suggest that 5-FU-induced changes in cell cycle regulation of oral cancer cells might associate with an alteration of G1 cyclins expression. p21 was remarkably up-regulated, but it was speculated that its activity might be cancelled by an increased binding to CDK4.

Comparison of the expression profile of metastasis-associated genes between primary and circulating cancer cells in oral squamous cell carcinoma

Tumor metastasis is a complex process involving several distinct steps such as escape from a primary tumor, dissemination through the circulation, lodgment in small vessels at distinct sites, penetration of the vessel wall and growth in the new site as a secondary tumor. To compare the expression profile of metastasis-associated genes between circulating cancer cells in peripheral blood and cells in the primary lesion of oral squamous cell carcinoma (OSCC), we employed a combination analysis of laser captured microdissection (LCM) and immunomagnetic separation (IMS) techniques for capturing primary and circulating cancer cells, respectively. Total RNAs were then extracted from each cell and mRNA expression of CK19, matrix metalloproteinases (MMP-1, -2, -7, -9) and CD44, including its variant forms (CD44s, v6, v9), were analyzed by RT-PCR. Although CD44 including its variant forms were expressed in 20%(CD44s) to 30%(v6, v9) of the primary lesion, 40%(v6) to 90%(CD44s) of blood samples were CD44-positive. Furthermore, MMPs were expressed in 30%(MMP-1, -2) to 60%(MMP-7) of primary samples, whereas most blood samples were negative for the expression of MMPs. These results suggested that circulating cancer cells might express different characteristics after being released from the primary lesion.

The differences between late graft loss group and long-term graft survival group in renal transplantation

In renal transplantation, the long-term graft survival rate has not been improved. Until now, the differences between late graft loss and long-term graft survival have still not been estimated thoroughly. We have attempted to define clinical risk factors and parameters for late graft loss by comparing the differences in these two groups. Data from the Osaka University Database were assessed on 156 renal allografts during a 7-yr period. Thirty-six patients comprised the late graft loss group (patients in this group had graft function without need for dialysis for more than 3 yr post-transplantation, afterwards lost the allograft: 'loss group'). One hundred and twenty patients comprised the long-term graft survival group (patients in this group had graft function without need for dialysis until 31 December 1999: 'survival group'). Various immunological and non-immunological parameters were included in an univariate regression analysis. This analysis showed that donor age (P < 0.01), HLA mismatch number (P < 0.01) and a repeat of acute rejection (P < 0.01) were significant factors. Serum creatinine levels at 3 months (P = 0.01), proteinuria at 1 yr (P < 0.01) and antihypertensive treatment at 2 yr (P = 0.03) after transplantation were predictive of the risk of late graft loss. CsA trough concentration at 3-6 months (P < 0.05) and body mass index increase at 1 yr (P = 0.046) were elevated in the loss group. These results from a single centre suggest that immunological as well as non-immunological factors are associated with the pathogenesis of late graft loss.

A cell line with multinucleated giant cell formation established from a human giant cell tumor of tendon sheath--preliminary report

We first established a cell line with unique giant cell formation properties from a human giant cell tumor of tendon sheath (GCTTS) arising in the right ankle of a 7-year-old girl. The specimen for cell culture taken from the tumor was heterotransplanted into the back of a BALB/c (nu/nu) nude mouse. An in-vitro cell line was established from a tumor that grew after this heterotransplantation. Only mononuclear cells were observed in the primary culture, and these remained constant in growth. Multinucleated giant cells appeared at passage 3 and were constantly observed thereafter. The fusion of mononuclear cells into giant cells was verified by light and phase-contrast microscopy. This cell line was confirmed to be derived from a human by karyotype analysis and DNA fingerprinting. The cell-doubling time was 150 h. This cell line should be useful for studies of the mechanism of multinucleation in giant cell tumors.

A case of inguinal endometriosis with difficulty in preoperative diagnosis

An unusual case of endometriosis involving the right round ligament in a 40-year-old woman is presented. After giving birth to two children, she first noticed a tender mass in the right groin at the age of 36. It didn't change in size but pain appeared at the age of 38, disturbing her daily life. A poorly circumscribed elastic hard mass, measuring 3 cm in diameter, was palpable in her right inguinal region. Magnetic resonance imaging demonstrated a 2x3 cm mass in the right inguinal canal. At operation, a mass was found to be in continuity with the round ligament at the inguinal canal. Histological diagnosis was endometriosis. After operation, she was completely relieved of pain. It is important to include endometriosis in the differential diagnosis for painful inguinal masses in women of childbearing age.

The pharmacokinetics of fosfestrol and diethylstilbestrol in chronic hemodialysis patients with prostate cancer

BACKGROUND

Fosfestrol drip infusion therapy is an available endocrinotherapy for prostate cancer. But since there have been few reports of its use in chronic dialysis patients, the pharmacokinetics of fosfestrol in these patients remains unclear. We conducted fosfestrol drip infusion therapy as an induction therapy in chronic hemodialysis patients with prostate cancer.

METHODS

Two male patients were included in this study. One was a 68-year-old man who had been in hemodialysis for 15.7 years and had stage B2 prostate cancer. The other was a 74-year-old man who had been in hemodialysis for 4.4 years and had stage C prostate cancer. A total of 250 mg of fosfestrol was dissolved in 250 mL of 5% glucose solution and administered by drip infusion. The drug was given subcutaneously during 14 consecutive days and a luteinizing hormone-releasing hormone agonist was injected on day 15.

RESULTS

Serum fosfestrol levels increased rapidly after the drip infusion was started and remained at high levels during infusion, but fell quickly after the treatment ended. Diethylstilbestrol (DES) was also detected in blood after the infusion was started and its levels peaked when infusion ended. But on the next day, neither fosfestrol nor DES were detected in the blood of the patients. Moreover, neither fosfestrol nor DES was detected in the blood of the two patients before administering fosfestrol on day 15. Fosfestrol was quickly eliminated from the blood after hemodialysis was started, while DES remained in the blood during hemodialysis. The adverse reactions were mild hepatic dysfunction and gynecomastia.

CONCLUSIONS

Fosfestrol drip infusion therapy appeared to be safe as an endocrinotherapy for prostate cancer in chronic hemodialysis patients.

Synchronous multifocal osteosarcoma with lymphatic spread in the lung: an autopsy case report

Synchronous multifocal/multicentric osteosarcoma (MOS) is a rare variant of osteosarcoma. We report here an autopsy case of a 15-year-old boy with MOS. Radiological examinations showed multiple sclerotic lesions in the left distal femur and in the ipsilateral proximal tibia without pulmonary metastasis at the first examination. Histological examination showed osteoblastic-type osteosarcoma. Despite high-dose chemotherapy the patient died of multiple bone and lung involvements 6 months after the initial diagnosis. Autopsy examination revealed prominent invasion of the tumor cells into lymphatic vessels and pleural dissemination without the formation of bulky, nodular metastasis in the lungs. Metastases in pulmonary hilar lymph nodes were noted without metastasis in other organs. Immunohistochemistry revealed that p53 protein was positive in most of the tumor cells. In summary, the present case was characterized by multiple bone involvement and prominent lymphatic spread of sarcoma cells in the lungs.

Twenty-six-years' survival with multiple bone metastasis of malignant pheochromocytoma

The prognosis of metastatic pheochromocytoma is poor in general. There have been few instances of long-term survival reported. We report a case of a 44-year-old woman who has survived for 26 years after bone metastasis. She was diagnosed as having pheochromocytoma arising in the left adrenal medulla in 1974. Metastasis of pheochromocytoma in the first and third lumbar vertebrae and the right ilium was observed at the same time. The primary lesion was removed, and posterior lumbar spinal fusion was performed for immobilization. The metastatic lesion in the ilium was left untouched. After 26 years, she is well despite a recurrence of the tumors in the skull and a new metastasis in the left abdomen.

Periosteal Ewing's sarcoma: radiological imaging and histological features

Periosteal Ewing's sarcoma is very rare. In this report, we describe three cases of periosteal Ewing's sarcoma, illustrating the principal clinical, radiographic, and histologic features. The patients were aged 15, 16, and 20 years old, with an average of 17 years. The tumor occurred in the humerus in two and in the femur in one. Plain radiography showed a laminated periosteal reaction with a Codman's triangle over a subperiosteal soft-tissue mass or saucerization. The unusual site of Ewing's sarcoma was clearly visualized by computed tomography (CT) and magnetic resonance imaging (MRI) and confirmed by histological examination. Chemotherapy and/or irradiation was employed before and after wide excision. The patients have survived an average of 6 years after the primary surgery.